                   COURT OF APPEALS OF VIRGINIA


Present: Judges Elder, Bray and Annunziata
Argued at Richmond, Virginia


CHARTER INTEGRATED SERVICES AND
 HOME INDEMNITY COMPANY
                                           MEMORANDUM OPINION* BY
v.   Record No. 2243-01-4                   JUDGE LARRY G. ELDER
                                               APRIL 30, 2002
RICHARD J. SKOFF


        FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

          Kevin W. Cloe (Charles F. Midkiff; Midkiff,
          Muncie & Ross, P.C., on brief), for
          appellants.

          (Richard Skoff, pro se, on brief).


     Charter Integrated Services and Home Indemnity Company

(employer) appeal from a decision of the Workers' Compensation

Commission (commission) finding employer responsible for medical

treatment rendered to Richard Skoff (claimant) by Dr. Michael

Hoffstetter.   On appeal, employer contends the evidence failed

to prove Dr. Hoffstetter's treatment was causally related to

claimant's compensable injury.    We hold credible evidence

supported the commission's conclusion that Dr. Hoffstetter's

treatment was causally related to claimant's industrial injury,

and we affirm the commission's decision.



     * Pursuant to Code § 17.1-413, this opinion is not
designated for publication.
     On appeal of a decision of the commission, we construe the

evidence in the light most favorable to the party prevailing

below, and we must uphold the commission's findings of fact if

the record contains credible evidence to support them.     See,

e.g., Lynchburg Foundry Co. v. Goad, 15 Va. App. 710, 712, 427

S.E.2d 215, 217 (1993).

     Code § 65.2-603(A)(1) provides that for "[a]s long as

necessary after a [compensable industrial] accident, the

employer shall furnish or cause to be furnished, free of charge

to the injured employee, a physician chosen [in the manner

prescribed by the Workers' Compensation Act] and such other

necessary medical attention."    Whether the employer is

responsible for medical expenses under this code section depends

upon "(1) whether the medical service was causally related to

the industrial injury; (2) whether such other medical attention

was necessary; and (3) whether the treating physician made a

referral of the patient."     Volvo White Truck Corp. v. Hedge, 1

Va. App. 195, 199, 336 S.E.2d 903, 906 (1985).    A claimant bears

the burden of proof on these issues by a preponderance of the

evidence.    McGregor v. Crystal Food Corp., 1 Va. App. 507, 508,

339 S.E.2d 917, 918 (1986).    However,

            [w]hether "such other medical attention" be
            deemed necessary is for the attending
            physician or . . . [c]ommission to
            determine, not the employer. So long as a
            causal relationship between the industrial
            accident and the complaints which are the
            subject of the referral is shown, the
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             employer is financially responsible for the
             medical attention which the attending
             physician deems necessary, subject to review
             by the [c]ommission.

Jenson Press v. Ale, 1 Va. App. 153, 159, 336 S.E.2d 522, 525

(1985) (citation omitted) (decided under former Code § 65.1-88,

predecessor to Code § 65.2-603).

     Furthermore, an employer's liability extends to "'all the

medical consequences and sequelae that flow from the primary

injury.'"     American Filtrona Co. v. Hanford, 16 Va. App. 159,

163, 428 S.E.2d 511, 513 (1993) (quoting 1 Arthur Larson, The

Law of Workmen's Compensation § 13.11 (1992)).     "'[E]xacerbation

of the claimant's condition resulting from antibiotics,

antitoxins, sedatives, pain killers, anesthesia, . . . or

corrective or exploratory surgery' is compensable."     Id.

(quoting Larson, supra, § 13.21(a) (footnotes omitted)).

     Finally, "'[m]edical evidence is not necessarily

conclusive, but is subject to the commission's consideration and

weighing.'    The testimony of a claimant may also be considered

in determining causation, especially where the medical testimony

is inconclusive."     Dollar Gen'l Store v. Cridlin, 22 Va. App.

171, 176, 468 S.E.2d 152, 154 (1996) (quoting Hungerford Mech.

Corp. v. Hobson, 11 Va. App. 675, 677, 401 S.E.2d 213, 215

(1991)) (citation omitted).

     Employer conceded before the commission "that Dr. [Thomas

C.] Schuler and Dr. [Joseph K.] Statkus are treating physicians

                                 - 3 -
in this matter" and that Dr. Statkus referred claimant to

Dr. Hoffstetter.   On appeal, employer contests only the

commission's conclusion that the medical treatment provided by

Dr. Hoffstetter was causally related to claimant's 1995 injury.

We hold that credible evidence in the record supports the

commission's finding that claimant's three visits to

Dr. Hoffstetter were, in fact, causally related to his

compensable back injury.

     Dr. Schuler, the physician who performed claimant's back

surgeries in 1998, originally expressed much uncertainty about

the source of claimant's ongoing pain after those surgeries.

However, on August 18, 2000, Dr. Schuler opined that claimant's

ongoing pain was "directly related" to his industrial injury.

Dr. Schuler listed claimant's five diagnoses as lumbar

postlaminectomy syndrome, lumbar radiculopathy, bilateral

sacroiliitis, chronic pain syndrome and fibromyalgia.    He noted

claimant's "ongoing complaints of pain that date back to the

time of his accident" and opined that "[claimant's] ongoing

problems," thereby implicitly incorporating the immediately

preceding list of diagnoses, "are directly related to his

accident and the subsequent treatment for that."   Thus, credible

evidence supports a finding that Dr. Schuler found a direct

connection between claimant's injury and his chronic pain.

     Claimant first saw Dr. Hoffstetter on referral from

Dr. Statkus, who had been treating claimant's chronic pain on
                              - 4 -
referral from Dr. Schuler.   Dr. Statkus made the referral based

on claimant's reports of memory loss and confusion which began

after he developed a post-surgical infection and underwent

debridement of his back surgery site on February 22, 1998.

Dr. Statkus noted that the worsening of the episodes caused him

to "wonder about some kind of embolic event" which may have

occurred as a result of claimant's infection.   Dr. Statkus's

referral to Dr. Hoffstetter, at a minimum, was designed to

determine whether a direct causal connection existed between

claimant's surgery and his memory loss.   Thus, it was causally

related to claimant's compensable injury.

     Further, the results of Dr. Hoffstetter's examination and

testing indicated that claimant's memory difficulties were

"attributed to pain and concurrent depression," and Dr. Statkus

opined that claimant's "depression [was] secondary to [his]

chronic pain."   Thus, Dr. Schuler's opinion that claimant's

chronic pain was caused by his compensable injury provided a

direct causal connection between claimant's injury and his first

two visits to Dr. Hoffstetter.

     Dr. Schuler's opinion that claimant's "ongoing complaints

of pain" resulted from his compensable injury also provides a

sufficient causal connection between claimant's injury and his

third visit to Dr. Hoffstetter.   Dr. Statkus referred claimant

to Dr. Hoffstetter on this occasion because claimant was

experiencing headaches which were worsening and were severe
                              - 5 -
enough "that [claimant] cannot do much of anything."     Claimant

testified that he had had only one headache in his life prior to

his back surgery and that he underwent "surgery [for a sinus

problem] and took care of that.   No other headaches."   Thus,

Dr. Schuler's opinion that claimant's ongoing pain from several

diagnosed conditions was caused by his compensable injury was

sufficient to provide the necessary link between claimant's

injury and Dr. Hoffstetter's treatment of claimant for

headaches.

     For these reasons, we hold credible evidence supports the

commission's award, and we affirm.

                                                           Affirmed.




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