Patricia Lamalfa v. Janis Hearn et al., No. 39, September Term, 2017

EXPERT WITNESS TESTIMONY – BASES OF OPINION TESTIMONY BY
EXPERT – MARYLAND RULE 5-703 – FACTS OR DATA REASONABLY
RELIED UPON BY TESTIFYING EXPERT – DISCLOSURE TO JURY –
ELEMENTS FOR DISCLOSURE – Court of Appeals held that trial court did not abuse
its discretion or err in “admitting” plaintiff’s post-accident medical treatment records into
evidence under Maryland Rule 5-703. Court of Appeals concluded that “disclosed” under
Maryland Rule 5-703(b) means that evidence is admissible if it satisfies four elements set
forth in Maryland Rule 5-703(b), and that such evidence may, in trial court’s discretion, be
disclosed to jury to explain factual bases for expert’s opinion. Under circumstances of
case, medical records satisfied four elements of Maryland Rule 5-703(b) because they were
trustworthy, unprivileged, reasonably relied upon by defense expert in forming his
opinions, and necessary to illuminate defense expert’s testimony. Court of Appeals also
concluded that, even if disclosure, i.e., admission, of medical records under Maryland Rule
5-703 was error, such error was harmless, as plaintiff failed to demonstrate that she was
prejudiced by admission of medical records or their use at trial; record contains no
indication that jury placed undue weight on medical records.
Circuit Court for Baltimore City
Case No. 24-C-14-005520

Argued: December 4, 2017
                                         IN THE COURT OF APPEALS

                                              OF MARYLAND

                                                   No. 39

                                             September Term, 2017
                                   ______________________________________

                                            PATRICIA LAMALFA

                                                      v.

                                            JANIS HEARN ET AL.
                                   ______________________________________

                                             Barbera, C.J.
                                             Greene
                                             Adkins
                                             McDonald
                                             Watts
                                             Hotten
                                             Getty,

                                                   JJ.
                                   ______________________________________

                                              Opinion by Watts, J.
                                   ______________________________________

                                             Filed: February 2, 2018
       In Maryland, it is well established that “[a]n expert may give an opinion based on

facts contained in reports, studies, or statements from third parties, if the underlying

material is shown to be of the type reasonably relied upon by experts in the field.” U.S.

Gypsum Co. v. Mayor and City Council of Balt., 336 Md. 145, 176, 647 A.2d 405, 420

(1994) (citations omitted). This Court has stated that “the underlying reports, data, or

statements themselves may be admitted into evidence for the purpose of explaining the

basis of the expert’s opinion.” Id. at 176, 647 A.2d at 420 (citations omitted). This process

is formalized under Maryland Rule 5-703(b), which provides, in pertinent part, that, “[i]f

determined to be trustworthy, necessary to illuminate testimony, and unprivileged, facts or

data reasonably relied upon by an expert pursuant to section (a) may, in the discretion of

the court, be disclosed to the jury even if those facts and data are not admissible in

evidence.” In Brown v. Daniel Realty Co., 409 Md. 565, 601, 976 A.2d 300, 321 (2009),

this Court explained that, from Maryland Rule 5-703(b), we distilled “four elements [that]

must be satisfied for a document to be admissible under [Maryland R]ule[ 5-703]. The

document must be (1) trustworthy, (2) unprivileged, (3) reasonably relied upon by an expert

in forming her or his opinion, and (4) necessary to illuminate that expert’s testimony.”

       This case concerns admission, under Maryland Rule 5-703(b), of medical records

of the plaintiff that a defense expert relied upon in forming his opinions. Specifically, in

the Circuit Court for Baltimore City (“the circuit court”), Patricia Lamalfa, Petitioner, sued

Janis Hearn, Respondent, for negligence related to a motor vehicle accident. At a jury trial,

during Respondent’s medical expert’s testimony, the circuit court admitted into evidence,

over Petitioner’s objection, four of Petitioner’s post-accident medical treatment records
that the expert relied upon in forming his opinions. At the close of all of the evidence, the

circuit court granted a motion for judgment in Petitioner’s favor on negligence, and ruled

that the jury would determine “the amount of damages, if any[,] that should be awarded.”

Petitioner requested that the jury enter a verdict for economic and non-economic damages

in an amount from $50,000 to $150,000, including damages for emotional distress. The

jury returned a verdict in Petitioner’s favor in the amount of $10,576.05, which included

the full amount of Petitioner’s medical bills in the amount of $9,926.05, plus $650.00 for

non-economic damages.       Consistent with the jury’s award, the circuit court entered

judgment in Petitioner’s favor and against Respondent in the amount of $10,576.05.

Petitioner appealed, and the Court of Special Appeals affirmed the circuit court’s judgment.

Petitioner filed in this Court a petition for a writ of certiorari, which we granted.

       Against this backdrop, we consider whether the circuit court properly admitted four

medical records into evidence under Maryland Rule 5-703, and, specifically, whether

“disclosed” under Maryland Rule 5-703(b) means “admitted.” We hold that the circuit

court did not abuse its discretion or err in admitting Petitioner’s post-accident medical

treatment records into evidence under Maryland Rule 5-703. Specifically, we conclude

that “disclosure” means that evidence is admissible under Maryland Rule 5-703(b) where

the evidence satisfies the four elements set forth in Maryland Rule 5-703(b), and that such

evidence may, in a trial court’s discretion, be disclosed to the jury to explain the factual

bases for an expert’s opinion. Additionally, under the circumstances of this case, the

medical records satisfied the four elements of Maryland Rule 5-703(b) because they were

trustworthy, unprivileged, reasonably relied upon by the defense expert in forming his


                                             -2-
opinions, and necessary to illuminate the defense expert’s testimony. And, we conclude

that, even if disclosure, i.e., admission, of the medical records under Maryland Rule 5-703

was error, such error was harmless as Petitioner has failed to demonstrate that she was

prejudiced by admission of the medical records or their use at trial; the record contains no

indication that the jury placed undue weight on the medical records.

                                    BACKGROUND

       On October 14, 2011, Petitioner, a resident of Brooklyn, New York, was in

Maryland to attend a family member’s wedding. On the way to the wedding, Petitioner

was sitting in the rear passenger seat of a small SUV that was being driven by her son,

Steven Lamalfa (“Steven”). Steven drove the SUV southbound on Interstate 95 and onto

an exit ramp, where it came to a complete stop. While stopped, the SUV was rear-ended

by a vehicle that was being driven by Respondent.

       Emergency medical technicians responded to the scene, but Petitioner did not seek

medical treatment at that time. Petitioner, Steven, and the other occupants of the SUV—

Steven’s girlfriend, Gina Illardo; Petitioner’s friend, Brigitte Rivera (“Rivera”); and

Steven’s infant daughter—eventually left the scene of the accident and attended the

wedding. After the wedding, Petitioner and the SUV’s other occupants went to a hotel for

the night. The next morning, Petitioner went to the emergency room at Mercy Medical

Center (“Mercy”) in Baltimore City complaining of lower back pain and some pain in her

left forearm. Petitioner was treated at Mercy, released that same day, and returned to New

York that night.

       On October 21, 2011, a week after the accident, Petitioner sought medical treatment


                                           -3-
from Yury Koyen, M.D., of Relief Medical, P.C. in Brooklyn, New York, who specializes

in physical medicine and rehabilitation. At that time, Petitioner complained of upper and

lower back pain, pain in both arms, pain in her left hip, periodic numbness in her right

hand, pain in her right shoulder, weakness in her left arm, tailbone pain that was worsened

by sitting, and emotional distress related to the accident, including flashbacks, fear of

sitting in a car, and claustrophobia. Dr. Koyen recommended that Petitioner undergo

physical therapy and chiropractic treatment, as well as diagnostic testing in the form of

MRIs and X-rays.

       In October of 2011, Petitioner also started experiencing severe abdominal pain;

however, a CT scan of Petitioner’s abdomen and pelvis performed on October 31, 2011,

was normal. Later, on March 7, 2012, Sampath Kumar, M.D., performed surgery on

Petitioner to repair an epigastric hernia. Apparently, the epigastric hernia was a recurrent

issue for Petitioner, who had surgery to repair an epigastric hernia in 1984.

       In the meantime, on November 7, 2011, Petitioner had an MRI of her right shoulder

performed, which revealed a rotator cuff injury. In December 2014, over three years later,

Petitioner visited Jaspreet Sekhon, M.D., who ordered another MRI, which revealed a

rotator cuff tear. Thereafter, Petitioner underwent arthroscopic surgery on her right

shoulder.

       On September 23, 2014, Petitioner filed in the circuit court a complaint against




                                            -4-
Respondent, alleging negligence.1         Specifically, Petitioner alleged that Respondent

negligently operated her motor vehicle and caused Petitioner’s injuries. Petitioner sought

damages in excess of $75,000. From February 16 to 18, 2016, the case was tried before a

jury. At trial, as part of the plaintiffs’ case, Petitioner and Steven testified,2 and videotaped

de bene esse depositions of Dr. Koyen, Dr. Kumar, and Dr. Sekhon were played for the

jury.3

         Petitioner, who was fifty-four years old at the time of trial, testified that she worked

as a hairdresser from the age of eighteen until approximately within a year of the accident,

and that she did not have difficulties performing her job or otherwise have problems with

her right shoulder prior to the accident. Petitioner acknowledged, however, that, in 1984,

she had hernia repair surgery. As to the accident on October 14, 2011, Petitioner testified

that, when the SUV in which she was a passenger was rear-ended, she “was thrust forward,

sideways[,]” she hit her head, and she recalled her “shoulder or something hitting [her


         1
         In the complaint, Steven and Rivera were also named as plaintiffs. Rivera settled
her claims before trial. Steven’s claims were tried with Petitioner’s. The jury returned a
verdict in Steven’s favor, and the circuit court entered judgment in his favor, in the amount
of $8,575.66. Steven did not appeal, and he is not a party in this Court.
       Additionally, the plaintiffs originally included John B. Hearn, Jr. (“John”),
Respondent’s husband, as a defendant, suing him for negligence and negligent entrustment;
on the first day of trial, however, those claims were dismissed with prejudice. John is not
a party in this Court.
       2
         Because Steven’s testimony is not relevant to the issue in this case, we do not
summarize his testimony.
       3
         As the Court of Special Appeals noted in its reported opinion in this case, “[t]he
video depositions were not transcribed and the DVD recordings are not in the record.”
Lamalfa v. Hearn, 233 Md. App. 141, 144 n.4, 163 A.3d 205, 207 n.4 (2017). Thus, as the
Court of Special Appeals did, “we summarize the expert testimony based only upon the
excerpts provided by [Respondent] in the appendix to her brief.” Id. at 144 n.4, 163 A.3d
at 207 n.4.

                                               -5-
right] shoulder or grabbing [her] shoulder and [her] left knee.” Petitioner testified that, the

evening of the accident, she began experiencing pain in her lower back and her left knee,

and she went to Mercy the next morning. As to her abdomen, Petitioner testified that, after

the accident, “[i]t started feeling weak[,]” she noticed she could not “move things or pick

things up[,]” and “then [she] started feeling a protrusion.” According to Petitioner, as a

result of the protrusion and upon “realiz[ing] what it could be[,]” she went to see Dr.

Kumar, who performed surgery to repair a hernia. Petitioner testified that, between the

accident and when she first started noticing problems with her abdomen, she had not

experienced any other traumatic event to her stomach or abdominal area.

       As to her right shoulder, Petitioner testified that after the accident she began

experiencing right shoulder pain that “got progressively worse.” According to Petitioner,

she was unable to pick up her grandchildren, lift pots and pans, or stretch too high because

her right shoulder pained her and would “lock in place.” Petitioner testified that she did

not seek immediate medical treatment for her right shoulder because she had moved in

with her parents, and her mother was already providing care to her stepfather, who had

undergone full knee replacement surgery. Petitioner testified that, in December 2014, she

visited Dr. Sekhon, who recommended surgery for her right shoulder. Petitioner testified

that she underwent arthroscopic surgery on her right shoulder, and that recovery following

the surgery was “[l]ong and arduous.” According to Petitioner, for approximately twelve

or thirteen weeks after surgery, she had to wear a sling with a bolster on her arm at all

times, except when bathing. Petitioner testified that, while wearing the sling and bolster,

“[s]leeping was horrendous and still is.” And, Petitioner testified that her right shoulder


                                             -6-
was “still impaired[,]” that she could not “lift it past a certain level[,]” and that she could

not “bear any weight on it.”

       On Petitioner’s behalf, Dr. Koyen testified by video deposition that, to a reasonable

degree of medical certainty, among other things, Petitioner’s hernia and the rotator cuff

tear to her right shoulder were caused by the October 14, 2011 accident. Dr. Koyen opined

that the rotator cuff tear to Petitioner’s right shoulder, as seen on the MRI of November 7,

2011, was consistent with a traumatic event, and is a common injury following a motor

vehicle accident. Dr. Koyen acknowledged that the records from Petitioner’s visit to the

Mercy emergency room from October 15, 2011 (“the Mercy record”) did not include any

mention of complaints of right shoulder pain or abdominal pain. Dr. Koyen testified that,

on November 22, 2011, he prepared a report of his treatment of Petitioner, covering the

period from October 21, 2011, the date of his first examination of Petitioner, to the date of

the report (“the Koyen record”). Dr. Koyen acknowledged that, during Petitioner’s initial

visit on October 21, 2011, she did not complain of abdominal pain. Dr. Koyen testified,

however, that, in his report, he noted that Petitioner complained of “severe pains in [her]

abdominal and pelvic area[,]” and, as a result, a CT scan of Petitioner’s abdomen was

performed on October 31, 2011. Dr. Koyen acknowledged that the CT scan of Petitioner’s

abdomen was normal.

       Dr. Kumar testified by video deposition that he performed surgery for a recurrence

of an epigastric hernia. Dr. Kumar testified that, on March 19, 2012, after the surgery to

repair the hernia, he saw Petitioner for a routine follow-up appointment, that she was

healing well, and that he did not see her again after that visit. Dr. Kumar testified that, to


                                             -7-
a reasonable degree of medical certainty, Petitioner’s epigastric hernia was caused by the

accident, and, specifically, the pressure of the seat belt against Petitioner’s abdominal wall

during the accident. When asked whether, to a reasonable degree of medical certainty, the

circumstance that Petitioner had previously had an epigastric hernia repaired made her

more susceptible to another hernia occurring during the accident, Dr. Kumar testified: “It’s

hard to tell. Well, because of when I did the surgery, . . . the previous repair was good. So

I believe this is the result of the accident because of the impact, rather than weak tissue.”

       Dr. Sekhon testified by video deposition that, several years after the accident, he

examined Petitioner and ordered an MRI of her right shoulder, which revealed a rotator

cuff tear. On cross-examination, Dr. Sekhon acknowledged that he was seeing certain

medical reports for the first time at deposition—specifically, the 2011 MRI, the Mercy

record, and the Koyen record. Dr. Sekhon also conceded that he did not have any of

Petitioner’s medical records preceding the accident to determine if she had injuries or pain

to her right shoulder before the accident.

       Respondent’s case consisted of her testimony and the testimony of Louis Halikman,

M.D., an orthopedic surgeon. The circuit court accepted Dr. Halikman as an expert in

orthopedic surgery, and ruled that Dr. Halikman would be permitted to testify “as a

physician” as to other matters, but would not be permitted to offer an opinion outside of

the field of orthopedic surgery. Dr. Halikman testified that, on December 28, 2015, at

Respondent’s counsel’s request, he examined Petitioner. During his examination, Dr.

Halikman noted that Petitioner is left-handed, and that her upper arms each measured the

same circumference. According to Dr. Halikman, these observations were important


                                             -8-
because he would have expected Petitioner’s right arm to have been substantially smaller

in girth than the left, given that her right arm was not her dominant arm and that she had

recently had surgery on her right shoulder. Dr. Halikman testified that “[t]he fact that her

muscle bulk is the same on both sides [told him] that she is probably using both of her arms

in as close to natural fashion as possible.”

       Dr. Halikman testified that, in addition to taking Petitioner’s medical history and

examining Petitioner, he reviewed and relied upon four of Petitioner’s post-accident

medical treatment records in formulating his opinions as to Petitioner’s injuries.

Specifically, Dr. Halikman testified that he relied upon the following four medical records:

(1) the Mercy record, marked as Defense Exhibit 2; (2) the Koyen record, marked as

Defense Exhibit 3; (3) an “Initial Chiropractic Examination” report prepared on October

25, 2011, by an unidentified chiropractor (“the Chiropractic record”), marked as Defense

Exhibit 4; and (4) an “Initial Consultation” report dated December 13, 2011, by Aleksandr

Levin, M.D., of Diagnostic Medicine, P.C. (“the Levin record”), marked as Defense

Exhibit 5.

       Respondent’s counsel offered the Mercy record into evidence and Petitioner’s

counsel objected “to the document coming in[.]” At a bench conference, Petitioner’s

counsel explained:

       Your Honor, I would object to the document coming in. The expert can
       certainly testify to it and obviously all his testimony is evidence in the case.
       However, the document itself is a hearsay document. It contains hearsay
       statements. It contains expert findings, opinions, and it contains secondary
       and probably even tertiary hearsay statements. . . . I would also, Your Honor,
       argue that in permitting some records in and not others also is far more
       prejudic[ial] than probative in that it’s going to allow certain documents to


                                               -9-
       go back to the jury room without the benefit of having all of the documents.
       So on all of those grounds, Your Honor, I would object.

Respondent’s counsel responded that Petitioner “had the opportunity to put in any

documents that he wanted to and chose not to do it. It is a document that [Dr. Halikman]

relied on in forming his opinion. And I believe it is, you know, allows it to come into

evidence.”   Respondent’s counsel urged that the Mercy record “should come into

evidence.” Immediately thereafter, the circuit court stated: “Objection’s overruled. So

admitted. It’s being relied on by this expert in his review and opinion.” The circuit court

reiterated: “Objection is noted. However, Court overrules the objection and allows its

admission. As the witness testified that he reviewed this and relied on it in reaching his

opinion.” Thus, the Mercy record was admitted into evidence.

       Respondent’s counsel offered into evidence the other three medical records that Dr.

Halikman relied upon in forming his opinion—i.e., the Koyen record, the Chiropractic

record, and the Levin record. Petitioner’s counsel made the “[s]ame objection” as to

admission of those medical records, and the circuit court overruled the objections and

admitted the medical records into evidence.

       The Mercy record, dated October 15, 2011, consisted of sixteen pages, including a

page containing a section labeled “History of Present Illness,” that stated that Petitioner

had been “involved in a rear-ended motor vehicle crash” the day before. That section noted

that Petitioner “immediately, upon impact, reached over to the left side of the car to secure

[her granddaughter’s] car seat[,]” and that Petitioner “did not experience any immediate

back pain[.]” The section stated that, over the course of the afternoon and evening



                                           - 10 -
following the accident, Petitioner began to experience “the onset of left-sided lower back

pain[,]” and, at the time of her visit to Mercy, was complaining of left-sided lower back

pain and “of a much lighter pain in the left forearm.” In a section labeled “Physical

Examination: General,” the Mercy record noted that Petitioner “ambulate[d] . . . with a

slight limp but not much difficulty[,]” and that Petitioner “appear[ed] in no acute distress.”

The “Physical Examination: General” section stated that Petitioner’s abdomen was

“[s]oft[,]” and that there was “positive straight leg raising, [but that] she ha[d] difficulty

with the lateral oblique motion on the left side.” As to Petitioner’s extremities, the Mercy

record reported that Petitioner had “full range of motion of all joints.” The Mercy record

stated that the treatment plan for Petitioner included discharge with instructions to rest, to

apply heat to affected areas, and to take over-the-counter pain medication as needed. The

discharge summary stated that Petitioner should follow up with her doctor if her symptoms

did not begin to improve after a week.

       The Koyen record, prepared on November 22, 2011, consisted of five pages. In the

Koyen record, Dr. Koyen stated that he first examined Petitioner on October 21, 2011, one

week after the accident, and that Petitioner reported “sustain[ing] injuries to the head, left

shoulder[,] and coccyx[, i.e., tailbone].” In a section labeled “Chief Complaints,” Dr.

Koyen observed as follows:

       The patient complains of the flashbacks of the accident; neck pains radiating
       to the right arm and upper back, and to the left arm and forearm; low back
       pains; left hip pains; periodical numbness in the right hand; right shoulder
       pains; weakness in the left arm; fear of sitting in a car; coccyx pains worsened
       by sitting; claustrophobia after accident.

In a “Review of Systems” section, Dr. Koyen noted: “Patient admits to sharp neck pains


                                            - 11 -
radiating to the left upper extremity and associated with numbness; sharp lumbosacral

pains [that are] provoked by sitting.” As to Petitioner’s generalized appearance during the

physical examination, Dr. Koyen observed that Petitioner was “in acute pain distress[,]”

and was experiencing pain getting on and off the examination table. As to the physical

examination of Petitioner’s shoulders, Dr. Koyen noted, in relevant part, “[r]ight rotator

cuff area tenderness[,]” that the “[r]ight shoulder’s joint showed tenderness[,]” and that

“[s]houlders’ motion is painful bilaterally, right more than left.” Dr. Koyen observed that

Petitioner was “[p]ositive” on tests for nerve impingement of her right shoulder. Dr.

Koyen’s physical examination showed “[n]o remarkable tenderness” in Petitioner’s chest

or abdomen.

       In a section labeled “Recommendations,” Dr. Koyen recommended, in relevant part,

that Petitioner: begin physical therapy three to four times per week for her right shoulder,

among other areas; continue to take Aleve; consider undergoing an MRI of her right

shoulder if problems persisted; and have an X-ray of her right shoulder. In a section labeled

“Treatment,” Dr. Koyen detailed the treatments, tests, and procedures that Petitioner had

undergone following her initial appointment and the results. Dr. Koyen reported that,

“[b]ecause of severe pains in the abdominal and pelvis area, CT scan of the abdomen/

pelvis was performed and showed no acute inflammatory processes[.]” Additionally, Dr.

Koyen stated that, “[b]ecause of severe pains in the right shoulder, MRI of the right

shoulder was performed and revealed possible impingement of the supraspinatus muscle

and rotator cuff intrasubstance tear involving supraspinatus and infraspinatus tendons.” Dr.

Koyen diagnosed Petitioner with, among other things, “[r]ight shoulder trauma with rotator


                                           - 12 -
cuff tear and impingement” and “[a]bdominal trauma.”

       The Chiropractic record, consisting of five pages, was completed by an unidentified

chiropractor on October 25, 2011, the date that Petitioner was examined. The Chiropractic

record contained handwritten notations describing the reasons for Petitioner’s visit,

Petitioner’s past medical history, and Petitioner’s then-present complaints. In the “Present

Complaints” section, the chiropractor circled “Neck Pain & Stiffness Left/Right” that

“Radiates” to the “Left . . . Shoulder[,]” right shoulder pain, and left arm pain with

“Numbness & Tingling Down to . . . Forearm[.]” The section labeled “Orthopedic &

Neurologic Tests” showed that the chiropractor did not perform a “Shoulder Depression

Test” used to detect “the presence of adhesions or injury to the soft tissues of the cervical

spine[,]” or three other shoulder tests used to detect “impingement, tears or pathology[.]”

In the “Diagnosis” section, the chiropractor circled diagnostic codes and diagnosed

Petitioner with thoracolumbar radiculopathy, lumbar, thoracic, and cervico-thoracic joint

dysfunction, a whiplash injury, headaches, and spinal subluxation. The chiropractor did

not circle the diagnostic codes for shoulder injury or shoulder pain.

       The Levin record, dated December 13, 2011, consisted of three pages, and was titled

an “Initial Consultation” and was addressed to Dr. Koyen. Dr. Levin reported that

Petitioner complained “of right shoulder pain, lower back pain radiating to the left leg, left

knee pain, and weakness in the left leg.” In the section labeled “Physical Examination,”

Dr. Levin noted that Petitioner was “in no acute distress[,]” that her abdomen was “[s]oft,

not distended, no tenderness[,]” and that an examination of Petitioner’s shoulders and

upper extremities revealed “[n]o tenderness on palpation or decreased range of motion of


                                            - 13 -
both shoulders, elbows, wrists, and hands.” Dr. Levin observed, however, “tenderness” of

the lumbar spine. Dr. Levin recorded his “Initial Impressions” as follows: “1. Post-

traumatic lumbosacral sprain/strain[ and] 2. Rule-out lumbar radiculitis.” (Paragraph break

omitted).    Dr. Levin recommended “EMG/NCV tests of the lower extremities with

paraspinal muscles in order to rule-out possible lumbar radiculopathy, entrapment

neuropathy, [and] polyneuropathy.” In a section labeled “Plan,” Dr. Levin recommended

“[s]oft tissue mobilization/ spine manipulation[,]” and that Petitioner consult her primary

care provider and “[a]void heavy lifting, carrying, excessive bending, prolonged sitting or

standing.”

       Based on his review of these medical records and his examination of Petitioner, Dr.

Halikman opined, to a reasonable degree of medical certainty, that Petitioner “did not

sustain an injury to her right shoulder as a result of th[e] accident.” Dr. Halikman

explained:

       First of all, as I mentioned, there is no immediate complaint of pain. If you
       injured your shoulder you don’t need someone to tell you that it is injured.
       You would know it, you would be pointing it out to someone you were
       seeing. Also, when we look at the results of the imaging studies, there was -
       - the shoulder problem was clearly degenerative and it progressed over a
       period of time which is what you would expect. Degenerative conditions by
       their very nature progress over a period of time.

              In addition, [Petitioner]’s occupation as a hairdresser is one of a
       number of different occupations that predispose patients to shoulder
       problems. . . . [H]airdressers, . . . anybody who works with their arms in
       elevated positions develop . . . impingement. And that is the rotator cuff
       rubbing underneath the top of the shoulder. . . . The presentation that she had,
       in my opinion, was typical for a person who had worked as a hairdresser for
       many, many years.

Additionally, Dr. Halikman opined that the MRI of Petitioner’s right shoulder from


                                            - 14 -
November of 2011 showed degeneration, and not an acute injury. Dr. Halikman testified

that, if a rotator cuff tear had occurred at the time of the accident, he would have expected

Petitioner “to have had treatment, injections, physical therapy and so forth and so on[,]”

but that none of those things occurred.         Dr. Halikman testified that a patient who

experiences an acute tear to the rotator cuff would “have immediate acute pain and []

usually cannot lift the arm up. You can’t miss it.” Dr. Halikman noted that no such

findings were present at the time that Petitioner visited the emergency room at Mercy, and

that, “[i]n fact, there’s no mention at all of any complaints referable to the shoulder.”

       According to Dr. Halikman, Petitioner’s medical records showed that Petitioner did

not initially complain of abdominal pain, and that both Dr. Koyen and Dr. Levin reported

that Petitioner’s abdomen was normal. Dr. Halikman opined that, when the Levin record

was prepared on December 13, 2011, almost two months after the accident, “it would be

reasonable to conclude that if a patient had a problem referable to those areas, it would

have been evident by th[en], but it was not.”

       After Respondent rested, Petitioner’s counsel moved for judgment “on the issues of

contributory negligence and negligence as a matter of law[.]” In response, Respondent’s

counsel stated that she knew of “no reason” why the circuit court should not grant the

motion because, “[l]ike [she] said in the beginning, . . . it’s a rear-ender.” The circuit court

granted the motion for judgment in Petitioner’s favor, ruling: “[T]he [c]ourt grants [the]

motion and directs a verdict as to negligence of [Respondent] is established in this case,

and that there is no contributory negligence on the part of [Petitioner or Steven].” The

circuit court noted that the remaining issue in the case was “the matter of damages[.]” As


                                             - 15 -
to the issue of damages, Respondent’s counsel moved for judgment, and the circuit court

denied the motion. The circuit court ruled that, “under the circumstances, it’s a factual

dispute to be sent to the jury for its determination as to the amount of damages, if any that

should be awarded.” Thereafter, the circuit court instructed the jury, and counsel made

closing arguments.

       During closing argument, Petitioner’s counsel argued that both Petitioner’s

recurrence of an epigastric hernia and the rotator cuff tear to her right shoulder resulted

from the accident. Petitioner’s counsel asked the jury to award Petitioner all of her past

medical expenses totaling $9,926.05 and non-economic damages in an amount from

$50,000 to $150,000.

       Respondent’s counsel argued that the evidence did not show that the accident caused

Petitioner’s hernia and right shoulder rotator cuff tear. Respondent’s counsel mentioned

the four medical records admitted into evidence, and argued that: (1) Petitioner did not

complain of right shoulder pain or abdominal pain during her visit to the emergency room

at Mercy on October 15, 2011, the day after the accident; (2) Petitioner did not complain

of abdominal pain during her initial visit to Dr. Koyen on October 21, 2011, a week after

the accident, although she mentioned right shoulder pain; (3) although Petitioner

complained of right shoulder pain during her chiropractic visit on October 25, 2011, there

was no mention of an abdomen complaint, and no diagnosis of a shoulder injury; and (4)

Petitioner’s right shoulder was not tender, and had full range of motion, and Petitioner’s

abdomen was soft, but not tender, during her visit to Dr. Levin on December 13, 2011.

Respondent’s counsel argued that the evidence did not support finding that the two


                                           - 16 -
surgeries Petitioner underwent—to repair the hernia and her right shoulder—were causally

related to the accident, and that, accordingly, the evidence did not support an award for

non-economic damages in the amount that Petitioner requested.

       The circuit court provided a special verdict sheet to the jury, which deliberated on

the issue of damages. Question 1 on the special verdict sheet asked “[w]hat measure of

damages, if any, do you find the Plaintiff, Patricia Lamalfa, is entitled?” That question was

followed by blank lines for “Past Medical Expenses,” “Non-Economic Damages (Pain,

Suffering, Physical Impairment, etc.),” and for total damages. The jury returned a verdict

in Petitioner’s favor, and awarded Petitioner all of her past medical expenses totaling

$9,926.05, as well as non-economic damages totaling $650.00, for a total award of

$10,576.05. Consistent with the jury’s award, on February 25, 2016, the circuit court

entered judgment in Petitioner’s favor against Respondent in the amount of $10,576.05.

       Petitioner noted an appeal, contending that the circuit court erred in admitting the

four medical records into evidence. On June 28, 2017, in a reported opinion, the Court of

Special Appeals affirmed the circuit court’s judgment and held that the circuit court did

not abuse its discretion in admitting the medical records into evidence under Maryland

Rule 5-703. See Lamalfa v. Hearn, 233 Md. App. 141, 155, 163 A.3d 205, 213 (2017).

The Court of Special Appeals concluded that the medical records satisfied the requirements

for disclosure under Maryland Rule 5-703(b) because the medical records were not

privileged, were reasonably relied upon by Dr. Halikman, were sufficiently trustworthy,

and were necessary to aid the jury in understanding Dr. Halikman’s opinion. See id. at

153-54, 163 A.3d at 212. The Court of Special Appeals explained, in pertinent part, as


                                           - 17 -
follows:

               There is no significant difference between disclosure and admission
       of a writing under [Maryland] Rule 5-703 because to be able to use the
       writing to assess the credit, if any, to be accorded the opinion of the expert
       witness who relied upon it, the fact finder must be able to read the document,
       not just glance at it in passing. What is significant is that the writing is not
       to be used substantively (unless otherwise admissible for its substance). It is
       for that reason that the rule directs that, “upon request, the court shall instruct
       the jury to use the facts and data relied upon by the testifying expert only for
       the purpose of evaluating the validity and probative value of the expert’s
       opinion or inference.” Md. Rule 5-703(b).

              Here, the essence of [Petitioner]’s complaint is that the jurors could
       have misused the contents of the medical reports because the reports were
       with them in the jury room during deliberations. Any problem with how the
       jurors might have used the reports was not a function of their being in the
       jury room but of [Petitioner]’s failure to request a limiting instruction under
       [Maryland] Rule 5-703(b) either upon their admission, at the close of the
       evidence, or during defense counsel’s closing argument. Had she done so,
       the court would have been required to instruct the jurors not to use the
       medical reports substantively—the very concern she now raises on appeal.
       Thus, her failure to request a limiting instruction is a waiver of this issue on
       appeal.

Lamalfa, 233 Md. App. at 155, 163 A.3d at 213 (emphasis in original) (brackets and

citation omitted).

       Thereafter, Petitioner filed in this Court a petition for a writ of certiorari, raising

the following two issues:

       1.     Were Defense Exhibits 2-5 inadmissible hearsay due to the failure of
              authentication as a condition precedent to the business records
              exception to the hearsay rule?

       2.     Did the trial court err by admitting medical records pursuant to
              Maryland Rule 5-703 without an appropriate foundation for
              establishing the truthfulness of the records?

On September 12, 2017, this Court granted the petition. See Lamalfa v. Hearn, 456 Md.



                                             - 18 -
55, 170 A.3d 291 (2017).

                                        DISCUSSION4

                                  The Parties’ Contentions

       Petitioner contends that the circuit court erred in admitting the four medical records

into evidence pursuant to Maryland Rule 5-703. Petitioner argues that the medical records

were otherwise inadmissible documents admitted for the truth of the matters asserted

therein, and, as such, violated the rule against hearsay. Petitioner asserts that disclosure

under Maryland Rule 5-703(b) does not mean that documents relied upon by an expert that

are otherwise inadmissible are admissible into evidence or permitted to be taken to the jury

room during deliberations. Stated otherwise, Petitioner maintains that disclosure is not

comparable to admission for purposes of Maryland Rule 5-703(b). Instead, Petitioner

contends that disclosure under Maryland Rule 5-703(b) means that documents that an

expert relies upon may be discussed in the presence of the jury or, at most, the jury may

review the documents during the expert’s testimony. Petitioner argues that, from a public

policy standpoint, if the circuit court’s action is not determined to be error, then a trial court

could admit into evidence any document that is otherwise inadmissible simply because an

expert relies upon the document. At oral argument before this Court, Petitioner repeatedly

referred to this as an “end run” around the rule against hearsay.

       Petitioner asserts that, assuming arguendo “disclosure” means “admission,” the


       4
        Although Petitioner raised two issues in the petition for a writ of certiorari, on brief
in this Court Petitioner raised the following single issue: “Did the trial court err by
admitting medical records pursuant to Maryland Rule 5-703 where the medical records
were inadmissible hearsay and no other exception to the hearsay rule applied?”

                                              - 19 -
circuit court was required to make findings as to whether the medical records fulfilled the

four requirements of Maryland Rule 5-703(b)—namely, whether the medical records were

trustworthy, unprivileged, reasonably relied upon by Dr. Halikman in forming his opinion,

and necessary to illuminate Dr. Halikman’s testimony. Petitioner does not dispute that the

medical records were unprivileged and reasonably relied upon by Dr. Halikman in forming

his opinion. Petitioner maintains, however, that Respondent failed to demonstrate that the

medical records were trustworthy or necessary to illuminate Dr. Halikman’s testimony.

Specifically, Petitioner contends that the circuit court abused its discretion by failing to

exercise its discretion to inquire into the issue of trustworthiness and the necessity to

illuminate. Petitioner acknowledges that silence on a trial court’s part does not necessarily

mean a failure to exercise discretion, but argues that, in this case, in admitting the records,

the circuit court expressly stated only that Dr. Halikman relied upon the medical records.

According to Petitioner, this means that the circuit court did not exercise its discretion in

determining whether the medical records were trustworthy and necessary to illuminate Dr.

Halikman’s testimony.

       Finally, Petitioner contends that admission of the medical records was not harmless

error, as the medical records were inadmissible hearsay, and did not satisfy the

requirements of the business records exception to the rule against hearsay. Petitioner

argues that admission of the medical records allowed “the jury to place und[ue] weight on

those select documents as compared to the verbal testimony and overall evidence.”

Petitioner asserts that a limiting instruction would have been ineffective because the harm

occurred once the medical records were admitted into evidence and permitted to be with


                                            - 20 -
the jury during deliberations, “instead of simply [being] disclosed[.]”

       Respondent counters that, for purposes of Maryland Rule 5-703, there is no real

distinction between disclosing and admitting a document.           Respondent argues that

Maryland Rule 5-703 provides a trial court with discretion not only as to whether to

disclose a document to the jury, but also as to how that document is to be disclosed.

Respondent asserts that, by failing to request a limiting instruction as to the disclosure of

the medical records, as provided for in the Rule, Petitioner waived the ability to challenge

how the jury used the medical records.

       Respondent contends that the medical records were admissible under, and satisfied

all of the requirements of, Maryland Rule 5-703(b) because they were not privileged, were

reasonably relied upon by Dr. Halikman in forming his opinion, trustworthy, and necessary

to illuminate Dr. Halikman’s testimony. As to trustworthiness, Respondent argues that the

medical records were inherently trustworthy under this case’s circumstances for several

reasons, including that the medical records were prepared by the treating hospital and

Petitioner’s treating physicians. Respondent also asserts that the medical records were

trustworthy because they were obtained from medical providers by Petitioner’s counsel

and provided to Respondent during discovery, and, at trial, Petitioner offered into evidence

the medical bills generated by those medical providers at trial to support Petitioner’s claim

for damages. Respondent maintains that the medical records were necessary to illuminate

both Dr. Halikman’s and Dr. Koyen’s testimony, as both doctors testified that they

reviewed the records to formulate their opinions.

       Respondent contends that Petitioner has failed to show prejudice due to the


                                           - 21 -
admission of the medical records, or that admission of the medical records was manifestly

wrong. Respondent argues that the record is devoid of any indication that the jury placed

undue weight on the medical records, or placed any more weight on the medical records

than on other evidence.

      In a reply brief, Petitioner contends that Maryland Rule 5-703’s plain language

distinguishes between disclosure and admissibility, by use of the word “disclosed.”

                                   Standard of Review

      In Brown, 409 Md. at 583-84, 976 A.2d at 310-11, this Court set forth the following

applicable standard of review:

             It is often said that a trial court’s ruling on the admissibility of
      evidence is reviewed pursuant to the abuse of discretion standard. Such
      rulings, it is maintained, are left to the sound discretion of the trial court and
      will not be reversed on appeal absent a showing of abuse of that discretion.
      We have stated, however, that:

             Application of the abuse of discretion standard depends on
             whether the trial [court]’s ruling under review was based on a
             discretionary weighing of relevance in relation to other factors
             or on a pure conclusion of law. When the trial [court]’s ruling
             involves a weighing, we apply the more deferential standard.
             On the other hand, when the trial [court]’s ruling involves a
             legal question, we review the trial court’s ruling de novo.

             Additionally, Maryland Rule 5-103 provides, in pertinent part:

             (a) Effect of erroneous ruling. Error may not be predicated
             upon a ruling that admits or excludes evidence unless the party
             is prejudiced by the ruling.

             Thus, even if manifestly wrong, we will not disturb an evidentiary
      ruling by a trial court if the error was harmless. The party maintaining that
      error occurred has the burden of showing that the error complained of likely
      affected the verdict below. It is not the possibility, but the probability, of
      prejudice which is the object of the appellate inquiry. Courts are reluctant to


                                            - 22 -
       set aside verdicts for errors in the admission or exclusion of evidence unless
       they cause substantial injustice.

(Cleaned up).5 Of course, the issue of what “disclosed” means as used in Maryland Rule

5-703(b) is a legal issue that we review without deference. See Hall v. Univ. of Md. Med.

Sys. Corp., 398 Md. 67, 82, 919 A.2d 1177, 1186 (2007) (“If the trial judge’s ruling

involves a pure legal question, we generally review the trial court’s ruling de novo.”

(Cleaned up)); see also Brown, 409 Md. at 583, 976 A.2d at 311. However, the issue of

whether the circuit court properly disclosed the medical records pursuant to Maryland Rule

5-703(b) raises a question of whether the circuit court abused its discretion as Maryland

Rule 5-703(b) expressly provides for an exercise of “discretion[.]” Hence, in this instance,

we determine whether the trial court erred or abused its discretion in disclosing, i.e.,

admitting into evidence, the medical records under Maryland Rule 5-703(b).

                                    Maryland Rule 5-703

       Maryland Rule 5-703, entitled “Bases of Opinion Testimony by Experts,” provides,

in its entirety:

       (a) In general. The facts or data in the particular case upon which an expert

       5
           As the Court of Special Appeals has explained:

       “Cleaned up” is a new parenthetical intended to simplify quotations from
       legal sources. See Jack Metzler, Cleaning Up Quotations, J. APP. PRAC. &
       PROCESS (forthcoming 2018), https://perma.cc/JZR7-P85A. Use of
       “cleaned up” signals that the current author has sought to improve readability
       by removing extraneous, non-substantive clutter (such as brackets, quotation
       marks, ellipses, footnote signals, internal citations or made un-bracketed
       changes to capitalization) without altering the substance of the quotation.

Loren J. Chassels v. Benjamin L. Krepps, ___ Md. App. ___, ___ A.3d ___, No. 954, Sept.
Term, 2016, 2017 WL 5989052, *3 n.3 (Md. Ct. Spec. App. Dec. 4, 2017).

                                            - 23 -
       bases an opinion or inference may be those perceived by or made known to
       the expert at or before the hearing. If of a type reasonably relied upon by
       experts in the particular field in forming opinions or inferences upon the
       subject, the facts or data need not be admissible in evidence.

       (b) Disclosure to jury. If determined to be trustworthy, necessary to
       illuminate testimony, and unprivileged, facts or data reasonably relied upon
       by an expert pursuant to section (a) may, in the discretion of the court, be
       disclosed to the jury even if those facts and data are not admissible in
       evidence. Upon request, the court shall instruct the jury to use those facts
       and data only for the purpose of evaluating the validity and probative value
       of the expert’s opinion or inference.

       (c) Right to challenge expert. This Rule does not limit the right of an
       opposing party to cross-examine an expert witness or to test the basis of the
       expert’s opinion or inference.

       This Court has remarked that “it has been the practice in this jurisdiction for some

years to permit an expert to express his or her opinion upon facts in the evidence which he

or she has heard or read, upon the assumption that these facts are true.” Cooper v. State,

434 Md. 209, 230, 73 A.3d 1108, 1120 (2013) (cleaned up). “Maryland Rule 5-703(a)

codifies this, permitting an expert to base his or her opinion on first-hand knowledge,

hearsay, or a combination of the two.” Id. at 230, 73 A.3d at 1120 (cleaned up). To be

sure, “if evidence constitutes inadmissible hearsay, it cannot be admitted as substantive

evidence, [but] Maryland Rule 5-703(b) permits a trial judge, in his or her discretion, to

admit evidence as the factual basis for the expert’s opinion[.]” Id. at 230, 73 A.3d at 1120

(citation omitted). However, for a document to be “admissible” under Maryland Rule 5-

703(b), “four elements must be satisfied”—“[t]he document must be (1) trustworthy, (2)

unprivileged, (3) reasonably relied upon by an expert in forming her or his opinion, and (4)

necessary to illuminate that expert’s testimony.” Brown, 409 Md. at 601, 976 A.2d at 321.



                                           - 24 -
       In Alban v. Fiels, 210 Md. App. 1, 21, 61 A.3d 867, 878-79 (2013), the Court of

Special Appeals elaborated on the relationship between Maryland Rule 5-703(a) and (b),

explaining:

              Most certainly, an expert may give an opinion based on facts
       contained in reports, studies, or statements from third parties, if the
       underlying material is shown to be of the type reasonably relied upon by
       experts in the field. The focus of the language in Rule 5-703(a) that facts or
       data forming the basis for an expert’s opinion may be relied on if of a type
       reasonably relied upon by experts in the particular field ordinarily relates to
       hearsay evidence. If such information received from others is inadmissible
       hearsay, it ordinarily comes in not as substantive evidence but only to explain
       the factual basis for the testifying expert’s opinion. Regardless of why the
       facts or data within the meaning of Rule 5-703(a) are not admissible as
       substantive evidence, when they are permitted for Rule 5-703(a) purposes,
       they are not admitted as substantive evidence. Thus, upon request, the court
       shall instruct the jury to use those facts and data only for the purpose of
       evaluating the validity and probative value of the expert’s opinion or
       inference.

              In other words, Rule 5-703(a) does not operate to admit as substantive
       evidence facts or data that are otherwise inadmissible. The facts or data
       relied upon are admissible, if at all, only to explain how the expert reached
       an opinion. Thus, unless inadmissible as a matter of law, inadmissible
       evidence, if it satisfies Rule 5-703, may be admitted, in the court’s discretion,
       to explain the factual basis for an expert’s opinion.

(Cleaned up).

       In Brown, 409 Md. at 606, 976 A.2d at 324, this Court held that the trial court did

not abuse its discretion in allowing the defendants to introduce into evidence an un-

redacted report under Maryland Rule 5-703, and that, “[e]ven had it been error to admit the

un-redacted report, [the plaintiff] failed to persuade us that she was prejudiced by its

admission or its use at trial.” In Brown, id. at 571, 976 A.2d at 303, a lead-based paint

case, the plaintiff conducted a de bene esse deposition of the president of ARC



                                            - 25 -
Environmental, an environmental expert, who identified an un-redacted report that ARC

had prepared when it tested the subject property; the report identified the paint condition

as intact on thirty-six of thirty-eight locations tested, and identified the other two locations

as having paint that was in fair condition, meaning that 10% or less of the surface was

cracked or worn. During a jury trial, the plaintiff did not offer into evidence the de bene

esse deposition in their case-in-chief or otherwise attempt to introduce the un-redacted

ARC report. See id. at 572, 976 A.2d at 304. Instead, the plaintiff called an expert in

childhood lead poisoning, and the plaintiff’s counsel showed the expert a version of the

ARC report in which the description of the condition of the paint at the tested locations

was redacted. See id. at 572, 976 A.2d at 304. The trial court permitted the plaintiff’s

counsel to hand the expert a redacted copy of the ARC report and stated that defense

counsel could show the expert the un-redacted report on cross-examination. See id. at 574,

976 A.2d at 305.

       During the defense’s case, defense counsel read into evidence the transcript of the

de bene esse deposition of the expert and defense counsel also offered into evidence the

un-redacted ARC report. See id. at 576, 976 A.2d at 306. The plaintiff made an objection,

which the trial court overruled. See id. at 576, 976 A.2d at 306. In closing argument, both

parties referenced the un-redacted ARC report. See id. at 576-79, 976 A.2d at 306-08. In

response to the question of whether there was chipping, peeling, or flaking paint at the

subject property while the plaintiff lived there, the jury found in the negative. See id. at

579, 976 A.2d at 308. The trial court entered judgment in the defendants’ favor; the

plaintiff moved for a new trial, arguing that the trial court had erred, in relevant part, by


                                             - 26 -
allowing the defendants to introduce the un-redacted ARC report; the trial court denied the

motion; and, the plaintiff appealed. See id. at 579, 976 A.2d at 308. The Court of Special

Appeals affirmed the trial court’s judgment. See id. at 579-80, 976 A.2d at 308.

       In this Court, the plaintiff argued that the trial court erred in allowing the defendants

to offer into evidence the un-redacted ARC report, which, the plaintiff asserted, was

irrelevant because it detailed the condition of the subject property five years after she had

moved out; the plaintiff also maintained that she was prejudiced by the un-redacted report

because it described the paint at the subject property as being intact for the most part. See

id. at 600, 976 A.2d at 320-21. This Court observed that, with respect to the four elements

that “must be satisfied for a document to be admissible under” Maryland Rule 5-703, the

plaintiff did not argue that the un-redacted ARC report was privileged or untrustworthy,

and instead contended that the report was neither relied upon by her experts nor necessary

to illuminate their testimony. See id. at 601, 976 A.2d at 321. This Court disagreed with

the plaintiff on both of those points. See id. at 601-02, 976 A.2d at 321-22.

       We concluded that the plaintiff’s contention that the un-redacted ARC report was

irrelevant was waived because the plaintiff failed to request a limiting instruction under

Maryland Rule 5-703, or otherwise object to the manner in which the defendants relied on

the un-redacted ARC report in their closing argument. See id. at 603, 976 A.2d at 323.

The record did not demonstrate that the un-redacted ARC report “was admitted for any

purpose other than to illuminate the testimony of [the plaintiff]’s experts[,]” and,

accordingly, the contention as to relevance took “aim only at the manner in which [the

defendants] relied on the evidence.” Id. at 603-04, 976 A.2d at 323. We explained:


                                            - 27 -
               [The plaintiff] concedes that she never requested a limiting instruction
       under Rule 5-703(b) . . . ; however, she seeks to excuse her failure by
       claiming that [the defendant]s did not raise Rule 5-703 as a basis for
       admitting the Un-Redacted ARC Report. Her excuse is not convincing.
       Even if [the defendant]s never cited expressly the rule, the joint stipulation
       provided by the parties reveals that [the defendant]s argued before the trial
       court that the un-redacted report was admissible because [the plaintiff]’s
       experts relied on it. Additionally, as with any evidence that potentially could
       be misused, [the plaintiff] could have requested a limiting instruction under
       Rule 5-105 as well. Moreover, [the plaintiff] did not object when, during
       closing argument, [defense] counsel cited the Un-Redacted ARC Report as
       evidence that the paint at the Subject Property was “intact” while [the
       plaintiff] resided there.

Id. at 604, 976 A.2d at 323 (cleaned up). This Court also determined that the plaintiff had

“fail[ed] to establish that she was prejudiced by the [defendant]s’ use of the Un-Redacted

ARC Report, even if the report was admitted erroneously as evidence relevant to whether

peeling, chipping, or flaking paint existed at the Subject Property” when the plaintiff lived

there. Id. at 605, 976 A.2d at 323. Accordingly, we held not only that the trial court did

not abuse its discretion in permitting the un-redacted report to be introduced into evidence,

but also that, even if it had been error, the plaintiff had failed to demonstrate “that she was

prejudiced by its admission or its use at trial.” Id. at 606, 976 A.2d at 324.

       In Gillespie v. Gillespie, 206 Md. App. 146, 166, 160, 47 A.3d 1018, 1030, 1026

(2012), a child custody case, the Court of Special Appeals held that the trial “court was

permitted to admit” under Maryland Rule 5-703 a report documenting a psychiatric

evaluation of a mother because an expert witness had relied upon the report in forming her

opinions. In that case, during a custody modification trial, Dr. Snyder, a psychologist

appointed by the trial court to prepare a psychological evaluation of both the mother and

father, testified. See id. at 160, 47 A.3d at 1026. During Dr. Snyder’s testimony, the trial


                                            - 28 -
court realized that Dr. Snyder had just received a report prepared by a Dr. Lish, in which

Dr. Lish diagnosed the mother with bipolar disorder. See id. at 160, 47 A.3d at 1026. The

trial court concluded that it was appropriate for Dr. Snyder to review the Lish report. See

id. at 161, 47 A.3d at 1027. After Dr. Snyder reviewed the Lish report, the children’s best

interest attorney moved to have the report admitted into evidence. See id. at 159-60, 161,

47 A.3d at 1026, 1027. The mother objected, but the trial court overruled the objection

and admitted the Lish report into evidence. See id. at 161, 47 A.3d at 1027. Dr. Snyder

then testified about the parents’ strengths and weaknesses. See id. at 161, 47 A.3d at 1027.

At the conclusion of the trial, the trial court ruled that there had been a material change in

circumstances, and modified physical custody by placing the children in the primary care

and custody of the father; the trial court maintained joint legal custody, but provided that

the father would serve as the tie-breaker in the event of an impasse. See id. at 164-65, 47

A.3d at 1029. In so ruling, the trial court explained that events had occurred “that indicate

there’s extreme deterioration of any mental condition that Mother suffers from.” Id. at 164,

47 A.3d at 1029 (brackets omitted).

       On appeal, in pertinent part, the mother contended that the trial court had erred in

admitting the Lish report into evidence and relying upon it in reaching its conclusions. See

id. at 165, 47 A.3d at 1029. The Court of Special Appeals disagreed, and, after quoting

Maryland Rule 5-703(b), stated:

       Therefore, the [trial] court was permitted to admit the Lish Report because
       Dr. Snyder considered it in reaching her opinions and conclusions, even
       though the Lish Report contained otherwise inadmissible hearsay. The [trial]
       court was permitted to consider the Lish Report for the purpose of evaluating
       the validity and probative value of Dr. Snyder’s opinion.


                                            - 29 -
Id. at 166, 47 A.3d at 1030. The Court of Special Appeals also rejected the mother’s

contention that the trial court had impermissibly considered the Lish report as substantive

evidence, determining that the trial “court was permitted to consider the Lish Report to

evaluate the validity of Dr. Snyder’s opinion, and there [was] no indication that the [trial]

court considered the Lish Report as substantive evidence.” Id. at 168-69, 47 A.3d at 1031.

The Court of Special Appeals concluded that, “even if the [trial] court erroneously

considered the Lish Report as substantive evidence, such error was harmless” because the

mother “testified that she had been diagnosed with bipolar disorder, and her testimony

regarding her bipolar diagnosis was properly admitted as substantive evidence.” Id. at 169,

47 A.3d at 1032. As such, the Court of Special Appeals determined that the mother had

failed to demonstrate prejudice. See id. at 169, 47 A.3d at 1032.

                                         Analysis

       Here, we hold that the circuit court did not abuse its discretion or err in admitting

the medical records—the Mercy record, the Koyen record, the Chiropractic record, and the

Levin record—into evidence under Maryland Rule 5-703. Specifically, we conclude that

“disclosure” means that evidence is admissible under Maryland Rule 5-703(b) where the

evidence satisfies the four elements set forth in Maryland Rule 5-703(b), and that such

evidence may, in a trial court’s discretion, be disclosed to the jury to explain the factual

bases for an expert’s opinion. Additionally, under the circumstances of this case, the

medical records satisfied the four elements for disclosure under Maryland Rule 5-703(b)

because they were trustworthy, unprivileged, reasonably relied upon by Dr. Halikman in



                                           - 30 -
forming his opinions, and necessary to illuminate Dr. Halikman’s testimony. And, we

conclude that, even if disclosure, i.e., admission, of the medical records under Maryland

Rule 5-703 was error, such error was harmless, as Petitioner has failed to demonstrate that

she was prejudiced by admission of the medical records or their use at trial; the record

contains no indication that the jury placed undue weight on the medical records.

       We begin by examining the plain language of Maryland Rule 5-703(a), which

provides that, so long as facts or data are “of a type reasonably relied upon by experts in

the particular field in forming opinions or inferences upon the subject,” an expert’s opinion

may be based on such facts or data, regardless of whether the facts or data would “be

admissible in evidence.” Stated otherwise, an expert may rely on both admissible or

otherwise inadmissible facts or data in forming his or her opinion, provided the facts or

data are the kind that experts in that particular field would reasonably rely upon in forming

opinions. Maryland Rule 5-703(b) provides that, if such facts or data are “determined to

be trustworthy, necessary to illuminate testimony, and unprivileged,” and are “reasonably

relied upon by an expert pursuant to” Maryland Rule 5-703(a), a trial court has the

discretion to order that such facts or data “be disclosed to the jury even if those facts and

data are not admissible in evidence.” Significantly, however, as Maryland Rule 5-703(b)

provides, “[u]pon request,” the trial court shall instruct the jury that such facts or data are

disclosed, or admitted, not as substantive evidence, but instead “only for the purpose of

evaluating the validity and probative value of the expert’s opinion or inference.” It is

incumbent upon the party who would like that point made clear to the jury to request a

limiting instruction.


                                            - 31 -
       To be sure, Maryland Rule 5-703(b) refers to the term “disclosed” to the jury, and

not to the term “admitted” with respect to facts or data reasonably relied upon by a

testifying expert. We are unpersuaded, however, that the plain language of Maryland Rule

5-703(b), and the use of the term “disclosed,” somehow distinguishes between “disclosure”

and “admission” such that “disclosed” does not mean “admitted” for purposes of the Rule

where the four elements of Maryland Rule 5-703(b) are satisfied. Rather, in our view, in

agreement with the Court of Special Appeals, for purposes of Maryland Rule 5-703(b),

“disclosure” of facts or data reasonably relied upon by an expert witness means

“admission” of the information at issue provided that the four elements of the Rule are

fulfilled.

       Notably, Maryland Rule 5-703 does not define the term “disclosed” or otherwise

limit the term to something short of admission into evidence.            Indeed, contrary to

Petitioner’s contention, nothing in Maryland Rule 5-703 purports to limit disclosure to

either allowing an expert to testify about the facts or data that the expert relied upon or

permitting the jury to review the facts or data only during the expert’s testimony.

Presumably, had the term “disclosed” been intended to have such a meaning where only

certain narrow modes of disclosure were permissible, Maryland Rule 5-703 would have so

specified. We discern no appreciable difference between disclosure and admission of facts

or data under Maryland Rule 5-703 because, as the Court of Special Appeals, with the

Honorable Deborah S. Eyler writing for the Court, aptly stated, “to be able to use the

writing [containing the facts or data] to assess the credit, if any, to be accorded the opinion

of the expert witness who relied upon it, the fact finder must be able to read the document,


                                            - 32 -
not just glance at it in passing.” Lamalfa, 233 Md. App. at 155, 163 A.3d at 213. In sum,

nothing in the plain language of Maryland Rule 5-703(b)—i.e., the use of the word

“disclosed”—prohibits the documents at issue from being given to the jury just as if the

documents had been admitted into evidence.

       Additionally, we observe that, in applying Maryland Rule 5-703, both this Court

and the Court of Special Appeals have interpreted disclosure to mean admission. See, e.g.,

Cooper, 434 Md. at 230, 73 A.3d at 1120 (“[I]f evidence constitutes inadmissible hearsay,

it cannot be admitted as substantive evidence, [but] Maryland Rule 5-703(b) permits a

trial judge, in his or her discretion, to admit evidence as the factual basis for the expert’s

opinion[.]” (Emphasis added) (citation omitted)); Brown, 409 Md. at 601, 976 A.2d at 321

(“[F]our elements must be satisfied for a document to be admissible under” Maryland Rule

5-703. (Emphasis added)); Alban, 210 Md. App. at 21, 61 A.3d at 879 (“Thus, unless

inadmissible as a matter of law, inadmissible evidence, if it satisfies Rule 5-703, may be

admitted, in the court’s discretion, to explain the factual basis for an expert’s opinion.”

(Emphasis added)); Gillespie, 206 Md. App. at 166, 47 A.3d at 1030 (“[T]he [trial] court

was permitted to admit the Lish Report because Dr. Snyder considered it in reaching her

opinions and conclusions, even though the Lish Report contained otherwise inadmissible

hearsay.” (Emphasis added)).

       We readily acknowledge that in none of these cases did this Court or the Court of

Special Appeals expressly address the meaning of “disclosed,” or whether “disclosed”

means “admitted” for purposes of Maryland Rule 5-703(b). However, it is evident that

both this Court and the Court of Special Appeals have treated disclosure as admission for


                                            - 33 -
purposes of Maryland Rule 5-703(b) if the four elements are satisfied. In both Brown and

Gillespie, the trial court clearly admitted into evidence the contested document. See

Brown, 409 Md. at 576, 976 A.2d at 306 (Defense counsel “offered into evidence the Un-

Redacted ARC Report . . . . [The plaintiff] objected when [the defendant]s introduced the

Un-Redacted ARC Report into evidence, but her objection was overruled.”); Gillespie, 206

Md. App. at 159-60, 161, 47 A.3d at 1026, 1027 (The children’s best interest attorney

“moved to have the Lish Report . . . admitted into evidence. Mother objected to the

admission of the Lish Report[.] . . . Thereafter, the court admitted the Lish Report . . . into

evidence.”). In other words, in each case, the contested document was admitted into

evidence, not simply shown to a jury or discussed by the expert—i.e., the procedures that

Petitioner contends constitute “disclosure,” but fall short of “admission,” for purposes of

Maryland Rule 5-703(b). And, significantly, in analyzing and applying Maryland Rule 5-

703(b), both this Court and the Court of Special Appeals referred to “admission,” and

variations thereof, rather than “disclosure.” See Brown, 409 Md. at 601, 603, 604, 976

A.2d at 321, 322, 323; Gillespie, 206 Md. App. at 166, 169, 47 A.3d at 1030, 1031.

       At oral argument, in response to a question as to whether this Court might look to

Maryland Rule 5-703’s counterpart in the Federal Rules of Evidence for guidance

concerning “inadmissibility,” Respondent’s counsel stated that the relevant Federal Rule

of Evidence was distinguishable and “stricter” than Maryland Rule 5-703(b) with respect

to disclosure of facts and data relied upon by an expert. Upon review of Federal Rule of

Evidence 703—the federal counterpart to Maryland Rule 5-703—we conclude that Federal

Rule of Evidence 703 varies from the Maryland Rules on this point, and sets forth a


                                            - 34 -
different standard for disclosure of facts and data relied upon by an expert. As such,

Federal Rule of Evidence 703 does not provide guidance with respect to the meaning or

requirements of “disclosed” for purposes of Maryland Rule 5-703(b). Federal Rule of

Evidence 703, concerning the bases of an expert’s opinion testimony, provides, in full:

      An expert may base an opinion on facts or data in the case that the expert has
      been made aware of or personally observed. If experts in the particular field
      would reasonably rely on those kinds of facts or data in forming an opinion
      on the subject, they need not be admissible for the opinion to be admitted.
      But if the facts or data would otherwise be inadmissible, the proponent of the
      opinion may disclose them to the jury only if their probative value in helping
      the jury evaluate the opinion substantially outweighs their prejudicial effect.

Advisory Committee Notes concerning the 2000 amendments to Federal Rule of Evidence

703 elaborate:

      Rule 703 has been amended to emphasize that when an expert reasonably
      relies on inadmissible information to form an opinion or inference, the
      underlying information is not admissible simply because the opinion or
      inference is admitted. . . .

      When information is reasonably relied upon by an expert and yet is
      admissible only for the purpose of assisting the jury in evaluating an expert’s
      opinion, a trial court applying this Rule must consider the information’s
      probative value in assisting the jury to weigh the expert’s opinion on the one
      hand, and the risk of prejudice resulting from the jury’s potential misuse of
      the information for substantive purposes on the other. The information may
      be disclosed to the jury, upon objection, only if the trial court finds that the
      probative value of the information in assisting the jury to evaluate the
      expert’s opinion substantially outweighs its prejudicial effect. If the
      otherwise inadmissible information is admitted under this balancing test, the
      trial judge must give a limiting instruction upon request, informing the jury
      that the underlying information must not be used for substantive purposes.
      See Rule 105. In determining the appropriate course, the trial court should
      consider the probable effectiveness or lack of effectiveness of a limiting
      instruction under the particular circumstances.




                                           - 35 -
       Federal Rule of Evidence 703 requires that, where the proponent of an expert’s

opinion seeks to disclose the otherwise inadmissible underlying facts or data, not only must

the facts and data be of the type that experts in that particular field would reasonably rely

upon, but also, the trial court must engage in a balancing test, weighing the probative value

of the facts and data in helping the jury evaluate the expert’s opinion against the prejudicial

effect of the facts and data. Only if the probative value “substantially outweighs” the

prejudicial effect may the trial court permit disclosure of the facts and data to the jury. By

contrast, nothing in Maryland Rule 5-703(b) or Maryland case law requires a trial court to

weigh the probative value of the facts and data underlying an expert’s opinion against their

prejudicial effect before permitting disclosure to a jury. Instead, as we explained in Brown,

409 Md. at 601, 976 A.2d at 321, “four elements must be satisfied for a document to be

admissible under” Maryland Rule 5-703—“[t]he document must be (1) trustworthy, (2)

unprivileged, (3) reasonably relied upon by an expert in forming his or her opinion, and (4)

necessary to illuminate that expert’s testimony.”        Simply put, the requirements for

disclosure under Federal Rule of Evidence 703 are distinct from the requirements for

disclosure under Maryland Rule 5-703, and Federal Rule of Evidence 703 does not

illuminate the meaning of or requirements for disclosure under Maryland Rule 5-703.

       In short, we conclude that disclosure means admission for purposes of Maryland

Rule 5-703 where the four elements of Maryland Rule 5-703(b) are satisfied. It is obvious,

however, that what makes the difference with respect to admission of facts or data

reasonably relied upon by a testifying expert under Maryland Rule 5-703(b), as opposed to

the admission of evidence generally, is the limiting instruction provided for in Maryland


                                            - 36 -
Rule 5-703(b)—namely, that facts or data reasonably relied upon by a testifying expert are

not admitted as substantive evidence, unless otherwise admissible for their substance, but

rather are to be used “only for the purpose of evaluating the validity and probative value of

the expert’s opinion or inference.” It cannot be overemphasized that Maryland Rule 5-

703(b) expressly provides that, upon request, the trial court shall instruct the jury that facts

or data reasonably relied upon by a testifying expert are used to assess the validity and

probative value of the expert’s opinion, not as substantive evidence.

       At oral argument, Petitioner’s counsel readily admitted that he did not request that

the circuit court give the limiting instruction provided for in Maryland Rule 5-703(b).

Oddly, Petitioner’s counsel contended that the limiting instruction provided for in

Maryland Rule 5-703(b) would “work[]” only if the documents were “merely disclosed[,]”

and not physically provided to the jury during deliberations.             Petitioner’s counsel

essentially argued that, once documents containing facts or data reasonably relied upon by

a testifying expert go to the jury room, a limiting instruction would be of no value. We

disagree. Petitioner’s counsel’s contention—that a limiting instruction is useless after

documents are physically provided to a jury during deliberations—is antithetical to the

purpose of limiting instructions and contradicts the manner in which trial courts

traditionally use such instructions. Indeed, limiting instructions are routinely used where

evidence has been admitted for one purpose, but is not to be considered for another purpose.

See, e.g., Md. R. 5-105 (“Where evidence is admitted that is admissible as to only party or

for one purpose but not admissible as to another party or for another purpose, the court,

upon request, shall restrict the evidence to its proper scope and instruct the jury


                                             - 37 -
accordingly.”); Balt. Gas and Elec. Co. v. Flippo, 112 Md. App. 75, 105-06, 684 A.2d 456,

471 (1996), aff’d, 348 Md. 680, 705 A.2d 1144 (1998) (“It should be obvious that, if the

admissibility of a drawing is within the discretion of the trial judge, it is equally within the

judge’s discretion to admit it for a limited purpose only. . . . [W]e certainly perceive no

abuse of discretion in the limiting instruction.”). In short, we reject the premise that

incurable harm occurs once documents containing facts or data reasonably relied upon by

an expert are admitted into evidence and physically provided to the jury during

deliberations, and that a limiting instruction is ineffective if requested under those

circumstances. Limiting instructions are tailored to explain to the jury how to consider

evidence that is admitted. And, significantly, a jury is presumed to follow a trial court’s

instruction. See Collins v. Nat’l R.R. Passenger Corp., 417 Md. 217, 252, 9 A.3d 56, 77

(2010) (“Jurors are presumed to have followed the instructions provided to them by the

court, our legal system necessarily proceeds upon that presumption.” (Cleaned up)).

       From our perspective, although we have addressed the significant issue of whether

under Maryland Rule 5-703(b) disclosure means admission if the four elements of the Rule

are satisfied, Petitioner’s failure to request a limiting instruction at any point with respect

to the medical records—either at the time of their admission, at the close of the evidence,

or during Respondent’s counsel’s closing argument—constitutes a waiver of any issue as

to the weight that the jury may have accorded the medical records. See Brown, 409 Md.

at 603, 976 A.2d at 323 (This Court concluded that the plaintiff’s argument as to the

relevance of the contested document was waived because the plaintiff “did not request a

limiting instruction under Maryland Rule 5-703 and did not object to the manner in which


                                             - 38 -
[the defendants] relied on the [document] in their closing argument.”). Stated otherwise,

Petitioner had the opportunity to request a limiting instruction so that the jury would be

instructed to consider the medical records only for the purpose of evaluating the validity

and probative value of Dr. Halikman’s opinion, and not as substantive evidence, but failed

to do so. Thus, Petitioner waived any contention that the jury may have considered the

medical records as substantive evidence.

       We are unpersuaded by Petitioner’s contention that holding that disclosure means

admission under Maryland Rule 5-703 works an “end run” around the rule against hearsay

and permits a trial court to admit into evidence any document that is otherwise inadmissible

simply because an expert witness relies upon it. Our holding—that disclosure means

admission for purposes of Maryland Rule 5-703 where evidence satisfies the four elements

of Maryland Rule 5-703(b)—does not circumvent the rule against hearsay, or otherwise

open the floodgates for trial courts to admit into evidence any and all documents containing

facts or data relied upon by a testifying expert. Importantly, Maryland Rule 5-703(b) has

built-in safeguards in the form of four requirements that must be satisfied for a trial court

to admit facts or data relied upon by a testifying expert—namely, “[t]he document must be

(1) trustworthy, (2) unprivileged, (3) reasonably relied upon by an expert in forming her or

his opinion, and (4) necessary to illuminate that expert’s testimony.” Brown, 409 Md. at

601, 976 A.2d at 321. These four requirements serve a gatekeeping function with respect

to disclosure to a jury of facts or data relied upon by an expert witness pursuant to Maryland

Rule 5-703.    Simply put, facts or data relied upon by a testifying expert are not

automatically disclosable to a jury under Maryland Rule 5-703 merely because the


                                            - 39 -
testifying expert relies upon them; rather, the facts or data must satisfy the four elements

set forth in Maryland Rule 5-703(b) to be disclosed to the jury.

       Here, with respect to those four elements, we determine that the record demonstrates

that the medical records in this case satisfied the four elements for disclosure under

Maryland Rule 5-703(b) because they were trustworthy, unprivileged, reasonably relied

upon by Dr. Halikman in forming his opinions, and necessary to illuminate Dr. Halikman’s

testimony.6 As an initial matter, we note that, although it would have been the better

practice for the circuit court to announce that the four elements set forth in Maryland Rule

5-703(b) had been satisfied or to make findings with respect to the four elements, the lack

of such an announcement or findings, in this case, does not preclude a determination that

the prerequisites for disclosure of the medical records were satisfied. Although Maryland

Rule 5-703(b) provides that a trial court must “determine[]” that the four elements are

fulfilled before, in its discretion, permitting facts or data reasonably relied upon by a

testifying expert to disclosed to the jury, Maryland Rule 5-703(b) does not expressly

require that the trial court announce its determinations or findings on the record.

Nevertheless, a trial court should be extremely cautious when permitting disclosure under

Maryland Rule 5-703(b), and the trial court should take care to make known its



       6
         As to records or reports being reasonably relied upon by the expert witness, it goes
without saying that only the portion of the underlying record or report on which the expert
has testified that he or she relied upon would be admissible. Stated otherwise, to the extent
that an expert testifies to having relied on only a portion or segment of a record or report,
the trial court, in its discretion, after determining the existence of the other relevant factors
set forth in Maryland Rule 5-703(b), should admit only the portion of the record or report
reasonably relied upon by the expert witness.

                                             - 40 -
determinations with respect to the four elements of Maryland Rule 5-703(b), i.e., the trial

court should determine that the four elements are satisfied before allowing disclosure.

       The circuit court is presumed to know and properly apply the law. See Aventis

Pasteur, Inc. v. Skevofilax, 396 Md. 405, 426, 914 A.2d 113, 125 (2007) (“It is a well-

established principle that trial judges are presumed to know the law and apply it properly.”

(Cleaned up)). In this case, just because the circuit court expressly mentioned only one of

the four elements of Maryland Rule 5-703(b)—reliance by Dr. Halikman in reaching his

opinion—does not mean that the circuit court failed to consider whether the other three

elements were satisfied. See id. at 426, 914 A.2d at 125-26 (“We presume judges to know

the law and apply it, even in the absence of a verbal indication of having considered it. . . .

[T]rial judges are not obliged to spell out in words every thought and step of logic.”

(Cleaned up)). In other words, the circuit court’s correct statement concerning one of the

elements for disclosure under Maryland Rule 5-703 does not necessarily lead to the

conclusion that the circuit court somehow misapplied the law with respect to the other three

elements. Indeed, on brief, Petitioner acknowledges that silence on the part of the circuit

court does not necessarily or automatically mean that the circuit court failed to exercise its

discretion to consider and determine whether the four elements for disclosure under

Maryland Rule 5-703 had been met. Specifically, Petitioner states that, “[o]rdinarily,

where a judge is silent on applying discretion to the admission of evidence, the appellate

court will not necessarily interpret the silence as a failure to apply discretion.” (Citation

omitted). Although determining on-the-record that the four factors were satisfied may have

been the better practice, it is clear that the circuit court did not abuse its discretion by failing


                                              - 41 -
to expressly announce that it had considered and determined the other three elements before

ruling. And, the circuit court’s failure to make such an announcement does not preclude

the conclusion that the requirements for disclosure under Maryland Rule 5-703(b) were

met.7

        Under the distinctive circumstances of this case, it is clear, based on the record, that

the medical records satisfied all four elements of Maryland Rule 5-703(b). Here, as stated

above, Petitioner does not dispute that the medical records were unprivileged and

reasonably relied upon by Dr. Halikman in forming his opinion, but contends that

Respondent failed, and the circuit court made no inquiry, to demonstrate that the medical

records were trustworthy or necessary to illuminate Dr. Halikman’s testimony. Thus, in



        7
        As stated, Maryland Rule 5-703(b) requires only that it be “determined” by the trial
court that the four elements of Maryland Rule 5-703(b) are satisfied before the trial court
may, in its discretion, disclose to the jury facts or data reasonably relied upon by an expert
witness. Maryland Rule 5-703(b)—unlike other Rules—does not require that the trial court
announce on the record its determinations. See, e.g., Md. R. 4-246(b) (“The court may not
accept the waiver [of the right to a jury trial] until, after an examination of the defendant
on the record in open court conducted by the court, the State’s Attorney, the attorney for
the defendant, or any combination thereof, the court determines and announces on the
record that the waiver is made knowingly and voluntarily.” (Emphasis added)); Md. R.
15-203(a) (“If the court summarily finds and announces on the record that direct
contempt has been committed, the court may defer imposition of sanctions until the
conclusion of the proceeding during which the contempt was committed.” (Emphasis
added)).
       In our view, the best practice under Maryland Rule 5-703(b) is for a trial court to
explain on the record that it has considered each of the four elements set forth in the Rule
and determined whether they are satisfied. Because Maryland Rule 5-703(b) does not
currently require an express announcement by the trial court that the four elements of
Maryland Rule 5-703(b) have been satisfied, we refer the issue of whether Maryland Rule
5-703(b) should require an announcement to the Standing Committee on Rules of Practice
and Procedure for consideration.


                                             - 42 -
this case, two of the four elements are not in dispute. We agree that the medical records

were unprivileged and reasonably relied upon by Dr. Halikman in forming his opinions,

and we examine only the elements of trustworthiness and necessity to illuminate Dr.

Halikman’s testimony.       The record demonstrates that the medical records were

trustworthy—the medical records were prepared by the treating hospital and Petitioner’s

own treating physicians post-accident. And, Respondent indicates on brief that Petitioner’s

counsel provided the medical records to Respondent’s counsel before trial. Also, the

medical bills generated by the providers who authored the medical records were offered

into evidence by Petitioner to support her claim for damages.8

       Likewise, the record demonstrates that the medical records were necessary to

illuminate Dr. Halikman’s testimony. Petitioner filed the complaint in 2014, three years

after the accident; during the interim, Petitioner sought medical treatment from the four

providers whose records are at issue for a variety of alleged medical conditions. Dr.

Halikman testified that he relied upon the medical records to form his opinion—that the



       8
         When medical bills are introduced into evidence to support a plaintiff’s claim for
damages, the trial court necessarily makes a finding, either implicitly or explicitly, that the
medical bills reflect amounts that are fair and reasonable. See, e.g., Kujawa v. Balt. Transit
Co., 224 Md. 195, 208, 167 A.2d 96, 102 (1961) (“In excluding [] other medical bills, the
[trial] court did not require the personal appearance of the billing doctors. The only
requirement was that the plaintiffs should ‘have evidence’ that the charges were reasonable.
The medical bills, absent a showing of reasonableness, were properly excluded. Evidence
of the amount or payment of medical bills does not establish the reasonable value of the
services for which the bills were rendered or justify recovery therefor.” (Citations
omitted)); Desua v. Yokim, 137 Md. App. 138,143, 768 A.2d 56, 58-59 (2001) (“In order
for the amounts paid or incurred for medical care to be admissible as evidence of special
damages, there ordinarily must be evidence that the amounts are fair and reasonable.”
(Citation omitted)).

                                            - 43 -
injury to Petitioner’s right shoulder did not result from the car accident and that any injury

to the abdomen would have been evident within months after the accident, but was not—

and, given the nature of Petitioner’s complaints and the time period over which Petitioner

sought medical treatment, the medical records were necessary to illuminate Dr. Halikman’s

testimony and to aid the jury in understanding the basis for Dr. Halikman’s opinion. In

short, all four elements for disclosure under Maryland Rule 5-703(b) were fulfilled, and

the circuit court did not abuse its discretion or err in admitting the medical records into

evidence. We reiterate that, under the circumstances of this case, there was sufficient

information in the record that the medical records satisfied the four elements of Maryland

Rule 5-703(b). In general, however, a trial court should make known its determination

with respect to the four elements of Maryland Rule 5-703(b), as there may be instances in

which, even though a trial court is presumed to know and properly apply the law, the record

will not reflect sufficient information from which an appellate court may conclude that all

four elements have been satisfied.

       Because there was no error on the circuit court’s part, and because, by failing to

request a limiting instruction, Petitioner waived any issue as to the weight the jury may

have accorded the medical records, we need not examine whether there was harmless error.

Nonetheless, we conclude that, even if admission of the medical records was error, such

error was harmless. Petitioner has failed to demonstrate prejudice from admission of the

medical records, or to otherwise show that the jury placed undue weight on the medical

records. The record is completely devoid of any indication that the jury placed undue

weight on the medical records, or even that the jury placed more weight on the medical


                                            - 44 -
records than on the other evidence adduced at trial. Cf. Gillespie, 206 Md. App. at 169, 47

A.3d at 1031-32 (“[A]ssuming arguendo the [trial] court erred in admitting the Lish Report

into evidence as substantive evidence, the error was harmless. . . . The burden is on the

complaining party to show prejudice as well as error. The complaining party must

demonstrate that the prejudice was likely or substantial.” (Cleaned up)).

       In sum, we hold that the circuit court properly admitted the medical records under

Maryland Rule 5-703. This is so because “disclosed” means “admitted” under Maryland

Rule 5-703(b) if the evidence at issue satisfies the four elements set forth in Maryland Rule

5-703(b), and such evidence may, in a trial court’s discretion, be disclosed to the jury to

explain the factual bases for an expert’s opinion. In this case, the medical records satisfied

the four elements for disclosure under Maryland Rule 5-703(b) because they were

trustworthy, unprivileged, reasonably relied upon by Dr. Halikman in forming his opinions,

and necessary to illuminate Dr. Halikman’s testimony.9

       Accordingly, we affirm the judgment of the Court of Special Appeals.

                                    JUDGMENT OF THE COURT OF SPECIAL
                                    APPEALS AFFIRMED. PETITIONER TO PAY
                                    COSTS.

       9
        Because we hold that the medical records were properly admitted into evidence
under Maryland Rule 5-703(b), we do not address whether the medical records were
admissible under an exception to the rule against hearsay as Respondent contends—
namely, that the medical records were otherwise admissible as statements of a then existing
mental, emotional, or physical condition pursuant to Maryland Rule 5-803(b)(3), as
statements for purposes of medical diagnosis or treatment pursuant to Maryland Rule 5-
803(b)(4), as business records under Maryland Rule 5-803(b)(6), or under the catchall or
residual exception of Maryland Rule 5-803(b)(24). Simply put, whether the medical
records were admissible pursuant to an exception to the rule against hearsay would have
no effect on our holding that the medical records were properly admitted pursuant to
Maryland Rule 5-703(b).

                                            - 45 -
