                 IN THE COMMONWEALTH COURT OF PENNSYLVANIA

American Airlines, Inc., Sedgwick               :
Claims Management Services, Inc.                :
and New Hampshire Insurance                     :
Company                                         :
                  Petitioners                   :
                                                :
                v.                              : No. 644 C.D. 2018
                                                : Submitted: October 12, 2018
Workers’ Compensation Appeal                    :
Board (Neves),                                  :
                Respondent                      :


BEFORE:         HONORABLE MARY HANNAH LEAVITT, President Judge
                HONORABLE ANNE E. COVEY, Judge
                HONORABLE MICHAEL H. WOJCIK, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION
BY PRESIDENT JUDGE LEAVITT                                          FILED: March 22, 2019

                American Airlines, Inc., Sedgwick Claims Management Services, Inc.,
and New Hampshire Insurance Company petition for review of an adjudication of
the Workers’ Compensation Appeal Board (Board) that granted Robert Neves’
(Claimant) claim petition for benefits under the Workers’ Compensation Act (Act).1
In doing so, the Board affirmed the decision of the Workers’ Compensation Judge
(WCJ) that Claimant proved that he suffered a disabling injury at work. Discerning
no error, we affirm the Board.
                Claimant worked for American Airlines, Inc. (Employer) for nine years
as a baggage handler. On February 3, 2015, Claimant filed a claim petition alleging


1
    Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §§1–1041.4, 2501–2710.
that he suffered a “heart attack, myocardial infarction, [and] damage to the heart
muscle” as a result of lifting baggage at work on January 5, 2015. Reproduced
Record at 2a (R.R.__). Claimant sought total disability benefits plus penalties for
Employer’s failure to issue a notice of compensation payable (NCP). Employer filed
an answer denying the allegations. The matter was assigned to a WCJ.
             Claimant testified by deposition on April 9, 2015. He stated that his
duties for Employer included loading and unloading customer luggage and other
cargo. On January 5, 2015, while at work, Claimant lifted a piece of luggage
weighing around 90 pounds and placed it onto a cart. Not “feeling right” after lifting
the bag, Claimant started sweating and experiencing heart palpitations. Notes of
Testimony (N.T.), 4/9/2015, at 7, 26; R.R. 41a, 60a. Claimant told his co-worker he
was not feeling well and went to the onsite nurse’s office. The nurse gave Claimant
aspirin and called an ambulance. He was taken to Mercy Fitzgerald Hospital, where
he had two stents inserted in his cardiac arteries. Claimant was hospitalized for three
days.
             On January 11, 2015, Claimant suffered another cardiac episode after
an argument with his wife. He was hospitalized until January 25, 2015, at Virtua
Marlton Hospital in New Jersey, where two additional stents were inserted.
             Claimant testified that he suffers from coronary artery disease and
diabetes. Until 2012, he smoked two packs of cigarettes a day. Claimant suffered
his first heart attack in September 2012. After the first heart attack, he was diagnosed
with hypertension and hypothyroidism. He stopped drinking alcohol; reduced his
smoking to one pack of cigarettes a week; and began exercising regularly. Claimant
was out of work until he returned to his position as a baggage handler in June 2014,
which he did without informing his cardiologist.


                                           2
             Before the WCJ, at a hearing on November 12, 2015, Claimant testified
that he had a defibrillator implanted in July 2015. He continues to experience
shortness of breath and sees his treating cardiologist, Howard Gitter, M.D.,
approximately once a week.
             Claimant offered the deposition testimony of Dr. Gitter, a board
certified cardiologist, who began treating Claimant in October 2012, after his first
heart attack. At that time, Dr. Gitter tested Claimant’s ejection fraction, which
measures the heart’s ability to contract. Dr. Gitter explained that patients with
ejection fractions over 55 percent are considered normal. Less than 50 percent is
considered mildly impaired; less than 40 percent is considered mild to moderately
impaired; less than 35 percent is considered moderately to severely impaired; and
less than 30 percent is severely impaired. N.T., 10/28/2015, at 13-14; R.R. 102a-
103a. After Claimant’s 2012 heart attack, his ejection fraction fell below 30 percent.
             Dr. Gitter testified that Claimant’s condition slowly improved until
April 2014, when he stopped experiencing chest discomfort. Claimant’s ejection
fraction improved to 35 to 40 percent, which, in Dr. Gitter’s opinion, demonstrated
mild impairment. Although Claimant had recovered from the 2012 heart attack, Dr.
Gitter expressed concern to Claimant about his return to work as a baggage handler.
Nevertheless, Claimant did so in June 2014.
             Dr. Gitter testified that he next saw Claimant on February 2, 2015.
Claimant’s ejection fraction had dropped to 30 to 35 percent, demonstrating
moderate to severe impairment. Dr. Gitter determined that Claimant had an acute
myocardial infarction at work on January 5, 2015, which was “not [] a heart attack,
per se” according to enzyme analysis. N.T., 10/28/2015, at 12; R.R. 101a. At his
next visit in April 2015, a nuclear stress test and echogram indicated Claimant’s


                                          3
ejection fraction was between 28 and 35 percent.           Because a prophylactic
defibrillator implant is recommended for patients with an ejection fraction below 35
percent, Dr. Gitter recommended one for Claimant. This procedure was done in July
2015.
             Dr. Gitter stated that Claimant is “absolutely … disabled from his job.”
Id. at 17; R.R. 106a. He opined that Claimant’s disability resulted from the work
incident of January 5, 2015. Dr. Gitter explained that Claimant could work in a
sedentary job with a 10 to 15-pound lifting restriction.
             On cross-examination, Dr. Gitter testified that Claimant had recovered
from his 2012 heart attack based on his increased ejection fraction percentages; his
performance on follow-up stress tests; and his lack of complaints. During a treadmill
stress test, Claimant worked for ten minutes and achieved 113 percent of the
predicted heart rate. Dr. Gitter described this as “excellent.” Id. at 31; R.R. 120a.
Claimant no longer complained about his shortness of breath and chest tightness.
             Dr. Gitter agreed that Claimant’s argument with his wife on January 11,
2015, was a stressful event that caused Claimant to be readmitted for another cardiac
catheterization. However, Dr. Gitter did not believe that a personal confrontation
could affect Claimant’s heart to the same extent as physical overexertion.
             Employer offered the deposition testimony of Andrew Meshkov, M.D.,
who is board certified in cardiovascular medicine and conducted an independent
medical examination (IME) of Claimant on February 25, 2016. Dr. Meshkov
testified that Claimant’s 2012 heart attack caused “irreversible cardiac damage to
the front wall of his left ventricle.” N.T., 3/24/2016, at 12; R.R. 201a. Dr. Meshkov
stated that he would not have released Claimant to return to his job with Employer
after the 2012 heart attack. He reviewed Claimant’s medical history and explained


                                          4
that Claimant’s obstructive sleep apnea, high cholesterol, diabetes and tobacco and
alcohol use all contributed to Claimant’s increased risk of cardiac events.
             Dr. Meshkov concluded that on January 5, 2015, Claimant suffered a
“very, very small myocardial infarction,” caused by his severe multi-vessel coronary
artery disease and the physical exertion of Claimant’s job as a baggage handler. Id.
at 28; R.R. 217a. Claimant also suffered a small myocardial infarction on January
11, 2015. Dr. Meshkov concluded that the January 11, 2015, event was unrelated to
the January 5, 2015, event.
             Dr. Meshkov opined that Claimant is disabled as a result of his “severe
chronic coronary disease and the major myocardial infarction” Claimant suffered in
2012. Id. at 32; R.R. 221a. However, Dr. Meshkov did not believe that the January
2015 events caused Claimant’s present disability. He stated that the most significant
factor in Claimant’s disability was the September 2012 heart attack. Dr. Meshkov
concluded that Claimant has recovered from his 2015 cardiac episodes and is capable
of light work and light physical activity. He opined that Claimant will require
lifetime care for his cardiac issues, which are the result of Claimant’s 2012 heart
attack.
             The WCJ concluded that Claimant proved that he suffered a disabling
injury while working for Employer on January 5, 2015.             The WCJ credited
Claimant’s testimony about his past medical history, the January 5, 2015, event and
his ongoing symptoms. The WCJ found that Claimant’s testimony was supported
by medical records, diagnostic tests, and the clinical observations of both Drs. Gitter
and Meshkov.
             The WCJ credited Dr. Gitter’s testimony that during the incident of
January 5, 2015, Claimant’s heart was put under stress and oxygen delivery to his


                                          5
heart was diminished due to the exertion of lifting and straining, which caused heart
scarring and diminished function. The WCJ accepted Dr. Gitter’s opinion that
although Claimant has suffered severe coronary artery disease since 2012, the
January 5, 2015, incident was the cause of his present inability to work. In support,
the WCJ noted that Dr. Gitter’s opinions were supported by Claimant’s credible
testimony, his own clinical observations as Claimant’s treating physician since 2012,
and diagnostic test results.
              The WCJ found Dr. Meshkov credible in part. The WCJ credited Dr.
Meshkov’s testimony that Claimant suffered a severe heart attack in 2012 and two
subsequent heart attacks in 2015. However, the WCJ discredited Dr. Meshkov’s
testimony that Claimant’s ongoing disability and need for medical care was
unrelated to the work-related cardiac event that occurred on January 5, 2015.
              Consistent with the above findings, the WCJ granted Claimant’s claim
petition and awarded benefits to Claimant at the rate of $457.09 per week retroactive
to January 6, 2015, and ongoing.
              Both parties appealed to the Board. Employer argued that the WCJ
erred in holding that Claimant proved he suffered a disabling work-related injury,
and Claimant argued that the WCJ erred in the calculation of his average weekly
wage. The Board affirmed the WCJ’s decision to grant the claim petition, holding
that it was supported by substantial evidence. As to Claimant’s cross-appeal, the
Board remanded for the WCJ to make further findings on Claimant’s average weekly
wage.    Following a hearing on April 20, 2017, the WCJ confirmed its prior
computation of Claimant’s earnings and compensation rate.2 Employer appealed the


2
  Claimant did not appeal the WCJ’s decision; therefore, his average weekly wage is no longer at
issue.
                                               6
WCJ’s second decision for the sole purpose of obtaining an order from the Board
making its prior order final. The Board granted this request, and Employer’s appeal
of the Board’s grant of Claimant’s claim petition is ready for disposition.
               On appeal,3 Employer raises several issues.4 First, it contends that the
WCJ capriciously disregarded evidence in finding that Claimant proved a disabling
work-related injury. Second, it contends that the WCJ’s findings of fact are based
upon incompetent expert medical testimony. Third, it contends that the WCJ did not
issue a reasoned decision.
               In its first issue, Employer contends that the WCJ capriciously
disregarded the overwhelming evidence that Claimant’s heart attack in 2012, which
was not work-related, is the cause of Claimant’s disability up to and after the event
at work on January 5, 2015. In addition, the WCJ capriciously disregarded the
second cardiac event on January 11, 2015, which Employer characterizes as “an
aggravating and/or superseding event in the ‘chain of events’ that affected the
Claimant’s cardiac condition[.]” Employer Brief at 19.
               Capricious disregard of evidence “occurs where the fact finder willfully
and deliberately disregards competent and relevant evidence that one of ordinary
intelligence could not possibly have avoided in reaching a result.”                      Wise v.
Unemployment Compensation Board of Review, 111 A.3d 1256, 1262 (Pa. Cmwlth.
2015). More specifically, a capricious disregard of evidence occurs “where the
factfinder has refused to resolve conflicts in the evidence, has not made essential


3
  Our review determines whether there has been a violation of constitutional rights, whether errors
of law have been committed, whether board procedures were violated, or whether necessary
findings of fact are supported by substantial evidence. Reed v. Workers’ Compensation Appeal
Board (Allied Signal, Inc.), 114 A.3d 464, 468 n.3 (Pa. Cmwlth. 2015). Additionally, when raised,
this Court will review for capricious disregard of evidence. Id.
4
  For purposes of this opinion, we have consolidated Employer’s issues.
                                                7
credibility determinations or has completely ignored overwhelming evidence
without comment.” Id. at 1263. It is the responsibility of the factfinder to resolve
the conflicts in the testimony and explain why it has accepted, or rejected, each piece
of relevant evidence. Id. The Pennsylvania Supreme Court has explained that
review for capricious disregard of competent evidence is an “appropriate component
of appellate consideration in every case in which such question is properly brought
before the court.” Leon E. Wintermyer, Inc. v. Workers’ Compensation Appeal
Board (Marlowe), 812 A.2d 478, 487 (Pa. 2002).
             The WCJ summarized the testimony of each witness, including that of
Dr. Gitter and Dr. Meshkov. The WCJ specifically found that Claimant suffered a
severe myocardial infarction in 2012; the WCJ did not disregard that event. The
WCJ considered the testimony of both medical experts about Claimant’s medical
history, and he resolved the conflict between them.           Specifically, the WCJ
discredited Dr. Meshkov’s testimony that the January 5, 2015, work incident was
not a cause of Claimant’s disability.
             Nor did the WCJ disregard Claimant’s cardiac event on January 11,
2015, which Employer contends was “an aggravating and/or superseding event in
the ‘chain of events’ that affected the Claimant’s cardiac condition[.]” Employer
Brief at 19. The WCJ considered, but rejected, the possibility that the January 11,
2015, incident was responsible for Claimant’s ongoing disability. Rather, the WCJ
found that the January 5, 2015, incident was responsible for Claimant’s present
symptoms. The WCJ reached these conclusions on causation on the basis of the
medical evidence and Claimant’s testimony. The WCJ’s “express consideration and
rejection” of the medical evidence “by definition, is not capricious disregard.”
Williams v. Workers’ Compensation Appeal Board (USX Corp.-Fairless Works),


                                          8
862 A.2d 137, 145 (Pa. Cmwlth. 2004). We reject Employer’s claim that the WCJ
capriciously disregarded evidence.
             In its second issue, Employer argues that the WCJ erred in relying upon
Dr. Gitter’s expert testimony, which Employer asserts was equivocal and legally
incompetent. When the causal connection between an injury and disability is not
obvious, unequivocal medical evidence is needed to establish that connection.
Ingrassia v. Workers’ Compensation Appeal Board (Universal Health Services,
Inc.), 126 A.3d 394 (Pa. Cmwlth. 2015). Equivocal medical testimony can render a
medical opinion incompetent. Spotts v. Workmen’s Compensation Appeal Board
(Superior Tube Co.), 541 A.2d 446 (Pa. Cmwlth. 1988). Competency is “merely a
question of whether the witnesses’ opinion is sufficiently definite and unequivocal
to render it admissible.” Cerro Metal Products Co. v. Workers’ Compensation
Appeal Board (PLEWA), 855 A.2d 932, 937 (Pa. Cmwlth. 2004) (quoting Cramer
v. Workmen’s Compensation Appeal Board (Uni-Marts & PMA Group), 627 A.2d
231, 233 (Pa. Cmwlth. 1993)). This Court has explained that “medical evidence is
unequivocal as long as the medical expert, after providing a foundation, testifies that
in his professional opinion he believes or thinks the facts exist.” Cerro Metal
Products, 855 A.2d at 937. That a medical expert admits to some uncertainty,
reservation or lack of information with respect to scientific or medical details does
not render the opinion equivocal. Id.
             Employer argues that Dr. Gitter’s opinion was equivocal and
incompetent because he did not address the many factors affecting the Claimant’s
ability to work. These factors include: (1) Claimant’s heart attack in September
2012; (2) Claimant’s preexisting and ongoing severe coronary artery disease; (3)




                                          9
Claimant’s second heart attack on January 11, 2015; and (4) Claimant’s episodes of
chest pain after the incident on January 11, 2015, that led to a defibrillator implant.
             Employer points out that Dr. Gitter specifically testified that the
Claimant “did not have a heart attack per se” on January 5, 2015, as confirmed by
enzyme analysis at Mercy Fitzgerald Hospital. N.T., 10/28/2015, at 12; R.R. 101a.
Indeed, the WCJ so found. When asked whether Claimant’s symptoms were due to
Claimant’s ongoing heart condition, Dr. Gitter testified as follows:

             Well I don’t know that I can say that. Something acutely
             occurred on January 5 because for six months he was apparently
             fine. He hadn’t come in to see me.

Id. at 35; R.R. 124a. Employer asserts that this testimony constitutes the very
definition of equivocal testimony. We disagree.
             A medical expert’s opinion on causation must be reviewed as a whole.
Casne v. Workers’ Compensation Appeal Board (STAT Couriers, Inc.), 962 A.2d 14
(Pa. Cmwlth. 2008). A medical opinion does not become equivocal on the basis of
a single phrase extracted from a deposition. Terek v. Workmen’s Compensation
Appeal Board (Somerset Welding & Steel, Inc.), 668 A.2d 131 (Pa. 1995); see also
Jordan v. Workmen’s Compensation Appeal Board (Consolidated Electrical
Distributors), 704 A.2d 1063 (Pa. 1997) (explaining that one sentence should not be
extracted from a physician’s 27-page deposition to conclude that his opinion was
equivocal). Dr. Gitter unequivocally opined that Claimant experienced a cardiac
episode on January 5, 2015, that enhanced his pre-injury symptoms, and it was that
event that has disabled him from his job.
             Furthermore, and contrary to Employer’s assertions, Dr. Gitter’s
opinion fully addressed the 2012 heart attack, Claimant’s other health issues and the
reason why Claimant’s defibrillator was not implanted until July 2015. While
                                          10
Claimant suffered from type 2 diabetes, hypertension, hypothyroidism, and anxiety,
and used tobacco, Dr. Gitter pointed out that Claimant had these issues under control
with medications and lifestyle changes. Further, Dr. Gitter opined that Claimant had
recovered from his 2012 heart attack. As to Claimant’s defibrillator, Dr. Gitter
explained that after a heart episode, a patient’s ejection fraction can improve.
Cardiologists wait 90 days to determine whether a patient should receive a
defibrillator.     Thus, Dr. Gitter did not immediately order a defibrillator after
Claimant’s January 5, 2015, episode.
                 In effect, Employer argues that the WCJ should have relied on Dr.
Meshkov’s medical opinion that Claimant’s present disability was unrelated to the
January 5, 2015, work incident but, rather, was caused by Claimant’s preexisting
and chronic coronary artery disease. The WCJ found this testimony neither credible
nor persuasive but, rather, credited Dr. Gitter’s testimony that Claimant sustained a
disabling heart attack as a result of his strenuous position working for Employer.
The WCJ based his credibility determination on Dr. Gitter’s familiarity with
Claimant’s conditions as his treating physician. We decline to revisit the WCJ’s
credibility determinations. See Minicozzi v. Workers’ Compensation Appeal Board
(Industrial Metal Plating, Inc.), 873 A.2d 25, 28-29 (Pa. Cmwlth. 2005) (explaining
that this Court is bound by the WCJ’s credibility determinations).
                 In its third issue, Employer argues that the WCJ did not issue a reasoned
decision because he did not adequately explain why Claimant’s cardiac event at
work on January 5, 2015, was disabling even though Claimant had suffered a major
heart attack in 2012. That heart attack was such that the treating cardiologist advised
against Claimant’s return to his job as a baggage handler. Employer also contends




                                             11
that the WCJ failed to explain how, or to what extent, the January 11, 2015, cardiac
event affected Claimant’s condition.
             Section 422(a) of the Act states that parties are “entitled to a reasoned
decision containing findings of fact and conclusions of law based upon the evidence
as a whole which clearly and concisely states and explains the rationale for the
decisions so that all can determine why and how a particular result was reached.”
77 P.S. §834. Accordingly, the WCJ “shall specify the evidence upon which the
[WCJ] relies and state the reasons for accepting it in conformity with this section.”
Id. A decision is reasoned “if it allows for adequate review by the [Board] without
further elucidation and if it allows for adequate review by the appellate courts under
applicable review standards.” Daniels v. Workers’ Compensation Appeal Board
(Tristate Transport), 828 A.2d 1043, 1052 (Pa. 2003).
             Where medical experts testify by deposition, a WCJ’s resolution of
conflicting evidence must be supported by more than the bald statement that one
expert is more credible than another. Dorsey v. Workers’ Compensation Appeal
Board (Crossing Construction Co.), 893 A.2d 191, 194-95 (Pa. Cmwlth. 2006). The
WCJ must explain his credibility finding in objective terms.         Id.    Credibility
determinations, unless arbitrary or capricious, will be upheld on appeal.
             Here, the WCJ cited objective reasons for why he credited Dr. Gitter’s
deposition testimony, i.e., it was supported by Claimant’s own testimony and
diagnostic test results. The WCJ also observed that Dr. Gitter has been Claimant’s
treating physician since 2012. Viewing the record as a whole, the WCJ rejected Dr.
Meshkov’s opinion that Claimant’s ongoing disability and future medical care was
unrelated to the January 5, 2015, work incident. Because the WCJ’s stated reasons




                                         12
for his credibility determinations are supported by the record, his decision was
reasoned under Section 422(a).
            For all of the foregoing reasons, this Court affirms the Board’s
adjudication.
                                 _____________________________________
                                 MARY HANNAH LEAVITT, President Judge




                                      13
            IN THE COMMONWEALTH COURT OF PENNSYLVANIA

American Airlines, Inc., Sedgwick       :
Claims Management Services, Inc.        :
and New Hampshire Insurance             :
Company                                 :
                  Petitioners           :
                                        :
            v.                          : No. 644 C.D. 2018
                                        :
Workers’ Compensation Appeal            :
Board (Neves),                          :
                Respondent              :

                                    ORDER


            AND NOW, this 22nd day of March, 2019, the order of the Workers’
Compensation Appeal Board dated April 13, 2018, is hereby AFFIRMED.


                                    _____________________________________
                                    MARY HANNAH LEAVITT, President Judge
