                                             COURT OF APPEALS OF VIRGINIA


              Present: Judges AtLee, Malveaux and Senior Judge Annunziata
UNPUBLISHED


              Argued by teleconference


              WADE PROTUS PHILLIPS
                                                                           MEMORANDUM OPINION* BY
              v.     Record No. 1963-16-4                               JUDGE MARY BENNETT MALVEAUX
                                                                                AUGUST 8, 2017
              LOUDOUN COUNTY, VIRGINIA


                            FROM THE VIRGINIA WORKERS’ COMPENSATION COMMISSION

                               Julie H. Heiden (Koonz, McKenney, Johnson, DePaolis &
                               Lightfoot, LLP, on brief), for appellant.

                               Justin R. Main (Michael S. Bliley; Siciliano, Ellis, Dyer &
                               Boccarosse PLC, on brief), for appellee.


                     Wade Phillips (“claimant”) appeals a decision of the Virginia Workers’ Compensation

              Commission (“the Commission”) finding that treatment he received from an unauthorized medical

              provider was not compensable by Loudoun County (“employer”). Specifically, claimant argues the

              Commission erred in finding he did not demonstrate a “good reason” to have a surgery performed

              by a non-treating physician. For the reasons that follow, we affirm the Commission’s decision.

                                                       I. BACKGROUND

                     This Court views the evidence in the light most favorable to employer, the prevailing

              party before the Commission. Staton v. Bros. Signal Co., 66 Va. App. 185, 188, 783 S.E.2d 539,

              540 (2016).

                     Claimant, a Loudoun County deputy sheriff, was injured during an arrest in 2006. While

              attempting to restrain a suspect, claimant’s right arm and wrist struck a hard surface. Claimant


                     *
                         Pursuant to Code § 17.1-413, this opinion is not designated for publication.
experienced wrist and forearm pain which eventually spread to his shoulder and neck. Claimant

was awarded temporary total disability benefits and lifetime medical benefits for his injury.1 He

returned to work in December 2006. However, despite treatment by a number of physicians, his

symptoms persisted.

        In July 2008, Dr. Paul Mecherikunnel examined claimant. Dr. Mecherikunnel, who

became claimant’s treating physician, diagnosed a neuroma in claimant’s right forearm.

Dr. Mecherikunnel reviewed claimant’s medical records and noted that claimant had sought pain

management from several physicians and received different medications from each of them.

That September, Dr. Mecherikunnel operated on claimant’s right forearm and, among other

things, excised the neuroma.

        After the surgery, claimant experienced substantial pain relief that continued for

approximately one year. Claimant then noticed an increase in pain and a decline in the mobility

and functionality of his right arm.

        By mid-2013, claimant was suffering from incessant arm pain. He also complained of

numbness and tingling in the extremity. Subsequently, Dr. Lee Selznick implanted a spinal cord

stimulator in claimant’s back. The stimulator provided significant pain relief for two to three

months. After this period of time, claimant’s pain began to increase while his right arm’s

strength and dexterity began to deteriorate. Although the stimulator continued to provide some

relief, claimant lost strength in his arm until he could no longer raise it to direct traffic.

        Dr. Mecherikunnel examined claimant in September 2014. He noted claimaint’s ongoing

problems with pain and loss of right arm functionality and that claimant appeared stressed,

        1
         That award terminated on December 13, 2006. A stipulated order entered by the
Commission on March 12, 2009, resolved claimant’s subsequent claims for benefits filed in
February and March 2008. The parties stipulated that claimant had suffered a change in
condition for which he was entitled to a resumption of temporary total disability benefits from
January 29, 2008 until October 26, 2008. Claimant also received permanent partial disability
payments from January 13, 2011 through May 4, 2011.
                                              -2-
shaky, and sweaty. Claimant kept his right hand in his pocket, rubbed it constantly, and showed

signs of extensive nail biting on that hand. Dr. Mecherikunnel recommended that claimant check

with his pain management specialists about possible adjustments to his medications or spinal

cord stimulator. He also noted a “great concern” that claimant was experiencing “a somatoform

disorder” in which claimant’s stresses presented as right arm and hand pain. He opined that

claimant should have a case manager consider a psychiatric evaluation to determine the root

cause of the problems and how best to manage them.

       Claimant later testified that when he left Dr. Mecherikunnel’s office after this

examination, his understanding was that “there was nothing more [Dr. Mecherikunnel] could do

for me.” Claimaint acknowledged Dr. Mecherikunnel referred him back to his pain management

specialists for adjustments to his pain medication, but stated that he “didn’t want to do that.” He

also testified that he thought his spinal cord stimulator was adjusted after the examination, but

that he could not be sure this was done.

       Roughly one week later, following a referral by his family physician, claimant was

examined by Dr. Ivica Ducic, a board-certified plastic surgeon with a focus on peripheral nerve

surgery. Without ordering diagnostic tests, and without reviewing claimant’s medical records or

discussing claimant’s medical history with Dr. Mecherikunnel, Dr. Ducic determined that he

could intervene surgically to help claimant. Dr. Ducic instructed claimant to contact his

workers’ compensation case manager to obtain approval for the surgery, and told claimant that

until the surgery he should continue his current course of treatment. Claimant filed a claim for

benefits seeking “approval of wrist surgery” in October 2014.

       One month after his examination by Dr. Ducic, claimant returned for the operation. In

the interim, Dr. Ducic neither spoke with Dr. Mecherikunnel nor examined claimant’s medical




                                                -3-
records. During the surgery, Dr. Ducic removed two putative neuromas, which he did not send

to a pathologist, and excised the radial sensory nerve.

       After this surgery, claimant experienced improved dexterity in his right arm. However,

his arm still “act[ed] up.” During a follow-up examination in April 2015, claimant reported to

Dr. Ducic that after a recent shooting practice, his hand was “quite aggravated” by pain which

persisted for weeks.2 During another follow-up examination that August, claimant reported

intermittent shooting pain and experienced deep pain at several points on his right forearm.

Dr. Ducic concluded that claimant had clearly regressed since his previous visit.

       In October 2015, claimant visited Dr. Alok Gopal for pain and medication counseling.

Dr. Gopal noted that claimant continued to experience severe arm pain when engaged in certain

work duties. The following month, claimant visited Dr. George Van Osten for pain and

medication counseling and reported aching, stabbing pain in his right arm. Claimant also related

that after working outdoors for several hours in cold and damp conditions, his arm pain increased

until he was forced to cease work for a number of days. Claimant told Dr. Van Osten that he

wanted some medication to take for such “flare[-]ups.”

       Prior to a hearing on claimant’s claim for Dr. Ducic’s surgery, Dr. Mecherikunnel

prepared a letter in which he opined the surgery was not necessary, reasonable, or causally

related to claimant’s work injury. Dr. Mecherikunnel criticized Dr. Ducic for operating without

reviewing claimant’s medical history, stating that it was his belief that before operating, any

reasonable physician would have reviewed the patient’s history and would have wanted to know

why previous treatments had failed to provide relief. Dr. Mecherikunnel concluded his letter by

opining that there was “clear psychopathology” in claimant’s pain presentation. He noted that

       2
          Claimant filed two additional claims in 2015, each of which alleged either compensable
consequences of his 2006 injury or new work-related injuries arising from firing a firearm. The
parties stipulated to the deputy commissioner that claimant sustained compensable consequences
of his 2006 injury while firing a firearm.
                                                -4-
claimant’s medical records indicated a pattern of claimant seeking treatment from different

practitioners, reporting improvement for some time, and then moving on to other practitioners

and reporting the same symptoms. He also opined that claimant’s habits of massaging his right

forearm, sitting on his right hand, and biting his right fingers were inconsistent with a

neuropathic pain pattern.

       After an evidentiary hearing on January 7, 2016, the deptuty commissioner dismissed

claimant’s claim for the surgery performed by Dr. Ducic. Claimant requested review by the full

Commission.

       The full Commission, with one dissent, determined that claimant did not meet the

requirements for finding unauthorized medical treatment compensable by an employer. The

Commision found that when Dr. Mecherikunnel last treated claimant, he recommended that

claimant seek adjustments to his medication and spinal cord stimulator. Since claimant failed to

follow his physician’s treatment recommendations, however, it was not possible to find that

Dr. Mecherikunnel’s recommended treatment was inadequate. Further, the Commission noted

that claimant’s pain and other symptoms did not permanently resolve after Dr. Ducic’s surgery.

The Commission also credited Dr. Mecherikunnel’s opinion, as claimant’s treating physician,

that claimant had established a pattern of seeking treatment from different practitioners,

reporting improvements in his condition, and then moving on to new practitioners with renewed

symptoms. The Commission further credited Dr. Mecherikunnel’s opinion that Dr. Ducic’s

surgery was not reasonable or necessary and that his performance of surgery, without a thorough

review of claimant’s medical records, was “unreasonable in itself.”




                                                -5-
                                          II. ANALYSIS

       Claimant argues that his treatment by an unauthorized medical provider was compensable

under the “other good reasons” exception of Code § 65.2-603(C).3 Thus, the cost of his

treatment by Dr. Ducic should be borne by employer. We disagree.

       “According to well established principles, ‘factual findings of the [C]ommission that are

supported by credible evidence are conclusive and binding upon this Court on appeal.’” Boys &

Girls Club of Va. v. Marshall, 37 Va. App. 83, 90, 554 S.E.2d 104, 107 (2001) (quoting S. Iron

Works, Inc. v. Wallace, 16 Va. App. 131, 134, 428 S.E.2d 32, 34 (1993)). Consequently, “we

are bound by the [C]ommission’s findings of fact . . . even if there is evidence in the record that

would support a contrary finding.” Anderson v. Anderson, 65 Va. App. 354, 361, 778 S.E.2d

132, 136 (2015) (quoting Artis v. Ottenberg’s Bakers, Inc., 45 Va. App. 72, 83-84, 608 S.E.2d

512, 517 (2005) (en banc)). Under this standard of review, we may set aside factual findings of

the Commission only where they are “plainly wrong and without evidence to support them.”

Owens v. York Fire & Rescue, 38 Va. App. 354, 359, 564 S.E.2d 150, 152 (2002).

       The Virginia Workers’ Compensation Act provides that, where an employee is injured in

an accident arising out of and in the course of his employment, “the employer shall furnish or

cause to be furnished” an authorized medical treatment provider—that is, “a physician chosen by

the injured employee from a panel of . . . physicians selected by the employer.” Code

§ 65.2-603(A). However, an employee may seek employer compensation for treatment rendered

       3
         On brief, claimant also argues his unauthorized medical treatment was compensable by
employer because he sought that treatment when faced with a medical emergency. However,
claimant’s assignment of error encompasses only the “other good reasons” exception of Code
§ 65.2-603(C), not the emergency treatment exception. Rule 5A:20(c) “require[s] us to hold that
[an] issue is waived because it was not part of [an] appellant’s assignment of error on . . . brief.”
Simmons v. Commonwealth, 63 Va. App. 69, 75 n.4, 754 S.E.2d 545, 548 n.4 (2014); see also
Ceres Marine Terminals v. Armstrong, 59 Va. App. 694, 698 n.1, 722 S.E.2d 301, 304 n.1
(2012) (noting, in an appeal from the Commission, that “[u]nder our rules, we only address
arguments encompassed by an appellant’s express ‘assignment of error’ in his brief”). Thus, we
do not consider claimant’s emergency treatment argument.
                                                -6-
by an unauthorized physician in an emergency, due to the employer’s failure to provide medical

care, or “for other good reasons.” Code § 65.2-603(C). This Court has “emphasized that

‘reimbursement for unauthorized medical treatment should be the rare exception’ and that ‘when

an employee seeks treatment other than that provided by the employer or ordered by the

[C]ommission, he or she does so at his or her own peril and risks not being reimbursed.’” H.J.

Holz & Son v. Dumas-Thayer, 37 Va. App. 645, 653-54, 561 S.E.2d 6, 10 (2002) (quoting

Shenandoah Prods., Inc. v. Whitlock, 15 Va. App. 207, 212, 421 S.E.2d 483, 486 (1986)).

       In Whitlock, this Court established a tripartite test for determining when the “other good

reasons” exception applies. Application of the statutory exception requires the record to support

that (1) the claimant acted in good faith in seeking the unauthorized treatment; (2) “the treatment

provided by the employer was inadequate treatment for the employee’s condition[,]” and (3) “the

unauthorized treatment . . . was medically reasonable and necessary.”4 Whitlock, 15 Va. App. at

212, 421 S.E.2d at 486; see also Dumas-Thayer, 37 Va. App. at 653, 561 S.E.2d at 10.

       Whether the treatment provided by the employer was inadequate and the unauthorized

medical treatment was medically reasonable and necessary are mixed questions of law and fact.

Dumas-Thayer, 37 Va. App. at 654-55, 561 S.E.2d at 11. “Thus, the [C]ommission’s

conclusions regarding the necessity of the alternative treatment and inadequacy of the treatment

actually provided are not binding on appeal.” Id. at 655, 561 S.E.2d at 11. In reviewing both

issues, “we are guided by the principle that the opinion of the treating physician is entitled to

great weight.” Id. “However, ‘medical evidence is not necessarily conclusive[; it] is subject to

the [C]ommission’s consideration and weighing.’” Id. (first alteration in original) (quoting




       4
        We note that neither the deputy commissioner nor the Commission made findings on
the “good faith” prong of the Whitlock test. Consequently, we confine our review to the
remaining two Whitlock factors.
                                              -7-
Hungerford Mech. Corp. v. Hobson, 11 Va. App. 675, 677, 401 S.E.2d 213, 215 (1991)). We

review the relevant Whitlock factors below.

                                   A. Adequacy of Treatment

       Claimant argues Dr. Mecherikunnel’s authorized medical treatment was inadequate for

two reasons. First, claimant’s lack of improvement under Dr. Mecherikunnel’s care

demonstrated the inadequacy of his treatment. Claimant points to Dr. Ducic’s removal of two

putative neuromas as evidence that claimant suffered from an overlooked condition which

negatively impacted his ability to recover and prevented Dr. Mecherikunnel’s recommended

treatment from improving his condition. Second, claimant points to his “huge improvement”

after Dr. Ducic’s surgery as evidence that Dr. Mecherikunnel’s authorized treatment was

inadequate.

       The record supports the Commission’s finding that claimant did not follow

Dr. Mecherikunnel’s recommended treatment. Claimant admitted he did not want to pursue

modifying his pain medication. Further, while claimant was not certain he had his spinal cord

stimulator adjusted after last seeing Dr. Mecherikunnel, the record does not indicate such an

adjustment was made. Instead, claimant consulted Dr. Ducic, without authorization,

approximately a week after he received Dr. Mecherikunnel’s recommendation. Just one month

after the initial consultation, Dr. Ducic performed the unauthorized surgery.

       The Commission’s finding that claimant did not follow his treating physician’s

recommended treatment is supported by credible evidence and thus binding upon us on appeal.

Marshall, 37 Va. App. at 90, 554 S.E.2d at 107. Since claimant did not follow that course of

treatment, and did not persuasively explain why that treatment could not have helped, there is no

basis upon which we can say that the treatment provided by the employer through




                                               -8-
Dr. Mecherikunnel was inadequate for claimant’s condition. See Whitlock, 15 Va. App. at 212,

421 S.E.2d at 486.

       The Commission was entitled to reject claimant’s assertion that he experienced “huge

improvement” after Dr. Ducic’s surgery and that such improvement demonstrated the

inadequacy of Dr. Mecherikunnel’s treatment. While claimant experienced some improvement

after Dr. Ducic performed surgery, his right arm still “act[ed] up.” Six months later, during a

follow-up visit, claimant reported that firearms practice caused his right hand to become “quite

aggravated” by weeks-long pain. Claimant subsequently filed additional claims based upon

these complications. During another follow-up examination, ten months after Dr. Ducic

performed surgery, claimant reported shooting pain and exhibited deep pain, and Dr. Ducic

concluded claimant’s condition had regressed. Claimant also continued missing work due to his

symptoms, reporting work-related arm pain to pain management specialists, and requesting

medication for “flare[-]ups.” Thus, the record does not support claimant’s assertion that

Dr. Ducic’s surgery resulted in “huge improvement” in claimant’s condition, and there is no

basis for concluding that claimant’s post-operative condition in any way reflects upon the

adequacy of Dr. Mecherikunnel’s authorized medical treatment. Instead, the record supports

Dr. Mecherikunnel’s medical opinion that some or all of claimant’s ongoing symptoms are the

consequence of psychological factors, rather than purely somatic issues for which inadequate

treatment was rendered.

       Because claimant did not follow his authorized medical provider’s recommended course

of treatment, and because Dr. Ducic’s surgery failed to resolve claimant’s symptoms and thus

cannot speak to the efficacy of Dr. Mecherikunnel’s treatment, we affirm the Commission’s

finding on the question of the adequacy of the treatment provided by employer.




                                               -9-
                        B. Medically Reasonable and Necessary Treatment

       Claimant argues that the relief he experienced after Dr. Ducic’s unauthorized surgery

demonstrates that the surgery was medically reasonable and necessary. Specifically, claimant

points to his significant post-operative reduction in pain and need for pain medication as

dispositive evidence.

       Here, as above, we note that while claimant experienced some improvement immediately

after his unauthorized surgery, that improvement proved fleeting. Following Dr. Ducic’s

surgery, claimant continued to experience substantial pain and debility from, and further

compensable consequences of, his 2006 injury. Claimant also continued to seek new medication

for “flare[-]ups.” Thus, we conclude that any short-term, post-operative reduction in claimant’s

pain or need for pain medication is not dispositive of whether Dr. Ducic’s surgery was medically

reasonable and necessary. See Whitlock, 15 Va. App. at 212, 421 S.E.2d at 486.

       We also note the Commission credited Dr. Mecherikunnel’s opinion that Dr. Ducic’s

surgery was not reasonable or necessary. We will not second-guess this credibility

determination; our “well-established standard” of review does not permit us to “‘make [our] own

determination of the credibility of witnesses.’” Layne v. Crist Elec. Contr., Inc., 64 Va. App.

342, 345, 768 S.E.2d 261, 262 (2015) (alteration in original) (quoting McKellar v. Northrop

Grumman Shipbuilding Inc., 63 Va. App. 448, 451, 758 S.E.2d 104, 105 (2014)).

       Dr. Mecherikunnel opined that before performing surgery, a physician acting reasonably

would have reviewed the patient’s medical history, and Dr. Ducic testified he conducted no such

review. Such a physician also would have ordered pre-operative diagnostic tests, and Dr. Ducic

testified he ordered no such tests. Such a physician also would have sent the putative neuromas

he removed to a pathology lab for examination, and Dr. Ducic testified he did not do this.




                                              - 10 -
       Dr. Mecherikunnel also opined, as claimant’s treating physician, that claimant’s pain

resulted from psychopathological factors, not a physiological condition. Such factors, by

definition, would render surgical intervention not medically reasonable and necessary. Because

the treating physician’s opinion ordinarily “is entitled to great weight,” Dumas-Thayer, 37

Va. App. at 655, 561 S.E.2d at 11, the Commission was entitled to rely upon

Dr. Mecherikunnel’s opinion if they found it credible.

       For these reasons, we affirm the Commission’s conclusion that the unauthorized

treatment received by claimant was not medically reasonable and necessary.

                                      III. CONCLUSION

       The record does not support that the treatment provided to claimant by employer was

inadequate treatment or that the unauthorized treatment received by claimant was medically

reasonable and necessary. Thus, the “other good reasons” exception to Code § 65.2-603(C) does

not apply. We therefore affirm the Commission’s ruling that claimant’s unauthorized medical

treatment was not compensable by employer.

                                                                                        Affirmed.




                                              - 11 -
