                    IN THE COURT OF APPEALS OF IOWA

                                   No. 15-0287
                             Filed February 24, 2016


KRAFT FOODS, INC., and
INDEMNITY INSURANCE CO., N.A.,
     Petitioners-Appellants,

vs.

YUSUF SHARIFF,
     Respondent-Appellee.
________________________________________________________________

      Appeal from the Iowa District Court for Polk County, Richard G. Blane II,

Judge.



      An employer challenges a judicial-review decision affirming the workers’

compensation commissioner’s grant of temporary disability benefits and alternate

medical care to the claimant. AFFIRMED.



      Peter J. Thill and Jordan A. Kaplan of Betty, Neuman & McMahon, P.L.C.,

Davenport, for appellants.

      William J. Bribriesco, Anthony J. Bribriesco, and Andrew W. Bribriesco of

William J. Bribriesco & Associates, Bettendorf, for appellee.



      Considered by Potterfield, P.J., and Doyle and Tabor, JJ. Blane, S.J.,

takes no part.
                                         2



TABOR, Judge.

      Employer Kraft Foods, Inc., and its insurance company, challenge the

award of benefits to Yusuf Shariff for injuries he sustained in a work-related

motor vehicle accident. Kraft contends the district court erred in concluding the

workers’ compensation commissioner’s medical-causation finding was supported

by substantial evidence under Iowa Code section 17A.19(10)(f)(3) (2013). Kraft

emphasizes the commissioner’s reversal of the deputy’s arbitration decision that

discounted Shariff’s claims, but found the testimony of the employer’s on-site

physician to be credible.

      Even considering the deputy’s veracity determinations, the record viewed

as a whole supports the agency’s final action. Accordingly, like the district court,

we find substantial evidence supporting the commissioner’s ruling and affirm.

I.    Facts and Prior Proceedings

      Shariff started working for Kraft in 1999 and held various production

positions in the Davenport plant until 2004. That year, he received a promotion

to unit safety coordinator, serving as a liaison between workers and management

on safety devices, ergonomics, and issues under the Occupational Safety and

Health Act (OSHA). Shariff was reappointed to that position every two years until

November 2010, when he declined to continue as safety coordinator but agreed

to stay on until Kraft found and trained his replacement.

      As the unit safety coordinator, on February 23, 2011, Shariff was driving a

coworker back from a medical appointment in a Kraft vehicle when they were

rear-ended by another vehicle while stopped at a red light.        Shariff recalled
                                         3



striking his head on the steering wheel and momentarily losing consciousness.

Shariff complained of pain immediately after the collision, according to the

deposition of his passenger, Alejandro Lopez. Lopez considered the accident to

be serious because the work vehicle was a total loss.

      An ambulance transported Shariff to the hospital, where medical

personnel took x-rays of his chest, cervical spine, and left knee, and performed a

CT (computed tomography) scan of his head.           Dr. Daniel Knight diagnosed

Shariff with a head injury and abrasion, cervical sprain, and contusions. Dr.

Knight prescribed Motrin and Vicodin and discharged Shariff.

      The next day, February 24, Shariff was evaluated by Dr. Rick Garrels, who

is board certified in occupational medicine and who provided medical services at

the Kraft plant. According to Dr. Garrels’s notes, Shariff likely struck his head on

the steering wheel and briefly lost consciousness as a result of the collision.

After examining Shariff, Dr. Garrels diagnosed him with a closed-head injury,

right cervical and shoulder pain, low back pain, and left knee pain. Dr. Garrels

recommended Shariff take time off work and treat his injuries with “ice, rest,

baclofen, tramadol, and prednisone.” Shariff returned to Dr. Garrels four days

later with complaints of low back and shoulder pain, headaches, nausea, and

dizziness.   Dr. Garrels recognized signs of a concussion and recommended

imaging studies and physical therapy.

      In early March 2011, Shariff saw radiologists for MRI (magnetic resonance

imaging) of his brain, cervical, lumbar spine, and right shoulder. The brain and

cervical images revealed no abnormal results. Dr. Raymond Harre reviewed the
                                         4



lower-back images, finding degenerative changes in the discs at L5-S1, L4-5,

and L3-4. Dr. Harre detected lumbar facet spondylosis with mild lateral recess

stenosis bilaterally at L4-5. Regarding the right shoulder, Dr. Harre diagnosed

Shariff with mild acromioclavicular degenerative joint disease, a superior labrum

anterior-posterior (SLAP) tear, and a partial thickness tear of the supraspinatus

tendon with longitudinal extension.

       On March 10, 2011, Shariff reported back to Dr. Garrels, stating his

headaches were lessening but he was experiencing some vertigo. Shariff also

said his neck and shoulder pain was improving with therapy but pain continued in

his low back and left knee. Dr. Garrels gave Shariff a cortisone injection in his

right shoulder and released him to work the next day with restrictions.          Dr.

Garrels also ordered an MRI of Shariff’s left knee, which revealed a small bone

contusion on the medial femoral condyle.

       During late March and early April 2011, Dr. Garrels began to grow

impatient and disenchanted with Shariff. On March 24, Shariff told Dr. Garrels he

continued to have headaches.          Dr. Garrels noted Shariff displayed “quite

dramatic” pain behaviors, including some moaning.         Dr. Garrels also noted a

right shoulder labral tear, neck and low back pain, closed head injury with

headaches and dizziness, and a history of left knee meniscectomy. Dr. Garrels

changed Shariff’s medications and referred him to Dr. John Wright for a

neurology evaluation, Dr. Phillip Kent for a neuropsychology evaluation,1 and Dr.

Suleman Hussain for a right-shoulder evaluation. In a later email with nurse


1
  Shariff later reported he was offended by Dr. Kent’s questions during their initial
consultation, so he refused to return for additional services.
                                          5



case-manager Vickie Kenney, Dr. Garrels wrote he had “lost all respect” for

Shariff.

       At a March 30 appointment with Dr. Hussain, an orthopedic surgeon,

Shariff reported discomfort in his right shoulder that started after the work-related

collision. Dr. Hussain’s examination revealed weakness of the right shoulder,

some reduced range of motion, and pain. After reviewing the imaging, the doctor

opined Shariff had a superior labral deformity and signal abnormality, as well as

potential rotator cuff deficit, which may include a full thickness longitudinal split.

Dr. Hussain recommended a course of physical therapy, and if therapy was not

beneficial, he suggested treating Shariff’s condition as an acute rotator cuff

injury, with arthroscopic intervention.

       Following a March 31 consultation, Dr. Wright assessed Shariff with post-

traumatic headaches and prescribed the pain reliever Frova. Shariff missed a

follow-up appointment with Dr. Wright scheduled for April 18.2 Upon learning of

the missed appointments, Dr. Garrels wrote to nurse Kenney: “Obviously, he’s

going to miss every [appointment] scheduled.           He is trying to create the

perception that he has memory loss. . . . I am not surprised at the extreme

nature of his manipulation.”

       Meanwhile, in late March 2011, Kraft moved Shariff to the graveyard shift

in the sanitation department. Shariff testified he remained on pain medication at

that time and his new schedule caused him to suffer from insomnia. He cited




2
 The record shows other instances of Shariff missing medical appointments scheduled
during this time period.
                                          6



those circumstances as the reason for missing some of his medical

appointments.

       Shariff participated in physical therapy for his shoulder two to three times

a week during April 2011. The company physical therapist reported Shariff was

motivated and had improved his strength but still experienced discomfort when

attempting a full range of motion. During a follow-up orthopedic appointment on

April 27, Dr. Hussain found Shariff had a symptomatic rotator-cuff tear, along with

potential biceps pathology and acromioclavicular arthrosis and recommended

surgery. Shariff consented to the surgery, and the claims administrator approved

the surgical procedure. On the date of Shariff’s appointment, the case manager

memorialized her conversation with Dr. Hussain, stating Dr. Hussain agreed

Shariff’s rotator-cuff tear looked “fresh” and was related to the car accident.

       Shariff returned to Dr. Garrels on May 2, complaining back and knee pain.

Dr. Garrels expressed skepticism concerning Shariff’s motivations and “assessed

back and knee pain of an unclear etiology, right shoulder pain, and headaches of

an unclear etiology.” Dr. Garrels noted he was going to “wait and see” if Shariff

changed his mind about “neuropsych testing, if he does not then I will probably

not consider the headache work related . . . he could just be making up all of the

symptoms.”

       Two days later, Dr. Garrels took the initiative to call Dr. Hussain to discuss

“causation issues” in Shariff’s workers’ compensation case. Dr. Garrels left an

impression with Dr. Hussain that Dr. Garrels believed Shariff was malingering.

Also on May 4, 2011, Dr. Garrels sent Dr. Hussain a follow-up letter thanking him
                                        7



for discussing their “mutual patient.” Dr. Garrels wrote: “As you are aware, he

was involved in a motor vehicle accident about two months ago, along with

another co-worker. He’s had numerous reports of injury from the rear-end MVA,

while the co-worker had no subsequent injuries.”    Dr. Garrels asserted both he

and the company’s physical therapist had evaluated Shariff without detecting any

“acute shoulder findings.” Dr. Garrels then asked Dr. Hussain whether, based on

Dr. Hussain’s clinical exam and the MRI, Dr. Hussain believed Shariff’s shoulder

condition was acute and caused by the accident or chronic and preexisting.

       Dr. Hussain responded that Shariff’s imaging and his own physical-exam

findings were consistent with a chronic, longstanding rotator-cuff-impingement

problem likely present prior to the accident.   But Dr. Hussain added that he

believed Shariff’s condition likely resulted from exacerbation of his preexisting

impingement pathology. Dr. Garrels responded with an email on May 14, 2011,

in which Dr. Garrels expressed his opinion that Shariff was “attempting to have

Work Comp pick up all of his chronic health issues.” Dr. Garrels then wrote:

      In your answer to it being a chronic condition you used the word
      exacerbation. That terminology would tie the active treatment to
      the MVA. I was under the assumption from our conversation that
      his current state could just be explained by the underlying chronic
      degenerative state. If this is the case, could you resend the letter
      with clarification.

      On that same day, Dr. Hussain sent a revised letter to Dr. Garrels,

removing any reference to exacerbation of a preexisting condition. On May 16,

2011, Dr. Garrels called Shariff to express his “final opinion” that Shariff had

reached maximum medical improvement (MMI) from the motor vehicle accident.

In his note memorializing the conversation, Dr. Garrels also recounted his
                                          8



interaction with Dr. Hussain, saying Dr. Hussain “concurred that the shoulder

pathology is degenerative in nature.” In closing, Dr. Garrels noted: “I let [Shariff]

know that for me to remain involved in the care of an individual felt to be

malingering would be to perpetuate Workers’ Comp fraud which I had no desire.”

       Shariff filed a workers’ compensation claim in May 2011.

       In July 2011 Dr. David Field conducted an independent medical

examination of Shariff. After reviewing MRI results and physician assessments,

Dr. Field opined it was “very likely” Shariff sustained an injury to his right

shoulder in the February motor vehicle accident. Dr. Field found it difficult to

determine if the collision resulted in a new injury to Shariff’s rotator cuff or if the

condition preexisted the accident, but in his opinion, the collision was at least a

contributing factor to Shariff’s development of pain. In Dr. Field’s words, the

work-related collision “certainly aggravated, flared up, or ‘lit up’ Shariff’s right

shoulder problems.” At the request of Kraft’s counsel, Dr. Garrels responded,

stating Dr. Fields only observed Shariff at a single visit and was unable to

“appreciate the fact the shoulder never exhibited any objective examination

findings which represent an acute injury.”

       On August 31, 2011, Dr. Hussain wrote a letter expressing his belief

neither he nor Dr. Field could properly evaluate the cause of Shariff’s complaints

because both of them only observed the right shoulder. Dr. Hussain indicated

the person in the best position to opine as to causation would be Dr. Garrels, and

Dr. Hussain deferred to Dr. Garrels’s opinion because Dr. Garrels had the

opportunity to examine Shariff’s condition “from the beginning.”
                                        9



       Shariff’s attorney arranged for another IME on October 19, 2011, this time

with Dr. Robin Epp. She diagnosed Shariff with the following conditions:

       1. Right shoulder pain with MRI arthrogram with evidence of a
       SLAP tear in the superior labrum and a partial thickness tear of the
       supraspinatus.
       2. Left knee pain after trauma.
       3. Neck pain.
       4. Bilateral SI joint pain and low back pain.
       5. Post-traumatic headaches.

       In Dr. Epp’s opinion, Shariff’s MRI abnormalities, his current symptoms,

and his need for shoulder surgery were all causally related to the February 2011

work-related collision.

       Kraft then hired Dr. William Boulden to perform a review of Shariff’s

medical records. In Dr. Boulden’s view, the MRI revealed a mild superior labral

tear or, perhaps, an abnormality of a small cleft, but not a full tear. Dr. Boulden

opined Shariff’s shoulder symptoms may have been caused by the work accident

but questioned whether the accident caused the SLAP tear and also opined

Shariff did not need shoulder surgery. Later, Dr. Boulden performed an IME of

Shariff, who initially refused to cooperate and had to be ordered by the agency to

participate.   Dr. Boulden believed Shariff was professing more pain and

dysfunction of his shoulder than indicated by the MRI. Dr. Boulden reiterated his

belief shoulder surgery would result in a “very poor” outcome. He also did not

believe the collision “caused the pathological findings” in Shariff’s shoulder. In

his deposition testimony, Dr. Bolden acknowledged he did not see any medical

records showing Shariff’s shoulder was symptomatic before the accident. Dr.
                                         10



Bolden also agreed it was more likely than not that the accident caused Shariff’s

pain symptoms.

       Finally, Shariff’s attorney arranged for another IME with board-certified

neurosurgeon Dr. Robert Milas.         After hearing Shariff’s description of the

accident and examining him, Dr. Milas opined Shariff’s headaches, as well as the

condition of his lumbar spine, cervical spine, and right shoulder, were a direct

result of the collision.

       A deputy workers’ compensation commissioner held a hearing on

February 13, 2012, taking live testimony from Shariff and Dr. Garrels. In her

thirty-six-page arbitration decision issued on July 31, 2013, the deputy concluded

Shariff “failed to prove by a preponderance of the evidence that his ongoing

shoulder complaints were a result of the work injury” and also failed to prove he

sustained permanent disability as a result of the collision. The deputy likewise

rejected Shariff’s claim for an award of alternate medical care. Shariff filed an

intra-agency appeal.       The commissioner issued a thirty-five-page appeal

decision, reversing the deputy and ordering Kraft to pay temporary disability

benefits. The commissioner also held the employer liable for alternative medical

care, specifically ordering “Dr. Garrels no longer to participate in the care of

claimant as the relationship between claimant and Dr. Garrels is irreparably

broken and would not likely result in a healthy doctor-client relationship.”

       Kraft petitioned for judicial review.   The district court found substantial

evidence to support the commissioner’s findings regarding causation and upheld
                                        11



the benefit award.   Kraft now appeals from the district court’s order on judicial

review.

II.    Standard of Review and Foundational Principles

       In appeals from a district court’s judicial-review order, the question is

whether we reach the same decision as the district court when we apply Iowa

Code chapter 17A, the Iowa Administrative Procedure Act (IAPA). Staff Mgmt. v.

Jimenez, 839 N.W.2d 640, 653-54 (Iowa 2013).              If we reach the same

conclusion, we affirm; if we reach a different conclusion, we reverse. Westling v.

Hormel Foods Corp., 810 N.W.2d 247, 251 (Iowa 2012).

       Both our court and the district court review final agency action. See Iowa

State Fairgrounds Sec. v. Iowa Civ. Rights Comm’n, 322 N.W.2d 293, 294 (Iowa

1982) (interpreting prior version of IAPA and noting that upon “judicial review, the

district court reviews the final agency decision, not the hearing officer’s

proposal”). If the agency decision runs afoul of any of the grounds listed in

section 17A.19(10) and the person seeking relief can show prejudice, the district

court may reverse or modify the agency’s decision. Id.

       Among the grounds for relief on judicial review is the absence of

“substantial evidence” to support the commissioner’s factual determinations

when the agency record is viewed as a whole.          Iowa Code § 17A.19(10)(f).

Evidence is “substantial” if its quantity and quality “would be deemed sufficient by

a neutral, detached, and reasonable person, to establish the fact at issue when

the consequences resulting from the establishment of that fact are understood to

be serious and of great importance.” Id. § 17A.19(10)(f)(1).
                                         12



       Particularly pertinent to the challenge before us is the legislature’s

definition of the phrase “when that record is viewed as a whole,” which provides:

       [T]he adequacy of the evidence in the record before the court to
       support a particular finding of fact must be judged in light of all the
       relevant evidence in the record cited by any party that detracts from
       that finding as well as all of the relevant evidence in the record cited
       by any party that supports it, including any determinations of
       veracity by the presiding officer who personally observed the
       demeanor of the witnesses and the agency’s explanation of why
       the relevant evidence in the record supports its material findings of
       fact.

Id. § 17A.19(10)(f)(3) (emphasis added).

       The “presiding officer” is the deputy commissioner who conducts the

arbitration hearing. See Neal v. Annett Holdings, Inc., 814 N.W.2d 512, 532

(Iowa 2012) (Mansfield, J., dissenting) (quoting State Fairgrounds, 322 N.W.2d at

295, for the proposition that a disagreement on the facts between the deputy and

the commissioner may “affect the substantiality of the evidence supporting” the

final agency action).

       According to the definition at section 17A.19(10)(f)(3), when we assess

whether substantial evidence supports the agency decision, we “consider the

credibility determination by the presiding officer who had a chance to observe the

demeanor of the witnesses.            When analyzing the deputy’s credibility

determination, we look at the facts relied upon by the expert and circumstances

contained in the record.” Jimenez, 839 N.W.2d at 654.

       If the evidence before the agency is open to a fair difference of opinion,

we must find substantial evidence supports the commissioner’s decision. Id. We
                                       13



will not consider evidence insubstantial merely because we may draw different

conclusions from the record than the commissioner drew. Id.

       Generally, causation questions fall into the exclusive domain of medical

experts. See Cedar Rapids Cmty. Sch. Dist. v. Pease, 807 N.W.2d 839, 845

(Iowa 2011). The commissioner may reject expert opinion, in whole or in part,

particularly when there is competing testimony. Id. at 845, 850. A reviewing

court may not accept the competing expert’s opinions as a means to reverse the

commissioner’s findings of fact on medical causation. Id. at 850 (stating we

accord deference to the commissioner on the issue of medical causation

because that issue presents “a question of fact that is vested in the

[commissioner’s] discretion”).

III.   Analysis

       Kraft describes its challenge to the commissioner’s decision as a review

for substantial evidence, “but with a twist.”   The twist is the commissioner’s

rejection of the deputy’s determinations concerning the veracity of claimant

Shariff and Kraft’s company doctor, Rick Garrels.      The employer asks us to

reverse the final agency action because the commissioner’s decision was not

supported by substantial evidence in the record viewed as a whole as envisioned

by section 17A.19(10)(f)(3).

       A. Observations of demeanor

       Kraft is correct that when deciding if the agency action stems from factual

findings not supported by substantial evidence, the court’s assessment of the

adequacy of the evidence must include consideration of the deputy’s
                                         14



determinations of veracity based on his or her personal observation of witness

demeanor at the arbitration hearing. See Iowa Code § 17A.19(10)(f)(3). But

section 17A.19(10)(f)(3) does not require this court to accord weight to a deputy’s

veracity determinations when the deputy’s determinations are not based on his or

her personal observations of demeanor evidence.            The commissioner is

generally free to reweigh the evidence in the agency record. See id. § 17A.15(2)

(allowing fact findings to be prepared by someone other than person who

presided at reception of evidence “unless demeanor of witnesses is a substantial

factor”); see also Trade Prof’ls, Inc. v. Shriver, 661 N.W.2d 119, 125 (Iowa 2003).

       In rejecting Shariff’s compensation claim, the deputy offered a critique of

the claimant’s credibility.   But her concerns did not stem from watching his

demeanor and listening to his delivery on the witness stand. The deputy opined:

       At the time of evidentiary hearing, claimant provided knowledgeable
       testimony, delivered in a clear manner. Claimant’s physical
       presentation was consistent with his reported ongoing complaints.
       However, upon review of the remainder of the evidentiary record,
       the undersigned is given some pause as to the weight to be
       properly provided to claimant’s testimony and subjective reports of
       pain.

The deputy concluded Shariff’s “personal feelings” about the handling of his

workers’ compensation claim drew his “credibility into question.” She stated:

“While I believe claimant may wholeheartedly believe what he asserts, I find little

support for his assertions outside of claimant’s own testimony. Therefore, while

claimant was a pleasant man at the time of evidentiary hearing, the undersigned

is unable to find his testimony credible.”
                                        15



       The deputy’s determination Shariff lacked credibility was not anchored in

her observations of him. In fact, all of the deputy’s comments about Shariff’s live

testimony were favorable to Shariff. She described him as “knowledgeable” and

“clear” and deemed his appearance to be consistent with his complaints. The

deputy also found him to be “pleasant” and sincere in his own assertions. The

deputy questioned the weight to give Shariff’s testimony only “upon review of the

remainder of the evidentiary record.”

       In declining to adopt the deputy’s findings in the intra-agency appeal, the

commissioner wrote:

       [T]he presiding deputy simply stated that she believes claimant
       believes what he asserts, but she found little support for his
       assertions outside of his own testimony.        Such credibility
       assessment of the deputy is based upon her review of the medical
       records and not upon her personal observations of claimant or his
       demeanor at the hearing.

       We agree with the commissioner’s reasoning.             Because Shariff’s

demeanor was not a substantial factor in the deputy’s determination, we, like the

district court, are not troubled by the commissioner’s divergent fact findings on

this point.

       We also consider the deputy’s determination Dr. Garrels was a credible

witness. Much of the deputy’s reliance on Dr. Garrels’s opinions stemmed from

the deputy’s review of medical records and not her observation of his demeanor

at the arbitration hearing. For example, the deputy found because Dr. Garrels

acted as Shariff’s authorized physician throughout the course of treatment, his

opinion was entitled to greater weight than the one-time evaluation by Dr. Epp.

The commissioner was entitled to and did rebuff that conclusion, noting our
                                           16



supreme court has rejected the notion that, as a matter of law, a treating

physician’s view will be given more weight than a physician who examines the

patient in anticipation of litigation, citing Gilleland v. Armstrong Rubber Co., 524

N.W.2d 404, 408 (Iowa 1994).

       It is true the deputy also stated: “Observation of Dr. Garrels at the time of

evidentiary hearing and in the limited deposition testimony video provided for

review[3] gives the undersigned no pause regarding the veracity of Dr. Garrels’s

testimony.” The deputy did not mention any specific aspects of his demeanor,

but to the extent the deputy’s veracity determination concerning Dr. Garrels was

based on her personal observations of him at the hearing, we will consider that

determination as part of our substantial-evidence review.           See Iowa Code §

17A.19(10)(f)(3). We likewise consider the commissioner’s “explanation of why

the relevant evidence in the record supports its material findings of fact.” See id.

       B. Substantial-evidence review

       Upon de novo review of the record, the commissioner offered the following

four-point rationale for finding Shariff had proved his medical conditions were

caused by the February 2011 work-related accident.




3
   The deputy received a video exhibit prepared by Shariff’s counsel that juxtaposed
deposition clips of Dr. Garrels and Dr. Hussain with textual statements regarding
claimant’s position. The deputy decided to give that exhibit “negligible weight” because
she believed the clips were taken out of context. The only weight the deputy gave the
exhibit related to her observation of the doctors’ demeanor during the video depositions.
Because the same exhibit was available to the commissioner, he was equally able to
make credibility determinations based on the doctors’ demeanors while being deposed.
See generally Macaulay v. Wachovia Bank, 569 S.E.2d 371, 376 (S.C. Ct. App. 2002)
(finding appellate court was placed in “equal position to judge [witness’s] credibility”
when testimony was through video deposition).
                                         17



               First, claimant’s assertions that he had no chronic
       headaches and no back, neck, chronic left knee, and right shoulder
       pain before the stipulated injury in this case is unrebutted. . . .
       [T]here is no evidence in this record that claimant had any
       symptoms involving those areas before the stipulated injury. If
       such conditions had existed, they did not require restrictions as to
       claimant's functional ability and did not require ongoing medical
       care. Dr. Garrels’ opinions as to claimant’s pre-injury baseline of
       function border on fictitious.
               Second, claimant has exhibited chronic complaints of
       headaches, low back, left knee, and right shoulder pain since the
       motor vehicle accident. No physician in this case, other than Dr.
       Garrels, suggests that these complaints are false or unreal. . . .
       Neither Dr. Garrels nor Dr. Hussain has explained satisfactorily how
       they arrived at the opinion that this ongoing and chronic pain
       somehow was transformed into a non-work related condition shortly
       after Dr. Hussain recommended surgery for what he termed as an
       exacerbation of claimant’s prior shoulder condition. Claimant
       clearly has not returned to this figurative baseline . . . . The
       suggestion to diminish the work injury of claimant that this accident
       was minor defies logic after a simple review of the accident
       photos—not even defendants are asserting that claimant’s initial
       pain was not caused by the accident.
               Third, although Dr. Hussain has refused to provide a
       causation opinion other than deferring to Dr. Garrels, four other
       board certified physicians, Drs. Field, Milas, Boulden, and Epp,
       sufficiently agree that the motor vehicle accident caused claimant’s
       current pain. These physicians simply disagree as to course of
       future treatment options. Even Dr. Hussain continues to believe the
       pain warrants surgery, he merely defers to Dr. Garrels as to the
       cause of the ongoing pain.
               Finally, following a review of the entire record in this
       contested case, it is found that in this particular case, Dr. Garrels’
       views lack objectivity.

       The commissioner discussed in detail Dr. Garrels’s hostility toward Shariff,

which we find well-documented in the agency record. Noting Dr. Garrels has a

“significant and professional history of providing objective medical opinions

before the division,” the commissioner sharply rebuked Dr. Garrels’s conduct in

persuading Dr. Hussain to alter his opinion “in this particular case”:
                                            18



       It must also be noted that this contested appeal is quite likely the
       first time where it has been clearly proven that an occupational
       medicine doctor actually lobbied a medical specialist to change his
       opinion in a manner favorable to an employer and thus directly
       interfere with the specialist’s recommended and authorized
       treatment of the work injury, which had been voluntarily accepted
       by the employer and insurer. . . . In a workers’ compensation
       context, such advocacy is permissible by a physician employed for
       that purpose by an employer or insurer, but this is not . . .
       permissible for a physician employed to treat a work injury under
       the Iowa Code.[4]

       On appeal, Kraft contends the commissioner’s rationale is not supported

by substantial evidence because it rests too heavily on Shariff’s subjective pain

complaints and the rejection of Dr. Garrels’s testimony on a “cold record.”

       The temperature of the record does not matter here. This contested case

does not rise or fall on the demeanor of the live witnesses. The question here is

medical causation. The commissioner, as the fact finder, determines the weight

to give expert opinions on that issue. See Sherman v. Pella Corp., 576 N.W.2d

312, 321 (Iowa 1998). Giving credence to the opinions expressed by Dr. Field,

Dr. Milas, Dr. Epp, and even Dr. Boulden, following their IMEs, the commissioner

found the February 2011 work injury was the cause of Shariff’s headaches, as

well as his neck, back, and shoulder conditions. As a reviewing court, we are not

in a position to find that Dr. Garrels’s contrary view “trumps” the other medical

causation evidence cited by the commissioner—even if we consider the deputy’s

determination that Dr. Garrels’s demeanor during his testimony did not raise red


4
  After criticizing “the objectivity of Dr. Garrels,” the commissioner also found “claimant
has not shown an ideal level [of] respect for his engagement with the workers’
compensation system and obtaining his own medical treatment commensurate with his
assertions of ongoing pain.” The commissioner found it “difficult to discern” the level of
claimant’s disrespect resulting “from his perception of hostility from Dr. Garrels and what
level was attempting to control his outcome.”
                                       19



flags concerning his veracity. See Jimenez, 839 N.W.2d at 654 (stating if the

evidence before the agency is open to a fair difference of opinion, a reviewing

court must find substantial evidence supports the commissioner’s decision).

      We find substantial evidence in the record to support the commissioner’s

decision. Accordingly, we affirm the award of temporary disability benefits and

alternative medical care.

      AFFIRMED.
