         IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Pocono Medical Center                   :
and Qual-Lynx, Inc.,                    :
                                        :
                         Petitioners    :
                                        :
             v.                         : No. 427 C.D. 2019
                                        : Submitted: August 30, 2019
Workers’ Compensation Appeal            :
Board (Springer),                       :
                                        :
                         Respondent     :

BEFORE:     HONORABLE MARY HANNAH LEAVITT, President Judge
            HONORABLE PATRICIA A. McCULLOUGH, Judge
            HONORABLE MICHAEL H. WOJCIK, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION
BY JUDGE WOJCIK                                         FILED: July 16, 2020

            The Pocono Medical Center and Qual-Lynx, Inc. (collectively,
Employer) petition for review of an order of the Workers’ Compensation Appeal
Board (Board) that affirmed an order of a Workers’ Compensation Judge (WCJ)
granting Sharon Springer’s (Claimant) Review Petition alleging a major depressive
disorder, denying her Penalty Petitions and denying Employer’s Modification and
Termination Petitions. Employer asserts that the WCJ erred in determining that
Claimant suffered an exacerbation of her preexisting major depressive disorder and
that the WCJ’s critical finding in this regard is not supported by substantial
competent medical evidence. Upon review, we affirm.
                                   I. Background
             On December 30, 2009, Claimant sustained a work-related injury in the
nature of an exacerbation of chronic cervical radiculopathy while working for
Employer as a phlebotomist when she was attacked by a patient. Claimant received
benefits pursuant to a notice of compensation payable (NCP). In March 2015,
Employer filed a Modification Petition seeking to modify Claimant’s benefits from
total status to partial status as a result of an impairment rating evaluation (IRE)
conducted on February 27, 2015. On September 16, 2015, Claimant filed a Review
Petition seeking to expand the description of her work injury to include major
depressive disorder. Employer then filed a Termination Petition alleging that
Claimant had fully recovered from her work injuries as of August 13, 2015.
Claimant filed three Penalty Petitions alleging that Employer failed to pay medical
bills related to her work injury. The petitions were consolidated and heard by a WCJ.
The relevant findings and evidence pertaining to the Review Petition and major
depressive disorder may be summarized as follows.
             In support of her Review Petition, Claimant testified that, prior to her
2009 work injury, she suffered from migraine headaches and treated with Behzad
Maghsoudlou, M.D. (Dr. Maghsoudlou). Claimant admitted she also suffered from
depression, but she always associated her depression with her migraines. She
testified she had never seen a psychiatrist until after her work injury. Since her work
injury, she feels depressed and anxious because she is unable to take care of herself
and she needs assistance to do anything. She testified that she does not want her
friends to see her like this, and she spends most of her time in her house. She is
anxious when she is around people. Claimant stated that she was hospitalized in
2015 because she was despondent and wanted to die. Soon thereafter, she began
treating with Matthew Berger, M.D. (Claimant’s Psychiatrist), a psychiatrist. WCJ’s

                                          2
Op., 2/23/18, Finding of Fact (F.F.) No. 1; Certified Record (C.R.), Notes of
Testimony (N.T.), 1/22/16, at 19-21.
             Claimant also presented the deposition testimony of Claimant’s
Psychiatrist. Claimant’s Psychiatrist testified that he began treating Claimant on
July 31, 2015, after she attempted to take her own life. He diagnosed Claimant with
“major depression, recurrent.” Claimant’s Psychiatrist linked Claimant’s depression
to her work injury because she was fully functional and able to work prior to the
work injury. However, after the work injury, she developed depression secondary
to her chronic pain from the work injury. Claimant’s Psychiatrist testified that, in
2015, Claimant had a psychiatric hospitalization when she decided to kill herself
because the pain became too much for her. F.F. No. 9; Reproduced Record (R.R.)
at 22a-23a, 27a-28a, 15a.
             In opposition to Claimant’s Review Petition, Employer submitted the
deposition testimony of Robert Cohn, M.D. (Employer’s Psychiatrist), who is board
certified in psychiatry and who evaluated Claimant on December 9, 2015, and took
a history from Claimant and reviewed her medical records. Employer’s Psychiatrist
testified that Claimant had a history of depression and had been diagnosed with and
treated for depression and anxiety prior to the 2009 work injury. He opined that
Claimant had linked her migraine headaches with her depression in her mind.
Employer’s Psychiatrist agreed that Claimant suffered from recurrent major
depressive disorder. However, he did not link the depressive disorder to her work
injury. On cross examination, Employer’s Psychiatrist admitted that depression and
anxiety can be aggravated or exacerbated by a traumatic event. He also agreed that
if someone is unable to do the things that she did prior to an injury that this could
lead to depression and anxiety. He also agreed that these conditions brought on by


                                         3
the inability to function normally can take time to develop. F.F. No. 15; R.R. at 40a,
43a-54a, 59a-61a.
             Employer also presented the medical records of Dr. Maghsoudlou, who
treated Claimant for migraines and depression in the year prior to the work injury.
R.R. at 69a-79a. His records show that Claimant sought and received treatment
primarily for her migraine headaches. R.R. at 69a, 72a, 74a-78a. His records note
that Claimant was also depressed and anxious and that he prescribed antidepressants
for her. Dr. Maghsoudlou did not testify.
             Ultimately, the WCJ accepted as credible Claimant’s testimony based
on her bearing and demeanor as she testified and accepted her testimony as fact.
With regard to the psychiatric opinions, the WCJ found:

             It is found as fact that both of the psychiatrists in this
             matter agree that [] Claimant is suffering from major
             depressive disorder. [Claimant’s Psychiatrist] relates the
             depressive disorder to the work-injury. [Employer’s
             Psychiatrist] does not. [Employer’s Psychiatrist] admits
             that a major injury could exacerbate [] Claimant’s pre-
             existing depression. He gives no convincing reason why
             that is not the case in this matter.

F.F. No. 18. The WCJ found Claimant’s Psychiatrist, as her treating psychiatrist,
more credible than Employer’s Psychiatrist. To the extent their medical opinions
conflicted, the WCJ accepted the opinions expressed by Claimant’s Psychiatrist over
Employer’s Psychiatrist. Id.
             Critically, the WCJ found that “Claimant [] suffered an exacerbation of
her preexisting major depressive disorder as a result of her work-injury.” F.F. No.
20. The WCJ concluded that Claimant has proven by sufficient, competent, and
credible evidence that she suffers from a recurrence of major depressive disorder as


                                          4
a result of her work injury. By Decision and Order dated February 23, 2018, the
WCJ granted Claimant’s Review Petition and expanded the description of her work
injury to include the recurrence of her major depressive disorder. The WCJ also
denied Employer’s Modification and Termination Petitions and Claimant’s Penalty
Petitions.
               Employer appealed to the Board, which affirmed. Employer now
petitions this Court for review.1

                                           II. Issues
               The issue on appeal is whether the WCJ erred or abused his discretion
by granting Claimant’s Review Petition to expand the description of her work injury
to include an exacerbation of her major depressive disorder. Employer argues that
the WCJ’s critical finding in this regard is not supported by substantial, competent
evidence because Claimant’s Psychiatrist did not have a complete medical history
and never testified that Claimant’s preexisting depression was aggravated or
exacerbated by the work injury. Where a medical expert has no knowledge of a
claimant’s medical history, his testimony on causation is not competent. Employer
also argues that the WCJ erred by shifting the burden to Employer to disprove
causation.


                                       III. Discussion
               In workers’ compensation cases, the WCJ is the ultimate fact-finder and
has exclusive province over questions of credibility and evidentiary weight. A&J

       1
         Our review is limited to determining whether the WCJ’s findings of fact were supported by
substantial evidence, whether an error of law was committed or whether constitutional rights were
violated. Section 704 of the Administrative Agency Law, 2 Pa. C.S. §704; Phoenixville Hospital v.
Workers’ Compensation Appeal Board (Shoap), 81 A.3d 830, 838 (Pa. 2013).
                                                5
Builders, Inc. v. Workers’ Compensation Appeal Board. (Verdi), 78 A.3d 1233 (Pa.
Cmwlth. 2013). The WCJ may accept the testimony of any witness, including a
medical witness, in whole or in part. Id. We are bound by the WCJ’s credibility
determinations. Id.
               Moreover, it is irrelevant whether the record contains evidence
supporting findings other than those made by the WCJ; the crucial inquiry is whether
the evidence supports the findings actually made. Id. Therefore, we must examine
the entire record to see if it contains evidence a reasonable person might find
sufficient to support the WCJ’s findings. Id. If the record contains such evidence,
the findings must be upheld, even though the record may contain conflicting
evidence. Id. Additionally, we must view the evidence in the light most favorable
to the prevailing party and give it the benefit of all inferences reasonably deduced
from the evidence.         Hutz v. Workers’ Compensation Appeal Board (City of
Philadelphia), 147 A.3d 35 (Pa. Cmwlth. 2016).
               A WCJ may review and correct an NCP at any time. Section 413(a) of
the Workers’ Compensation Act;2 Cinram Manufacturing, Inc. v. Workers’
Compensation Appeal Board (Hill), 975 A.2d 577, 582 (Pa. 2009). It is the
claimant’s burden to establish the work-relatedness of any newly alleged injury.
Cinram Manufacturing, 975 A.2d at 582. “An employee who experiences an injury
based on the aggravation of a pre-existing condition is entitled to benefits if she
shows that the aggravation arose in the course of employment, the aggravation was
related to the employment, and disability resulted.”                 Chik-Fil-A v. Workers’
Compensation Appeal Board (Mollick), 792 A.2d 678, 689 (Pa. Cmwlth. 2001).
Where the causal relationship between the work incident and the injury is not


      2
          Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §771.
                                                6
obvious, unequivocal medical evidence is necessary. Jeannette District Memorial
Hospital v. Workmen’s Compensation Appeal Board (Mesich), 668 A.2d 249, 251
(Pa. Cmwlth. 1995).
              Expert medical testimony is unequivocal where the medical expert
provides a foundation and testifies that in his professional opinion, he believes or
thinks a fact exists. Kimberly Clark Corp. v. Workers’ Compensation Appeal Board
(Bromley), 161 A.3d 446, 467 (Pa. Cmwlth. 2016), appeal denied, 174 A.3d 1027
(Pa. 2017). To establish a causal connection, the expert “medical witness must
testify, not that the injury or condition might have or possibly came from the assigned
cause, but that in his professional opinion the result in question did come from the
assigned cause.” Lewis v. Workmen’s Compensation Appeal Board, 498 A.2d 800,
802 (Pa. 1985). “[W]here the foundation for the medical evidence is contrary to the
established facts in the record, or is based on assumptions not in the record, the
medical opinion is valueless and not competent.” AT&T v. Workers’ Compensation
Appeal Board (Hernandez), 707 A.2d 649, 653 (Pa. Cmwlth. 1998). However, the
fact that a medical expert does not have all of a claimant’s medical records goes to
the weight given the expert’s testimony, not its competency. Huddy v. Workers’
Compensation Appeal Board (U.S. Air), 905 A.2d 589, 593 n.9 (Pa. Cmwlth. 2006).
              Whether medical evidence is equivocal is a question of law reviewable
by this Court.    Southwest Airlines/Cambridge Integrated Service v. Workers’
Compensation Appeal Board (King), 985 A.2d 280, 286 (Pa. Cmwlth. 2009). A
determination of whether an expert’s opinion is equivocal must be based on that
expert’s testimony as a whole, not on a small portion taken out of context.
Liveringhouse v. Workers’ Compensation Appeal Board (ADECCO), 970 A.2d 508,
515 (Pa. Cmwlth. 2009).


                                           7
             In Chik-Fil-A, the claimant testified that she injured her back in 1995
and that she had no prior injuries. The claimant’s doctor indicated that he did not
review her medical records and that his opinion was based entirely on the records
pertaining to the claimant’s work injury in 1995. The claimant, however, had neck
and back problems prior to her work injury and had previously treated with a
chiropractor. The claimant’s doctor testified that if the claimant’s medical history
was not what she indicated, his opinion would be incorrect. On this basis, this Court
determined that the testimony of the claimant’s doctor was incompetent. Chik-Fil-
A, 792 A.2d at 689.
             Similarly, in Southwest Airlines, a claimant’s doctor had no knowledge
of her prior head injuries when he testified concerning her work-related head injury.
The doctor did not review the claimant’s medical records, which revealed prior
injuries and symptoms similar to the work injury. The claimant obfuscated her
medical history by claiming that she had suffered no prior injuries and that she had
“never had any problems with or received treatment for[ ] headaches, migraines,
dizziness, blackouts or memory loss.” Southwest Airlines, 985 A.2d at 282. This
Court noted that the doctor’s “opinions were based on an incomplete and inaccurate
medical history, as well as [the c]laimant’s personal opinion of causation.” Id. at
287. Therefore, the doctor’s medical opinion was incompetent. Id.
             Relying on this precedent, Employer argues that Claimant’s
Psychiatrist’s testimony is likewise incompetent because he did not have a proper
foundation of Claimant’s mental health and was unaware of her depression prior to
the injury. Employer points to Claimant’s Psychiatrist’s testimony that, “to the best
of my knowledge – obviously, I don’t know her prior to this injury, but based on
what she’s telling me and the fact that she has no psychiatric history that we’re aware


                                          8
of, my understanding is, she was fully functional.” R.R. at 27a. Claimant’s
Psychiatrist also testified that Claimant “has no previous history of depression.”
R.R. at 32a. In addition, Claimant’s Psychiatrist never testified that Claimant’s
depression was an exacerbation or aggravation of her underlying condition.
             Although Claimant’s Psychiatrist may not have had a complete medical
history, he was aware of her underlying condition, whereas in both Southwest
Airlines and Chik-Fil-A, the experts were entirely unaware of any injuries or
symptoms prior to work-related injuries.          Claimant’s Psychiatrist diagnosed
Claimant with “major depression, recurrent.” R.R. at 28a (emphasis added). He
explained that “she has major depression and that it’s been going on for an extended
period, that this isn’t her first, you know -- it wasn’t like she’d never been seen by a
psychiatrist before and last month she developed this, but that she’s had it for a
while.” Id. In fact, Employer’s Psychiatrist, having reviewed Dr. Maghsoudlou’s
medical records, similarly diagnosed Claimant with “a major depressive disorder
that has been recurrent over time.” R.R. at 54a. He likewise explained that recurrent
depression “comes and . . . goes.” R.R. at 54a.
             As to causation, Claimant’s Psychiatrist testified that her current
debilitating depression was caused by the work injury because, prior to the work
injury, “[s]he was fully functional” and able to work. R.R. at 27a, 32a. After the
work injury occurred, she “had . . . physical changes which led to the chronic pain
and the change in lifestyle.” R.R. at 27a. She was no longer able to do anything for
herself and she was unable to work. R.R. at 27a. She reported that “she was [having]
difficulty getting out of bed, she couldn’t do housework, she had difficulty lifting,
playing with children, pushing and pulling, sitting, standing, working. She found
she was more irritable, short-tempered. She was no longer playing with her children,


                                           9
no longer able to participate in social settings.” R.R. at 26a. Claimant’s Psychiatrist
testified that “[a] lot of what is driving her depression is the pain” from the work
injury. R.R. at 32a. Claimant’s Psychiatrist explained that, “it’s a vicious cycle”;
“the more depressed you become, the lower your pain tolerance; the higher your pain
is, the more you become depressed.” R.R. at 26a. He opined that if her pain went
away and her functionality returned, her depression would subside. RR. at 32a.
             As for Claimant’s Psychiatrist’s statements regarding no history of
depression prior to the work injury, when those statements are read within context
of his entire testimony, the inference is clear that Claimant’s Psychiatrist was
referring to the absence of any disabling depression prior to the injury because she
was “fully functional” and able to work. R.R. at 32a. Even Employer’s Psychiatrist
testified that Claimant’s “history of depression” was not a “disabling factor in terms
of her work.” R.R. at 56a. Although Claimant’s Psychiatrist did not use the terms
“exacerbation” or “aggravation,” he did use the term “recurrent” to indicate her
underlying condition had returned.
             Upon review, Claimant’s Psychiatrist consistently opined that her
current major depression was “recurrent” and brought on by the chronic pain and
lifestyle changes caused by the work injury and her inability to function normally.
R.R. at 27a, 32a. His diagnosis was not contrary to the established facts in the record
or based on assumptions not in the record. For these reasons, we reject Employer’s
contention that Claimant’s Psychiatrist’s causation opinion was incompetent.
             In addition, support for the WCJ’s finding that Claimant sustained
work-related exacerbation of her underlying depression may be found in the
testimony offered by Employer’s Psychiatrist. Although Employer’s Psychiatrist
did not agree that Claimant’s depression was related to the work injury, he conceded


                                          10
on cross-examination that such depression may be aggravated or exacerbated by a
traumatic event. R.R. at 65a. He also conceded that if someone is unable to do
things that she was capable of doing prior to the injury that this could lead to
depression and anxiety and that such symptoms can take time to develop. R.R. at
65a-66a.
              Employer argues that this evidence cannot carry Claimant’s burden and
that the WCJ erred by shifting the burden to Employer to disprove causation.
Contrary to Employer’s assertions regarding burden shifting, the WCJ did not shift
the burden to Employer to disprove causation; the burden properly remained with
Claimant to establish the work-relatedness of her disabling depression. Claimant’s
Psychiatrist credibly testified that Claimant’s current depression was caused by the
chronic pain and lifestyle changes from the work injury. Nevertheless, a party’s
burden may be met where the necessary proof is introduced by his adversary. SKF
USA, Inc. v. Workers’ Compensation Appeal Board (Smalls), 728 A.2d 385, 388 n.3
(Pa. Cmwlth. 1999). Employer’s evidence provides additional support for the WCJ’s
finding that Claimant suffered an exacerbation of her preexisting major depressive
disorder.


                                   III. Conclusion
              Based on the foregoing, we conclude that the WCJ’s finding that
Claimant “suffered an exacerbation of her preexisting major depressive disorder as a
result of her work injury,” F.F. No. 20, is supported by substantial, competent medical
evidence. Thus, we discern no error in the WCJ’s decision to grant Claimant’s
Review Petition.




                                          11
                   Accordingly, we affirm.




                                       MICHAEL H. WOJCIK, Judge




Jude Fizzano Cannon did not participate in the decision of this case.




                                         12
        IN THE COMMONWEALTH COURT OF PENNSYLVANIA


Pocono Medical Center                   :
and Qual-Lynx, Inc.,                    :
                                        :
                        Petitioners     :
                                        :
            v.                          : No. 427 C.D. 2019
                                        :
Workers’ Compensation Appeal            :
Board (Springer),                       :
                                        :
                        Respondent      :



                                  ORDER


           AND NOW, this 16th day of July, 2020, the order of the Workers’
Compensation Appeal Board, dated March 12, 2019, is AFFIRMED.




                                      __________________________________
                                      MICHAEL H. WOJCIK, Judge
