This appeal arises pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 401.001 et seq. (1989 Act). A contested case hearing was held on February 10, 2025, in (city), Texas, with (administrative law judge) presiding as the administrative law judge (ALJ). The ALJ resolved the disputed issues by deciding that: (1) the compensable injury of (date of injury), does not extend to a left shoulder rotator cuff tear, left shoulder supraspinatus tendinosis, left shoulder infraspinatus tendinosis, left shoulder acromioclavicular (AC) joint arthritis, left bicep tendinosis, left knee tear of the posterior horn medial meniscus, left knee chondromalacia, left wrist non-displaced fracture of ulnar styloid process, left upper extremity (UE) complex regional pain syndrome (CRPS), C3-4 disc protrusion, C3-4 cervical radiculopathy, C3-4 moderate foraminal stenosis, C4-5 disc protrusion, multi-level cervical spondylosis, L4-5 disc bulge, L4-5 spondylosis, or L4-5 neural foraminal stenosis; (2) the appellant/cross-respondent (claimant) reached maximum medical improvement (MMI) on October 31, 2023; and (3) the claimant’s impairment rating (IR) is 10%.
The claimant appealed the ALJ’s extent-of-injury, MMI, and IR determinations. The respondent/cross-appellant (self-insured) responded, urging affirmance of the ALJ’s extent-of-injury determination. The self-insured cross-appealed the ALJ’s determinations of MMI and IR, contending that the assigned IR is inconsistent with the ALJ’s extent-of-injury determination.
DECISION
Affirmed in part and reversed and rendered in part.
The parties stipulated, in part, that the claimant sustained a compensable injury on (date of injury), that extends to a left shoulder strain, left wrist sprain, and left knee contusion; and (Dr. S) was appointed by the Texas Department of Insurance, Division of Workers’ Compensation (Division) as the most recent designated doctor to address the issues of MMI, IR, and extent of injury. The claimant, a child nutrition employee, was injured on (date of injury), when she tripped and fell, landing on her left side.
EXTENT OF INJURY
The ALJ’s determination that the compensable injury of (date of injury), does not extend to a left shoulder rotator cuff tear, left shoulder supraspinatus tendinosis, left shoulder infraspinatus tendinosis, left shoulder AC joint arthritis, left bicep tendinosis, left knee tear of the posterior horn medial meniscus, left knee chondromalacia, left wrist non-displaced fracture of ulnar styloid process, left UE CRPS, C3-4 disc protrusion, C3-4 cervical radiculopathy, C3-4 moderate foraminal stenosis, C4-5 disc protrusion, multi-level cervical spondylosis, L4-5 disc bulge, L4-5 spondylosis, or L4-5 neural foraminal stenosis is supported by sufficient evidence and is affirmed.
MMI AND IR
Section 401.011(30)(A) defines MMI as “the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.” Section 408.1225(c) provides that the report of the designated doctor has presumptive weight, and the Division shall base its determination of whether the employee has reached MMI on the report of the designated doctor unless the preponderance of the other medical evidence is to the contrary.
Section 408.125(c) provides that the report of the designated doctor shall have presumptive weight, and the Division shall base the IR on that report unless the preponderance of the other medical evidence is to the contrary, and that, if the preponderance of the medical evidence contradicts the IR contained in the report of the designated doctor chosen by the Division, the Division shall adopt the IR of one of the other doctors. 28 Tex. Admin. Code § 130.1(c)(3) (Rule 130.1(c)(3)) provides, in part, that the assignment of an IR for the current compensable injury shall be based on the injured employee’s condition as of the MMI date considering the medical record and the certifying examination.
The ALJ determined that the claimant reached MMI on October 31, 2023, with a 10% IR in accordance with the certification of Dr. S, the designated doctor. Dr. S initially examined the claimant for the purpose of determining extent of injury, MMI, and IR on November 21, 2024, and issued alternative certifications. In the first certification, Dr. S certified that the claimant reached MMI on October 31, 2023, with a 10% IR for the conditions of left shoulder pain, left wrist pain, left knee pain, left knee contusion, and left wrist sprain. As this certification did not rate the compensable left shoulder strain, it cannot be adopted. In his second certification, Dr. S determined that the claimant had not reached MMI based, in part, on the extent-of-injury conditions in dispute. As we have affirmed the ALJ’s determination that the extent-of-injury conditions are not compensable, this certification cannot be adopted.
Following the February 10, 2025, CCH, the ALJ sent Dr. S a letter of clarification (LOC) with additional medical records because the ALJ was concerned that he did not have all the records for his prior examination. Dr. S responded to the LOC on February 21, 2025, stating that he did not receive the additional records with the LOC, but that he believed he had sufficient records for the purpose of his report. The ALJ sent Dr. S a second LOC on March 11, 2025, resending the medical records. The ALJ also requested that Dr. S provide a certification that rates a left shoulder strain, left wrist sprain, left knee contusion, and a left shoulder rotator cuff tear. Dr. S responded to the second LOC on March 19, 2025, and stated that the additional records did not change his opinion. He also issued an amended certification to rate the conditions specified by the ALJ, which was adopted by the ALJ. As this certification considers a left shoulder rotator cuff tear, which we have affirmed is not part of the compensable injury, it cannot be adopted. Therefore, we reverse the ALJ’s determinations that the claimant reached MMI on October 31, 2023, and the claimant’s IR is 10%.
There are three more certifications in the record. (Dr. B), the initial designated doctor, examined the claimant on June 11, 2024, and certified that the claimant reached MMI on August 30, 2023, with a 0% IR based on the conditions of left shoulder pain, left wrist pain, and left knee pain. As this certification does not consider or rate any of the compensable conditions, it cannot be adopted.
(Dr. Sn), the carrier-selected required medical examination doctor, examined the claimant on January 21, 2025, and issued two alternative certifications. For the compensable conditions plus the disputed conditions, Dr. Sn certified that the claimant reached MMI on March 8, 2024, with a 4% IR. As this certification considers and rates the conditions which we have affirmed are not part of the compensable injury, it cannot be adopted. Dr. Sn also issued a certification that the claimant reached MMI on August 30, 2023, with a 0% IR based on the compensable conditions of a left shoulder strain, left wrist sprain, and left knee contusion. This certification correctly rates the entire compensable injury and is in compliance with the Guides to the Evaluation of Permanent Impairment, fourth edition (1st, 2nd, 3rd, or 4th printing, including corrections and changes as issued by the American Medical Association prior to May 16, 2000) (AMA Guides). Therefore, we render a new decision that the claimant reached MMI on August 30, 2023, and the claimant’s IR is 0%.
SUMMARY
We affirm the ALJ’s determination that the compensable injury of (date of injury), does not extend to a left shoulder rotator cuff tear, left shoulder supraspinatus tendinosis, left shoulder infraspinatus tendinosis, left shoulder AC joint arthritis, left bicep tendinosis, left knee tear of the posterior horn medial meniscus, left knee chondromalacia, left wrist non-displaced fracture of ulnar styloid process, left UE CRPS, C3-4 disc protrusion, C3-4 cervical radiculopathy, C3-4 moderate foraminal stenosis, C4-5 disc protrusion, multi-level cervical spondylosis, L4-5 disc bulge, L4-5 spondylosis, or L4-5 neural foraminal stenosis.
We reverse the ALJ’s determination that the claimant reached MMI on October 31, 2023, and render a new decision that the claimant reached MMI on August 30, 2023.
We reverse the ALJ’s determination that the claimant’s IR is 10% and render a new decision that the claimant’s IR is 0%.
The true corporate name of the insurance carrier is (a self-insured governmental entity) and the name and address of its registered agent for service of process is
(NAME)
(ADDRESS)
(CITY), TEXAS (ZIP CODE).
Cristina Beceiro
Appeals Judge
CONCUR:
Carisa Space-Beam
Appeals Judge
Margaret L. Turner
Appeals Judge