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 May 1, 2025, with the record closing on August 1, 2025, in (city), Texas, with (administrative law judge) presiding as the administrative law judge (ALJ). The ALJ resolved the disputed issues by determining that: (1) the compensable injury of (date of injury), extends to chronic pain syndrome; (2) the respondent/cross-appellant (claimant) reached maximum medical improvement (MMI) on September 11, 2024; and (3) the impairment rating (IR) is five percent. The appellant/cross-respondent (carrier) appealed, disputing the ALJ’s determination on the extent of injury. The claimant cross-appealed, disputing the ALJ’s MMI and IR determinations. The appeal file does not contain a response from the claimant to the carrier’s appeal.
DECISION
Reversed and rendered.
The parties stipulated, in part, that the claimant sustained a compensable injury on (date of injury), that extends to at least a right tibial pilon fracture, right fibula fracture, right Lisfranc dislocation, and right 5th metatarsal base fracture. The claimant was injured while installing sheets of metal on a roof. The claimant slipped from the top of the roof and fell about 25 feet, landing on his feet.
EXTENT OF INJURY
The Texas courts have long established the general rule that “expert testimony is necessary to establish causation as to medical conditions outside the common knowledge and experience” of the fact finder. Guevara v. Ferrer, 247 S.W.3d 662 (Tex. 2007). The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection. Appeals Panel Decision (APD) 022301, decided October 23, 2002; APD 131641, decided August 29, 2013. See also City of Laredo v. Garza, 293 S.W.3d 625 (Tex. App.—San Antonio 2009, no pet.) citing Guevara.
In the discussion portion of her decision the ALJ noted that (Dr. C), the treating doctor, stated the claimant had chronic pain in his right foot, was referred to pain management, and when attending an appointment on October 18, 2024, chronic pain disorder was noted with the possibility of further treatment. The ALJ further noted that while a diagnosis, by itself, is insufficient to prove causation, there was a sequence of events in this case that “provided a strong, logically traceable connection between the injury event and the condition of chronic pain.” The ALJ stated the claimant suffered a significant injury on (date of injury), which included a pilon fracture, and that the claimant reported numbness in his toes, ankle range of motion deficits, and began showing a decline. The ALJ also stated that diagnostic imaging noted post-traumatic arthritis, “which is a common complication following a comminuted pilon fracture.” We note that post-traumatic arthritis has not been determined to be part of the compensable injury at this time.
Numerous medical records in evidence starting from the date of injury reference pain and severe pain; however, none of the records in evidence contain a diagnosis for chronic pain syndrome. Dr. C diagnosed the claimant with “chronic pain in the right foot” beginning in September 2024, but there is no record from Dr. C diagnosing chronic pain syndrome or giving any explanation how the compensable injury caused chronic pain syndrome. In a medical record dated October 8, 2024, (Dr. H) diagnosed the claimant with “chronic pain disorder;” however, Dr. H did not explain how the compensable injury caused chronic pain syndrome. Under the facts of this case the ALJ’s determination that the compensable injury extends to chronic pain syndrome is so against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust. Accordingly, we reverse the ALJ’s determination that the compensable injury of (date of injury), extends to chronic pain syndrome and render a new decision that the compensable injury of (date of injury), does not extend to chronic pain syndrome.
MMI/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 Texas Department of Insurance, Division of Workers’ Compensation (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 the claimant reached MMI on September 11, 2024, with a five percent IR as certified by (Dr. L), a subsequent designated doctor, who considered and rated chronic pain syndrome in addition to the accepted conditions. Given that we have reversed the ALJ’s determination that the compensable injury extends to chronic pain syndrome and rendered a new decision that the compensable injury does not extend to chronic pain syndrome, Dr. L’s certification does not consider and rate the compensable injury. Accordingly, we reverse the ALJ’s determinations that the claimant reached MMI on September 11, 2024, with a five percent IR.
(Dr. K), the previously assigned designated doctor on MMI and IR, examined the claimant on March 11, 2025, and certified the claimant reached MMI on September 11, 2024, with a five percent IR. However, in an unappealed finding of fact the ALJ found that Dr. K’s certification could not be adopted and issued a presiding officer’s directive requesting a new designated doctor, which resulted in Dr. L’s certification discussed above.
In evidence is a report from Dr. C dated November 20, 2024, regarding MMI and IR. However, although the corresponding Report of Medical Evaluation (DWC-69) shows Dr. C’s signature it does not specify a date of MMI or assigned IR or specify that the claimant had not reached MMI. Rule 130.1(d)(1) provides in part that a certification of MMI, determination of permanent impairment, and assignment of an IR (if permanent impairment exists) for the current compensable injury requires completion, signing, and submission of the DWC-69 and narrative report. Dr. C’s report is not in compliance with Rule 130.1(d)(1) and cannot be adopted.
The only other certification in evidence is from (Dr. Cl), a doctor acting in place of the treating doctor. Dr. Cl examined the claimant on November 7, 2024. Dr. Cl certified the claimant reached MMI on November 7, 2024, and assigned a nine percent IR. Dr. Cl’s accompanying narrative report reflects the conditions considered were a right tibial pilon fracture, right fibula fracture, right Lisfranc dislocation, and right 5th metatarsal base fracture, which is the compensable injury in this case. Based on range of motion deficits Dr. Cl assigned three percent impairment for right ankle plantar flexion, three percent impairment for right ankle dorsiflexion, two percent for right hindfoot inversion, and one percent impairment for eversion, for a total nine percent IR. Dr. Cl’s certification considers the compensable injury and was made in accordance 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). Accordingly, we render a new decision that the claimant reached MMI on November 7, 2024, and that the claimant’s IR is nine percent, as certified by Dr. Cl.
SUMMARY
We reverse the ALJ’s determination that the compensable injury of (date of injury), extends to chronic pain syndrome and render a new decision that the compensable injury of (date of injury), does not extend to chronic pain syndrome.
We reverse the ALJ’s determination that the claimant reached MMI on September 11, 2024, and render a new decision that the claimant reached MMI on November 7, 2024.
We reverse the ALJ’s determination that the claimant’s IR is five percent and render a new decision that the claimant’s IR is nine percent.
The true corporate name of the insurance carrier is TEXAS MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is
JEANETTE WARD, PRESIDENT AND CEO
2200 ALDRICH STREET
AUSTIN, TEXAS 78723.
Carisa Space-Beam
Appeals Judge
CONCUR:
Cristina Beceiro
Appeals Judge
Margaret L. Turner
Appeals Judge