Appeals Panel Requires Expert Evidence for Midline Annular Disc Tear

The Appeals Panel has reversed the decision of a Hearing Officer who concluded that that a small midline annulus tear at L4-5, as diagnosed by a claimant’s MRI, was a part of the compensable injury. The Appeals Panel rendered judgment that the annulus tear was not a result of the compensable injury. Because every impairment rating rendered in the case had included this or some other unrelated diagnosis, the Appeals Panel reversed the Hearing Officer’s decision that the claimant had reached MMI with a permanent whole body impairment rating. The appeals panel remanded the case to the Hearing Officer to obtain a new designated doctor examination on the issues of MMI and IR.

In Appeals Panel Decision Number 152531, decided March 7, 2016, the Appeals Panel considered the appeal of a carrier that disagreed with the Hearing Officer’s determination of extent of injury, MMI and IR. The Appeals Panel agreed with the carrier that the claimant’s L4-5 midline annulus tear required proof of causation by expert testimony and, further, that the claimant had not offered such proof at the Benefit Contested Case Hearing .

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. See APD 022301, decided October 23, 2002. See also Guevara v. Ferrer, 247 S.W.3d 662 (Tex. 2007). To be probative, expert testimony must be based on reasonable medical probability. City of Laredo v. Garza, 293 S.W.3d 625 (Tex. App.- San Antonio 2009, no pet.) citing Insurance Company of North America v. Meyers, 411 S.W.2d 710, 713 (Tex. 1966).

The hearing officer also determined that the compensable injury extends to the MRI findings of the lumbar spine taken on September 25, 2013 (a small midline annulus tear at L4-5). The hearing officer stated the following in her Discussion:

. . . the neurosurgeon persuasively explained that the mechanism of injury was consistent with the MRI findings of the lumbar spine taken on September 25, 2013, which resulted in surgery to the lumbar spine in January of 2014.

However, (Dr. S), the claimant’s surgeon, does not in any of his reports in evidence reference or discuss a small midline annulus tear at L4-5 or the September 25, 2013, MRI. Instead, Dr. S discusses a herniated disc at L4-5, and opined that the producing cause of that herniation was the lifting, holding, and squatting with a 50- pound load at work.

There were no medical reports in evidence, including those from Dr. S, that explain how the compensable injury caused a small midline annulus tear at L4-5. Therefore, we reverse that portion of the hearing officer’s determination that the compensable injury extends to the MRI findings of the lumbar spine taken on September 25, 2013 (a small midline annulus tear at L4-5), and we render a new decision that the compensable injury does not extend to the MRI findings of the lumbar spine taken on September 25, 2013 (a small midline annulus tear at L4-5).

The decision highlights the importance of carefully reading medical reports relating to causation. Unless the diagnosis is of a very commonly understood condition, the Appeals Panel will require proof of causation by an expert medical professional.