ADJ11574921 · April 8, 2022

The WCJ and WCAB found that the PQME Dr. Stone's opinion, which relied on treating physicians Dr. Aptekar and Dr. Abaci, was substantial medical evidence based on reasonable medical probability and adequate examination, rejecting the contrary opinion of Dr. Navani who was not a PQME and did not review all records.

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

PQME Dr. Stone's diagnosis of CRPS was based on his own physical examinations, review of voluminous medical records, and application of the Budapest Criteria.

Favours Applicant prevailed

This diagnosis was found to be substantial medical evidence supporting Applicant's claim and was relied upon by the WCJ and WCAB to deny Defendant's Petition for Reconsideration.

From the decision · page 4Applicant was examined by PQME Robert Stone, D.C., who issued several reports. There was a dispute amongst the medical providers as to whether or not Applicant had developed CRPS. PQME Stone requested and received a consult from Annu Navani, M.D., on this issue. Dr. Navani concluded that Applicant did not have CRPS. PQME Stone considered Dr. Navani's opinion and rejected it, ultimately agreeing with doctors Aptekar, Abaci, Kaisler- Meza and Cheng that Applicant DID have CRPS.

Treating physicians Dr. Aptekar and Dr. Abaci conducted physical examinations showing objective signs consistent with CRPS, which were relied upon by PQME Stone.

Favours Applicant prevailed

Their findings provided a medical basis for Dr. Stone's diagnosis and were accepted as substantial evidence by the WCJ and WCAB.

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

Dr. Navani's contrary opinion denying CRPS was rejected because she was not a PQME, did not review all medical records, and lacked substantial evidence to support her conclusion.

Favours Applicant prevailed

This rejection upheld the credibility and substantiality of Dr. Stone's diagnosis, favoring Applicant's claim.

From the decision · page 4Applicant was examined by PQME Robert Stone, D.C., who issued several reports. There was a dispute amongst the medical providers as to whether or not Applicant had developed CRPS. PQME Stone requested and received a consult from Annu Navani, M.D., on this issue. Dr. Navani concluded that Applicant did not have CRPS. PQME Stone considered Dr. Navani's opinion and rejected it, ultimately agreeing with doctors Aptekar, Abaci, Kaisler- Meza and Cheng that Applicant DID have CRPS.

Dr. Stone diagnosed Complex Regional Pain Syndrome (CRPS) based on his own examinations, review of medical records, and consideration of the Budapest Criteria, rejecting the contrary opinion of Dr. Navani.

Dr. Stone's opinion was found to be substantial medical evidence and was relied upon by the WCJ and WCAB.

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

Dr. Aptekar diagnosed CRPS based on physical examinations showing tenderness, limited motion, pain, and reduced grip strength in the left wrist and hand.

His diagnosis was relied upon by Dr. Stone and the WCJ as substantial evidence.

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

Dr. Abaci diagnosed CRPS based on physical signs including atrophy, limited mobility, sensory testing abnormalities, and weakness in the left hand and wrist.

His diagnosis was relied upon by Dr. Stone and the WCJ as substantial evidence.

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

Dr. Navani, a treatment consult, concluded no evidence of CRPS based on absence of skin, hair, nail changes, temperature or sweating abnormalities, allodynia, and hyperpathia at her examination.

Her opinion was considered and rejected by Dr. Stone and the WCJ as not substantial evidence due to lack of record review and expertise.

From the decision · page 4Applicant was examined by PQME Robert Stone, D.C., who issued several reports. There was a dispute amongst the medical providers as to whether or not Applicant had developed CRPS. PQME Stone requested and received a consult from Annu Navani, M.D., on this issue. Dr. Navani concluded that Applicant did not have CRPS. PQME Stone considered Dr. Navani's opinion and rejected it, ultimately agreeing with doctors Aptekar, Abaci, Kaisler- Meza and Cheng that Applicant DID have CRPS.

E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922

Medical opinion must be predicated on reasonable medical probability, based on pertinent facts, adequate examination and history, and set forth reasoning in support of conclusions.

The WCJ and WCAB applied this standard to find Dr. Stone's opinion substantial medical evidence.

From the decision · page 2Based on our review and for the reasons stated in the report, we are persuaded that Dr. Stone appropriately relied on the diagnoses of treating physicians, Dr. Aptekar and Dr. Abaci, and that Dr. Stone's opinion is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also be framed in terms of reasonable medical probability, it must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions. (Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; Escobedo v. Marshalls (2005) 70 Cal.Comp.Cases 604, 612 (Appeals Board en banc), 70 Cal.Comp.Cases 1506 (writ den.).)

McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408

Medical opinion must be framed in terms of reasonable medical probability and not be speculative.

The WCJ and WCAB applied this standard to find Dr. Stone's opinion substantial medical evidence.

From the decision · page 2Based on our review and for the reasons stated in the report, we are persuaded that Dr. Stone appropriately relied on the diagnoses of treating physicians, Dr. Aptekar and Dr. Abaci, and that Dr. Stone's opinion is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also be framed in terms of reasonable medical probability, it must not be speculative, it must be based on pertinent facts and on an adequate examination and history, and it must set forth reasoning in support of its conclusions. (Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; Escobedo v. Marshalls (2005) 70 Cal.Comp.Cases 604, 612 (Appeals Board en banc), 70 Cal.Comp.Cases 1506 (writ den.).)

Labor Code section 4628

Labor Code section 4628 governs the PQME process and medical evaluations.

PQME Stone complied with this statute in his evaluations and reports.

From the decision · page 5PQME Stone reviewed all of the relevant medical evidence, and complied with Labor Code section 4628. The opinions of PQME Stone are not conclusory nor are they based on speculation, but rather are well-supported.

Physical examinations by Dr. Aptekar and Dr. Abaci showing tenderness, limited motion, pain, reduced grip strength, atrophy, sensory abnormalities, and weakness in the left upper extremity

From the decision · page 1Defendant questions the substantiality of the CPRS diagnosis by treating physicians Robert Aptekar, M.D., and Peter Abaci, M.D., in part, because there is "no evidence that any type of physical examination took place." (Petition for Reconsideration, at p. 4:13-15.) However, the summary of applicant's August 27, 2019 office visit with Dr. Aptekar, contained within the September 23, 2019 report of panel qualified medical examiner (PQME) Robert Stone, D.C., specifically states, "The applicant was here for a follow up..." (Dr. Stone's 9/23/19 report, at p. 2, Joint Exhibit 4, emphasis added.) Dr. Aptekar's August 13, 2020 report, as summarized in Dr. Stone's March 8, 2021 report clearly describes a physical examination of applicant noting, "The patient was seen for routine follow up.... Left wrist was tender to palpation. Motion was limited. Rotation was painful. Grip strength was reduced...." (Dr. Stone's 3/8/21 report, at p. 18, Joint Exhibit 1, emphasis added.) The same evidence of a physical examination is true of Dr. Abaci's September 21, 2020 visit note, which was also summarized in Dr. Stone's March 8, 2021 report. The summary states:

Objective findings by PQME Dr. Stone including left hand allodynia, hypoesthesia to pinprick, weakened grip strength, atrophy, and temperature changes

From the decision · page 6Applicant was personally examined by the PQME, on more than one occasion. PQME Stone himself found objective evidence of left hand allodynia, hypoesthesia to pinprick, weakened left hand/grip strength, atrophy and temperature changes. The findings by PQME Stone serve to supplement and reinforce the opinions and findings of the treating doctors. Again, there is no evidence that any of the treatment reports are inaccurate, and there is no error for PQME Stone to have relied upon the treatment records to analyze his own determinations. Further, Defendant is citing excerpts/summary of treatment records, and many/most of those records were not offered into evidence. It is inappropriate to cite to documents not in evidence.