ADJ12221781 · February 9, 2021

The WCJ found the CRPS diagnosis supported by competent, unrebutted medical evidence including the QME and treating physician, and found the 73% PPD rating supported by substantial evidence based on the QME's impairment calculations and relevant precedent.

From the decision · page 3INTRODUCTION Defendant seeks reconsideration of my November 25, 2020, Findings and Award. Therein, I concluded, inter alia, (1) that applicant's otherwise admitted industrial injury has resulted in Complex Regional Pain Syndrome (hereinafter "CRPS") and (2) that the level of permanent partial disability (PPD) arising from the industrial injury is 73 percent. The latter finding formed the basis for the award. On reconsideration, defendant contends that the evidence at trial does not support these two findings because the CRPS diagnosis made by the state-assigned Qualified Medical Evaluator (QME) was inconsistent with the fifth edition of the American Medical Association Guides to the Evaluation of Permanent Impairment (hereinafter "AMA Guides"). The petition is timely and appears to be verified. A verified answer has been filed.

The QME, Dr. Albert Retodo, diagnosed CRPS based on his expertise and examination, despite not documenting all AMA Guides criteria, and explained why the AMA Guides criteria are guidelines, not strict requirements.

Favours Applicant prevailed

This supported the finding that the applicant suffers from CRPS, which was a key basis for the permanent disability rating.

From the decision · page 7To the extent defendant disputes the validity of the CRPS diagnosis due to Dr. Retodo's inability to document at least eight of the 11 "objective diagnostic criteria" identified in Table 16-16 of the AMA Guides, I find that the QME gave a thorough and persuasive explanation, in his deposition, as to why he (1) did not find it appropriate to look for all 11 and (2) arrived at the CRPS diagnosis on the basis of his professional training and specialized experience with treatment of the condition. Although the AMA Guides, in section 16.5e, appear to require a finding that at least eight criteria are present, Dr. Retodo testified that the text is considered by physicians to be a guideline and not a universal bright-line standard.

Applicant's credible and unrebutted testimony described symptoms consistent with CRPS, supporting the diagnosis.

Favours Applicant prevailed

The applicant's testimony reinforced the medical opinions and supported the diagnosis.

From the decision · page 5Applicant was the only trial witness and his testimony is summarized on pages 7-8 of the Opinion. In relevant part, he testified that, with respect to his right upper extremity, (1) it has become much more sensitive to various stimuli since the injury, (2) the skin changes color, (3) the hair is more coarse, (4) the fingernails grow at a different rate and have a different quality, (5) it is cooler than the left, and (6) the hand sweats more. He also described a number of physical limitations relative to the right hand and wrist, as a result of which he now primarily uses his non- dominant left hand for everyday tasks.

The QME's impairment rating of 45% whole person impairment, adjusted to 73% permanent partial disability, was found to accurately reflect the applicant's level of disability based on actual symptoms and functional limitations.

Favours Applicant prevailed

This supported the award of permanent partial disability benefits at the 73% level.

From the decision · page 6independent analysis. I also found that Dr. Retodo, in his deposition, convincingly explained how and why he diagnosed applicant with CRPS without looking for all 11 of the criteria listed in the AMA Guides. With respect to PPD, I concluded that the evidence supports the QME's impairment calculations as set forth in the report in joint exhibit 1, irrespective of whether applicant suffers from a particular condition. As such, I adopted the Disability Evaluation Unit expert rater's opinion and found that the 45 percent WPI described in that QME report yields a final rating of 73 percent PPD, after adjustment for age and occupation.

Diagnosed right wrist injury with subsequent development of CRPS with reasonable medical probability; calculated 75% upper extremity impairment or 45% whole person impairment; testified that 8 of 11 AMA Guides criteria not required for diagnosis; impairment rating based on actual symptoms and functional limitations, not just diagnosis.

The WCJ found Dr. Retodo's diagnosis and impairment rating persuasive and supported by his expertise and testimony, including his explanation of the AMA Guides criteria and impairment rating methodology.

From the decision · page 4More germane to the contentions on reconsideration, the parties jointly offered into evidence a QME report issued by Albert Retodo, M.D., as well as the transcript of his deposition. The report, found in joint exhibit 1, is summarized on page 2 of the Opinion. In it, after conducting a physical examination of the injured worker and reviewing a substantial volume of medical records, Dr. Retodo reaches the diagnosis of right wrist injury "with subsequent development of [CRPS]," established with reasonable medical probability. He goes on to use the CRPS portion of chapter 16 of the AMA Guides to calculate 75 percent upper extremity impairment, or 45 percent whole person impairment (WPI).

Diagnosed CRPS using Budapest Criteria; treating physician who concurred with CRPS diagnosis.

The WCJ found Dr. Schonwald's diagnosis credible and consistent with the record, supporting the CRPS diagnosis.

From the decision · page 4discussed on page 5 of the Opinion, Dr. Schonwald relied on the Budapest Criteria1 to find that applicant suffers from CRPS. In general, I found the report to reflect a high level of expertise in the diagnosis and treatment of the condition. The treatment reports in applicant's exhibits 2 and 3, issued between 2016 and 2019, also all reflect the CRPS diagnosis, as does Dr. Schonwald's brief 2018 report at pages 32-33 of applicant's exhibit 1.

AMA Guides to the Evaluation of Permanent Impairment

Used as impairment rating methodology, not as a strict diagnostic tool for CRPS.

From the decision · page 6Contrary to defendant's characterization, the diagnostic criteria set forth in the CRPS section of the AMA Guides are not a legal standard. The AMA Guides represent an impairment rating methodology that is currently one of the means of establishing PPD under the Labor Code. They are not, however, a diagnostic tool. MV Transportation v. Workers' Comp. Appeals Bd. (Williams) (2010) 75 Cal. Comp. Cases 656, 659. Thus, while it is undisputed that the medical evidence does not reflect eight or more of the 11 criteria being documented on examination, the question before me was whether substantial medical evidence supports the allegation that applicant suffers from CRPS. As discussed beginning on page 8 of the Opinion,

California Labor Code

Labor Code

Governs permanent disability ratings and impairment evaluations.

From the decision · page 3INTRODUCTION Defendant seeks reconsideration of my November 25, 2020, Findings and Award. Therein, I concluded, inter alia, (1) that applicant's otherwise admitted industrial injury has resulted in Complex Regional Pain Syndrome (hereinafter "CRPS") and (2) that the level of permanent partial disability (PPD) arising from the industrial injury is 73 percent. The latter finding formed the basis for the award. On reconsideration, defendant contends that the evidence at trial does not support these two findings because the CRPS diagnosis made by the state-assigned Qualified Medical Evaluator (QME) was inconsistent with the fifth edition of the American Medical Association Guides to the Evaluation of Permanent Impairment (hereinafter "AMA Guides"). The petition is timely and appears to be verified. A verified answer has been filed.

Applicant's credible and unrebutted testimony describing symptoms consistent with CRPS, including skin color changes, hair and nail changes, temperature differences, and sweating in the right upper extremity.

From the decision · page 5Applicant was the only trial witness and his testimony is summarized on pages 7-8 of the Opinion. In relevant part, he testified that, with respect to his right upper extremity, (1) it has become much more sensitive to various stimuli since the injury, (2) the skin changes color, (3) the hair is more coarse, (4) the fingernails grow at a different rate and have a different quality, (5) it is cooler than the left, and (6) the hand sweats more. He also described a number of physical limitations relative to the right hand and wrist, as a result of which he now primarily uses his non- dominant left hand for everyday tasks.