ADJ19324168 · December 4, 2025

The PQME report was found not to be substantial medical evidence as it failed to fully address causation for all claimed injuries and lacked sufficient reasoning, necessitating further development of the record.

From the decision · page 5Here, in her October 14, 2024 report, Dr. Hopkins noted that applicant's "neck pain has improved but he continues to have vague low back pain" which is "diffuse in the lumbar paraspinal muscles." (Exhibit B, p. 14.) She similarly opined that applicant has "intermittent discomfort in the shoulders and wrists" and "intermittent diffuse pain in his knees." (Ibid.) With respect to applicant's hips, she noted complaints of groin and leg pain "with prolonged sitting, standing or walking" as well as "significant degenerative changes in the hips" and "decreased range of motion bilaterally." (Ibid.) She ultimately concluded that applicant did not sustain injury AOE/COE to the lumbar spine, cervical spine, shoulders, wrists, knees, or hips. (Id. at p. 15.) Although she explained that osteoarthritic changes contributed to applicant's hip complaints, she failed to fully address whether applicant's employment was also contributing factor and if not, why. She noted also that applicant "never reported or sought care for low back pain while employed[,]" but as the parties are well aware, lack of reporting and/or treatment does not preclude injury AOE/COE. Further reasoning is necessary. Considering the foregoing, we do not believe that the report of Dr. Hopkins, as it currently stands, is substantial medical evidence.

Dr. Hopkins' report did not fully address causation for hip complaints and non-orthopedic claims.

Favours Applicant prevailed

This lack of full reasoning and incomplete addressing of claims led to the report being rejected as substantial evidence, necessitating further proceedings.

From the decision · page 5Here, in her October 14, 2024 report, Dr. Hopkins noted that applicant's "neck pain has improved but he continues to have vague low back pain" which is "diffuse in the lumbar paraspinal muscles." (Exhibit B, p. 14.) She similarly opined that applicant has "intermittent discomfort in the shoulders and wrists" and "intermittent diffuse pain in his knees." (Ibid.) With respect to applicant's hips, she noted complaints of groin and leg pain "with prolonged sitting, standing or walking" as well as "significant degenerative changes in the hips" and "decreased range of motion bilaterally." (Ibid.) She ultimately concluded that applicant did not sustain injury AOE/COE to the lumbar spine, cervical spine, shoulders, wrists, knees, or hips. (Id. at p. 15.) Although she explained that osteoarthritic changes contributed to applicant's hip complaints, she failed to fully address whether applicant's employment was also contributing factor and if not, why. She noted also that applicant "never reported or sought care for low back pain while employed[,]" but as the parties are well aware, lack of reporting and/or treatment does not preclude injury AOE/COE. Further reasoning is necessary. Considering the foregoing, we do not believe that the report of Dr. Hopkins, as it currently stands, is substantial medical evidence.

Applicant timely objected to the PQME report and reserved right to depose Dr. Hopkins.

Favours Applicant prevailed

This indicated the record was incomplete and justified further development to ensure due process.

From the decision · page 6Here, the record is lacking on the issue of injury AOE/COE to the teeth/jaw, psyche, anxiety, and insomnia. Further, applicant issued a timely objection to the Declaration of Readiness to Proceed preceding trial. Per the evidentiary record, applicant issued an initial objection to the PQME report and reserved his right to depose Dr. Hopkins in a letter dated December 4, 2024. (Exhibit 1.) Thereafter, in response to defendant's Declaration of Readiness Proceed, applicant filed a subsequent objection dated February 25, 2025, wherein he noted that he was in the process

Applicant has complaints of pain in neck, back, hips, knees, shoulders, wrists; no industrial causation found for orthopedic body parts; non-orthopedic claims not addressed; report lacks full reasoning on causation.

Report did not fully address whether employment was a contributing factor to hip complaints and did not address non-orthopedic claims, thus not substantial evidence.

From the decision · page 5Here, in her October 14, 2024 report, Dr. Hopkins noted that applicant's "neck pain has improved but he continues to have vague low back pain" which is "diffuse in the lumbar paraspinal muscles." (Exhibit B, p. 14.) She similarly opined that applicant has "intermittent discomfort in the shoulders and wrists" and "intermittent diffuse pain in his knees." (Ibid.) With respect to applicant's hips, she noted complaints of groin and leg pain "with prolonged sitting, standing or walking" as well as "significant degenerative changes in the hips" and "decreased range of motion bilaterally." (Ibid.) She ultimately concluded that applicant did not sustain injury AOE/COE to the lumbar spine, cervical spine, shoulders, wrists, knees, or hips. (Id. at p. 15.) Although she explained that osteoarthritic changes contributed to applicant's hip complaints, she failed to fully address whether applicant's employment was also contributing factor and if not, why. She noted also that applicant "never reported or sought care for low back pain while employed[,]" but as the parties are well aware, lack of reporting and/or treatment does not preclude injury AOE/COE. Further reasoning is necessary. Considering the foregoing, we do not believe that the report of Dr. Hopkins, as it currently stands, is substantial medical evidence.

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

A medical opinion is not substantial evidence if based on inadequate medical histories or examinations, or lacking reasoning behind conclusions.

The PQME report was found lacking in reasoning and incomplete on causation, thus not substantial evidence.

From the decision · page 4Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687], "[a] medical opinion is not substantial evidence if it is based on facts no longer germane, on inadequate medical histories or examinations, on incorrect legal theories, or on surmise, speculation, conjecture, or guess. (citations.) Further, a medical report is not substantial evidence unless it sets forth the reasoning behind the physician's opinion, not merely his or her conclusions. (citation.)" "A medical report which lacks a relevant factual basis cannot rise to a higher level than its own inadequate premises. Such reports do not constitute substantial evidence to support a denial of benefits. (citation.)" (Kyle

Labor Code sections 5701, 5906; McClune v. Workers' Comp. Appeals Bd. (1998) 62 Cal.App.4th 1117

The Appeals Board has discretionary authority to develop the record to provide due process and fully adjudicate issues.

The record was incomplete on non-orthopedic claims; further development was ordered to ensure due process and a fair hearing.

From the decision · page 6It is also well established that the Appeals Board has the discretionary authority to develop the record when appropriate to provide due process or fully adjudicate the issues. (Lab. Code, § 5701, 5906; Tyler v. Workers' Comp. Appeals Bd. (1997) 56 9 Cal.App.4th 389 [62 Cal.Comp.Cases 924]; see McClune v. Workers' Comp. Appeals Bd. (1998) 62 Cal.App.4th 1117 [63 Cal.Comp.Cases 261].) Under both the California and United States Constitutions, all parties to a workers' compensation proceeding retain the fundamental right to due process and a fair hearing. (Rucker v. Workers' Comp. Appeals Bd. (2000) 82 Cal.App.4th 151, 157-158 [97 Cal Rptr. 2d 852, 65 Cal.Comp.Cases 805].) A fair hearing is "... one of `the rudiments of fair play' assured to every litigant..." (Id. at p. 158.) As stated by the California Supreme Court in Carstens v. Pillsbury (1916) 172 Cal. 572, "the commission... must find facts and declare and enforce rights and liabilities, - in short, it acts as a court, and it must observe the mandate of the constitution of the United States that this cannot be done except after due process of law." (Id. at p.

Applicant's lack of reporting or treatment for low back pain during employment does not preclude injury AOE/COE.

From the decision · page 5Here, in her October 14, 2024 report, Dr. Hopkins noted that applicant's "neck pain has improved but he continues to have vague low back pain" which is "diffuse in the lumbar paraspinal muscles." (Exhibit B, p. 14.) She similarly opined that applicant has "intermittent discomfort in the shoulders and wrists" and "intermittent diffuse pain in his knees." (Ibid.) With respect to applicant's hips, she noted complaints of groin and leg pain "with prolonged sitting, standing or walking" as well as "significant degenerative changes in the hips" and "decreased range of motion bilaterally." (Ibid.) She ultimately concluded that applicant did not sustain injury AOE/COE to the lumbar spine, cervical spine, shoulders, wrists, knees, or hips. (Id. at p. 15.) Although she explained that osteoarthritic changes contributed to applicant's hip complaints, she failed to fully address whether applicant's employment was also contributing factor and if not, why. She noted also that applicant "never reported or sought care for low back pain while employed[,]" but as the parties are well aware, lack of reporting and/or treatment does not preclude injury AOE/COE. Further reasoning is necessary. Considering the foregoing, we do not believe that the report of Dr. Hopkins, as it currently stands, is substantial medical evidence.

Applicant timely objected to PQME report and reserved right to depose Dr. Hopkins, indicating incomplete record development for non-orthopedic claims.

From the decision · page 6Here, the record is lacking on the issue of injury AOE/COE to the teeth/jaw, psyche, anxiety, and insomnia. Further, applicant issued a timely objection to the Declaration of Readiness to Proceed preceding trial. Per the evidentiary record, applicant issued an initial objection to the PQME report and reserved his right to depose Dr. Hopkins in a letter dated December 4, 2024. (Exhibit 1.) Thereafter, in response to defendant's Declaration of Readiness Proceed, applicant filed a subsequent objection dated February 25, 2025, wherein he noted that he was in the process