Ervin C. Caldwell v. Health Team Critical Care Transport, LLC

IN THE INTERMEDIATE COURT OF APPEALS OF WEST VIRGINIA

ERVIN C. CALDWELL, FILED
Claimant Below, Petitioner March 24, 2025
ASHLEY N. DEEM, CHIEF DEPUTY CLERK
v.) No. 24-ICA-345 (JCN: 2020016417) INTERMEDIATE COURT OF APPEALS
OF WEST VIRGINIA

HEALTH TEAM CRITICAL CARE TRANSPORT, LLC,
Employer Below, Respondent

MEMORANDUM DECISION

Petitioner Ervin C. Caldwell appeals the July 31, 2024, order of the Workers’
Compensation Board of Review (“Board”). Respondent Health Team Critical Care
Transport, LLC, (“HTCCT”) filed a response.1 Mr. Caldwell did not reply. The issue on
appeal is whether the Board erred in affirming the claim administrator’s order, which
denied authorization for left L5-S1 microdiscectomy, pre-admission testing, and a post-
operative visit.

This Court has jurisdiction over this appeal pursuant to West Virginia Code § 51-
11-4 (2024). After considering the parties’ arguments, the record on appeal, and the
applicable law, this Court finds no substantial question of law and no prejudicial error. For
these reasons, a memorandum decision affirming the Board’s order is appropriate under
Rule 21 of the Rules of Appellate Procedure.

On December 26, 2019, while working for HTCCT, Mr. Caldwell suffered an injury
to his low back when he attempted to stop a patient from falling during a transfer. Mr.
Caldwell reported that he felt a popping and burning sensation followed by immediate pain.
On the same day, Mr. Caldwell was seen in the emergency department at Charleston Area
Medical Center. The claim administrator issued an order dated January 7, 2020, holding
the claim compensable for lumbar strain.

Mr. Caldwell began treating with James Harman, D.O., a neurosurgeon, on January
8, 2020. Mr. Caldwell reported low back pain radiating down his left leg. Based on his
symptoms, Dr. Harman indicated that Mr. Caldwell may be suffering from sacroiliitis. Mr.
Caldwell began physical therapy on January 17, 2020. On February 13, 2020, Mr. Caldwell
underwent an MRI of the lumbar spine, revealing mild to moderate degenerative disc

1
Mr. Caldwell is represented by James D. McQueen, Jr., Esq. HTCCT is
represented by Jane Ann Pancake, Esq., and Jeffrey B. Brannon, Esq.

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disease at L5-S1, with a mild central disc bulge. Mr. Caldwell followed up with Dr. Harman
on February 14, 2020. Mr. Caldwell indicated that the physical therapy had decreased his
pain. Dr. Harmon opined that the disc bulge was not contributing to the claimant’s pain but
that instead, it was caused by the sacroiliac joint. Dr. Harman further opined that sacroiliitis
was the “most likely” diagnosis and requested authorization for sacroiliac injections and
additional physical therapy for the treatment of sacroiliitis.

Mr. Caldwell was evaluated by Prasadarao Mukkamala, M.D., on December 1,
2020. Mr. Caldwell reported low back pain radiating down his left leg. Dr. Mukkamala
disagreed with Dr. Harman’s diagnosis of sacroiliitis and stated that there is no credible
medical evidence to diagnose sacroiliitis. Dr. Mukkamala explained that the low back pain
could explain the sacroiliac joint symptoms, as the symptoms overlap. Dr. Mukkamala
opined that Mr. Caldwell had not reached maximum medical improvement (“MMI”) for
his compensable injury. On May 4, 2021, Mr. Caldwell was reevaluated by Dr.
Mukkamala. Dr. Mukkamala reiterated that he did not believe that sacroiliitis should be a
compensable condition in this claim because there was no evidence of sacroiliitis clinically
or radiologically. Further, Dr. Mukkamala opined that Mr. Caldwell had reached MMI for
lumbar strain, that he could return to work with no restrictions, and that he required no
further medical treatment.

On July 11, 2022, Mr. Caldwell followed up with Dr. Harmon and reported that the
left SI joint injection provided 80% relief but only lasted one week. Mr. Caldwell stated
that he would like to pursue surgical treatment.

On April 12, 2023, Mr. Caldwell underwent a lumbar MRI, revealing a progressive
herniation of the left L5-S1 compressing the S1 root. On May 5, 2023, Mr. Caldwell was
seen by Dr. Harmon and reported left low back pain radiating down the buttock, hamstring,
to the calf. On June 13, 2023, Mr. Caldwell underwent left L5-S1 microdiscectomy. The
pre- and post-operative diagnosis was left L5-S1 disc herniation with radiculopathy. On
September 8, 2023, Mr. Caldwell had a post-operative follow up with Dr. Harmon and
reported no radicular symptoms into his leg.

Mr. Caldwell was evaluated by Bruce Guberman, M.D., on December 7, 2022. Mr.
Caldwell reported low back pain radiating down his left leg, with numbness and weakness
in his left leg. Dr. Guberman diagnosed Mr. Caldwell with post-traumatic sacroiliitis on
the left side. Dr. Guberman attributed the sacroiliitis to the compensable injury. Dr.
Guberman opined that Mr. Caldwell was not at MMI and recommended a left sacroiliac
joint fusion.

On May 25, 2023, the claim administrator issued an order denying authorization for
left L5-S1 microdiscectomy surgeon and assist surgeon fees, pre-admission testing, and a
post-operative visit based on a finding that the request was neither medically necessary nor

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reasonably required for a compensable condition of the claim. Mr. Caldwell protested this
order.

Mr. Caldwell was evaluated by Philip Chandler, M.D., on March 2, 2024. Dr.
Chandler opined that no further treatment was indicated for the compensable condition of
lumbar sprain. On March 5, 2024, Mr. Caldwell was reevaluated by Dr. Guberman. Dr.
Guberman assessed chronic posttraumatic musculoligamentous strain/sprain of the lumbar
spine, aggravation of preexisting L5-S1 disc herniation resulting in left-sided
radiculopathy, status post left L5-S1 microdiscectomy on June 13, 2023, and history of
posttraumatic sacroiliitis on the left side. Dr. Guberman opined that the compensable injury
caused progression of the pre-existing L5-S1 disc disease causing left-sided radiculopathy,
significantly improved by the left L5-S1 microdiscectomy. Dr. Guberman opined that Mr.
Caldwell had reached MMI.

On July 31, 2024, the Board affirmed the claim administrator’s order denying
authorization for left L5-S1 microdiscectomy, pre-admission testing, and a post-op visit.
The Board found that Mr. Caldwell failed to establish that the requested left L5-S1
microdiscectomy, pre-admission testing, and post-operative visit were medically related
and reasonably required for treatment of the compensable condition. Mr. Calwell now
appeals the Board’s order.

Our standard of review is set forth in West Virginia Code § 23-5-12a(b) (2022), in
part, as follows:

The Intermediate Court of Appeals may affirm the order or decision of the
Workers’ Compensation Board of Review or remand the case for further
proceedings. It shall reverse, vacate, or modify the order or decision of the
Workers’ Compensation Board of Review, if the substantial rights of the
petitioner or petitioners have been prejudiced because the Board of Review’s
findings are:

(1) In violation of statutory provisions;
(2) In excess of the statutory authority or jurisdiction of the Board of Review;
(3) Made upon unlawful procedures;
(4) Affected by other error of law;
(5) Clearly wrong in view of the reliable, probative, and substantial evidence
on the whole record; or
(6) Arbitrary or capricious or characterized by abuse of discretion or clearly
unwarranted exercise of discretion.

Syl. Pt. 2, Duff v. Kanawha Cnty. Comm’n, 250 W. Va. 510, 905 S.E.2d 528 (2024).

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Mr. Caldwell argues that the Board failed to appropriately apply the Supreme Court
of Appeals of West Virginia’s (“SCAWV”) holding in Moore v. ICG Tygart Valley, LLC,
247 W. Va. 292, 879 S.E.2d 779 (2022), to the facts of this claim.2 Mr. Caldwell further
argues that the Board improperly ignored the expertise of his treating physician. Finally,
Mr. Caldwell argues that medical evidence establishes that lumbar disc surgery is
reasonable medical treatment for the progression of his compensable injury. We disagree.

The claim administrator must provide a claimant with medically related and
reasonably necessary treatment for a compensable injury. See West Virginia Code § 23-4-
3 (2005) and West Virginia Code of State Rules § 85-20 (2006).

Here, the Board determined that the evidence establishes that the treatment of left
L5-S1 microdiscectomy, pre-admission testing, and a post-operative visit was requested
for the condition of intervertebral disc disorders with radiculopathy of the lumbosacral
region. The Board noted that intervertebral disc disorders with radiculopathy of the
lumbosacral region is not a compensable component of the claim, and thus, found that the
requested treatment is not medically related and reasonably required for the compensable
injury.

Further, the Board noted that previously in this claim, the denial of authorization of
sacroiliac injections for the condition of sacroiliitis was affirmed by this Court because the
only compensable condition in this claim is lumbar strain. See Caldwell v. Health Team
Critical Care Transport, LLC, No. 23-ICA-347, 2023 WL 8931615 (W. Va. Ct. App. Dec.
27, 2023) (memorandum decision).3 The Board stated that:

In addressing the claimant’s argument that sacroiliitis should be a
compensable condition in the claim, the ICA found that the compensability
of sacroiliitis was not the issue before the Board; the issue was authorization
of treatment for sacroiliitis, which is not a compensable condition in the
claim. Likewise, the issue currently before the Board is authorization of
treatment for intervertebral disc disorders with radiculopathy of the
lumbosacral region, which is not a compensable condition of the claim.

2
The holding in Moore applies to the compensability determination of a claim. Thus
far, the SCAWV has declined to extend Moore to issues related to treatment authorization.
The issue properly before this Court in the instant claim is treatment authorization,
therefore, we decline to address any arguments related to the holding in Moore.
3
This decision was affirmed by the SCAWV on February 11, 2025. See Caldwell
v. Health Team Critical Care Transport, LLC, No. 24-121, 2025 WL 464320 (W. Va.
2025).

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Upon review, we conclude that the Board was not clearly wrong in finding Mr.
Caldwell failed to establish that the requested treatment is medically related and reasonably
necessary for treatment of lumbar strain. As the Supreme Court of Appeals of West
Virginia has set forth, “[t]he ‘clearly wrong’ and the ‘arbitrary and capricious’ standards
of review are deferential ones which presume an agency’s actions are valid as long as the
decision is supported by substantial evidence or by a rational basis.” Syl. Pt. 3, In re Queen,
196 W. Va. 442, 473 S.E.2d 483 (1996). With this deferential standard of review in mind,
we cannot conclude that the Board was clearly wrong in affirming the claim administrator’s
order denying left L5-S1 microdiscectomy, pre-admission testing, and a post-operative
visit.

We note that, similar to the previous issue in this claim before this Court, Mr.
Caldwell’s counsel is arguing that intervertebral disc disorders with radiculopathy of the
lumbosacral region are a progression of Mr. Caldwell’s compensable condition and thus
treatment should be authorized. However, this condition has not been requested to be added
as a compensable component of the claim. Thus, treatment is being requested for a
condition that is not currently compensable in this claim. This Court, again, declines to
reverse the Board’s order denying authorization for treatment of a noncompensable
condition.

Accordingly, we affirm the Board’s July 31, 2024, order.

Affirmed.

ISSUED: March 24, 2025

CONCURRED IN BY:

Chief Judge Charles O. Lorensen
Judge Daniel W. Greear
Judge S. Ryan White

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