Utah American Energy v. Labor Commission

2021 UT App 33
THE UTAH COURT OF APPEALS
U TAH A MERICAN ENERGY I NC . AND R OCKWOOD C ASUALTY
I NSURANCE C OMPANY I NC .,
Petitioners,
v.
LABOR C OMMISSION AND A DAM PILLING,
Respondents.
Opinion
No. 20190800-CA
Filed March 18, 2021
Original Proceeding in this Court
Bret A. Gardner and Kristy L. Bertelsen,
Attorneys for Petitioners
James M. Elegante, Dayton L. Hall,
Zachary C. Lindley, and Virginius Dabney,
Attorneys for Respondent Adam Pilling
JUDGE R YAN M. HARRIS authored this Opinion, in which
JUDGES M ICHELE M. C HRISTIANSEN F ORSTER
and DIANA H AGEN concurred.
HARRIS, Judge:
¶1 	The 	Labor 	Commission 	of 	Utah 	(the 	Commission)
awarded Adam Pilling permanent total disability benefits after
he sustained a head and neck injury at work. His employer, Utah
American Energy Inc. (UAE), and its insurer seek judicial review
of the Commission’s award, asserting that Pilling did not sustain
a 	significant 	industrial 	impairment 	that 	directly 	caused 	his
permanent 	total 	disability. 	We 	decline 	to 	disturb 	the
Commission’s award.

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BACKGROUND1
¶2 	Early one morning in May 2007, Pilling—a heavy-duty
diesel mechanic employed by UAE—hurried into a mine to work
on some machinery. In his haste, Pilling failed to see a steel beam
extending downward from the ceiling, and he struck the top of
his head on it. Even though Pilling was wearing a hard hat, the
blow knocked him to the ground. A coworker drove Pilling out
of the mine and he was able to finish his shift, but not without
persistent pain. In this opinion, we refer to these events as the
“Work Accident.”
¶3 	Before the Work Accident, Pilling suffered from chronic
low back and hip pain, but in the days following the Work
Accident, Pilling felt neck, back, jaw, and upper extremity pain
that he had not experienced before, so he reported the accident
to UAE the following day and sought medical attention. A local
physician 	diagnosed 	Pilling 	with 	cervical 	radiculitis,2 	and
recommended 	physical 	therapy 	and 	other 	tests. 	The 	tests
showed nothing out of the ordinary and, for a while, Pilling
1. “In reviewing an order from the Commission, we view the
facts in the light most favorable to the Commission’s findings
and recite them accordingly.” JBS USA v. Labor Comm’n, 2020 UT
App 86, n.1, 467 P.3d 905 (quotation simplified). And “due to the
extensive medical records presented in the record, we discuss
only 	those 	injuries 	and 	medical 	diagnoses 	necessary 	to
understand the issues presented.” See Fogleman v. Labor Comm'n,
2015 UT App 294, n.1, 364 P.3d 756 (quotation simplified).
2. Cervical radiculitis or radiculopathy “describes a compressed
nerve root in the neck.” Radiculopathy, Johns Hopkins Medicine,
https://www.hopkinsmedicine.org/health/conditions-and-diseas
es/radiculopathy [https://perma.cc/D9QW-AFQP].

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continued 	regular 	work 	duty 	with 	UAE 	while 	undergoing
physical therapy and chiropractic treatment for his symptoms.
¶4 	In early 2008, Pilling sought additional treatment for
continuing neck, back, and upper extremity pain, as well as pain
in his jaw, which physicians diagnosed as temporomandibular
joint (TMJ) dysfunction. On referral, a neurosurgeon in Salt Lake
City assessed Pilling’s record, and noted that the MRI scans were
normal but that X-ray images suggested there had been a slight
cervical compression fracture “that has gone on to heal, and heal
well.” Although Pilling was still complaining of cervical and
secondary jaw pain, the neurosurgeon found “nothing structural
in [Pilling’s] spine to indicate a reason for his having ongoing
problems,” and recommended physical therapy. Later that year,
a neurologist retained by UAE’s insurer evaluated Pilling, and
eventually opined, in October 2009, that “no further treatment
was necessary as a result of the [Work Accident].”
¶5 	In the meantime, UAE laid Pilling off in March 2008.
Pilling soon found another job as a heavy-duty diesel mechanic,
but after a few months he quit due to continued complaints of
pain. 	After 	that, 	Pilling 	attempted 	to 	continue 	working 	in
various occupations through July 2009, but due to complaints of
ongoing pain he has not been gainfully employed since.
¶6 	Over the next few years, Pilling sought treatment and
underwent several surgeries related to his preexisting low back
and 	hip 	issues. 	But 	he 	also 	continued 	to 	seek 	treatment,
including fusion surgery on his spine, that he asserted was
necessary for his neck, back and upper extremity issues caused
by 	the 	Work 	Accident. 	In 	previous 	proceedings 	before 	the
Commission, 	the 	parties 	entered 	into 	a 	joint 	stipulation,
approved in the form of an order by the Commission, which
provided that the spinal surgery and certain other treatment was
related to the Work Accident, and that the surgery—as well as
temporary 	total 	and 	permanent 	partial 	disability 	benefits—

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should be paid for by UAE and its insurer. In particular, the
parties stipulated that Pilling had “permanent work injuries
[that] would adversely affect his ability to maintain gainful
employment.” The propriety of the earlier Commission rulings
regarding 	temporary 	total 	and 	permanent 	partial 	disability
benefits is not at issue here.
¶7 	One of the issues presented in the earlier proceedings,
and the main issue presented here, is how much of Pilling’s
disability is caused by his preexisting hip and low back issues,
and how much is caused by the Work Accident. Over the course
of several years, physicians who treated and examined Pilling
grappled with that question, and came to various conclusions.
For example, while one doctor opined that Pilling’s spinal issues
from the Work Accident were the “direct cause” of his inability
to work, another opined that any work restrictions related to
“bending, stooping, squatting, lifting from floor level, sitting,
and walking, would be unrelated to the [Work Accident].”
Various 	doctors 	assessed 	Pilling’s 	cervical 	spine 	and 	TMJ
impairments—the 	ones 	related 	to 	the 	Work 	Accident—at
anywhere from an 8% to 24% impairment rating. Pilling was also
given 	a 	19% 	impairment 	rating 	for 	issues 	related 	to 	his
preexisting low back and hip problems.
¶8 	In 2014, and as amended in 2015, Pilling filed another
claim with the Commission, this time seeking an award of
permanent total disability benefits, and claiming that the Work
Accident rendered him permanently unable to work. The matter
proceeded to an evidentiary hearing before an administrative
law judge (ALJ), and at the hearing both sides presented starkly
contrasting 	evidence 	from 	experts 	regarding 	the 	cause 	of
Pilling’s 	work 	restrictions 	and 	disabilities. 	Pilling’s 	medical
expert opined that Pilling had no significant history of hip
problems, and only “a vague history of back problems as many
. . . 	workers may 	have,” 	and 	concluded 	that 	Pilling’s work
limitations were “obviously caused by the [Work Accident].”

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Pilling’s 	vocational 	expert 	concluded 	that 	Pilling’s 	work
impairments made him unable to “perform any work reasonably
available” and that he was “not a viable candidate for vocational
rehabilitation.” 	On 	the 	other 	hand, 	UAE’s 	medical 	expert
testified 	that 	Pilling’s 	hip 	and 	spine 	problems 	were
“degenerative” 	and 	pre-dated 	the 	Work 	Accident, 	and 	its
vocational expert opined that Pilling was qualified for, and
capable of performing, a number of employment opportunities
available near Pilling’s home. Due to the “conflicting medical
opinions,” the ALJ referred the matter to a medical panel.
¶9 	After 	reviewing 	Pilling’s 	medical 	records, 	the 	panel
ultimately found that the Work Accident “medically caused”
Pilling’s cervical spine and TMJ injuries but did not exacerbate
his preexisting hip and low back problems. The panel found that
the Work Accident caused Pilling to suffer a 16% whole-person
impairment: 13% from the cervical spine injury, and 3% from the
TMJ 	injury. 	These 	injuries, 	according 	to 	the 	panel, 	were
exclusively responsible for one work restriction—inability to do
overhead 	work 	or 	reach 	above 	shoulder 	height—and, 	in
combination 	with 	his 	preexisting 	issues, 	were 	partially
responsible for ten other work restrictions. The panel opined that
Pilling “was restricted from returning to work as a heavy-
equipment 	operator 	due 	to 	both 	his 	industrial 	and 	non-
industrial conditions.”
¶10 	After considering all of the evidence presented, the ALJ
found the medical panel’s opinion “persuasive” and accordingly
concluded 	that 	Pilling 	had 	established 	an 	entitlement 	to
permanent 	total 	disability 	benefits. 	Specifically, 	the 	ALJ
determined that Pilling’s injuries were “sufficient to support a
finding of significant impairment” because he “suffered a 16%
whole person impairment caused by his industrial cervical and
TMJ 	conditions 	and 	that 	he 	has 	medical 	and 	functional
limitations as a result of those work caused injuries.” The ALJ
further concluded that Pilling’s injuries were the direct cause of

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his 	permanent 	total 	disability, 	stating 	that 	the 	presence 	of
preexisting medical conditions “that were not caused by the
accident [and] that interact with the work injury does not change
the evidence that it was his work injury that caused him to
become unable to work.”
¶11 	UAE appealed the ALJ’s ruling to the Commission, and
asserted 	that 	Pilling 	had 	not 	demonstrated 	a 	“significant
impairment” 	from 	the 	Work 	Accident 	that 	was the 	“direct
cause” 	of 	his 	claimed 	permanent 	total 	disability. 	The
Commission 	rejected 	UAE’s 	arguments. 	The 	Commission
acknowledged Pilling’s preexisting conditions, but concluded
that “[t]he fact that Mr. Pilling’s non-industrial conditions also
contribute to many of his limitations does not defeat the direct
causal 	connection 	between 	the 	[W]ork 	[A]ccident 	and 	his
permanent total disability,” and stated that it “does not view the
limitations of Mr. Pilling’s concurrent, non-industrial hip and
low-back problems to be intervening factors that would sever
the direct causal connection because his work-related limitations
are still present.” Ultimately, the Commission affirmed the ALJ’s
award of permanent total disability benefits to Pilling.
ISSUES AND STANDARDS OF REVIEW
¶12 	UAE 	now seeks judicial 	review of 	the 	Commission’s
award, specifically challenging two aspects of the Commission’s
final determination. With regard to both challenges, UAE assails
the Commission’s interpretation of statutory provisions as well
as 	its 	application 	of 	law 	to 	the 	facts. 	We 	review 	the
Commission’s 	interpretation 	of 	statutory 	provisions 	for
correctness. See Oliver v. Utah Labor Comm’n, 2017 UT 39, ¶¶ 13,
28–30, 424 P.3d 22. But the Commission’s application of law to
the facts constitutes a mixed question of law and fact, see Provo
City v. Utah Labor Comm’n, 2015 UT 32, ¶ 17, 345 P.3d 1242,
which we review “either deferential[ly] or non-deferential[ly],
depending on whether the fact-finder is in a superior position to

Utah American Energy v. Labor Commission
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decide the question than the appellate court,” Davis v. Labor
Comm’n, 	2018 	UT 	App 	71, 	¶ 	5, 	424 	P.3d 	1105 	(quotation
simplified). Because the challenged issues in this case turn on
fact-intensive 	analyses, 	we 	apply 	the 	more 	deferential
“substantial-evidence standard.” See Fogleman v. Labor Comm’n,
2015 	UT 	App 	294, 	¶¶ 	23–25, 	364 	P.3d 	756 	(reviewing 	a
“significant impairment” determination under the substantial
evidence standard); see also Hutchings v. Labor Comm’n, 2016 UT
App 160, ¶ 23, 378 P.3d 1273 (stating that “[m]edical causation is
fundamentally a factual determination” that is reviewed under
the substantial evidence standard). “A decision is supported by
substantial evidence if there is a quantum and quality of relevant
evidence that is adequate to convince a reasonable mind to
support a conclusion.” Provo City, 2015 UT 32, ¶ 8 (quotation
simplified). “In conducting a substantial evidence review, we do
not 	reweigh 	the 	evidence 	and 	independently 	choose 	which
inferences we find to be the most reasonable.” Id. (quotation
simplified). “Instead, we defer to an administrative agency’s
findings because when reasonably conflicting views arise, it is
the agency’s province to draw inferences and resolve those
conflicts.” Id. (quotation simplified).
ANALYSIS
¶13 	In this case, we are asked to evaluate Pilling’s claim to
permanent total disability benefits. An employee’s entitlement to
such benefits is governed by two statutory provisions that,
“taken as a whole,” require “workers to prove six elements.” See
Provo City, 2015 UT 32, ¶ 6 (citing Utah Code Ann. § 34A-2-
413(1)(b), (c)). UAE does not contest Pilling’s ability to prove
four of the necessary elements, and places in question just two of
them. First, UAE argues that Pilling failed to demonstrate that he
“sustained 	a 	significant 	impairment 	or 	combination 	of
impairments as a result of the industrial accident . . . that gives
rise to the permanent total disability entitlement.” See Utah Code

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Ann. § 34A-2-413(1)(b)(i) (LexisNexis 2007). Second, UAE argues
that Pilling failed to establish that the Work Accident was “the
direct cause of [his] permanent total disability.” See id. § 34A-2-
413(1)(b)(iii). We analyze each of these two elements, in turn.
I
¶14 	We 	begin 	by 	addressing 	UAE’s 	contention 	that 	the
Commission misinterpreted and misapplied Utah Code section
34A-2-413(1)(b)(i) 	in 	determining 	that 	Pilling 	sustained 	a
“significant impairment” as a result of the Work Accident. We
first discuss the Commission’s interpretation of that provision,
and conclude that the Commission’s interpretation was correct.
We then discuss the Commission’s application of the law to the
facts, 	and 	conclude 	that 	substantial 	evidence 	supports 	the
Commission’s determination.
A
¶15 	“When 	confronted 	with 	questions 	of 	statutory
interpretation,” 	our 	goal 	is 	“to 	evince 	the 	true 	intent 	and
purpose of the Legislature.” Bryner v. Cardon Outreach, LLC, 2018
UT 52, ¶ 9, 428 P.3d 1096 (quotation simplified). In attempting to
ascertain that intent, we first look at the language the legislature
used. Id. (stating that “[t]he first step of statutory interpretation
is to look to the plain language”). If that language is “plain and
unambiguous,” then we will “not look beyond the same to
divine legislative intent.” Id. (quotation simplified). To ascertain
the plain meaning of statutory text, we read it “in light of its
linguistic, structural, and statutory context.” Oliver v. Utah Labor
Comm’n, 2017 UT 39, ¶ 20, 424 P.3d 22 (quotation simplified).
Each 	provision 	is 	considered 	in 	the 	context 	of 	the 	overall
statutory scheme, see Bryner, 2018 UT 52, ¶ 10, and in the context
of its subsection’s grammatical structure, see id. ¶ 12 (stating that
“the whole-text canon calls on the judicial interpreter to consider
the entire text, in view of its structure and of the physical and
logical relation of its many parts” (quotation simplified)). A

Utah American Energy v. Labor Commission
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statute “should be construed so that no part or provision will be
inoperative or superfluous, void or insignificant, and so that one
section will not destroy another.” State v. Jeffries, 2009 UT 57, ¶ 9,
217 P.3d 265 (quotation simplified).
¶16 	The statutory provision at issue here requires an injured
worker 	to 	prove 	that 	he 	or 	she 	“sustained 	a 	significant
impairment or combination of impairments as a result of the
industrial accident or occupational disease that gives rise to the
permanent total disability entitlement.” Utah Code Ann. § 34A-
2-413(1)(b)(i). 	Pilling 	contends—and 	the 	Commission
concluded—that this provision requires him to demonstrate only
that he suffered a “significant impairment . . . as a result of” the
Work Accident. UAE agrees that Pilling must demonstrate this,
but 	argues 	that 	the 	provision 	contains 	an 	additional
requirement: that Pilling also prove that his impairment “g[ave]
rise to the permanent total disability entitlement.” That is, UAE
asserts 	that 	subsection 	(i) 	requires 	Pilling 	not 	only 	to
demonstrate a causal link between the Work Accident and some
“significant impairment,” but also between the impairment and
the 	permanent 	total 	disability. 	We 	find 	UAE’s 	interpretive
arguments unpersuasive, for two reasons.
¶17 	First, the grammatical structure of subsection (i) supports
Pilling’s interpretation. A grammatical analysis involves, among
other 	things, 	tracing 	each 	modifying 	phrase 	to 	“its nearest
reasonable 	referent.” 	Bryner, 	2018 	UT 	52, 	¶ 	14. 	Indeed, 	“a
prepositive or postpositive modifier normally applies only to the
nearest reasonable referent.” Id. (quotation simplified). In the
statute at issue, the phrase “that gives rise” is a modifying
phrase, and the nearest reasonable referent, or antecedent, is
“the industrial accident,” not “a significant impairment.” See
Utah Code Ann. § 34A-2-413(1)(b)(i). Grammatically, then, the
thing that must “give[] rise to the permanent total disability
entitlement” is the “industrial accident or occupational disease”
that forms the basis for the injured worker’s claim. See id. Stated

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20190800-CA 	10 	2021 UT App 33
another way, the phrase “that gives rise to the permanent total
disability entitlement” modifies “industrial accident,” and helps
specify which accident—in industrial cases, there is sometimes
more than one—forms the basis for the claim. Thus, we agree
with the Commission that the grammatical structure of the
provision indicates that the legislature intended for subsection
(i) to require only that the worker prove that he or she has
suffered a “significant impairment . . . as a result of” the specific
accident—among many potential accidents—that forms the basis
for the worker’s claim for permanent total disability benefits. See
Fogleman v. Labor Comm’n, 2015 UT App 294, ¶ 20, 364 P.3d 756
(explaining 	that 	subsection 	(i) 	allows 	consideration 	only 	of
impairments that are “causally related to the Work Accident”).3
3. We acknowledge the statement in Fogleman that subsection (i)
“requires [an injured worker] to show that [the] impairment . . .
was sustained ‘as a result of’ the Work Accident and that it
‘gives rise to the permanent total disability.’” See Fogleman, 2015
UT App 294, ¶ 20 (emphasis added) (quoting Utah Code Ann.
§ 34A-2-413(1)(b)(i)). In a sense, this sentence from Fogleman
presents the same grammatical conundrum that the statute itself
does: it is unclear whether the antecedent to the word “it” in the
sentence is the “impairment” or the “Work Accident.” But even
if 	this 	sentence 	from 	Fogleman 	could 	be 	construed 	as 	an
endorsement of UAE’s position, that statement would be dicta
because the Fogleman court was not asked to resolve the same
statutory 	interpretation 	question 	presented 	to 	us 	here. 	The
question in Fogleman was whether, in assessing the significance
of 	an 	employee’s 	impairments, 	the 	impairments 	must 	be
causally related to the Work Accident. Id. ¶ 18. The Fogleman
court was not asked to weigh in on what the antecedent is to the
phrase 	“that 	gives 	rise.” 	See 	id. 	And 	the 	court 	ultimately
concluded that the Commission “did not err by reading the
statute as requiring it to disregard impairments it found to not
(continued…)

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¶18 	Second, 	the 	structure 	of 	the 	entire 	permanent 	total
disability statute also supports this interpretation. One of the
other 	six 	elements 	needed 	to 	establish 	permanent 	total
disability—one we discuss more fully below, see infra Part II—
already contains a requirement that the worker prove a causal
link between the industrial accident and the claimed permanent
total 	disability. 	See 	Utah 	Code 	Ann. 	§ 	34A-2-413(1)(b)(iii)
(requiring proof that “the industrial accident . . . is the direct
cause of the employee’s permanent total disability”); see also
Provo City v. Utah Labor Comm’n, 2015 UT 32, ¶¶ 20–22, 35–36,
345 P.3d 1242 (noting that this element is the statute’s causation
element, and requires claimants to prove both medical and legal
causation). If we were to adopt UAE’s interpretation, that would
mean that the statutory scheme would contain two separate
elements that each require proof of a causal link between the
accident and any permanent total disability, and that those two
elements 	would 	contain 	different 	governing 	language 	(one
requiring proof that the impairment caused by the accident
“gives rise” to the disability, and the other requiring proof that
the accident was the “direct cause” of the disability). As noted
above, we must construe statutes “so that no part or provision
will be inoperative or superfluous, void or insignificant, and so
that one section will not destroy another.” Jeffries, 2009 UT 57,
¶ 9 (quotation simplified). UAE’s interpretation would pit two
subsections of the same statute against each other, and would
create confusion about what a worker must prove in order to
show the necessary causal link. The better interpretation, in the
context 	of 	the 	overall 	statutory 	scheme, 	is 	that 	the 	statute
contains but one provision setting forth the requirements for
proving the causal link between the industrial accident and the
(…continued)
be causally related to the Work Accident,” id., a holding that is in
complete harmony with ours today.

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claimed 	permanent 	total 	disability, 	and 	that 	requirement 	is
found in subsection (iii), not subsection (i).
¶19 	In sum, when we read subsection (i) “in light of its
linguistic, structural, and statutory context,” see Oliver, 2017 UT
39, ¶ 20 (quotation simplified), its meaning is clear: this element
requires an injured worker to prove that he or she suffered a
“significant impairment or combination of impairments as a
result of” the specific accident (or disease) “that gives rise to” the
claim for permanent total disability benefits. That element—as
distinguished from the element in subsection (iii)—does not
require the worker to demonstrate a causal link between the
impairment and the permanent total disability. The Commission
did not err in its interpretation of subsection (i).
B
¶20 	Applying this interpretation of subsection (i) to the facts
of the case, the Commission determined that Pilling had suffered
a significant impairment as a result of the Work Accident. That
determination was supported by substantial evidence.
¶21 	“The 	question 	of 	whether 	a 	particular 	impairment 	is
‘significant’ . . . requires a court to evaluate the severity of the
impairment and determine whether the level of impairment
exceeds a minimum threshold.” Provo City, 2015 UT 32, ¶ 16. An
“impairment” 	is 	statutorily 	defined 	as 	“a 	purely 	medical
condition reflecting [a] . . . functional . . . loss.” Utah Code Ann.
§ 34A-2-102(1)(i) 	(LexisNexis 	2018).4 	Physical 	impairment
4. In this opinion, we analyze the relevant statutes as they were
codified in 2007, at the time of the Work Accident. See supra ¶ 13;
see also O’Connor v. Labor Comm’n, 2020 UT App 49, ¶ 17, 463
P.3d 85 (stating that “[t]he law as it existed at the time of [the
worker’s] injury . . . governs the amount of benefits to which he
is entitled”). Here, however, we cite to the current version for
(continued…)

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ratings, which assess the percentage of functional loss sustained
by the industrial accident, may inform this determination. See,
e.g., Provo City, 2015 UT 32, ¶ 24. However, Utah courts have
declined to define “significant impairment” in terms of an exact
impairment-rating percentage, instead choosing to evaluate the
severity of the impairment “in terms of the specific individual
who has suffered a work-related injury.” See Fogleman, 2015 UT
App 294, ¶ 27 (quotation simplified). We will defer to the
Commission’s “significant impairment” determination if there is
“substantial evidence” to support it. See id. ¶¶ 25, 29–30; see also
Provo City, 2015 UT 32, ¶¶ 17–18.
¶22 	With regard to the significance of Pilling’s industrial
injuries, UAE acknowledges that the medical panel assigned
Pilling a 16% whole-person impairment rating stemming from
the 	Work 	Accident, 	and 	that 	the 	Commission 	credited 	the
panel’s determination on that point. Nevertheless, UAE takes the
position that Pilling’s Work Accident impairment rating does not
qualify as “significant” because it does not accurately indicate
the degree to which the Work Accident impairments specifically
decreased 	Pilling’s 	ability 	to 	work. 	According 	to 	UAE, 	the
Commission, 	by 	adopting 	the 	panel’s 	rating, 	improperly
combined all of Pilling’s medical conditions in assessing the
significance of his impairment, and asserts that, when examined
on their own and apart from his non-industrial hip and lower
back limitations, Pilling’s limitations due to the Work Accident
are insignificant. We find this argument unpersuasive.
(…continued)
convenience, because although the substance of the statutory
definition of “impairment” has not materially changed since
2007, that definition is now codified in a different statutory
subsection. Compare Utah Code Ann. § 34A-2-102(8) (LexisNexis
2007) with Utah Code Ann. § 34A-2-102(1)(i) (LexisNexis 2018).

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¶23 	As noted above, the Commission already determined, in
previous proceedings and based on the parties’ stipulation, that
the Work Accident necessitated spinal surgery and led to at least
temporary total and permanent partial disability. In the context
of these current proceedings, evidence was presented to the
Commission that, solely as a result of the Work Accident, Pilling
can no longer do overhead work or reach above shoulder height.
Evidence was also presented to the Commission that the Work
Accident 	at 	least 	partially 	contributes—along 	with 	Pilling’s
preexisting issues—to another ten current and ongoing work
restrictions. In addition, the medical panel concluded that the
Work Accident caused Pilling to sustain a 16% whole-person
impairment 	rating. 	And 	while 	UAE 	certainly 	presented
conflicting evidence that indicated the possibility that Pilling
could 	resume 	work 	activities 	with 	few 	limitations, 	the
Commission 	found 	the 	contrary 	evidence—in 	particular 	the
report from the medical panel—to be persuasive.
¶24 	Under 	these 	circumstances, 	“substantial 	evidence”
supported the Commission’s decision. See Fogleman, 2015 UT
App 294, ¶¶ 25, 29–30. Indeed, our supreme court, in a similar
case, 	determined 	that 	the 	Commission’s 	“significant
impairment” conclusion was supported by substantial evidence
when the industrial accident resulted in a 6% whole-person
impairment 	rating 	and 	prevented 	the 	worker 	“from 	lifting,
pushing, or pulling more than 25 pounds or working at heights.”
See Provo City, 2015 UT 32, ¶¶ 23–24 (quotation simplified). In
our view, the injuries and limitations Pilling sustained as a result
of the Work Accident are at least as significant as those sustained
by the worker in Provo City.5 Accordingly, it follows that the
5. UAE asserts that only the 13% cervical spine impairment
should be considered in the “significant impairment” finding
because “[t]here is no medical opinion to support that the 3%
TMJ impairment prohibits Mr. Pilling from performing basic
(continued…)

Utah American Energy v. Labor Commission
20190800-CA 	15 	2021 UT App 33
Commission’s determination in this case—that Pilling sustained
a significant impairment as a result of the Work Accident—was
supported by substantial evidence.
II
¶25 	We now turn to UAE’s contention that the Commission
erred in concluding that Pilling’s Work Accident was the “direct
cause” of his permanent total disability. UAE argues that the
Commission 	misinterpreted 	the 	statutory 	requirements 	for
demonstrating 	medical 	causation 	when 	the 	claimant 	has
contributing non-industrial preexisting conditions. UAE then
argues that the Commission applied this incorrect interpretation
in determining that Pilling’s preexisting conditions did not sever
the 	direct 	causal 	connection 	between 	the 	Work 	Accident
impairments and Pilling’s permanent total disability. We first
analyze the Commission’s interpretation of the “direct cause”
subsection, 	and 	conclude 	that 	the 	Commission 	correctly
interpreted 	the 	section. 	We 	then 	discuss 	the 	Commission’s
application 	of 	the 	law 	to 	the 	facts, 	and 	conclude 	that 	the
Commission’s medical causation determination was supported
by substantial evidence.
A
¶26 	To 	qualify 	for 	permanent 	total 	disability 	benefits, 	an
employee must prove that a work accident “was the direct cause
of the employee’s permanent total disability.” Utah Code Ann.
§ 34A-2-413(1)(b)(iii). Our supreme court has interpreted this
(…continued)
work activities, gainful employment, prior employment, or other
work reasonably available.” But even if we were to exclude the
3% TMJ impairment from the analysis, we would still conclude
that 	the 	Commission’s 	significant 	impairment 	determination
was supported by substantial evidence.

Utah American Energy v. Labor Commission
20190800-CA 	16 	2021 UT App 33
“direct cause” requirement as potentially encompassing both
legal and medical causation, Provo City, 2015 UT 32, ¶¶ 20–21,
but only medical causation is at issue in this case. When an
employee 	has 	a 	preexisting 	condition, 	medical 	causation
“depends 	on 	whether 	[that] 	condition 	actually 	caused 	or
aggravated 	the 	specific 	injury 	or 	disability 	for 	which
compensation is sought.” Hutchings v. Labor Comm’n, 2016 UT
App 160, ¶ 20, 378 P.3d 1273. If a preexisting condition is the
“sole medical cause” of the injury or disability, then medical
causation is not present. See id. ¶ 21.
¶27 	In raising its medical causation challenge, UAE asserts
that 	the 	Commission 	applied 	the 	wrong 	standard 	for
determining medical causation. But in its briefing, UAE fails to
clearly articulate the medical causation standard it is advocating
for, and instead uses a variety of terms to describe that standard.
At different points in its briefing, UAE variously asserts that
medical causation is not established unless the Work Accident is
the “sole,” “greater,” “primary,” “independent,” “[]lone,” or
“only” cause of Pilling’s disabilities. In essence, UAE contends
that, where preexisting or nonindustrial conditions are present,
medical causation exists only where the employee establishes
that the workplace injury is the sole or dominant cause of the
disability. UAE therefore asserts that the Commission erred by
concluding that the requisite medical causal link can exist in a
situation where both a work accident and preexisting conditions
directly “contribute to” an employee’s disability.
¶28 	But our supreme court has clearly stated that medical
causation under subsection (iii) is present when an employee
demonstrates that a work accident is “the but-for cause of the
disability.” Provo City, 2015 UT 32, ¶ 20. Thus, UAE has it exactly
backward: medical causation exists “so long as the employee’s
condition is not solely the result of a pre-existing condition.” Cox
v. Labor Comm’n, 2017 UT App 175, ¶ 18, 405 P.3d 863 (quotation
simplified); 	accord Hutchings, 2016 UT App 160, ¶¶ 18, 	21.

Utah American Energy v. Labor Commission
20190800-CA 	17 	2021 UT App 33
Indeed, 	we 	have 	previously 	stated 	that 	“proving 	that 	the
industrial accident is a cause—as opposed to the cause—of the
condition requiring treatment satisfies the medical causation
standard.”6 Cox, 2017 UT App 175, ¶ 18; see also id. ¶ 21 (“The
question is not whether the accident contributed substantially to
[the worker’s] medical condition, but whether it contributed in
any 	degree.” 	(quotation 	simplified)). 	UAE’s 	argument 	is
therefore directly foreclosed by our supreme court’s causation
discussion in Provo City.
¶29 	Accordingly, the Commission correctly interpreted the
“direct 	cause” 	statutory 	subsection, 	as 	concerns 	medical
causation. It stated: “The fact that Mr. Pilling’s non-industrial
conditions also contribute to many of his limitations does not
defeat 	the 	direct 	causal 	connection 	between 	the 	[W]ork
6. In Cox, the causation question we were asked to consider arose
under section 34A-2-401(1) of the Utah Code, a provision that
authorizes 	workers’ 	compensation 	benefits 	to 	be 	paid 	to
employees who are “injured . . . by accident arising out of and in
the course of the employee’s employment.” See Cox v. Labor
Comm’n, 2017 UT App 175, ¶ 14, 405 P.3d 863 (quoting Utah
Code Ann. § 34A-2-401). But our supreme court has made clear
that the “direct cause” examination required by section 34A-2-
413(1)(b)(iii)—the provision we are asked to analyze in this
case—involves 	the 	same 	two 	causation 	components 	as 	the
section 401 causation examination, see Provo City v. Utah Labor
Comm’n, 2015 UT 32, ¶¶ 20–21, 345 P.3d 1242 (identifying both
medical causation and legal causation as potentially applicable
in section 413 cases, at least “where a preexisting condition is a
contributing factor to the disability”), and has defined medical
causation in section 413 cases by referring to cases arising under
section 401, see id. ¶ 20 (citing Allen v. Industrial Comm’n, 729 P.2d
15, 27 (Utah 1986), and Murray v. Utah Labor Comm’n, 2013 UT 38,
¶ 45, 308 P.3d 461).

Utah American Energy v. Labor Commission
20190800-CA 	18 	2021 UT App 33
[A]ccident and his permanent total disability. . . . Mr. Pilling’s
industrial condition plays a direct role in the overwhelming
majority of his limitations even if his non-industrial conditions
also play a concurrent role.” From a legal standpoint, this
statement is entirely correct—the Commission determined that
medical causation can be met where an employee’s workplace
injuries contributed to the disability “at least in part.” That is all
the law requires. See, e.g., Cox, 2017 UT App 175, ¶ 18.
B
¶30 	Finally, 	we 	must 	assess 	whether 	the 	Commission
correctly applied the “direct cause” element in subsection (iii) to
the facts of this case. The Commission determined, based upon
the evidence presented, that Pilling’s permanent total disability
was directly caused by the Work Accident. Because such a
determination requires evaluating complex medical records and
data, 	we 	defer 	to 	the 	Commission’s 	medical 	causation
determinations, and set them aside only where they are “not
supported by substantial evidence.” See Hutchings, 2016 UT App
160, ¶ 23 (quotation simplified) (also stating that “[m]edical
causation 	is 	fundamentally 	a 	factual 	determination” 	that 	is
reviewed under the substantial evidence standard). “A medical
panel’s 	report 	alone 	may 	provide 	substantial 	evidence 	to
support 	the 	Labor 	Commission’s 	determination 	of 	medical
causation.” Benson v. Utah Labor Comm’n, 2018 UT App 228, ¶ 8,
437 P.3d 1253 (per curiam). Merely pointing to conflicting facts
and evidence is insufficient to undermine substantial evidence
supporting the finding. See id. ¶ 7.
¶31 	In 	this 	case, 	substantial 	evidence 	supported 	the
Commission’s determination that the Work Accident medically
caused Pilling’s disabilities. In making this determination, the
Commission relied on the medical panel’s report opining that,
even ten years after the Work Accident, Pilling “continues to
have moderate pain . . . and limited activity involving his neck,

Utah American Energy v. Labor Commission
20190800-CA 	19 	2021 UT App 33
left TMJ/facial area and left arm that restrict his capacity to work
as a heavy equipment mechanic or with physical labor involving
his neck and left upper extremities.” The Commission was not
persuaded by the contrary medical opinions UAE presented,
which indicated that Pilling’s industrial injuries were sufficiently
healed and he was cleared for “all activities,” and it instead
determined that such evidence contradicted the medical panel’s
“thorough . . . and well-reasoned analysis of Mr. Pilling’s various
injuries and conditions.” The medical panel’s conclusion reflects
a comprehensive review of Pilling’s medical history, a physical
exam and interview of Pilling by the panel members, and a
detailed analysis of Pilling’s current workplace limitations. On
review, 	we 	conclude 	that 	the 	panel’s 	report 	constitutes
substantial 	evidence 	sufficient 	to 	support 	the 	Commission’s
medical causation finding.
CONCLUSION
¶32 	The 	Commission 	correctly 	interpreted 	the 	relevant
statutory provisions regarding an employee’s entitlement to
permanent total disability, and its fact-based determinations are
supported by substantial evidence. Accordingly, we decline to
disturb the Commission’s award of permanent total disability
benefits to Pilling.