ADJ11204383 · September 29, 2025

Two PQMEs with relevant expertise found the applicant's strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and employment did not contribute to them. No medical evidence contradicted their findings.

From the decision · page 12As noted above, two PQMEs with relevant expertise, Internist Dr. Ross and Neurologist Dr. Gorinstein, found after evaluating the applicant and reviewing his extensive treatment record that his strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and that his employment did not contribute to them. They both supported their findings appropriately, and their reports and findings meet the standards for substantial medical evidence set forth in Escobedo v. Marshalls (2005), 70 Cal.Comp.Cases 604, 621. There is no medical evidence in the record that counters their findings, and no reports from other doctors in their respective areas of expertise. The applicant's neurological injury is therefore found non-industrial.

Dr. Michaels' evaluation report was not substantial medical evidence on industrial causation or any significant litigated issue, thus medical-legal costs claimed were not compensable.

From the decision · page 5Premier's Petition does not raise any issue about the finding that the claimed injury was non- industrial, or that the treatment costs were non-compensable, so those issues are final. Premier is seeking recovery of the amounts it billed for Dr. Michaels' initial evaluation report and other services he provided on the initial date of service as claimed medical-legal costs. Because Dr. Michaels' report lacks adequate foundation and is not substantial medical evidence on any significant litigated issue, the recommendation is that the Petition be denied in full.

Dr. Michaels' evaluation report lacked adequate foundation and did not review relevant PQME reports.

Favours Defendant prevailed

This made the report not substantial medical evidence on industrial causation, the central issue, leading to denial of medical-legal costs.

From the decision · page 6Premier claims in its Petition for Reconsideration that the "primary reason" it was denied recovery for its claimed medical-legal expenses was that Dr. Michaels did not review the PQME reports (Petition for Reconsideration, 5th page; the Petition is not paginated). The fact that he did not review any significant records as part of his evaluation of the applicant, including the PQME reports, certainly made it more difficult for him to provide an evaluation that would have sufficient foundation to be substantial medical evidence on causation or any other significant issue in the case.

Two PQMEs with relevant expertise found the applicant's strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and employment did not contribute.

Favours Defendant prevailed

Their findings were supported by extensive medical literature and records, and no contrary medical evidence was presented, leading to finding the injury non-industrial.

From the decision · page 12As noted above, two PQMEs with relevant expertise, Internist Dr. Ross and Neurologist Dr. Gorinstein, found after evaluating the applicant and reviewing his extensive treatment record that his strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and that his employment did not contribute to them. They both supported their findings appropriately, and their reports and findings meet the standards for substantial medical evidence set forth in Escobedo v. Marshalls (2005), 70 Cal.Comp.Cases 604, 621. There is no medical evidence in the record that counters their findings, and no reports from other doctors in their respective areas of expertise. The applicant's neurological injury is therefore found non-industrial.

Dr. Michaels' evaluation report lacked adequate foundation and was not substantial medical evidence on industrial causation or any significant litigated issue.

Did not review PQME reports or relevant medical information; opinion was a bare conclusion without reasoning.

From the decision · page 5Premier's Petition does not raise any issue about the finding that the claimed injury was non- industrial, or that the treatment costs were non-compensable, so those issues are final. Premier is seeking recovery of the amounts it billed for Dr. Michaels' initial evaluation report and other services he provided on the initial date of service as claimed medical-legal costs. Because Dr. Michaels' report lacks adequate foundation and is not substantial medical evidence on any significant litigated issue, the recommendation is that the Petition be denied in full.

Found the applicant's strokes and Antiphospholipid Syndrome to be entirely non-industrial with extensive medical literature and record support.

Provided extensive discussion and references supporting non-industrial causation.

From the decision · page 11From the histories given in the various medical reports, the applicant suffered a series of minor strokes that started in 2007 and culminated in a more serious stroke in June 2008, while he was on vacation, which left significant residual effects, including left-sided weakness. He was only 27 at the time of the most serious stroke, and was diagnosed and subsequently treated for Antiphospholipid Syndrome, a condition that causes unusual clotting (Internal PQME Dr. Ross, Ex. D p. 27 § 28). Dr. Ross found that the strokes, and the condition that caused them, were entirely non-industrial, and provided an extensive discussion of what he based this on that included references to relevant medical literature as well as the applicant's medical records (Id. p. 28 § 31). His conclusions were confirmed by Neurology PQME Dr. Gorinstein, who provided a detailed discussion of the applicant's complaints, the cause of his series of strokes and cause of

Confirmed Dr. Ross's findings that the strokes were caused by a non-industrial condition and employment did not contribute.

Provided detailed discussion of applicant's complaints and cause of strokes supporting non-industrial causation.

From the decision · page 12As noted above, two PQMEs with relevant expertise, Internist Dr. Ross and Neurologist Dr. Gorinstein, found after evaluating the applicant and reviewing his extensive treatment record that his strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and that his employment did not contribute to them. They both supported their findings appropriately, and their reports and findings meet the standards for substantial medical evidence set forth in Escobedo v. Marshalls (2005), 70 Cal.Comp.Cases 604, 621. There is no medical evidence in the record that counters their findings, and no reports from other doctors in their respective areas of expertise. The applicant's neurological injury is therefore found non-industrial.

Found that psychological problems were partly due to non-industrial stroke condition and partly due to work-related stress, with no threshold met for industrial psychological injury.

Provided detailed analysis of causation percentages and supported by substantial medical evidence.

From the decision · page 13He gave a detailed analysis of his findings on causation in his initial report and discussed it further in his cross-examination (Ex. H). Focusing on the period in 2013, when the applicant reported that perceived harassment at work was at its most intense and therefore the chance of meeting the threshold for industrial causation for a psychological injury would be highest, and considering the applicant's own breakdown of the contribution of different factors to his psychological problems, he found that at least 40% of the applicant's psychological problems were due to the stroke condition that both Dr. Ross and Dr. Gorinstein found non-industrial, 50% were due to work-related stress and 10% to the perceived harassment. Of the work-related stress, he found that half (25% of the total) was due to stress from the cognitive and physical effects of the applicant's strokes, which would therefore be non-industrial, and half (25% of the total) was due to inherent stress of his job.

Escobedo v. Marshalls (2005) 70 Cal.Comp.Cases 604

A medical opinion must be framed in terms of reasonable medical probability, not speculative, based on pertinent facts and adequate examination, and set forth reasoning in support of conclusions.

Applied to evaluate the sufficiency of Dr. Michaels' and PQMEs' medical opinions on causation.

From the decision · page 3It is well established that decisions by the Appeals Board must be supported by substantial evidence. (Lab. Code, § 5903, 5952(d); Lamb v. Workmen's Comp. Appeals Bd. (1974) 11 Cal.3d 274 [39 Cal.Comp.Cases 310]; Garza, supra; LeVesque v. Workmen's Comp. Appeals Bd. (1970) 1 Cal.3d 627 [35 Cal.Comp.Cases 16].) "The term `substantial evidence' means evidence which, if true, has probative force on the issues. It is more than a mere scintilla, and means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion... It must be reasonable in nature, credible, and of solid value." (Braewood Convalescent Hosp. v. Workers' Comp. Appeals Bd. (Bolton) (1983) 34 Cal.3d 159, 164 [48 Cal.Comp.Cases 566], emphasis removed and citations omitted.) To constitute substantial evidence "... a medical opinion must 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." (Escobedo v. Marshalls (2005) 70 Cal.Comp.Cases 604, 621 (Appeals Board en banc).)

8 CCR § 9793(h)(3)

To be compensable as a medical-legal report, the report must be capable of proving or disproving a disputed medical fact essential to the resolution of a contested claim (8 CCR § 9793(h)(3)).

Applied to determine that Dr. Michaels' report was not compensable as it did not meet this standard.

From the decision · page 9The relevant Labor Code sections and regulations on medical-legal reports and evaluations were discussed in the Opinion on Decision, and that discussion will not be repeated here in full as duplicative. The most significant point for this discussion is that to be compensable as a medical-legal report, the report must be "capable of proving or disproving a disputed medical fact essential to the resolution of a contested claim" (8 CCR § 9793(h)(3)). The only "disputed medical fact" at the time Dr. Michaels evaluated the applicant that was "essential to the resolution of a contested claim" was industrial causation, and, for all the reasons discussed above, Dr. Michaels' report is not capable of proving or disproving it as it is not substantial medical evidence on that or any other contested issue. It is therefore not compensable.

Dr. Michaels' report lacked foundation and did not review PQME reports

From the decision · page 6Premier claims in its Petition for Reconsideration that the "primary reason" it was denied recovery for its claimed medical-legal expenses was that Dr. Michaels did not review the PQME reports (Petition for Reconsideration, 5th page; the Petition is not paginated). The fact that he did not review any significant records as part of his evaluation of the applicant, including the PQME reports, certainly made it more difficult for him to provide an evaluation that would have sufficient foundation to be substantial medical evidence on causation or any other significant issue in the case.

Two PQMEs with relevant expertise found non-industrial causation

From the decision · page 12As noted above, two PQMEs with relevant expertise, Internist Dr. Ross and Neurologist Dr. Gorinstein, found after evaluating the applicant and reviewing his extensive treatment record that his strokes were caused by a non-industrial condition, Antiphospholipid Syndrome, and that his employment did not contribute to them. They both supported their findings appropriately, and their reports and findings meet the standards for substantial medical evidence set forth in Escobedo v. Marshalls (2005), 70 Cal.Comp.Cases 604, 621. There is no medical evidence in the record that counters their findings, and no reports from other doctors in their respective areas of expertise. The applicant's neurological injury is therefore found non-industrial.