ADJ15225348 · December 12, 2023

The WCJ properly relied on Dr. Hindocha's Almaraz/Guzman rating as substantial medical evidence because it was based on reasonable medical probability, supported by specific findings including significant limitations in 7/8 ADL categories, unsuccessful surgeries, and muscle atrophy, and was consistent with applicant's testimony and medical records.

From the decision · page 1For the reasons stated in the WCJ's report, we agree that the opinions of panel qualified medical examiner (PQME) Rommel Hindocha is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also 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

Dr. Hindocha found significant limitations in 7 out of 8 activities of daily living (ADLs) for the applicant's right shoulder.

Favours Applicant prevailed

This supported the use of the Almaraz/Guzman rating over the strict AMA Guides rating as it more accurately reflected the applicant's disability.

From the decision · page 5The patient reports significant limitations in 7 /8 ADL categories. The patient is severely limited in his ADL's, with respect to his right upper extremity. The patient had the following relevant surgical procedures: right-sided supraspinatus, right-sided infraspinatus and right-sided subscapularis repair and a revision surgery for his right- sided subscapularis. The patient's supraspinatus and infraspinatus muscles arc atrophied. Evidently, the revision surgery was not successful and the patient's subscapularis remains tom, retracted and non-functional. The patient underwent a distal clavicle resection and acromial arthroplasty with respect to his right acromioclavicular joint.

The applicant underwent multiple surgeries including unsuccessful revision surgery and had muscle atrophy in the right shoulder.

Favours Applicant prevailed

These clinical findings justified the departure from the strict AMA Guides rating and supported the alternative Almaraz/Guzman rating.

From the decision · page 5The patient reports significant limitations in 7 /8 ADL categories. The patient is severely limited in his ADL's, with respect to his right upper extremity. The patient had the following relevant surgical procedures: right-sided supraspinatus, right-sided infraspinatus and right-sided subscapularis repair and a revision surgery for his right- sided subscapularis. The patient's supraspinatus and infraspinatus muscles arc atrophied. Evidently, the revision surgery was not successful and the patient's subscapularis remains tom, retracted and non-functional. The patient underwent a distal clavicle resection and acromial arthroplasty with respect to his right acromioclavicular joint.

Dr. Hindocha provided an AMA rating and an Almaraz/Guzman rating for the applicant's right shoulder injury, explaining that the strict AMA rating did not fully encompass the applicant's substantial physical limitations due to muscle atrophy, unsuccessful surgeries, and significant limitations in activities of daily living (ADLs). He concluded the Almaraz/Guzman rating more accurately reflected the applicant's condition and functional status.

Dr. Hindocha explained why the strict AMA Guides rating did not apply, citing specific clinical findings and functional limitations, and provided an alternative rating within the AMA Guides that more accurately reflected the applicant's disability.

From the decision · page 4Applicant was evaluated by QME Dr. Hindocha on December 27, 2021 who issued an initial report. There were three subsequent supplemental reports. Applicant ruptured three out of four right-sided shoulder rotator cuff tendons and right sided intra-articular biceps tendons. Applicant had two surgeries to repair his right shoulder and underwent physical therapy. Dr. Hindocha found applicant MMI in the fourth report and issued an AMA rating as well as an Almaraz/Guzman rating.

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

To be substantial medical evidence, a medical opinion must be predicated on reasonable medical probability, not speculative, based on pertinent facts and adequate examination, and set forth reasoning in support of conclusions.

The WCJ properly relied on Dr. Hindocha's opinion as substantial medical evidence because it met these criteria.

From the decision · page 1For the reasons stated in the WCJ's report, we agree that the opinions of panel qualified medical examiner (PQME) Rommel Hindocha is substantial medical evidence upon which the WCJ properly relied. To be considered substantial evidence, a medical opinion "must be predicated on reasonable medical probability." (E.L. Yeager Construction v. Workers' Comp. Appeals Bd. (Gatten) (2006) 145 Cal.App.4th 922, 928 [71 Cal.Comp.Cases 1687]; McAllister v. Workmen's Comp. Appeals Bd. (1968) 69 Cal.2d 408, 413, 416§ 17, 419 [33 Cal.Comp.Cases 660].) A physician's report must also 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

Milpitas Unified School District v. Workers' Comp. Appeals Bd. (Guzman III) (2010) 187 Cal. App. 4th 808

The AMA Guides are not to be literally and mechanically applied; physicians may use clinical judgment to provide a rating within the four corners of the Guides that more accurately reflects impairment.

Dr. Hindocha's use of the Almaraz/Guzman rating method was consistent with this standard, providing an alternative rating with explanation.

From the decision · page 7Pursuant to section 4660.1(d), the scheduled rating is prima facie evidence of an employee's permanent disability. However, the scheduled rating is rebuttable. (See Almaraz- Guzman III, supra, at pp. 852-853.) Specifically, the WPI portion of the scheduled rating may be rebutted by showing that "a different chapter, table, or method of assessing impairment of the AMA Guides more accurately reflects the injured employee's impairment than the chapter, table, or method used by the physician being challenged." (Almaraz-Guzman II, supra, at p. 1106.) Physicians must still evaluate permanent impairment while staying within the "four corners of the Guides" pursuant to the Labor Code. (Id. at p. 1101.)

Applicant's testimony at trial about difficulties with dressing, pain waking at night, and limitations in housework and yardwork.

From the decision · page 10Dr. Hindocha further provided an Almaraz/Guzman rating because of the significant limitations in 7/8 ADL categories. This is supported by the undisputed testimony that applicant had difficulties getting dressed, frequently woke up in the middle of the night due to pain, his limitations doing housework and yardwork (MOH SOE pg 3-4 lines 19-25; 1-4).