ADJ8492544 · September 29, 2026

The WCJ and WCAB found that the medical evidence did not constitute substantial evidence to support industrial causation of diabetes and sleep loss, relying on inconsistencies in medical opinions and lack of persuasive medical explanation.

From the decision · page 2Applicant claimed injury to her cervical spine, face consisting of the trigeminal nerve, headaches, sleep loss, hypertension, and diabetes while employed as a management analyst by defendant County of Monterey on April 30, 2008. Defendant admits injury to the cervical spine, face consisting of the trigeminal nerve, and headaches but disputes injury in the form of sleep loss and diabetes. The parties have selected Charles Martin, D.C., as the chiropractic Qualified Medical Evaluator (QME), Massoud Mahmoudi, D.O., Ph.D., as the QME in internal medicine, and A. K. Bhattacharyya, M.D., as the QME in neurology. On December 9, 2021, the parties proceeded to trial and framed for decision, in relevant part, the disputed body parts/systems of sleep loss, hypertension and diabetes. (Minutes of Hearing, dated December 9, 2021, at p. 3:3.) The parties also placed in issue permanent disability and “the applicability of the Combined Value Chart versus Additive Method for impairment.” (Id. at p. 3:6.) Neither party offered witness testimony, and the WCJ ordered the matter submitted for decision as of December 17, 2021. On February 2, 2022, the WCJ issued her F&A, determining in relevant part that applicant sustained her burden of establishing industrial injury in the form of hypertension, but not in the form of diabetes or sleep loss. (Finding of Fact No.

The WCJ found and the WCAB affirmed that the Combined Values Chart (CVC) was appropriately applied to combine impairment ratings, as the evidence did not support adding impairments due to lack of substantial medical evidence for diabetes and sleep loss as industrial injuries.

From the decision · page 2Applicant claimed injury to her cervical spine, face consisting of the trigeminal nerve, headaches, sleep loss, hypertension, and diabetes while employed as a management analyst by defendant County of Monterey on April 30, 2008. Defendant admits injury to the cervical spine, face consisting of the trigeminal nerve, and headaches but disputes injury in the form of sleep loss and diabetes. The parties have selected Charles Martin, D.C., as the chiropractic Qualified Medical Evaluator (QME), Massoud Mahmoudi, D.O., Ph.D., as the QME in internal medicine, and A. K. Bhattacharyya, M.D., as the QME in neurology. On December 9, 2021, the parties proceeded to trial and framed for decision, in relevant part, the disputed body parts/systems of sleep loss, hypertension and diabetes. (Minutes of Hearing, dated December 9, 2021, at p. 3:3.) The parties also placed in issue permanent disability and “the applicability of the Combined Value Chart versus Additive Method for impairment.” (Id. at p. 3:6.) Neither party offered witness testimony, and the WCJ ordered the matter submitted for decision as of December 17, 2021. On February 2, 2022, the WCJ issued her F&A, determining in relevant part that applicant sustained her burden of establishing industrial injury in the form of hypertension, but not in the form of diabetes or sleep loss. (Finding of Fact No.

The WCJ found no substantial evidence supporting industrial causation of diabetes and sleep loss based on medical opinions and objective testing inconsistencies.

Favours Defendant prevailed

This fact led to denial of industrial injury for diabetes and sleep loss, affecting impairment rating method and overall disability award.

From the decision · page 6Maryland Mines Corp. v. Industrial Accident Commission (Duncan) (1951) 104 Cal.App.2d 567, 570 [16 Cal.Comp.Cases 146].) Section 3202.5 provides that all parties and lien claimants shall meet the evidentiary burden of proof on all issues by a preponderance of the evidence, which is “evidence that, when weighed with that opposed to it, has more convincing force and the greater probability of truth.” (Lab. Code, § 3202.5.) Here, the WCJ has carefully weighed the evidence and determined that the reasoning of the internal medicine QME with respect to applicant’s allegation of industrially-related onset of diabetes is insufficient to support a finding of industrial causation.

The WCJ found that the Combined Values Chart was appropriately applied to combine impairment ratings due to lack of industrial causation for diabetes and sleep loss and no persuasive basis for addition.

Favours Defendant prevailed

This fact determined the method of impairment rating calculation and upheld the permanent disability award.

From the decision · page 10A generalized assertion that impairments from different body parts are “different” from each other and should thus be added (e.g., Ex. J19, Transcript of the Deposition of Massoud Mahmoudi, D.O., dated September 23, 2019, at p. 42:23) is not a sufficient basis upon which to rebut the PDRS. (Vigil, supra, 89 Cal.Comp.Cases at pp. 691-693.) Consequently, we do not identify a reasonable basis to depart from the application of the CVC as described in the permanent disability rating schedule. In summary, the WCJ has carefully reviewed the submitted and medical record and determined that the medical-legal record supports a finding of industrial causation of applicant’s hypertensive condition, but not the claimed diabetic or sleep disturbance conditions. Based on the evidence before us we conclude the WCJ appropriately weighed the medical evidence with respect to the claimed injured body parts and reached a reasonable determination based on the comparative 10

Opined industrial contribution to diabetes due to post-injury weight gain and to sleep disturbance due to chronic pain, but findings were not found to be substantial evidence by WCJ and WCAB.

The QME's opinion was based on applicant's weight gain and inactivity leading to diabetes and sleep disturbance, but lacked sufficient medical explanation and was inconsistent with objective testing.

From the decision · page 4The parties undertook the deposition of Dr. Mahmoudi on September 23, 2019, and inquired with respect to the relationship between applicant’s industrial injury in 2008 and the onset of diabetes in 2016. The QME confirmed that not everyone who experiences weight gain following an injury will develop diabetes. (Ex. J19, Transcript of Deposition of Massoud Mahmoudi, D.O., dated September 23, 2019, at p. 35:20.) The QME observed, “[applicant is] a specific person with a specific injury, so many things happened after the musculoskeletal injury, gaining weight, put on a bunch of different medications, which ordinarily somebody who’s obese does not take that much ibuprofen, and so we’re talking about a specific person, so we cannot generalize it.” (Id. at p. 37:1.) In response to inquiries by the parties, Dr. Mahmoudi explained in a 2021 supplemental report that “the causation link is the fall, the diabetes followed a trend of inactivity, weight gain, and finally diabetes.” (Ex. J18, Report of Massoud Mahmoudi, D.O., Ph.D., dated February 18, 2021, at p. 4.) The QME stated:

Opined that impairments from hypertension, diabetes, and sleep disturbance should be added rather than combined, but this was rejected due to lack of industrial causation for diabetes and sleep disturbance and lack of persuasive discussion for addition.

The WCJ and WCAB found no reasonable basis to depart from the Combined Values Chart as described in the permanent disability rating schedule.

From the decision · page 10(Ex. J19, Transcript of the Deposition of Massoud Mahmoudi, D.O., dated September 23, 2019, at p. 45:2.) Dr. Mahmoudi thus opines that the impairment arising out of applicant’s hypertensive, diabetic, and sleep impairment conditions should be added together. However, the WCJ has determined that applicant has not sustained her burden of establishing the latter two conditions of diabetes and sleep impairment are industrial, a determination which we affirm herein. Accordingly, there is no basis for the addition of the internal medicine conditions pursuant to Kite, supra, 78 Cal.Comp.Cases 213, or Vigil, supra, 89 Cal.Comp.Cases 686. Moreover, to the extent that applicant avers that her orthopedic or other impairment ratings should be added to her hypertension impairment rating, the record offers no specific, persuasive discussion from Dr. Mahmoudi or the other medical-legal evaluators addressing why the combination of the various ratings using the CVC is contraindicated, or why the addition of the hypertension rating to other specified body parts/systems is a more accurate reflection of applicant’s overall disability.

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 must set forth reasoning in support of conclusions.

Applied to evaluate the sufficiency of QME opinions on industrial causation of diabetes and sleep loss.

From the decision · page 9We cannot emphasize enough that 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), (emphasis added).) The term ‘synergy’ is not a “magic word” that immediately rebuts the use of the CVC. Instead, a physician must set forth a reasoned analysis explaining how and why synergistic ADL overlap exists. If parties are searching for a magic word to use during a doctor’s deposition, that word is “Why?”. Rather than focusing on whether a specific term, including the term synergy, was used, it is imperative that parties focus on an analysis that applies critical thinking based on the principles articulated in Escobedo to support a conclusion based on the facts of the case. Such an analysis must include a detailed description of the impact of ADLs and how those ADLs interact.

Lab. Code, §§ 4660, 4660.1; Ogilvie v. Workers’ Comp. Appeals Bd. (2011) 197 Cal.App.4th 1262; Kite, 78 Cal.Comp.Cases 213; Vigil, 89 Cal.Comp.Cases 686

Permanent Disability Rating Schedule (PDRS) and Combined Values Chart (CVC) are prima facie evidence of permanent disability; CVC is rebuttable with substantial medical evidence showing no overlap or synergistic effect on ADLs.

Applied to determine appropriate method for combining or adding impairment ratings.

From the decision · page 7Mahmoudi has opined that the resulting impairments should be added, rather than combined using the CVC. (Petition, at p. 14:10.) The Permanent Disability Rating Schedule (PDRS) is prima facie evidence of an injured employee’s permanent disability. (Lab. Code, §§ 4660, 4660.1; Ogilvie v. Workers’ Comp. Appeals Bd. (2011) 197 Cal.App.4th 1262, 1274–1277 [76 Cal.Comp.Cases 624] (Ogilvie).) The PDRS provides that the ratings for multiple body parts arising out of the same injury are “generally” combined using the Combined Values Chart (CVC), which is appended to the PDRS. (2005 PDRS, at p. 1-10.) Yet, because it is part of the PDRS, the CVC is rebuttable and a reporting physician is not precluded from utilizing a method other than the CVC to determine an employee’s whole person impairment so long as the physician’s opinion remains within the four corners of the AMA Guides. (Lab. Code, § 4660; Guzman, supra, 187 Cal.App.4th at pp. 818–829.) Accordingly, the use of the multiple disabilities table is discretionary depending upon whether it produces a rating that fully compensates an applicant for the effects of his or her injury. (Mihesuah v. Workers’ Comp. Appeals Bd. (1976) 55 Cal.App.3d 720, 728 [41 Cal.Comp.Cases 81, 87] (Mihesuah).)

Applicant's weight fluctuated before and after injury; no evidence of deconditioning directly from injury; applicant provided no trial testimony on this.

From the decision · page 5evidence “must be determined by the material facts upon which his opinion was based and by the reasons given for his opinion.” (Ibid.) Here, the QME reasons that applicant’s industrial injury caused inactivity which in turn resulted in weight gain, which eight years after the injury crossed an unspecified threshold resulting in the onset of diabetes. In her Report, the WCJ weighs the evidence supporting the evidence responsive to each of these developments. The WCJ observes that applicant’s weight fluctuated both before and after her industrial injury, with evidence of weight gain prior to the injury, and weight loss shortly thereafter. (Report, at p. 6.) Applicant initially reported to the QME that her weight prior to the injury as 135 lbs., but medical record from 2-3 days after the injury reflect a weight of 150 lbs. (Ex. J12, Report of Massoud Mahmoudi, D.O., Ph.D., dated June 30, 2015, at pp.

Applicant's subjective complaints of sleep disturbance were inconsistent with objective Epworth Sleepiness Scale and polysomnography test results.

From the decision · page 6Mahmoudi that she requires “medication to sleep; that her sleep remains fitful every night as reported by her husband; that Applicant complains of nightmares in which she is being stabbed in the neck; that when Applicant wakes in the morning, she is unrefreshed and neck pain is present; and that especially poor incidents of disturbed sleep coincided with ‘handwriting at work’ and [working] longer hours around the holidays.” (Petition, at p. 10:16.) Defendant’s Answer responds, however, that “[a]ll evidence cited by Applicant within the Petition relies upon the alleged subjective complaints raised by Applicant related to sleep disturbances.” (Answer, at p. 6:8.) The WCJ agreed, observing that in his initial evaluation in 2015 Dr. Mahmoudi administered an Epworth Sleepiness Scale test, wherein applicant scored 0 out of 24 points. (Ex. J12, Report of Massoud Mahmoudi, D.O., Ph.D., dated June 30, 2015, at p. 7.) This result was consistent with a prior administration of the Epworth testing as administered by Charles Martin, D.C., on February 9, 2015, also scored at 0 out of 24. (Ibid.) Dr. Mahmoudi nonetheless noted that “[a]lthough the Epworth was zero, due to sedation during the day, snoring, and weight gain I recommend a sleep study.” (Id. at p. 19.)