Kelley: A Carpal-Tunnel Rating Needed Better Medical Reasoning

After carpal-tunnel surgery, pain, numbness or trouble gripping can still make ordinary tasks difficult. If your disability rating seems disconnected from those limits, the medical report should explain how it reached the rating. A higher percentage needs that explanation too.

In Kelley v. Lawrence Berkeley National Laboratory, No. ADJ15858070 (WCAB Apr. 8, 2024), a truck driver challenged a 12 percent permanent-disability award for injuries to both upper extremities. The Workers’ Compensation Appeals Board found gaps in all three physicians’ reports, rescinded the award and returned the case for further proceedings. The path forward was a better medical record, rather than simply choosing the largest number.

Three reports left different gaps

Robert Kelley’s former treating physician, Jude Shadday, D.O., described wrist pain, tingling and difficulty grasping and lifting. Kelley had undergone carpal-tunnel release surgery on both wrists. Shadday assigned 6 percent whole-person impairment and stated that the standard rating under the AMA Guides was appropriate.

The Board’s assessment of Shadday’s report in Kelley focused on its foundation. The brief account of the history and examination made their adequacy difficult to assess. More decisively, the report gave conclusions without a solid medical explanation supporting them.

The qualified medical evaluator, Michael Kulick, M.D., examined Kelley and agreed with Shadday’s 6 percent whole-person impairment. But Kulick relied on Shadday’s reporting without disclosing an adequate independent basis for that rating. He had not reviewed the later report from Kelley’s new treating physician. That left the Board unable to rely on his rating either.

The new treating physician, Babak Jamasbi, M.D., supplied more detail. He took a history, examined Kelley and organized an extensive medical-record review. His report described repeated, reproducible grip measurements and explained a calculation using median-nerve pain and sensory impairment. That calculation produced 16 percent impairment for each upper extremity, which converted to 10 percent whole-person impairment each, combined to 19 percent.

Still, the discussion of Jamasbi’s report in Kelley identified a missing link. The report did not adequately explain why a departure from the strict application of the Guides was necessary or how the resulting whole-person impairment was justified. Its greater detail and higher percentage did not cure that gap.

An alternative rating needs a medical explanation

The rating schedule begins with the AMA Guides to the Evaluation of Permanent Impairment. A physician may use clinical judgment and another chapter, table or method within the Guides when it more accurately describes the impairment. The physician must explain the choice.

Kelley applied Milpitas Unified School District v. Workers’ Compensation Appeals Board (Guzman), 187 Cal.App.4th 808, 828–829 (2010). Its four-part explanation of the rating method calls for the physician to:

• Give the rating under a strict application of the Guides.
• Explain why that rating does not accurately reflect the worker’s impairment.
• Identify an alternative rating within the Guides.
• Explain why the alternative more accurately reflects the worker’s condition.

Those steps connect the medical findings to the proposed rating. Naming Almaraz/Guzman or stating that a percentage is accurate does not provide the medical reasoning. In Kelley’s case, the Board examined the actual explanation behind each report before deciding whether it could support an award.

For injuries on or after January 1, 2013, Labor Code section 4660.1(h) preserves the court’s holding in Guzman. Kelley’s claimed injury extended through May 2021. The Board’s analysis therefore has a practical use for workers whose rating dispute concerns how the Guides were applied to their actual limitations.

Whole-person impairment is one step in the disability rating

The numbers in this case describe different things. Six percent and 19 percent were competing medical assessments of whole-person impairment. Twelve percent was the permanent-disability rating in the judge’s award. They cannot be compared as though they were interchangeable final benefit percentages.

The order in Kelley rescinded the January 2024 findings and award. The Board returned the case for further proceedings; it did not substitute a new disability percentage. The medical reports needed a sufficient foundation before the disability dispute could be resolved on a developed record.

For a worker reviewing a rating, ask which number is the physician’s impairment assessment and which is the resulting permanent-disability rating. Then examine the medical reasons and the rating calculation supporting the disputed award. That keeps a disagreement about a medical method from becoming a misleading comparison between unlike numbers.

The Board returned the case for a better record

The defect was broader than one report losing to another. The Board concluded that none of the three reports supplied substantial medical evidence on the disputed rating. It explained its authority to develop an inadequate record and found that further reporting from Jamasbi appeared appropriate.

The directions for further proceedings in Kelley recommended a status conference so the judge could determine how discovery should proceed. The point of further reporting was to answer the medical questions left open by the existing reports, including the reason for the proposed rating method.

The Board also addressed a specific obstacle Kelley had raised: Getting an electromyography test, or EMG, approved through utilization review on the existing record. The judge had agreed that testing could help. The panel strongly encouraged the employer to authorize EMG testing and sensory and motor nerve-conduction studies to expedite the process.

That encouragement was separate from the formal order granting reconsideration and rescinding the award. It identified testing that could assist this record’s development. Counsel still needed to address the medical evidence and the procedures for obtaining it in the returned case.

Review the reasoning before comparing percentages

Keep every version of the treating physician’s and evaluator’s reports, including supplements and the medical records they identify. Compare the history, examination findings, ongoing hand limitations and stated reasons for the rating. Note whether a later report was available to the evaluator and whether it addresses a criticism of an earlier report.

If an alternative method is proposed, ask counsel to identify the doctor’s explanation for each step: The standard rating, its shortcomings for this worker, the alternative method and why the alternative fits the medical findings better. A response that repeats the percentage may leave the central problem unresolved.

Our Radilla analysis addresses the separate question of adding rather than combining impairments. Kelley concerns the foundation for the medical impairment assessment itself. Identifying which question the evidence must answer helps make a rating challenge specific and useful.