Charleston Area Med. Ctr. v. Thaxton

• Docket Number: 24-ICA-488
• Decision Date: 06 June 2025
• Citation: Charleston Area Med. Ctr. v. Thaxton, 24-ICA-488 (W. Va. ICA Jun 06, 2025)
• Parties: CHARLESTON AREA MEDICAL CENTER, INC., Employer Below, Petitioner v. KERRI THAXTON, Claimant Below, Respondent
• Court: West Virginia Intermediate Court of Appeals

1

CHARLESTON AREA MEDICAL CENTER, INC., Employer Below, Petitioner v. KERRI THAXTON, Claimant Below, Respondent

No. 24-ICA-488

West Virginia Intermediate Court of Appeals

June 6, 2025

(JCN 2022002009).

MEMORANDUM DECISION

Petitioner Charleston Area Medical Center ("CAMC") appeals the November 7, 2024, order of the Workers' Compensation Board of Review("Board").RespondentKerri L Thaxton filed a response.^[1] CAMC filed a reply.The issue on appeal is whether the Board erred in reversing the claim administrator's order, which denied the request of Ms Thaxton's treating surgeon, David Ede, M.D., to refer Ms Thaxton for a second opinion regarding treatment for the compensable injury to her right shoulder.

This Court has jurisdiction over this appeal pursuant to West Virginia Code § 51-11-4(2024).After considering the parties' arguments, the record on appeal, and the applicable law, this Court finds no substantial question of law and no prejudicial error.For these reasons, a memorandum decision affirming the Board's order is appropriate under Rule 21 of the Rules of Appellate Procedure.

On July 21, 2021, Ms. Thaxton sustained an occupational injury to her right shoulder while working for CAMC at its Teays Valley Hospital location.The occupational injury occurred while Ms. Thaxton was pulling a patient off of a hospital bed.Right shoulder x-rays were performed on July 26, 2021.The findings were that the bones and soft tissues were unremarkable, and there was no evidence of fracture or dislocation.The claim administrator issued an order dated August 12, 2021, holding the claim compensable for strain of unspecified muscle, fascia, and tendon at shoulder and upper arm level, initial encounter.

Ms. Thaxton underwent a right shoulder MRI on August 17, 2021, which revealed: (1) probable anterior superior labral tear; (2) mild diffuse glenohumeral cartilage thinning; (3) loss of normal fat signal in the rotator interval suggestive of adhesive capsulitis; (4) mild acromioclavicular joint osteoarthritis; (5) mild subacromial bursitis; and (6) abnormal diffuse low T1 signal, likely red marrow hyperplasia/related to anemia but nonspecific.

On August 24, 2021, Ms. Thaxton was seen at the CAMC Orthopedics Clinic by Tyler Halstead, PA-C, who noted that Ms. Thaxton reported right shoulder pain and limited range of motion, as well as that she had attended two physical therapy sessions in an attempt to address those issues.PA Halstead further noted that the MRI of the right shoulder showed subacromial bursitis, mild arthritis, and a probable SLAP tear.The assessment was SLAP lesion of right shoulder for which PA Halstead recommended a subacromial cortisone injection and increased physical therapy.PA Halstead's clinic notes also listed a diagnosis of subacromial bursitis of right shoulder joint.

Ms. Thaxton had follow-up appointment on October 12, 2021, and was examined by Dr. Ede.At that time, Ms. Thaxton reported excellent improvement with physical therapy.Dr. Ede advised her to continue light exercise for continued maintenance of the injury and released her to return to full duty work on October 18, 2021.However, Dr. Ede informed Ms. Thaxton that if she developed recurrent or worsening symptoms, surgical repair may be necessary.

Ms. Thaxton underwent an independent medical examination ("IME") with David Soulsby, M.D., on December 7, 2021.During the IME, Ms. Thaxton reported that her right shoulder was gradually getting worse.Specifically, she indicated that her range of motion and flexion continued to be painful, there was pain any time she attempted to raise her arm to the front, she experienced popping sensations, her arm had gone "dead" on one or two occasions, and that she had clavicle pain.Dr. Soulsby's assessment was labral tear right shoulder and impingement syndrome right shoulder.He determined that Ms. Thaxton had not reached maximum medical improvement ("MMI").Dr. Soulsby also found that further treatment was necessary because the injury was five months old and reasonable nonsurgical treatment had been unsuccessful.He opined that an arthroscopic evaluation of the shoulder with repair of the SLAP lesion and correction of the impingement syndrome was indicated.Dr. Soulsby evaluated Ms. Thaxton a second time on March 28, 2022.It was determined that her condition had not improved and that she had not reached MMI.

During a follow-up appointment on December 14, 2021, Dr. Ede and Ms. Thaxton discussed surgery for the right shoulder SLAP tear.On April 14, 2022, the claim administrator approved Dr. Ede's request for right shoulder arthroscopy with SLAP repair versus biceps tenodesis with possible subacromial decompression.

Dr. Ede performed surgery on May 2, 2022, for the preoperative diagnosis of SLAP tear right shoulder and the postoperative diagnosis of SLAP tear right shoulder and subscapularis partial tendon tear.The procedure performed was right shoulder arthroscopy with repair superior labrum anterior posterior tear and repair partial tear subscapularis tendon, right shoulder.

On September 20, 2022, the claim administrator approved Dr. Ede's request for an MRI arthrogram of Ms. Thaxton's right shoulder.The MRI was performed on September 27, 2022.Ms. Thaxton returned to Dr. Ede for a follow-up examination on October 4, 2022.At that time, Dr. Ede noted that Ms. Thaxton continued to have postsurgical pain in her right shoulder when performing certain movements.Dr. Ede opined that her subscapularis repair did not heal, and he recommended a revision subscapularis tendon repair.By order dated October 19, 2022, the claim administrator approved Dr. Ede's request to perform a right shoulder arthroscopy with revision subscapularis tendon repair.

On October 26, 2022, Dr. Ede performed a right shoulder arthroscopy with debridement of partial subscapularis tendon tear, biceps tenotomy, right shoulder.Ms. Thaxton's preoperative diagnosis was right shoulder pain status post arthroscopy with subscapularis tendon repair and SLAP repair.Her postoperative diagnosis was bicipital tendonitis and labral inflammation with very small subscapularis tendon tear.

Ms. Thaxton had a post-surgical follow-up with Dr. Ede on November 8, 2022.She reported that she had gone to physical therapy three times and rated her pain as a 4 out of 10.Dr. Ede recommended that Ms. Thaxton continue physical therapy and complete treatment.He discussed with her that there was a lot of inflammation around the labrum and biceps tendon.As such, Dr. Ede indicated to Ms. Thaxton that a biceps tenotomy would be a good surgical option for treatment.At this appointment, Dr. Ede administered a cortisone injection to address the inflammation.

Ms. Thaxton underwent an MRI of her right shoulder on May 9, 2023.The impression was degeneration and tear of anterior superior labrum.At a subsequent appointment on May 16, 2023, Dr. Ede noted that Ms. Thaxton reported her pain as 3 out of 10, she had limited range of motion and was experiencing right shoulder pain anterolaterally.Dr. Ede observed that Ms. Thaxton continued to have the anterolateral shoulder pain despite failed SLAP repair treated with biceps tenotomy.He indicated that the MRI was unrevealing in terms of finding an identifiable pathology for treatment, and that he would refer her for a second opinion.

Dr Soulsby evaluated Ms. Thaxton for a third time on June 7, 2023.He noted that she reported some improvement following her second surgery but that she was still experiencing discomfort.Specifically, Dr. Soulsby noted that Ms. Thaxton reported that she continued to have pain in the anterior and lateral aspect of the right shoulder, which was intermittent and associated with lifting, reaching overhead, and activities such as drying her hair.The second surgery relieved the constant pain.Ms. Thaxton reported that her motion was improving but was still somewhat limited, and...