Kluttz-Ellison v. Noah's Playloft Preschool

IN THE COURT OF APPEALS OF NORTH CAROLINA

2022-NCCOA-290

No. COA21-356

Filed 3 May 2022

I.C. Nos. 13-762104, 15-730144

ROBIN KLUTTZ-ELLISON, Employee, Plaintiff,

v.

NOAH’S PLAYLOFT PRESCHOOL, Employer, and ERIE INSURANCE GROUP,

Carrier, Defendants.

Appeal by Defendants from Opinion and Award entered 11 March 2021 by the

North Carolina Industrial Commission. Heard in the Court of Appeals 25 January

2022.

Shelby, Pethel & Hudson, P.A., by David A. Shelby, for Plaintiff-Appellee.

Hedrick Gardner Kincheloe & Garofalo, PLLC, by M. Duane Jones and Lindsay

N. Wikle, for Defendant-Appellants.

JACKSON, Judge.

¶1 Noah’s Playloft Preschool (“Defendant Noah’s Playloft”) and Erie Insurance

Group (“Defendant Erie”) (collectively “Defendants”) appeal an Opinion and Award

by the North Carolina Industrial Commission. After careful review, we affirm.

I. Background

¶2 This worker’s compensation case involves one claimant, Robin Kluttz-Ellison

(“Plaintiff”), who filed two separate claims following two different workplace

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accidents. The claims were eventually consolidated for hearing.

5 August 2013 Accident

¶3 Plaintiff is the owner and director of Noah’s Playloft Preschool, Inc. in

Salisbury, North Carolina. In 2010, Plaintiff underwent a total right knee

replacement performed by Dr. William Furr. On 5 August 2013, Plaintiff sustained

an injury to her left and right knees and left shoulder after falling off a ladder while

changing a lightbulb at the preschool. Plaintiff claimed workers’ compensation

benefits for injuries to her upper left extremity, both knees, both hips, and her neck.

Defendants accepted Plaintiff’s claim for her left knee injury but denied the

compensability of the injuries Plaintiff claimed for her left shoulder and right knee.

Defendants did, however, consent to pay for a one-time evaluation of Plaintiff’s right

knee by Dr. Marcus P. Cook, an orthopedic surgeon.

¶4 The disputed claims came on for a full evidentiary hearing before Deputy

Commissioner David Mark Hullender on 6 June 2016. Deputy Commissioner

Hullender entered an Opinion and Award on 12 December 2016. Based on the

testimony of Dr. Furr, who evaluated Plaintiff after the work accident, Deputy

Commissioner Hullender found in part that “Dr. Furr opined that there may be some

slight loosening of the hardware in Plaintiff’s right knee.” Deputy Commissioner

Hullender concluded that “Plaintiff sustained a material aggravation of her pre-

existing right knee condition and left shoulder condition . . . .” Deputy Commissioner

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Hullender awarded Plaintiff future medical treatment “including, but not limited to,

evaluation by [orthopedic surgeon Dr. James Comadoll] for her right knee and left

arm issues, possible revision of right knee arthroplasty and further physical therapy

to effect a cure or give relief to Plaintiff’s right knee and left shoulder pursuant to

N.C. Gen. Stat. § 97-25 and § 97-25.1.” Defendants subsequently provided Plaintiff

with an evaluation by Dr. Comadoll’s office on 7 February 2017.

15 May 2015 Accident

¶5 On 15 May 2015, Plaintiff tripped and fell over a child’s sleeping cot, landing

on her knees, and hitting her arm on a wooden cubby while working at the preschool.

Plaintiff filed for workers’ compensation benefits listing injuries to her right elbow,

hand, and lower arm as well as both knees. On 22 March 2016, Plaintiff filed a second

claim related to the 15 May 2015 accident, listing injuries to “her left lower arm,

elbow, hand and any other injuries causally related.” On 2 May 2017, Defendants

denied Plaintiff’s claim for benefits deriving from carpal tunnel syndrome in her left

hand as being unrelated to the 5 August 2013 accident. On 16 June 2017, Defendants

filed a second form denying Plaintiff’s claim for left carpal tunnel issues as being

unrelated to the 15 May 2015 accident.

Consolidation of Claims

¶6 On 25 August 2017, Plaintiff requested that her claim for injuries to her left

lower arm, elbow, hand, and other causally related injuries stemming from the 15

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May 2015 accident be assigning for hearing. On 13 September 2017, Plaintiff

requested that her claim for injuries to her left shoulder, both knees, hip, and neck

stemming from the 5 August 2013 accident be assigned for hearing, claiming that

Defendants had failed to authorize medical treatment recommended by Plaintiff’s

authorized treating physician. The claims were consolidated for hearing and the

matter came on for a full evidentiary hearing before Deputy Commissioner Jesse M.

Tillman on 27 April 2018.

¶7 At the hearing, Plaintiff testified about the injuries she sustained from the

accidents on 5 August 2013 and 15 May 2015 as well as the symptoms she was

currently experiencing. Plaintiff also testified that she had tried to lose weight using

various diets and methods in the past but had been unsuccessful. Following the

hearing, Plaintiff submitted expert witness testimony via deposition of orthopedic

surgeon Dr. Thomas Ginn, primary care provider Dr. Ronnie Barrier, bariatric

surgeon Dr. Eric Mallico, orthopedic surgeon Dr. William Furr, and orthopedic

surgeon Dr. James Comadoll. The record closed on 19 October 2018.

¶8 Deputy Commissioner Tillman entered an Opinion and Award on 24 January

2019. Deputy Commissioner Tillman concluded that Plaintiff had not proven that

the loosening of hardware in her right knee and therefore the need for revision

surgery was caused by the 5 August 2013 and/or the 15 May 2015 accidents. Deputy

Commissioner Tillman thus also concluded that Plaintiff's need for bariatric surgery

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was not causally related to the workplace injuries and denied her claim for medical

compensation in the form of weight loss management. On 1 February 2019, Plaintiff

appealed to the Full Commission and a hearing was scheduled for 11 June 2019.

¶9 On 29 May 2019, Plaintiff underwent right knee surgery performed by

orthopedic surgeon Dr. John Masonis. On 10 June 2019, Plaintiff filed a Motion to

Submit Additional Evidence to the Full Commission. The Commission continued the

hearing to 1 August 2019 and held Plaintiff’s motion in abeyance to allow Plaintiff to

obtain Dr. Masonis’s surgical notes. On 9 July 2019, Plaintiff filed a Motion to Submit

Additional Evidence/Motion to Allow Additional Depositions, requesting Plaintiff be

allowed to take the deposition of Dr. Masonis and re-take the deposition of Dr.

Comadoll. The Commission held this motion in abeyance as well and allowed the

parties to be heard at oral argument on 1 August 2019. The Commission granted

Plaintiff’s motions on 17 September 2019 and the parties conducted a second

deposition of Dr. Comadoll on 17 October 2019. Plaintiff also submitted the medical

records from her right knee surgery.

¶ 10 On 7 December 2020, the Commission entered an Opinion and Award. The

Commission concluded that Plaintiff’s right knee condition and resulting medical

treatment was compensable and awarded payment for the 29 May 2019 right knee

surgery. The Commission concluded that Plaintiff had failed to establish that her

need for weight loss treatment was directly related to the 5 August 2013 compensable

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injury and denied her claim for bariatric surgery.

¶ 11 On 22 December 2020, Plaintiff filed a Motion for Reconsideration and a

Motion to Allow Additional Evidence, contending that while the Commission found

the emergent requirement for Plaintiff’s weight loss was her need for revision of her

right knee replacement, the Commission incorrectly concluded that her weight loss

treatment was not directly related to her 5 August 2013 compensable injury. Plaintiff

also requested that medical records from her gastric bypass surgery, which was

performed on 5 November 2018, be admitted. On 29 December 2020, Defendants filed

a response, arguing the Opinion and Award should not be amended and Plaintiff

could have sought admission of the medical records when the record was reopened by

the Commission on 17 September 2019.

¶ 12 On 11 March 2021, without admitting additional evidence, the Commission

entered an Amended Opinion and Award, concluding that bariatric surgery was

medically necessary for Plaintiff to undergo right knee surgery and awarding

Plaintiff payment of medical expenses related to her gastric bypass surgery.

¶ 13 Defendants entered timely notice of appeal on 25 March 2021.

II. Analysis

¶ 14 Defendants’ appeal is limited to the Full Commission’s award of medical

treatment for Plaintiff’s right knee and bariatric surgeries.

A. Motions to Add Additional Evidence

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¶ 15 Defendants argue first that the Commission erred in granting Plaintiff’s 10

June 2019 and 9 July 2019 motions to add additional evidence because Plaintiff never

provided the necessary good grounds.

¶ 16 “Under our Workers’ Compensation Act, ‘the Commission is the fact finding

body.’” Adams v. AVX Corp., 349 N.C. 676, 680, 509 S.E.2d 411, 413 (1998) (quoting

Brewer v. Powers Trucking Co., 256 N.C. 175, 182, 123, S.E.2d 608, 613 (1962)).

Accordingly, “[t]he Commission has plenary power to receive additional evidence,”

Cummins v. BCCI Constr. Enters., 149 N.C. App. 180, 183, 560 S.E.2d 369, 371

(2002), “[i]f application is made to the Commission within 15 days from the date when

notice of award shall have been given . . . and, if good ground[s] be shown therefor[,]”

N.C. Gen. Stat. § 97-85(a) (2021). “[W]hether ‘good ground[s] be shown therefore’ in

any particular case is a matter within the sound discretion of the Commission, and

the Commission’s determination in that regard will not be reviewed on appeal absent

a showing of manifest abuse of discretion.” Lynch v. M. B. Kahn Constr. Co., 41 N.C.

App. 127, 131, 254 S.E.2d 236, 238 (1979). “A trial court may be reversed for abuse

of discretion only upon a showing that its actions are manifestly unsupported by

reason.” White v. White, 312 N.C. 770, 777, 324 S.E.2d 829, 833 (1985).

¶ 17 To determine whether the Commission abused its discretion in finding that

good grounds existed “to reopen the record for receipt of additional evidence in the

form of Plaintiff’s medical records regarding her May 29, 2019 revision of her right

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total knee arthroplasty and deposition testimonies from Dr. Masonis and Dr.

Comadoll[,]” we examine the reasons proffered by Plaintiff in her motions to allow

additional evidence.

¶ 18 When appealing Deputy Commissioner Tillman’s 24 January 2019 Opinion

and Award to the Full Commission, Plaintiff appealed Deputy Commissioner

Tillman’s conclusion that she had failed to prove that the loosening of the hardware

in her right knee and the related need for right knee surgery was caused by the 5

August 2013 accident. This conclusion was based in part on Deputy Commissioner

Tillman’s Finding of Fact 42:

42. Dr. Comadoll explained that trauma

characteristically would not cause Plaintiff’s hardware to

loosen. Typically, bone fracture would occur with trauma

that causes the loosening of arthroplasty hardware. There

is no evidence of bone fracture.

¶ 19 Plaintiff had yet to undergo the right knee surgery performed by Dr. Masonis

when Deputy Commissioner Tillman closed the record on 19 October 2018.

Accordingly, Plaintiff asserted the following in her 10 June 2019 Motion to Allow

Additional Evidence:

6. Upon information and belief intra-operative findings

made by Dr. Masonis at the time of Plaintiff’s revision

surgery may have direct implications on the issue of

whether Plaintiff’s August 5, 2013 injury by accident

caused the loosening of Plaintiff’s hardware.

7. Specifically, Dr. Comadoll testified, as the basis for

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Findings of Fact 42 and 43 that “bone fracture would occur

with trauma that causes loosening of arthroplasty

hardware.” Plaintiff upon information and belief, asserts

Dr. Masonis’ intraoperative findings may have a direct

bearing on whether fractures existed.

¶ 20 In her second motion for additional evidence, filed 9 July 2019, Plaintiff also

asserted:

4. Plaintiff believes that the necessity for the total knee

revision surgery was caused or aggravated by her August

5, 2013 fall at work.

5. Dr. James Comadoll, who treated Plaintiff for her

knee problems prior to Dr. Masonis, has reviewed

Plaintiff’s recent medical records and has signed an

affidavit in reference to that review. Based upon said

affidavit, Plaintiff believes Dr. Comadoll’s testimony will

be materially different based upon the findings and records

of Dr. Masonis.

¶ 21 Defendants argue that “no new evidence was produced to justify reopening the

evidentiary record” because Dr. Comadoll testified in his second deposition that Dr.

Masonis’s surgical notes indicated there was no fracturing of Plaintiff’s bone, as Dr.

Comadoll expected. Even if, as Defendants contend, the additional evidence was not

relied upon by Dr. Comadoll in the specific way that Plaintiff suggested it would be

in her motions, that does not negate the existence of good grounds to allow Plaintiff

to submit the medical records of her right knee surgery and re-depose Dr. Comadoll.

Our review of the Commission’s ruling does not occur in retrospect, but rather

examines the Commission’s prospective reasoning for reopening the record. Given

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the unavailability of Dr. Masonis’s surgical notes prior to Deputy Commissioner

Tillman issuing an Opinion and Award on 24 January 2019, Plaintiff showed the

necessary good grounds to submit additional evidence to the Commission and the

Commission’s decision to admit the additional evidence was not manifestly

unsupported by reason.

¶ 22 Defendants also argue that Plaintiff essentially used Dr. Comadoll’s second

deposition to “offer[] a new legal theory of out whole cloth, and ask[] Dr. Comadoll to

opine on that theory.” More particularly, Defendants label Plaintiff’s argument that

her 5 August 2013 work accident materially aggravated the pre-existing condition in

Plaintiff’s right knee as the new legal theory. Defendants contend they had no notice

of this argument until Plaintiff filed her supplemental brief within 30 days of Dr.

Comadoll’s deposition as allowed by the Commission’s 17 September 2019 order.1

Defendants argue that Plaintiff did not assert this theory in her motions or properly

preserve it in her Form 44 Application for Review to the Commission.

¶ 23 Rule 701 of the North Carolina Industrial Commission directs that “appellant

shall submit a Form 44 Application for Review stating with particularity all

assignments of error and grounds for review . . . .” 11 N.C. Admin. Code 23A.0701(d)

(2021). “Grounds for review and assignments of error not set forth in the Form 44

1 The briefs and supplemental briefs submitted by the parties to the Full Commission

do not appear in the Record on Appeal.

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Application for Review are deemed abandoned, and argument thereon shall not be

heard before the Full Commission.” Id. Typically, our Court has held this rule was

violated where the appellant failed to submit a Form 44 or to set forth the grounds

for appeal with particularity in another document such as a brief, but the Commission

nevertheless issued an Opinion and Award. See Roberts v. Wal-Mart Stores, Inc., 173

N.C. App. 740, 744, 619 S.E.2d 907, 910 (2005); Cooper v. BHT Enters., 195 N.C. App.

363, 368-69, 672 S.E.2d 748, 753-54 (2009).

¶ 24 In her Form 44, Plaintiff alleges

4. Specifically, Deputy Commissioner Tillman’s

Finding of Fact Number 35 finding that “The December 12,

2016 Opinion and Award does not conclude that if there is

hardware loosening, it was the direct result of the August

5, 2013 incident . . .” is error and contrary to Deputy

Hullender’s Opinion and Award. Plaintiff contends it was

error for Deputy Commissioner Tillman not to find the

issue of whether plaintiff’s hardware was loose, and that

loosening was caused by plaintiff’s August 5, 2013 accident

was precluded from determination by him and barred from

his consideration by res judicata.

Deputy Commissioner Tillman’s Finding of Fact 35 stated:

35. Deputy Commissioner Hullender, in his December

12, 2016 Opinion and Award, found as fact that Dr. Furr

stated that he was fearful that Plaintiff suffered some type

of trauma around her right knee prosthetic installed before

Plaintiff’s workplace accident of August 5, 2013 which

could have resulted in the loosening of the hardware within

the prostheses. The December 12, 2016 Opinion and

Award does not conclude that if there is hardware

loosening, it was a direct result of the August 5, 2013

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incident and refers Plaintiff for further evaluation and

treatment of her right knee at the direction of Dr.

Comadoll, pursuant to N.C. Gen. Stat. § 97-25[.]

¶ 25 In the 12 December 2016 Opinion and Award, Deputy Commissioner

Hullender made several findings about the testimony of Dr. Furr, the orthopedic

surgeon who performed Plaintiff’s original right knee replacement and evaluated

Plaintiff in 2013 and 2014 after her work accident. These findings included the

following:

40. Dr. Furr stated that in Plaintiff’s case he was fearful

that she had some type of trauma around her prosthesis,

particularly on the tibial component, and the bone scan

shows signs of loosening.

41. Dr. Furr stated that several factors are looked at

when determining whether there has been some trauma or

aggravation of a prosthetic by a fall including bone scans,

conditions before and after the reported fall, and other

diagnostic testing. Based on all of these factors, Dr. Furr

opined that Plaintiff injured both of her knees when she

fell off the ladder on August 5, 2013. Dr. Furr further

opined that when Plaintiff fell, she may have received some

type of trauma to the tibia which was enough to cause some

loosening.

...

44. Dr. Furr opined that Plaintiff had “some type of

manipulation where there was a twisting or manipulation

of the knee itself and make a contusion” and the “injury

resulted in her having continuous symptomology to the

point where ten months later a bone scan showed some

loosening.” While Dr. Furr cannot tell whether the

loosening is getting better or worse, he opined that “the

manipulation or injury itself from the fall is what initiated,

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aggressed, or aggravated this to occur.”

(Emphasis added.) Deputy Commissioner Hullender subsequently concluded that:

“The preponderance of the competent, credible evidence in the record established that

Plaintiff did sustain a material aggravation of her right knee and left shoulder as a

result of the August 5, 2013 accident.”

¶ 26 Although Plaintiff did not use the words “material aggravation” in her Form

44, we conclude that she satisfied her obligation to state with particularity the

assignments of error and grounds for review. Deputy Commissioner Hullender’s

conclusion that Plaintiff had sustained a material aggravation of her right knee was

rooted in his findings regarding Dr. Furr’s testimony, which indicated there was

loosening and “the fall is what . . . aggravated this to occur.” Plaintiff stated in her

Form 44 “that loosening was caused by plaintiff’s August 5, 2013 accident was

precluded from determination by [Deputy Commissioner Tillman.]” This statement

is sufficient to put Defendants on notice of the material aggravation theory, especially

considering the clear reference to Deputy Commissioner Hullender’s Opinion and

Award and given the findings contained therein.

¶ 27 Furthermore, in Plaintiff’s 9 July 2019 Motion to Submit Additional Evidence

and to Allow Additional Depositions, Plaintiff stated her belief “that the necessity for

the total knee revision surgery was caused or aggravated by her August 5, 2013 fall

at work.” (Emphasis added.) This statement would have noticed the material

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aggravation theory to Defendants prior to the Full Commission hearing on 1 August

2019.

¶ 28 For these reasons, we hold that the Full Commission did not abuse its

discretion in allowing Plaintiff’s motions to submit additional evidence in the form of

medical records from Plaintiff’s right knee surgery and Dr. Comadoll’s second

deposition.

B. Right Knee Surgery

¶ 29 Defendants argue next that the Commission erred by concluding that they

failed to rebut the Parsons presumption in relation to Plaintiff’s right knee surgery

and by awarding Plaintiff payment for the cost of her right knee surgery. Defendants

challenge Findings of Fact 29, 30, and 31 as being unsupported by competent

evidence.

¶ 30 In a workers’ compensation appeal, “[t]he reviewing court’s inquiry is limited

to two issues: whether the Commission’s findings of fact are supported by competent

evidence and whether the Commission’s conclusions of law are justified by its findings

of fact.” Hendrix v. Linn-Corriher Corp., 317 N.C. 179, 186, 345 S.E.2d 374, 379

(1986). “The Commission’s findings of fact are conclusive on appeal when supported

by such competent evidence, even though there is evidence that would support

findings to the contrary.” McRae v. Toastmaster, Inc., 358 N.C. 488, 496, 597 S.E.2d

695, 700 (2004) (internal marks and citation omitted). “Thus, on appeal, an appellate

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court does not have the right to weigh the evidence and decide the issues on the basis

of its weight. The court’s duty goes no further than to determine whether the record

contains any evidence tending to support the finding.” Deese v. Champion Int’l Corp.,

352 N.C. 109, 115, 530 S.E.2d 549, 552 (2000) (internal marks and citation omitted).

“The Commission’s conclusions of law are reviewed de novo.” McRae, 358 N.C. at 496,

597 S.E.2d at 701.

¶ 31 A workers’ compensation claimant has the initial burden of proving the

compensability of an injury—“of showing that the injury complained of resulted from

the accident.” Snead v. Sandhurst Mills, Inc., 8 N.C. App. 447, 451, 174 S.E.2d 699,

702 (1970). After satisfying this burden, the claimant is entitled to a presumption

that any further medical treatment for the “very injury the Commission has

previously determined to be the result of a compensable accident” is directly related

to that compensable injury. Parsons v. Pantry, Inc., 126 N.C. App. 540, 542, 485

S.E.2d 867, 869 (1997). The claimant is not required to prove causation again to

receive compensation for treatment; rather, the defendant-employer must rebut the

Parsons presumption by proving “the original finding of compensable injury is

unrelated to [the] present discomfort.” Id. “The employer may rebut the presumption

with evidence that the medical treatment is not directly related to the compensable

injury.” Perez v. Am. Airlines/AMR Corp., 174 N.C. App. 128, 135, 620 S.E.2d 288,

292 (2005). This evidence can include “expert testimony or affirmative medical

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evidence[.]” Id. at 137, 620 S.E.2d at 293.

¶ 32 Defendants contend that the testimony given by Dr. Comadoll in his first

deposition was enough to rebut the Parsons presumption “that the work injury was

not related to the need for surgery[.]”

¶ 33 In his first deposition, Dr. Comadoll offered the following relevant testimony:

[Plaintiff’s Counsel:] Okay. Now . . . after your PA saw

Ms. Kluttz-Ellison, did you, at some point, see Ms. Kluttz-

Ellison?

[Dr. Comadoll:] Yes.

[Plaintiff’s Counsel:] And did you make a determination as

to whether or not her right knee hardware was loose?

[Dr. Comadoll:] Yeah. Her -- her -- the part on the shin

bone radiographically looked loose, at the minimum.

[Plaintiff’s Counsel:] In your opinion, does Plaintiff have

loose hardware in her right total knee?

[Dr. Comadoll:] Yes.

...

[Defendants’ Counsel:] Okay. So the factors in Ms.

Ellison’s case that the [sic] most likely caused her

hardware in her right knee to loosen are possibly how the

alignment was when the -- when the hardware was initially

put in, and the fact of her weight?

[Dr. Comadoll:] Yes, ma’am.

[Defendants’ Counsel:] Do you have any reason to believe

that the August 5th, 2013 incident caused her hardware to

loosen?

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[Dr. Comadoll:] No.

...

¶ 34 Plaintiff, on the other hand, argues that Defendants “ignore[d] Dr. Comadoll’s

testimony that the 5 August 2013 fall from the ladder materially aggravated

Plaintiff’s loose right knee hardware[.]”

¶ 35 In his second deposition, Dr. Comadoll offered the following relevant

testimony:

[Plaintiff’s Counsel:] All right. So, if I understand your

testimony, your testimony is not that the trauma caused

the loosening of the hardware; is that right?

[Dr. Comadoll:] Correct.

[Plaintiff’s Counsel:] But materially aggravated it?

[Dr. Comadoll:] Correct.

[Plaintiff’s Counsel:] After re-reviewing Dr. Masonis’

records today, is that still your opinion?

[Dr. Comadoll:] Yes, sir.

[Plaintiff’s Counsel:] And do you hold that opinion to a

reasonable degree of medical probability or certainty?

[Dr. Comadoll:] Yes, sir.

[Plaintiff’s Counsel:] Is that opinion based on your review

of Ms. Kluttz-Ellison’s medical records, your own

examinations and medical records, her diagnostic testing?

[Dr. Comadoll:] The x-rays.

[Plaintiff’s Counsel:] X-rays.

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[Dr. Comadoll:] Once it -- once it breaks free, it is going to

continue to move --

[Plaintiff’s Counsel:] Right.

[Dr. Comadoll:] -- and continue to shift. And once it takes

on load, it’s going to exponentially shift.

[Plaintiff’s Counsel:] And would a fall from five or six feet

off a ladder be the type of trauma that would aggravate

that loosening?

[Dr. Comadoll:] Yes, sir.

[Plaintiff’s Counsel:] And, in your opinion, based on the

description of the accident and the opinion and award that

you just read, would that have materially aggravated her

loosening such that it required revision of her knee?

[Dr. Comadoll:] It could, yes.

[Plaintiff’s Counsel:] All right. And is that more likely

than not, in fact, what happened in Ms. Kluttz-Ellison’s

case?

[Dr. Comadoll:] I don’t know.

[Plaintiff’s Counsel:] Okay.

[Dr. Comadoll:] If -- and you can correct me if I’m -- if she

had a loose tibia, which she did, it will continue to erode

the bone and she will necessitate a revision of her knee, no

matter what. It was just a matter if [sic] timing.

[Plaintiff’s Counsel:] Right.

[Dr. Comadoll:] Now, if you ask me did the fall potentiate

that and shorten that timeline, the answer is yes.

¶ 36 If we view the above evidence in a light to favor Defendants, we could describe

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the testimony Dr. Comadoll gave in his first and second depositions as contrarian:

that Dr. Comadoll first concluded the work accident did not cause the hardware to

loosen and then later concluded the work accident did cause the hardware to loosen

in the form of a material aggravation. If we view the evidence in a light to favor

Plaintiff, we could describe the testimony Dr. Comadoll gave in his second deposition

as a clarification of his first deposition: that the work accident did not cause Plaintiff’s

right knee hardware to loosen, rather it only accelerated the loosening of the

hardware through a material aggravation of the prosthesis. Ultimately, the Parsons

presumption is intended to serve as a benefit to plaintiffs and not a burden, but

regardless of how we treat the differences in Dr. Comadoll’s deposition testimony,

this issue is resolved by the fact the Parsons presumption applies to the material

aggravation theory of compensability for Plaintiff’s right knee injury. See Parsons,

126 N.C. App. at 542, 485 S.E.2d at 869 (asserting that requiring a plaintiff to reprove

causation “is unjust and violates our duty to interpret the Act in favor of injured

employees”).

¶ 37 In its Conclusion of Law 4, the Commission stated that “Plaintiff’s right knee

injury was determined to be compensable by Deputy Commissioner Hullender’s

December 12, 2016 Opinion and Award. As neither party appealed the award, it is

conclusive and binding.” Deputy Commissioner Hullender concluded the injury was

compensable because “Plaintiff sustained a material aggravation of her pre-existing

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right knee condition . . . .” The Parsons presumption therefore applied to Plaintiff’s

right knee injury and gave Plaintiff the benefit of a presumption that the requested

medical treatment for her right knee was necessitated by her 5 August 2013 work

accident. Defendants thus had to produce evidence that the medical treatment

Plaintiff sought—the total revision of her right knee replacement—was not directly

related to the material aggravation of Plaintiff’s right knee that resulted from the 5

August 2013 work accident.

¶ 38 In examining the whole of Dr. Comadoll’s first and second deposition

testimony, Defendants have not presented any expert witness testimony or other

affirmative medical evidence that the 5 August 2013 accident did not materially

aggravate Plaintiff’s pre-existing right knee condition. Dr. Comadoll’s testimony in

his first deposition that the work accident did not cause the loosening does not refute

or counter his testimony that the work accident materially aggravated the loosening

and accelerated the need for surgery. Defendants failed to produce evidence that the

work accident did not result in a material aggravation of Plaintiff’s right knee.

Accordingly, Defendants failed to overcome the Parsons presumption that applied to

Plaintiff’s right knee injury.

¶ 39 Based on Dr. Comadoll’s first and second deposition testimony, there was at

least some competent evidence to support Findings of Fact 29, 30, and 31. Those

findings in turn support the Commission’s conclusions of law that Plaintiff’s need for

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right knee surgery was related to her 5 August 2013 work accident. Accordingly, we

hold that the Full Commission did not err in awarding Plaintiff compensation for the

treatment of her right knee injury, namely for the cost of her 29 May 2019 revision

right total knee arthroplasty.

C. Bariatric Surgery

¶ 40 Defendants lastly argue that the Commission erred in awarding compensation

for Plaintiff’s bariatric surgery because it is not directly related to Plaintiff’s

compensable injury. Specifically, Defendants challenge Conclusion of Law 8 as being

unsupported by Findings of Fact 23 and 24.

¶ 41 Here, the Commission’s relevant findings are as follows:

23. Dr. Comadoll referred Plaintiff to Eric John Mallico,

M.D., a board-certified surgeon who focuses his practice on

laparoscopic surgery. Dr. Mallico testified that it is very

typical and a part of protocol to not allow a patient to

undergo knee joint replacement surgery until the BMI of a

patient is below 40. Because of Plaintiff’s attempts at

weight loss, her partial success in losing weight and the

tremendous amount of weight she needs to lose, it is Dr.

Mallico’s opinion that the only way for her to be successful

in reducing her weight to achieve a BMI below 40 is to

undergo bariatric surgery.

24. Ronnie Barrier, M.D., Plaintiff’s primary care

medical provider, an expert in family medicine, testified

that he would also recommend that Plaintiff reduce her

BMI below 40 before undergoing total left knee

replacement and revision right total knee arthroplasty.

Dr. Barrier testified that it would be healthier if Plaintiff

did lose weight, but the emergent requirement for loss of

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weight derives from her need for her left total knee

replacement or revision of her right total knee

replacement.

¶ 42 The Commission’s relevant conclusion is as follows:

8. When an employee suffers a compensable injury,

“[m]edical compensation shall be provided by the

employer.” N.C. Gen. Stat. § 97-25(a) (2020). Medical

compensation is defined as “medical, surgical, hospital,

nursing, and rehabilitative services . . . and other

treatment . . . as may reasonably be required to effect a

cure or give relief and for such additional time as, in the

judgment of the Commission, will tend to lessen the period

of disability . . . .” N.C. Gen. Stat. § 97-2(19) (2020)

(emphasis added). “[I]n case of a controversy arising

between the employer and the employee, the Industrial

Commission may order necessary treatment.” N.C. Gen.

Stat. § 97-25(c) (2020). Both Dr. Mallico and Dr. Barrier

opined that reduction of Plaintiff’s BMI was necessary for

Plaintiff’s safety and to achieve an optimal outcome from

the revision right total knee arthroplasty surgery

prescribed to treat her compensable right knee injury.

Therefore, subject to the provisions of N.C. Gen. Stat. § 97-

25.1, Plaintiff is entitled to payment of medical expenses

incurred as a result of her bariatric surgery, as such

surgery was medically necessary to assist Plaintiff achieve

an optimal BMI to allow her to undergo the May 29, 2019

revision right total knee arthroplasty. N.C. Gen. Stat.

§§ 97-2(19), 97-25, 97-25.1 (2020).

¶ 43 North Carolina General Statute § 97-25 “contains three grounds upon which

an employer must provide future medical expenses[.]” Little v. Penn Ventilator Co.,

317 N.C. 206, 211, 345 S.E.2d 204, 208 (1986). “In order for the Commission to grant

an employee’s request to change treatment or health care provider, the employee

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must show by a preponderance of the evidence that the change is reasonably

necessary to effect a cure, provide relief, or lessen the period of disability.” N.C. Gen.

Stat. § 97-25(c) (2021). “‘Logically implicit’ in this statute is the requirement that the

future medical treatment be ‘directly related to the original compensable injury.’”

Parsons, 126 N.C. App. at 542, 485 S.E.2d at 869 (quoting Pittman v. Thomas &

Howard, 122 N.C. App. 124, 130, 468 S.E.2d 283, 286, disc. rev. denied, 343 N.C. 513,

472 S.E.2d 18 (1996)).

¶ 44 The question before this Court is whether Plaintiff’s bariatric surgery is

directly related to the compensable injury caused by her work accident on 5 August

2013. To answer this question, we must determine the degree of connection that is

required between future medical treatment and a compensable injury for the

treatment to be considered “directly related.” In doing so, we are guided by our

Supreme Court’s foundational principle for addressing workers’ compensation cases:

“our Work[ers’] Compensation Act should be liberally construed to effectuate its

purpose to provide compensation for injured employees or their dependents, and its

benefits should not be denied by a technical, narrow, and strict construction.”

Hollman v. City of Raleigh, 273 N.C. 240, 252, 159 S.E.2d 874, 882 (1968); see also

Adams, 349 N.C. at 680, 509 S.E.2d at 413.

¶ 45 Defendants argue that Plaintiff’s weight problems were not caused by or

directly resulted from the 5 August 2013 work accident; rather, Plaintiff’s weight

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problem preexisted the accident and therefore her need to undergo bariatric surgery

is not directly related to the compensable injury. Defendants suggest that at most

the need for weight loss surgery is indirectly related. We disagree.

¶ 46 As Plaintiff’s counsel contended at oral argument, there is a direct line

connecting the dots between Plaintiff’s original compensable injury and the

Commission’s award for bariatric surgery. The 5 August 2013 work accident

materially aggravated Plaintiff’s preexisting right knee condition. This material

aggravation in turn necessitated that Plaintiff undergo right knee surgery (the 29

May 2019 revision right total knee arthroplasty). For Plaintiff to undergo knee

surgery, she had to lose weight. According to Dr. Mallico, Plaintiff could not lose

weight fast enough due to her physical limitations for the knee surgery to be

conducted safely and optimally without undergoing weight loss surgery. By

connecting the dots, we can conclude that but for Plaintiff’s need to have right knee

surgery to treat her compensable injury, she would not have needed to undergo

bariatric surgery. Therefore, while the existence of Plaintiff’s weight problem was

not directly related to the 5 August 2013 accident, the need for bariatric surgery is

directly related.

¶ 47 This result aligns with the spirit of N.C. Gen. Stat. § 97-25. “Th[e] rule of

causal relation is the very sheet anchor of the Work[ers’] Compensation Act. It has

kept the Act within the limits of its intended scope,—that of providing compensation

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benefits for industrial injuries, rather than branching out into the field of general

health insurance benefits.” Duncan v. City of Charlotte, 234 N.C. 86, 91, 66 S.E.2d

22, 25 (1951). The Commission made Findings of Fact 23 and 24, which Defendants

concede are supported by competent evidence, indicating that based on the testimony

of Dr. Mallico and Dr. Barrier the only way for Plaintiff to lose the weight needed to

undergo right knee surgery was to undergo bariatric surgery first. Thus, an award

for bariatric surgery is not branching out into the field of general health insurance

benefits.

¶ 48 Accordingly, we hold that the Commission’s Findings of Fact 23 and 24 support

its Conclusion of Law 8, and therefore the Commission did not err in awarding

Plaintiff compensation for bariatric surgery.

III. Conclusion

¶ 49 For the foregoing reasons, we conclude that the Full Commission did not err in

allowing Plaintiff’s motions to submit additional evidence and depositions, did not err

in concluding that Plaintiff’s need for right knee surgery was related to her work

accident, and did not err in concluding that Plaintiff’s need for bariatric surgery was

directly related to her compensable injury.

AFFIRMED.

Judges COLLINS and GORE concur.