Diabetes as a “Confounding Condition” Supports Denial of CTS Claims Where the Board Persuasively Credits Non-Occupational Causation

1. Introduction

In John Moore v. United Coal Company, LLC (W. Va. Apr. 24, 2026) (memorandum decision), the Supreme Court of Appeals of West Virginia affirmed the Intermediate Court of Appeals of West Virginia (“ICA”), which had affirmed the Workers’ Compensation Board of Review (“BOR”) and the claim administrator’s rejection of John Moore’s workers’ compensation claim for carpal tunnel syndrome (“CTS”) as non-compensable.

Parties: John Moore (claimant/petitioner), an underground coal miner for approximately eight years, and United Coal Company, LLC (employer/respondent).

Core dispute: Whether Moore’s bilateral CTS was an occupational disease “developed in the course of and resulting from” employment under West Virginia Code § 23-4-1(f), given evidence of extensive vibrating-tool use and an alternative causal factor—diabetes—recognized in the workers’ compensation rules as a condition that can contribute to CTS.

2. Summary of the Opinion

The Court summarily affirmed under W. Va. R. App. P. 21, holding there was no reversible error in the ICA’s decision upholding the BOR. The Court emphasized its review framework: questions of law are reviewed de novo, while the BOR’s factual findings receive deference unless “clearly wrong,” citing Syl. Pt. 3, Duff v. Kanawha Cnty. Comm'n, 250 W. Va. 510, 905 S.E.2d 528 (2024).

The ICA (as quoted by the Supreme Court) found Dr. Austin Nabet’s report “more complete” on compensability because it addressed Moore’s diabetes, and noted that W. Va. Code of State Rules § 85-20-41.4 lists diabetes among medical conditions that frequently produce or contribute to CTS. The Supreme Court did not reweigh the competing medical opinions and affirmed the administrative outcome.

Dissent: Justice Wooton would have found the claim compensable, reasoning that the two medical opinions were of equal weight and that West Virginia Code § 23-4-1g(a) requires ties to be resolved in the claimant’s favor after weighing all evidence.

3. Analysis

3.1. Precedents Cited

  • Duff v. Kanawha Cnty. Comm'n, 250 W. Va. 510, 905 S.E.2d 528 (2024) (Syl. Pt. 3)
    Role in the decision: The majority’s affirmance is anchored in Duff’s appellate review structure—legal issues de novo; factual findings by the BOR are upheld unless “clearly wrong.” This framing is decisive in a record with competing medical causation opinions: if the BOR’s choice between experts is plausible and supported, appellate courts will not substitute their own weighing.
  • Barnett v. State Workmens' Comp. Comm'r, 153 W. Va. 796, 172 S.E.2d 698 (1970) (Syl. Pt. 1)
    Role in the dissent: Provides the classic three-part compensability test: (1) personal injury, (2) received in the course of employment, and (3) resulting from that employment. The dissent uses Barnett to argue Moore met all three elements through his work history and objective testing.
  • Emmel v. State Comp. Dir., 150 W. Va. 277, 145 S.E.2d 29 (1965) (Syl. Pt. 3)
    Role in the dissent: Supplies the requirement of a “causal connection” between employment and injury. The dissent concludes the causal connection is established by Moore’s vibrating-tool duties combined with EMG/NCS-confirmed CTS.
  • Moore v. United Coal Co., LLC, No. 25-ICA-137, 2025 WL 2781461 (W. Va. Ct. App. Sept. 30, 2025)
    Role in the decision: The Supreme Court relies on the ICA’s reasoning that Dr. Nabet’s opinion better addressed compensability because it integrated diabetes as a non-occupational contributor recognized by rule (W. Va. Code State R. § 85-20-41.4).

3.2. Legal Reasoning

The majority’s reasoning is procedural and deferential rather than substantive. It identifies the governing review standard (Duff v. Kanawha Cnty. Comm'n), then concludes the record does not show the BOR was “clearly wrong” in crediting Dr. Nabet’s causation analysis over Dr. Kominsky’s.

Two linked propositions do most of the work:

  1. Completeness on “compensability” matters. The ICA characterized Dr. Nabet’s report as “more complete” because it addressed diabetes as documented in the medical records. Implicitly, a causation opinion that does not grapple with a major alternative etiology can be discounted as less persuasive on whether the condition “result[ed] from” employment under W. Va. Code § 23-4-1(f).
  2. Regulatory recognition of confounders legitimizes reliance on them. By pointing to W. Va. Code State R. § 85-20-41.4, the ICA (and, by endorsement, the Supreme Court) signals that diabetes is not merely a speculative alternative cause; it is an expressly recognized contributor to CTS. That recognition supports administrative factfinders who attribute CTS to diabetes when the evidence reasonably supports that conclusion.

Notably, the majority does not engage the dissent’s central statutory argument under West Virginia Code § 23-4-1g(a) (tie-breaking in the claimant’s favor when evidence is equally weighted). Instead, it effectively treats the matter as one of factfinding discretion: the BOR found Dr. Nabet “more persuasive,” and appellate courts will not reweigh absent clear error.

3.3. Impact

Although issued as a memorandum decision, the ruling carries practical guidance for litigants and adjudicators in CTS and other occupational disease claims:

  • Claimants must address confounding conditions head-on. If the claimant has diabetes (or another recognized confounder), a causation report that fails to discuss it risks being deemed incomplete on compensability and therefore less persuasive.
  • Administrative discretion in weighing medical evidence is reinforced. The decision underscores that appellate review will generally not disturb the BOR’s choice between competing medical opinions unless the BOR is “clearly wrong” (Duff v. Kanawha Cnty. Comm'n).
  • Regulatory provisions can shape “persuasiveness.” By highlighting W. Va. Code State R. § 85-20-41.4 (diabetes) while the dissent emphasizes W. Va. Code State R. § 85-20-41.5 (vibration, grip force, awkward positioning), the case illustrates how the workers’ compensation rules provide a structured vocabulary for causation analysis—and how selective engagement with those provisions can affect outcomes.
  • Unresolved tension with § 23-4-1g(a). The dissent frames the dispute as an “equal weight” scenario requiring a claimant-favorable resolution under West Virginia Code § 23-4-1g(a). The majority’s silence leaves future litigants to argue when, exactly, evidence becomes “equal” as a matter of statutory application—and whether deeming one report “more complete” is sufficient to avoid the tie-breaker.

4. Complex Concepts Simplified

  • Compensability / “resulting from employment”: Even if a worker has a diagnosed condition, benefits generally require proof that work caused it or materially contributed to it. The fight here was over causation—work vibration/grip forces versus diabetes.
  • Occupational disease and confounding conditions: A “confounding condition” is a non-work medical factor (like diabetes) that can also cause or worsen the same condition claimed as work-related. Rules like W. Va. Code State R. § 85-20-41.4 and § 85-20-41.5 identify both medical and ergonomic contributors relevant to CTS causation.
  • EMG/NCS: Electromyography and nerve conduction studies are objective tests used to confirm nerve dysfunction consistent with CTS. They show the condition exists, but causation still must be proven.
  • Standard of review (de novo vs. clearly wrong): Courts independently decide legal questions (de novo), but largely defer to the BOR on factual determinations (like which doctor to believe) unless the BOR’s finding is plainly mistaken (“clearly wrong”).
  • Preponderance and tie-breaker under § 23-4-1g(a): Issues are resolved by weighing all evidence. If the evidence is truly equal on a disputed issue, the statute directs adoption of the resolution most consistent with the claimant’s position—an approach the dissent would have applied here.

5. Conclusion

John Moore v. United Coal Company, LLC confirms that, in CTS compensability disputes featuring competing medical causation opinions, appellate courts will generally defer to the BOR’s weighing of the evidence under the “clearly wrong” standard articulated in Duff v. Kanawha Cnty. Comm'n. The decision also highlights the practical importance of engaging recognized “confounding conditions” such as diabetes under W. Va. Code State R. § 85-20-41.4, as failure to address such factors may render an otherwise supportive causation opinion less persuasive on compensability. The dissent underscores a continuing interpretive pressure point: when evidence is truly in equipoise, the statutory directive in West Virginia Code § 23-4-1g(a) would require resolving the dispute in the claimant’s favor—a question the majority’s summary affirmance leaves for future development.