Archer Daniels Midland v. Donald Tuttle

IN THE COURT OF APPEALS OF IOWA

No. 24-0711
Filed May 7, 2025

ARCHER DANIELS MIDLAND,
Petitioner-Appellant/Cross-Appellee,

vs.

DONALD TUTTLE,
Respondent-Appellee/Cross-Appellant.
________________________________________________________________

Appeal from the Iowa District Court for Polk County, Christopher Kemp,

Judge.

An employer appeals a judicial review ruling affirming an agency decision

granting an employee’s request for alternate medical care for his head injury. The

employee cross-appeals the district court’s remand to the agency for a more

specific finding on his request for alternate care for his knee injury. REVERSED

ON APPEAL AND CROSS-APPEAL.

Brandon W. Lobberecht (argued) and Peter J. Thill of Betty, Neuman &

McMahon, P.L.C., Davenport, for appellant/cross-appellee.

Dennis Currell (argued), Cedar Rapids, for appellee/cross-appellant.

Heard at oral argument by Tabor, C.J., Langholz, J., and Doyle, S.J.*

*Senior judge assigned by order under Iowa Code section 602.9206 (2025).
2

TABOR, Chief Judge.

Donald Tuttle sustained two work-related injuries during his employment at

Archer Daniels Midland (ADM): a left knee injury and a head injury. The deputy

workers’ compensation commissioner granted Tuttle’s requests for alternate

medical care for both claims.1 On judicial review, the district court affirmed the

deputy’s grant of alternate medical care for Tuttle’s head injury but remanded the

claim involving care for his knee to the deputy for a more specific finding.

ADM appeals that judicial review order, advancing three arguments

concerning care for Tuttle’s head injury: (1) the court erred in finding ADM

unreasonably delayed treatment; (2) the court exceeded its jurisdiction and

authority by making new factual findings not considered or relied upon by the

deputy; and (3) even if the alleged treatment delay is actionable, the court erred in

finding it was unreasonable under Iowa Code section 85.27(4) (2023). As for the

knee injury, ADM argues the court erred in ordering a remand because there was

insufficient evidence to conclude its authorized treatment was unreasonable.

Tuttle cross-appeals, contending the remand was unnecessary because the

agency applied the correct standard in making its factual findings.2

We reverse the district court’s order affirming the head-injury portion of the

deputy’s alternate care decision. We also reverse the court’s remand and affirm

the deputy’s decision granting alternate care for Tuttle’s knee injury.

1
The commissioner delegated authority to a deputy commissioner to issue a final
agency decision in these matters.
2 Tuttle also challenges the district court’s “factual redetermination” of the status of

the treating physician for his head injury but does not contest the court’s affirmance
of the deputy on that alternate care decision.
3

I. Facts and Prior Proceedings

Tuttle started working at ADM as a maintenance mechanic in 2015. He

injured his left knee at work in January 2018. Tuttle returned to his job after that

injury. Then, in April 2022, he suffered a second work-related injury when he struck

his head on a metal pipe, fell, and lost consciousness.

Treatment for the knee injury. ADM chose the University of Iowa

Hospitals and Clinics (UIHC) as the authorized treatment provider for Tuttle’s knee

injury. UIHC performed an arthroscopy and partial medial meniscectomy in

February 2018. A post-operative MRI showed a retrograde drill tunnel in Tuttle’s

left tibial plateau. In November 2020, Dr. Matthew Bollier and Dr. Nicolas Noiseux

at UIHC asserted that “[t]he tibial tunnel is not the cause of Mr. Tuttle’s pain and is

not causing any damage in his knee.” They also opined that “Mr. Tuttle clearly has

advanced left knee arthritis and needs a knee replacement.”

Tuttle sought care on his own from Dr. Holly Duck at the Mayo Clinic. In

March 2022, Dr. Duck noted that “Tuttle has degenerative knee osteoarthritis” and

his previous treatments included “NSAIDS, modalities such as ice or heat, topical

creams such as voltaren gel, braces or wraps, physical therapy and injections.” At

that visit, Dr. Duck placed orders for an “ultrasound guided injection of

corticosteroid into the left pes anserine bursa/trigger point.” Dr. Duck also noted

that Tuttle would eventually need a total knee arthroplasty.3

Tuttle saw Leah Edquist, P.A.-C., at Dr. Duck’s office in January 2023.

Edquist noted that Tuttle received a “left knee intra-articular injection” at that visit,

3 The deputy described this procedure as knee replacement surgery.
4

and she advised Tuttle “that we should continue with conservative management

as long as possible.” Edquist noted that Tuttle understood that the injections

should continue as long as they provided him relief. She added:

I am hopeful that we can put off needing anything operative for
several years particularly given that he is at increased risk with his
prior history of MRSA in his ankle. Only when he [has] completely
exhausted nonoperative management should he consider knee
replacement on the left side. . . . We will plan to see him back on an
as-needed or yearly basis.

According to Tuttle’s wife, Michelle, UIHC did not offer the injections that

Tuttle received at the Mayo Clinic.4 Michelle also recalled that the doctors at UIHC

never advised Tuttle that he should wait until he exhausted nonoperative

treatments before considering knee replacement. Michelle explained that the knee

injections allowed Tuttle to return to work at ADM until his head injury.

Treatment for the head injury. When Michelle arrived at ADM on April 14,

2022, to pick her husband up from work, he was in the on-site nurse’s office

because he hit his head. Michelle took him to a scheduled doctor’s appointment

that afternoon where she “realized there was something really wrong with him.”

After that appointment, Michelle called ADM’s safety coordinator, Ryan Priddy. He

directed Michelle to take her husband to an urgent care clinic. The urgent care

clinic sent Tuttle to a hospital emergency room by ambulance. The emergency

room physician ordered a head CT and diagnosed Tuttle with a “closed head

injury,” “contusion of neck,” and “concussion without loss of consciousness.”

Tuttle’s discharge papers from the emergency room instructed him to follow up

4 Michelle was the only witness at the hearing before the deputy commissioner.

For clarity, we use her first name and refer to her husband as Tuttle.
5

with his primary care physician, Dr. Jill Flory, and to schedule “an appointment as

soon as possible for a visit in 1 week.”

Tuttle saw Dr. Flory for a follow-up appointment in late April 2022. He

continued to see Dr. Flory “every 7 to 12 days” so that she could monitor his

recovery from the head injury. Michelle testified that at some point, they learned

that “we were going to have to go to WorkWell, because ADM said they were not

going to pay for him to go to any further appointments to Dr. Flory’s.” Tuttle arrived

for an appointment at WorkWell on May 3 but left without seeing a doctor. 5 ADM

scheduled another appointment at WorkWell for May 16, but Tuttle did not attend. 6

After that, Tuttle continued his treatment with Dr. Flory.

Dr. Flory referred Tuttle to Dr. Opada Alzohaili, an endocrinologist in Detroit,

Michigan. Dr. Alzohaili diagnosed Tuttle with pituitary dysfunction and growth

hormone deficiency in February 2023. Dr. Alzohaili recommended that Tuttle

receive human growth hormone (HGH) injections for the rest of his life to treat

those conditions. Michelle testified that Tuttle’s “mood swings” and “balance

issues” improved when he started the HGH injections. She further testified that

the injections would not be covered through ADM’s group health insurance after

July 25, 2023.

5 Michelle testified that they left that appointment after waiting about thirty-five to

forty-five minutes because “there wasn’t a doctor available,” and WorkWell staff
didn’t “know if anyone from ADM” was coming to the appointment.
6 Michelle explained: “[T]he fact that nobody showed up with his appointment on

the 3rd, it seemed like they weren’t real serious about this whole head injury. He’s
had some bad experiences in the past with the doctors who ADM has chosen. He
just did not feel comfortable going back to ADM’s doctor.”
6

Meanwhile, Tuttle saw Dr. Erica Bellamkonda at the Mayo Clinic for a

consultation in September 2022. Dr. Bellamkonda opined that Tuttle was

“experiencing prolonged persistent concussive symptoms (post-concussion

syndrome) . . . following mild traumatic head injury/concussion.” She provided a

list of treatment recommendations to Tuttle’s counsel in May 2023.

Dr. Bellamkonda also reviewed Dr. Alzohaili’s recommendations, but she

explained that she could not comment on Tuttle’s hypothalamic-pituitary axis

because it was outside her scope of expertise. She advised that if “there continue

to be concerns regarding Mr. Tuttle’s hypothalamic-pituitary axis, another opinion

may be considered with direct referral to another endocrinologist.”

Tuttle also saw Dr. Jonathan Fields for an independent medical examination

(IME) arranged by ADM in September 2022. Dr. Fields diagnosed Tuttle with a

mild traumatic brain injury and postconcussion syndrome. He opined that Tuttle

“will need some ongoing treatment for his postconcussive syndrome” and

recommended that he follow the Mayo Clinic’s treatment plan.7 Dr. Fields provided

an updated opinion in February 2023 after reviewing Dr. Alzohaili’s

recommendations. Regarding the HGH injections, Dr. Fields recommended “a

referral for a 2nd opinion to a local endocrinologist at the Mayo Clinic or the

University of Iowa.”

Following that recommendation, ADM requested a second opinion on the

HGH injections from the Mayo Clinic and UIHC. The Mayo Clinic declined ADM’s

request. Dr. Amie Ogunsakin, an endocrinologist at UIHC, was willing to provide

7 ADM asserts that it authorized the Mayo Clinic to treat Tuttle’s head injury after

it received Dr. Fields’s IME report in October 2022.
7

a second opinion but—due to her workload—she was unavailable to evaluate

Tuttle until August 2023 at the earliest.

The alternate medical care proceedings. In July 2023, Tuttle requested

alternate medical care for his knee and head injuries. Tuttle sought authorization

to continue treatment for his knee injury with Dr. Duck at the Mayo Clinic. Tuttle

also sought authorization to continue treatment for his head injury, including the

prescribed HGH injections, with Dr. Alzohaili in Detroit. At the hearing on those

requests, the deputy commissioner heard Michelle’s testimony and considered the

parties’ exhibits and oral arguments.

The deputy granted Tuttle’s requests for both injuries, reasoning:

[W]ith respect to the knee injury, I find that the treatment being
offered by the Mayo Clinic, specifically Dr. Duck’s office, is more
extensive and better suited to treat [Tuttle’s] knee injury. There are
documented concerns with [Tuttle] having a total knee replacement
surgery, given his history of MRSA. That is the only treatment being
offered by the University of Iowa at this time. However, Dr. Duck is
providing yearly intra-articular injections, which provide [Tuttle] with
enough relief to delay the total knee replacement for the time being.
As such, the care being provided by Dr. Duck is better suited to treat
[Tuttle’s] knee injury and should be authorized.

The deputy continued:

With respect to [Tuttle’s] head injury, the issues are more
complicated. However, looking at the case from the beginning, it
does appear that Dr. Flory was the initial authorized treating
physician, and there is no evidence her authorization has been
revoked. The employer cannot interfere with the judgment of the
authorized treating physician, and must authorize treatment
modalities recommended by that provider. In this case, by way of
Dr. Flory’s referral, Dr. Alzohaili is also an authorized treating
physician, and his recommendations must be authorized. As such,
[ADM] is responsible for the HGH prescription he has recommended.
8

The deputy then addressed the delay in treatment for Tuttle’s head injury,

noting that ADM knew about Dr. Fields’s recommendation for a second opinion

since February 28, 2023.

Understanding that the Mayo Clinic declined the request for a second
opinion, the fact that there is no appointment scheduled at this time,
and none available until late August at the earliest, is an
unreasonable delay in treatment. [Tuttle] has already had to go off
the medication once, and only has insurance approval through his
group health for five more days. The injections have provided
benefit, and stopping the injections had a negative effect. As such,
it is unreasonable to make [Tuttle] wait until August or later for a
second opinion before authorizing the prescription.

Thus, the deputy ordered ADM “to authorize and pay for [Tuttle’s] treatment

related to his left knee at the Mayo Clinic with Dr. Duck’s office.” The deputy also

ordered ADM “to authorize and pay for [Tuttle’s] treatment related to his head injury

with Dr. Alzohaili, including authorization of the prescription for human growth

hormone injections.”

The judicial review proceedings. ADM petitioned for judicial review,

contending that the deputy erred in granting both alternate medical care requests.

Following the judicial review hearing, the district court remanded to the commission

“for a more specific finding regarding whether UIHC’s care was unreasonable with

respect to the knee injury” and affirmed the deputy’s alternate medical care

decision for the head injury. On the knee injury, the court reasoned:

The Deputy made findings supported by substantial evidence that
Dr. Duck’s treatment at Mayo Clinic was “more extensive and better
suited to treat [Tuttle’s] knee injury.” However, this finding only
comes into play after a determination ADM’s care is unreasonable.
Because that express finding is not in the Ruling, this case must be
remanded on that issue. The Deputy Commissioner shall clarify
whether ADM’s care plan of UIHC is unreasonable.
9

With respect to the head injury, the court first concluded that the “Deputy’s

finding that ‘Dr. Flory was the initial authorized treating physician, and there is no

evidence her authorization has been revoked’ was not supported by substantial

evidence.” But the court affirmed the deputy’s alternate medical care decision,

reasoning:

ADM contends that Mayo Clinic was the authorized treating
provider for Tuttle’s head injury starting in February 2023, following
the independent medical examination by Dr. Fields in September
2022.[8] Mayo Clinic declined treatment, and an endocrinologist at
the University of Iowa could not see Tuttle until August 2023. The
Deputy found that this was an unreasonable delay in treatment, and
therefore ADM’s offered treatment was not offered promptly. . . .
Substantial evidence supports this finding, especially since ADM did
nothing between setting a May 16, 2022, appointment at WorkWell
and the September 2022 IME. ADM’s request that Tuttle wait until
August 2023 to see their doctor at the University of Iowa would have
caused further delays in treatment. The Deputy found that the HGH
injections provided benefit, and stopping the injections had a
negative effect. The care authorized by ADM was inferior and less
extensive than other available care requested by Tuttle.

The court also concluded that the deputy’s order requiring ADM to authorize

Tuttle’s treatment related to his head injury with Dr. Alzohaili, including the

prescription for HGH injections, “was not an abuse of discretion.”

ADM and Tuttle both filed motions to reconsider, enlarge, or amend. The

court denied those motions. ADM appeals. Tuttle cross-appeals.

II. Scope and Standards of Review

The district court may grant relief on judicial review of an agency action only

when that action (1) prejudiced the petitioner’s substantial rights and (2) falls within

8 ADM asserted in its judicial review brief that it “authorized Mayo Clinic to treat

Claimant’s head injury after Dr. Fields’ October 17, 2022 report and
recommendations.” ADM maintains that assertion on appeal.
10

one of the criteria in Iowa Code section 17A.19(10). See Burton v. Hilltop Care

Ctr., 813 N.W.2d 250, 256 (Iowa 2012). “We assess whether we come to the same

conclusions as the district court.” Archer Daniels Midland v. Williams, 3 N.W.3d

231, 234 (Iowa Ct. App. 2023). Our standard of review depends on the issues

raised. See Jacobson Transp. Co. v. Harris, 778 N.W.2d 192, 196 (Iowa 2010).

For claims of factual error, we determine if the commissioner’s findings are

supported by substantial evidence. Iowa Code § 17A.19(10)(f). We are bound by

the fact findings “if supported by substantial evidence in the record as a whole.”

Meyer v. IBP, Inc., 710 N.W.2d 213, 218 (Iowa 2006). Evidence is substantial if it

“would be deemed sufficient by a neutral, detached, and reasonable person, to

establish the fact at issue when the consequences resulting from the establishment

of that fact are understood to be serious and of great importance.” Iowa Code

§ 17A.19(10)(f)(1). We do not ask “whether the evidence supports a different

finding; rather, our task is to determine whether substantial evidence, viewing the

record as a whole, supports the findings actually made.” Cedar Rapids Cmty. Sch.

Dist. v. Pease, 807 N.W.2d 839, 845 (Iowa 2011). When the application of law to

fact has been clearly vested in the commissioner’s discretion, we will reverse only

if the application is “irrational, illogical, or wholly unjustifiable.” See Iowa Code

§ 17A.19(10)(m).

The parties disagree on which standard we apply. On the one hand, ADM

maintains that our review is for correction of errors at law because the agency and

the district court were mistaken in their interpretation and application of

section 85.27(4). On the other hand, Tuttle urges substantial-evidence review.

Because the parties dispute the factual findings underpinning the agency’s
11

decision, we must first determine whether substantial evidence supports those

findings. See Jacobson Transp. Co., 778 N.W.2d at 196. From there, the parties

dispute the proper application of section 85.27(4) to the facts of Tuttle’s case. So

we must decide whether the agency’s application of the law is “irrational, illogical,

or wholly unjustifiable.” See id.

III. Analysis

We begin with the statute providing injured workers with a procedure to seek

alternate medical care. Iowa Code section 85.27(4) states:

[T]he employer is obliged to furnish reasonable services and
supplies to treat an injured employee, and has the right to choose
the care. If the employer chooses the care, the employer shall hold
the employee harmless for the cost of care until the employer notifies
the employee that the employer is no longer authorizing all or any
part of the care and the reason for the change in authorization. . . .
The treatment must be offered promptly and be reasonably suited to
treat the injury without undue inconvenience to the employee. If the
employee has reason to be dissatisfied with the care offered, the
employee should communicate the basis of such dissatisfaction to
the employer . . . following which the employer and the employee
may agree to alternate care reasonably suited to treat the injury. If
the employer and employee cannot agree on such alternate care, the
commissioner may, upon application and reasonable proofs of the
necessity therefor, allow and order other care.

This procedure “permits disputes over the medical care for compensable

injuries to be quickly resolved in advance of a contested case hearing on a claim

for workers’ compensation benefits.” R.R. Donnelly & Sons v. Barnett, 670 N.W.2d

190, 195 (Iowa 2003). The commissioner may order alternate care if the treatment

provided by the employer is not prompt or reasonably suited to treat the injury or if

the treatment causes “undue inconvenience to the employee.” Id. The employee

bears the burden of proving the medical care authorized by the employer is

unreasonable. Id. “Determining what care is reasonable under the statute is a
12

question of fact.” Long v. Roberts Dairy Co., 528 N.W.2d 122, 123 (Iowa 1995).

“[W]hen evidence is presented to the commissioner that the employer-authorized

medical care has not been effective and that such care is ‘inferior or less extensive’

than other available care requested by the employee, the commissioner is justified

by section 85.27 to order the alternate care.” Pirelli-Armstrong Tire Co. v.

Reynolds, 562 N.W.2d 433, 437 (Iowa 1997) (internal citation omitted).

For ease of analysis, we will first assess the parties’ arguments addressing

the district court’s ruling on Tuttle’s head injury. Then we will turn to their

arguments relating to the ruling on Tuttle’s knee injury.

A. Head Injury

First, ADM argues that the district court erred in finding that it unreasonably

delayed treatment under section 85.27(4) by seeking a second opinion regarding

the HGH injections prescribed by Dr. Alzohaili—who was not an authorized

treatment provider. ADM contends that when the district court “reversed the

Deputy’s finding that Dr. Alzohaili had been previously ‘authorized’ by ADM to treat

Tuttle’s head injury, it should have resulted in a reversal of the alternate care

decision on Tuttle’s head injury claim” because “[t]hat ‘authorization’ finding was

the entire basis of the argument proffered by Tuttle to the Deputy and the entire

basis for the Deputy granting alternative medical care to Tuttle.”

ADM maintains that it has no duty under section 85.27(4) to approve care

recommended by Dr. Alzohaili, “so long as ADM’s chosen and authorized provider,

Mayo Clinic, is providing treatment reasonably suited to treat the injury, promptly

and without undue inconvenience.” From there, the employer insists that it cannot

“‘delay’ or fail to provide ‘prompt’ treatment by following the recommendations of
13

its chosen/selected medical provider and refusing to approve/authorize care

recommended by an unauthorized provider.” ADM urges us to reverse the district

court because there is no evidence its authorized provider is not providing

“reasonable, prompt and convenient care” for Tuttle’s head injury.

Second, ADM argues that the district court exceeded its authority by making

new factual findings not considered by the deputy.9 For instance, ADM contends

that the court made a “new finding of a purported ‘delay’” in treatment. ADM also

claims that the court improperly found “[t]he care authorized by ADM was inferior

and less extensive than other available care requested by Tuttle.” ADM alleges

that the court impermissibly used these new findings to affirm the alternate care

ruling on different grounds than expressed by the deputy. Further confusing the

issue, in ADM’s view, the district court “appears to assume that Dr. Fields is a

chosen/authorized treatment provider of ADM, that his recommendations must be

followed by ADM, and that the failure to follow such recommendations can lead to

a ‘delay’ in treatment.” As ADM points out, Dr. Fields was a retained expert who

performed an IME, not a treating provider. Based on these flaws, ADM urges us

to “disregard any such findings” in our review.

9 As a purported cross-appeal claim, Tuttle also challenges the district court’s

“factual redetermination of Dr. Flory’s authorized treating provider status” for his
head injury. According to Tuttle, the “total lack of evidence in the record that ADM
ever provided Mr. Tuttle with a reasonable basis for the transfer of authorization
away from Dr. Flory supports the Deputy’s evidentiary factual finding Dr. Flory’s
authorized status was never revoked.” Thus, Tuttle alleges that “the district court
engaged in fact-finding and then utilized an inappropriate legal standard and a
‘scrutinizing analysis’ to conclude that Dr. Flory’s authorization was properly
revoked.” But Tuttle does not contest the district court’s affirmance of the head-
injury portion of the deputy’s alternate care decision. So we treat Tuttle’s claim as
an argument that we should affirm the deputy on a different ground. But, as we
explain, that ground lacks merit.
14

Third, ADM argues that even if the time between Dr. Fields’s

recommendation for a second opinion in February 2023 and Dr. Ogunsakin’s

availability to provide that opinion in August 2023 counted as a delay, the district

court erred in finding it was unreasonable under section 85.27(4). ADM contends

that the statute “implicitly contemplates the employer must play a role in causing

the delay” before it loses its right to choose who provides the medical care.

Building from that contention, ADM insists that characterizing Dr. Ogunsakin’s

booked schedule as unreasonable conduct of the employer is “unfair, unjust and

legally erroneous in the absence of evidence ADM could have done more or acted

differently to reach a quicker result.” Thus, as a fallback position, ADM urges that

we should reverse the district court’s ruling regarding Tuttle’s head injury by finding

there is insufficient evidence to show the delay in treatment was unreasonable

under section 85.27(4).

Tuttle responds that the district court correctly affirmed his request for

alternate care for his head injury. In his view, the record supported the deputy’s

finding that Dr. Alzohaili was an authorized treating provider and that ADM

unreasonably delayed medical care for Tuttle’s traumatic brain injury. He

emphasizes his wife’s testimony that his symptoms improved while he was

receiving the HGH injections and the deputy’s finding that it was “unreasonable to

make [him] wait until August or later for a second opinion before authorizing the

prescription.” Based on that record, Tuttle contends the “district court was bound
15

by the Deputy’s factual finding that ADM’s delay was unreasonable and correctly

affirmed that factual finding.” 10

Starting with ADM’s authorization argument, we agree with the district

court’s conclusion that the record lacked substantial evidence to support the

deputy’s finding that “Dr. Flory was the initial authorized treating physician, and

there is no evidence her authorization has been revoked.” (Emphasis added.)

Assuming without deciding that the emergency room discharge instructions initially

authorized Dr. Flory to treat Tuttle, no evidence suggested that ADM directed

Dr. Flory to provide continuing care for Tuttle’s head injury. To the contrary,

Michelle testified that she and Tuttle were informed that “we were going to have to

go to WorkWell, because ADM said they were not going to pay for him to go to any

further appointments” with Dr. Flory. And in explaining why Tuttle chose not to

attend the appointment ADM scheduled for him at WorkWell on May 16, 2022,

Michelle explained: “He just did not feel comfortable going back to ADM’s doctor.”

Thus, the record contradicted the deputy’s factual finding that there was “no

evidence” Dr. Flory’s authorization had been revoked. Michelle’s testimony was

evidence that ADM did not authorize Dr. Flory to provide continuing care for

Tuttle’s head injury. Yet Tuttle continued seeing Dr. Flory despite knowing the

employer directed him elsewhere. See Ramirez-Trujillo v. Quality Egg, L.L.C., 878

N.W.2d 759, 776–77 (Iowa 2016) (finding section 85.27(4) does not permit “an

10
Tuttle also challenges error preservation and urges us to dismiss ADM’s appeal
because “ADM’s failure to make any arguments regarding the final ruling of the
district court in its Ruling on Motions to Reconsider forfeited challenges to the final
findings and conclusions of the district court and agency.” We find no merit in
those arguments and decline to dismiss ADM’s appeal.
16

employee to take advantage of an employer by seeking compensation after the

fact for care the employee knew or should have known was not within the scope

of the employer’s prior authorization”). It follows that the deputy’s finding that “by

way of Dr. Flory’s referral, Dr. Alzohaili is also an authorized treating physician,

and his recommendations must be authorized” was likewise unsupported by

substantial evidence. As ADM explained, the deputy’s “flow of authorization”

finding with respect to Dr. Flory and Dr. Alzohaili underpinned the agency order

that ADM “authorize and pay for” the HGH injections Dr. Alzohaili prescribed.

Because substantial evidence did not support those findings, the deputy erred in

granting Tuttle’s alternate care request for his head injury based on that reasoning.

The deputy also erred in granting alternate care based on the alleged “delay

in treatment” between Dr. Fields’s recommendation for a second opinion on the

HGH injections and Dr. Ogunsakin’s availability. Section 85.27(4) gives the

employer the right to select the employee’s care. West Side Transp. v. Cordell,

601 N.W.2d 691, 693 (Iowa 1999). That right is qualified by requirements that the

treatment be “(1) prompt, (2) reasonably suited to treat the injury, and (3) without

undue inconvenience to the [employee].” Id. “[I]f the treatment the employer offers

fails to meet any one of these qualifications, the commissioner has the authority to

order alternate care, including care from a doctor chosen by the [employee].” Id.

It is Tuttle’s burden to prove that the care authorized by ADM is unreasonable.

See R.R. Donnelly & Sons, 670 N.W.2d at 195.

Tuttle hasn’t met that burden for his head injury. Because Dr. Alzohaili was

not an authorized provider, section 85.27(4)’s requirement that the “treatment must

be offered promptly” did not apply to the HGH injections he prescribed. See West
17

Side Transp., 601 N.W.2d at 693 (applying statutory requirements only to

treatment offered by the employer). Tuttle presented no evidence that the Mayo

Clinic—ADM’s chosen provider—recommended HGH injections. And Tuttle did

not argue that the Mayo Clinic’s treatment recommendations for his head injury

were unreasonable, unduly inconvenient, or not offered promptly. Nor did the

deputy make any such findings. On this record, the deputy erred in ordering

alternate care based on ADM’s alleged “unreasonable delay” in approving the

HGH injections. We reverse the district court’s ruling affirming the head-injury

portion of the deputy’s alternate care decision.

B. Knee Injury

Shifting to Tuttle’s knee injury, both ADM and Tuttle object to the remand.

For its part, ADM argues there is insufficient evidence to conclude its authorized

treatment was unreasonable. The employer contends the deputy incorrectly

focused on whether the unauthorized care Tuttle received from Mayo Clinic was

reasonable and beneficial but never found that the authorized care from UIHC was

unreasonable. ADM cites Lynch Livestock, Inc. v. Bursell, for the proposition that

an agency’s finding that “the treatment requested is reasonable does not result in

an ‘implicit’ finding that the authorized treatment was unreasonable.” No. 14-1133,

2015 WL 2394143, at *3 (Iowa Ct. App. May 20, 2015). ADM emphasizes that

UIHC and Mayo Clinic agree that Tuttle will eventually need a total knee

replacement—the only difference is that Mayo Clinic offers knee injections to

postpone the need for surgery. And while ADM acknowledges Tuttle presented

evidence that he “personally desired to pursue treatment only with Mayo Clinic for

his left knee rather than UIHC,” it insists that evidence “is insufficient as a matter
18

of law to deem UIHC’s treatments unreasonable.” See id. Thus, ADM urges us to

“reverse the District Court’s remand order and affirm the Court’s reversal[11] of the

alternate care decision regarding Tuttle’s left knee claim as a final adjudication.”

In his cross-appeal, Tuttle argues that the deputy’s factual finding that “the

treatment being offered by the Mayo Clinic . . . is more extensive and better suited

to treat [Tuttle’s] knee injury” is supported by substantial evidence and legally

equivalent to finding that UIHC’s recommended treatment is unreasonable. He

points to Pirelli-Armstrong, which affirmed that offering no care to the claimant is

the same as offering “no care reasonably suited to treat the injury.” 562 N.W.2d

at 436.12 Tuttle asserts that “[r]emand was unnecessary because the deputy

utilized the correct language in arriving at the fact-finding conclusion of

unreasonable care in her Alternate Medical Care Ruling.” As a remedy, Tuttle

urges that the “Alternate Medical Care Ruling regarding the medical care for [his]

knee injury by the Mayo Clinic should be reinstated following reversal of the district

court’s judicial review adjudications.”

We agree with Tuttle on this issue. The deputy correctly articulated the

legal standard for alternate care under Pirelli-Armstrong and confirmed that

“determining whether care is reasonable under the statute is a question of fact”

immediately before finding that the “treatment being offered by the Mayo

Clinic . . . is more extensive and better suited to treat [Tuttle’s] knee injury.” The

11
The district court ordered that the “Decision of the Deputy be REMANDED to
the agency for a more specific finding regarding whether UIHC’s care was
unreasonable with respect to the knee injury.” The court did not order reversal.
12 ADM responds that Pirelli-Armstrong “is not dispositive of this case nor are the

facts analogous.”
19

deputy further found there were “documented concerns with [Tuttle] having a total

knee replacement surgery, given his history of MRSA”; knee replacement surgery

was “the only treatment being offered by the University of Iowa at this time”; and

the injections Tuttle received from Mayo Clinic provided him “with enough relief to

delay the total knee replacement for the time being.” On our review, we find

substantial evidence in the record supports those findings. “The commissioner—

not the court—weighs the evidence, and we are obliged to broadly and liberally

apply those findings to uphold rather than defeat the commissioner’s decision.”

Long, 528 N.W.2d at 123.

True, the deputy did not expressly state that UIHC’s recommended

treatment was unreasonable. But we can deduce from the agency decision that

the deputy must have concluded UIHC’s offered treatment was ineffective and

inferior or less extensive than the treatment offered by the Mayo Clinic. See Pirelli-

Armstrong, 562 N.W.2d at 437; Bridgestone/Firestone v. Accordino, 561 N.W.2d

60, 62 (Iowa 1997) (“[T]he commissioner’s duty to furnish a reasoned opinion [is]

satisfied if it is possible to work backward and to deduce what must have been the

agency’s legal conclusions and its findings of fact.” (cleaned up)). The deputy’s

decision to grant alternate care for Tuttle’s knee injury was not based upon an

irrational, illogical, or wholly unjustifiable application of section 85.27(4). See Iowa

Code § 17A.19(10)(m). We reverse the district court’s ruling remanding the knee-

injury portion of the agency decision and affirm the deputy’s grant of alternate care

for Tuttle’s knee injury.

REVERSED ON APPEAL AND CROSS-APPEAL.