VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_20-vv-01553
Package ID: USCOURTS-cofc-1_20-vv-01553
Petitioner: Travis Lutz
Filed: 2020-11-09
Decided: 2022-11-17
Vaccine: influenza
Vaccination date: 2018-10-03
Condition: Shoulder injury related to vaccine administration (SIRVA)
Outcome: compensated
Award amount USD: 89235

AI-assisted case summary:
Travis Lutz filed a petition for compensation under the National Vaccine Injury Compensation Program on November 9, 2020, alleging he suffered a left shoulder injury related to vaccine administration (SIRVA) after receiving an influenza vaccine on October 3, 2018. The case was assigned to the Special Processing Unit. On October 11, 2022, the Chief Special Master issued a ruling on entitlement, finding that Mr. Lutz was entitled to compensation for his SIRVA. The ruling noted that the respondent contested only whether the onset of pain occurred within 48 hours of vaccination, but the Special Master found sufficient evidence in the medical records, which were contemporaneous to the injury, to establish that the pain began within six hours of the injection. The decision confirmed that all other requirements for a Table SIRVA injury were met, and that Mr. Lutz satisfied the additional requirements for entitlement, such as the duration of his injury and the lack of other awards or settlements. Subsequently, on November 17, 2022, a damages decision was issued. The respondent had filed a proffer on award of compensation, recommending an award of $89,235.85, comprising $85,000.00 for pain and suffering and $4,235.85 for out-of-pocket expenses. Mr. Lutz agreed with this proffered award. The Chief Special Master awarded Mr. Lutz the lump sum of $89,235.85, representing compensation for all damages available under the Vaccine Act.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_20-vv-01553-0
Date issued/filed: 2022-11-15
Pages: 6
Docket text: PUBLIC ORDER/RULING (Originally filed: 10/11/2022) regarding 37 Ruling on Entitlement, ( Signed by Chief Special Master Brian H. Corcoran. )(mpj) Service on parties made.
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Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 1 of 6
CORRECTED
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1553V
UNPUBLISHED
TRAVIS LUTZ, Chief Special Master Corcoran
Petitioner, Filed: October 11, 2022
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Findings of Fact; Onset; Influenza
HUMAN SERVICES, (Flu) Vaccine; Ruling on Entitlement;
Table Injury; Shoulder Injury Related
Respondent. to Vaccine Administration (SIRVA)
Ronald Craig Homer, Conway, Homer, P.C., Boston, MA, for Petitioner.
Andrew Henning, U.S. Department of Justice, Washington, DC, for Respondent.
FINDINGS OF FACT AND RULING ON ENTITLEMENT1
On November 9, 2020, Travis Lutz filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”), alleging that he suffered a left shoulder injury related to vaccine
administration (“SIRVA”), as defined in the Vaccine Injury Table, after receiving an
influenza (“flu”) vaccine on October 3, 2018. Petition at 1, ¶¶ 1-3. The case was assigned
to the Special Processing Unit of the Office of Special Masters (the “SPU”).
For the reasons set forth below, I find the onset of Petitioner’s left shoulder pain
occurred within 48 hours of vaccination, and that he has satisfied the other requirements
1 Because this unpublished Ruling contains a reasoned explanation for the action in this case, I am required
to post it on the United States Court of Federal Claims' website in accordance with the E-Government Act
of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling will be available to anyone with access to the internet. In accordance
with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I agree that
the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 2 of 6
of a Table shoulder injury related to vaccine administration (“SIRVA”). Petitioner is entitled
to compensation under the Vaccine Act.
I. Relevant Procedural History
Within a month of filing his petition, Mr. Lutz filed the medical records and a signed
declaration3 as required by the Vaccine Act. Exhibits 1-10, filed Nov. 20, 2020, ECF Nos.
6-7; see Section 11(c). On February 26, 2021, the case was activated and assigned to
the SPU (OSM’s adjudicatory system for attempting to resolve cases deemed likely to
settle). ECF No. 13.
On May 7, 2021, Petitioner filed additional signed declarations from his wife and
himself4 and an amended petition, providing further details regarding his alleged SIRVA
injury. Exhibits 11-12, ECF No. 16; Amended Petition, ECF No. 18. Approximately six
months later - on November 17, 2021 - he filed updated medical records and a status
report indicating he provided a demand and supporting documentation to respondent.
Exhibits 13, ECF No. 22; Status Report, ECF No. 25. On February 23, 2022, Respondent
filed a status report indicating he was willing to engage in litigative risk settlement
discussions. ECF No. 27.
Less than three months later, however, the parties had reached an impasse.
Status Report, filed June 20, 2022, ECF No. 32. Respondent filed his Rule 4(c) Report
setting forth his objections to compensation on September 27, 2022. ECF No. 36.
Specifically, he argues that Petitioner “has not clearly established that he suffered the
onset of his left shoulder pain within 48 hours of vaccination.” Id. at 6.
The matter is now ripe for adjudication.
II. Factual Findings and Ruling on Entitlement
A. Legal Standards
Before compensation can be awarded under the Vaccine Act, a petitioner must
demonstrate, by a preponderance of evidence, all matters required under Section
11(c)(1), including the factual circumstances surrounding his claim. Section 13(a)(1)(A).
In making this determination, the special master or court should consider the record as a
3 Rather than an affidavit, the statement provided by Petitioner is a declaration signed under penalty of
perjury as required pursuant to 28 U.S.C.A. § 1746.
4 These declarations were also signed under penalty of perjury as required pursuant to 28 U.S.C.A. § 1746.
2

Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 3 of 6
whole. Section 13(a)(1). Petitioner’s allegations must be supported by medical records or
by medical opinion. Id.
To resolve factual issues, the special master must weigh the evidence presented,
which may include contemporaneous medical records and testimony. See Burns v. Sec'y
of Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (explaining that a special
master must decide what weight to give evidence including oral testimony and
contemporaneous medical records). Contemporaneous medical records are presumed to
be accurate. See Cucuras v. Sec’y of Health & Hum. Servs., 993 F.2d 1525, 1528 (Fed.
Cir. 1993). To overcome the presumptive accuracy of medical records testimony, a
petitioner may present testimony which is “consistent, clear, cogent, and compelling.”
Sanchez v. Sec'y of Health & Hum. Servs., No. 11–685V, 2013 WL 1880825, at *3 (Fed.
Cl. Spec. Mstr. Apr. 10, 2013) (citing Blutstein v. Sec'y of Health & Hum. Servs., No. 90–
2808V, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)).
In addition to requirements concerning the vaccination received, the duration and
severity of petitioner’s injury, and the lack of other award or settlement,5 a petitioner must
establish that she suffered an injury meeting the Table criteria, in which case causation
is presumed, or an injury shown to be caused-in-fact by the vaccination she received.
Section 11(c)(1)(C).
The most recent version of the Table, which can be found at 42 C.F.R. § 100.3,
identifies the vaccines covered under the Program, the corresponding injuries, and the
time period in which the particular injuries must occur after vaccination. Section 14(a).
Pursuant to the Vaccine Injury Table, a SIRVA is compensable if it manifests within 48
hours of the administration of a flu vaccine. 42 C.F. R. § 100.3(a)(XIV)(B). The criteria
establishing a SIRVA under the accompanying QAI are as follows:
Shoulder injury related to vaccine administration (SIRVA). SIRVA manifests
as shoulder pain and limited range of motion occurring after the
administration of a vaccine intended for intramuscular administration in the
upper arm. These symptoms are thought to occur as a result of unintended
injection of vaccine antigen or trauma from the needle into and around the
underlying bursa of the shoulder resulting in an inflammatory reaction.
SIRVA is caused by an injury to the musculoskeletal structures of the
5 In summary, a petitioner must establish that he received a vaccine covered by the Program, administered
either in the United States and its territories or in another geographical area but qualifying for a limited
exception; suffered the residual effects of his injury for more than six months, died from his injury, or
underwent a surgical intervention during an inpatient hospitalization; and has not filed a civil suit or collected
an award or settlement for her injury. See Section 11(c)(1)(A)(B)(D)(E).
3

Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 4 of 6
shoulder (e.g. tendons, ligaments, bursae, etc.). SIRVA is not a neurological
injury and abnormalities on neurological examination or nerve conduction
studies (NCS) and/or electromyographic (EMG) studies would not support
SIRVA as a diagnosis (even if the condition causing the neurological
abnormality is not known). A vaccine recipient shall be considered to have
suffered SIRVA if such recipient manifests all of the following:
(i) No history of pain, inflammation or dysfunction of the affected shoulder
prior to intramuscular vaccine administration that would explain the alleged
signs, symptoms, examination findings, and/or diagnostic studies occurring
after vaccine injection;
(ii) Pain occurs within the specified time frame;
(iii) Pain and reduced range of motion are limited to the shoulder in which
the intramuscular vaccine was administered; and
(iv) No other condition or abnormality is present that would explain the
patient’s symptoms (e.g. NCS/EMG or clinical evidence of radiculopathy,
brachial neuritis, mononeuropathies, or any other neuropathy).
42 C.F.R. § 100.3(c)(10) (2017).
B. Factual Finding Regarding QAI Criteria for Table SIRVA
Respondent contests only the second criterion - whether the onset of Petitioner’s
pain occurred within 48 hours of vaccination. Rule 4(c) Report at 6-7; see 42 C.F.R. §
100.3(c)(10)(ii); see also 42 C.F.R. § 100.3(a)(XIV)(B) (requiring the first symptom or
manifestation of onset within 48 hours of vaccination for a SIRVA injury following receipt
of a flu vaccine). Emphasizing that Petitioner used terms such as “since” and “after” when
reporting his pain onset and indicated that his pain began within six hours of vaccination
in a later entry, Respondent insists that Petitioner has not establish a pain onset within
48 hours. Rule 4(c) Report at 6. He also argues that I may not make a finding regarding
onset based upon the claims of [P]etitioner alone, unsubstantiated by medical records, or
by a credible expert medical opinion.” Id. at 6-7 (citing Section 13(a)(1) and Lett v. Sec’y
of Health & Hum. Servs., 39 Fed. Cl. 259, 260 (1997)).
I do not find Respondent’s arguments to be persuasive. The contemporaneously
created medical records show (from the time he first sought treatment on October 30,
2018) that Petitioner consistently provided descriptions of pain onset within 48 hours of
4

Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 5 of 6
vaccination. Without fail, he attributed his injury to the flu vaccine he had received on
October 3, 2018. Id. And the record contains a dearth of evidence supporting a later pain
onset.
Thus, when Petitioner first reported his left shoulder pain on October 30, 2018, he
indicated “that the [sic] got his Flu shot on 10/3 and his shoulder has been hurting since
then.” Exhibit 4 at 5. When next seen for left shoulder pain for five months - since October,
Petitioner indicated the pain “[s]tarted after getting a flu shot.” Exhibit 2 at 37. At a visit
with an orthopedic surgeon on January 9, 2020 – more than 15 months post-vaccination,
Petitioner again linked his pain to the flu vaccine he received, indicating “[h]e began to
have pain approximately 6 hours after the injection.”
The term “after” is less clear, but “since” implies an immediate pain onset.
Definitions of the word “since” include the following: 1) “from a definite past time until now”
and 2) “from a particular time in the past until a later time.”6 And, although the more
specific time frame Petitioner later provided deviated slightly from his earlier reports of
more immediate pain, this timing – six hours post-vaccination - still falls well within the 48
hours required for a Table SIRVA injury. Additionally, the account was provided in
January 2020 – more than 15 months post-vaccination – meaning it inherently deserves
a bit less weight than more contemporaneous evidence.
Respondent appears to deem the Petitioner-provided statements contained in the
contemporaneously created medical records as equivalent to an “unsupported” injury
claim of the sort that Section 13(a)(1) of the Act defines as not a proper basis for recovery.
Rule 4(c) Report at 6-7. However, this is an incorrect characterization. Although these
entries were based upon information provided by Petitioner, they still should be afforded
greater weight than more current representations, as they were uttered
contemporaneously with Petitioner’s injury for the purposes of obtaining medical care.
The Federal Circuit has stated that “[m]edical records, in general, warrant consideration
as trustworthy evidence . . . [as they] contain information supplied to or by health
professionals to facilitate diagnosis and treatment of medical conditions.” Cucuras, 993
F.2d at 1528 (emphasis added). Thus, the Circuit has instructed that greater weight
should be accorded to this information even when the information is provided by
Petitioner.
6 These definitions can be viewed at the Merriam-Webster and Cambridge Dictionary. See (www.merriam-
webster.com/dictionary/since; https://dictionary.cambridge.org/us/dictionary/english/since
(last visited on Oct. 3, 2022).
5

Case 1:20-vv-01553-UNJ Document 44 Filed 11/15/22 Page 6 of 6
I thus find there is preponderant evidence to establish Petitioner suffered left
shoulder pain within 48 hours of vaccination – meaning Petitioner has satisfied the second
criterion for a Table SIRVA injury.
Respondent does not dispute any other Table SIRVA requirements, and the record
contains sufficient evidence showing Petitioner has satisfied the other QAI criteria. See
42 C.F.R. § 100.3(c)(10)(i) & (iii)-(iv). A thorough review of the record in this case does
not reveal a prior or current condition or abnormality which would explain Petitioner’s
condition or pain and limited range of motion (“ROM”) other than in Petitioner’s injured
left shoulder. Thus, all elements of a Table SIRVA claim have been preponderantly
established.
C. Other Requirements for Entitlement
Because Petitioner has satisfied the requirements of a Table SIRVA, he need not
prove causation. Section 11(c)(1)(C). However, he must satisfy the other requirements of
Section 11(c) regarding the vaccination received, the duration and severity of his injury,
and the lack of other award or settlement. Section 11(c)(A), (B), and (D). Respondent
does not dispute that Petitioner has satisfied these requirements in this case, and the
overall record contains preponderant evidence which fulfills these additional
requirements.
III. Conclusion
Based on the entire record in this case, I find that Petitioner has provided
preponderant evidence satisfying all requirements for a Table SIRVA. Petitioner is
entitled to compensation in this case.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
6

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DOCUMENT 2: USCOURTS-cofc-1_20-vv-01553-1
Date issued/filed: 2022-11-17
Pages: 4
Docket text: PUBLIC DECISION (Originally filed: 10/14/2022) regarding 40 DECISION Stipulation/Proffer ( Signed by Chief Special Master Brian H. Corcoran. )(mpj) Service on parties made.
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Case 1:20-vv-01553-UNJ Document 45 Filed 11/17/22 Page 1 of 4
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 20-1553V
UNPUBLISHED
TRAVIS LUTZ, Chief Special Master Corcoran
Petitioner, Filed: October 14, 2022
v.
Special Processing Unit (SPU);
SECRETARY OF HEALTH AND Damages Decision Based on Proffer;
HUMAN SERVICES, Influenza (Flu) Vaccine; Shoulder
Injury Related to Vaccine
Respondent. Administration (SIRVA)
Ronald Craig Homer, Conway, Homer, P.C., Boston, MA, for Petitioner.
Andrew Henning, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION AWARDING DAMAGES1
On November 9, 2020, Travis Lutz filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”), alleging that he suffered a left shoulder injury related to vaccine
administration (“SIRVA”), as defined in the Vaccine Injury Table, after receiving an
influenza (“flu”) vaccine on October 3, 2018. Petition at 1, ¶¶ 1-3. The case was assigned
to the Special Processing Unit of the Office of Special Masters.
On October 11, 2022, I issued a ruling on entitlement, finding Petitioner entitled to
compensation for his SIRVA injury. On October 13, 2022, Respondent filed a proffer on
award of compensation (“Proffer”) indicating Petitioner should be awarded $89,235.85,
representing compensation in the amounts of $85,000.00 for his pain and suffering and
$4,235.85 for his out-of-pocket expenses. Proffer at 1. In the Proffer, Respondent
1 Because this unpublished Decision contains a reasoned explanation for the action in this case, I am
required to post it on the United States Court of Federal Claims' website in accordance with the E-
Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic
Government Services). This means the Decision will be available to anyone with access to the
internet. In accordance with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact
medical or other information, the disclosure of which would constitute an unwarranted invasion of privacy.
If, upon review, I agree that the identified material fits within this definition, I will redact such material from
public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).

Case 1:20-vv-01553-UNJ Document 45 Filed 11/17/22 Page 2 of 4
represented that Petitioner agrees with the proffered award. Id. Based on the record as a
whole, I find that Petitioner is entitled to an award as stated in the Proffer.
Pursuant to the terms stated in the attached Proffer, I award Petitioner a lump
sum payment of $89,235.85, representing compensation in the amounts of
$85,000.00 for his pain and suffering and $4,235.85 for his unreimbursable
expenses in the form of a check payable to Petitioner. This amount represents
compensation for all damages that would be available under Section 15(a).
The Clerk of Court is directed to enter judgment in accordance with this decision.3
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
3 Pursuant to Vaccine Rule 11(a), entry of judgment can be expedited by the parties’ joint filing of notice
renouncing the right to seek review.
2

Case 1:20-vv-01553-UNJ Document 45 Filed 11/17/22 Page 3 of 4
THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
TRAVIS LUTZ,
Petitioner,
v. No. 20-1553V (ECF)
Chief Special Master Corcoran
SECRETARY OF HEALTH AND SPU
HUMAN SERVICES,
Respondent.
RESPONDENT’S PROFFER ON AWARD OF COMPENSATION
On November 9, 2020, Travis Lutz (“petitioner”) filed a petition for compensation
alleging a Shoulder Injury Related to Vaccine Administration (“SIRVA”). Petition at 1. On
September 27, 2022, respondent filed his Rule 4(c) Report recommending that entitlement to
compensation be denied. ECF No. 36. On October 11, 2022, Chief Special Master Corcoran
issued Findings of Fact and Ruling on Entitlement, finding that petitioner was entitled to vaccine
compensation for his SIRVA.1 ECF No. 37.
I. Items of Compensation
A. Pain and Suffering and Out-of-Pocket Expenses
Respondent proffers that petitioner should be awarded $85,000.00 in pain and suffering
and $4,235.85 in out-of-pocket expenses. See 42 U.S.C. § 300aa-15(a)(4). Petitioner agrees.
1 Respondent has no objection to the amount of the proffered award of damages set forth
herein. Assuming the Chief Special Master issues a damages decision in conformity with this
proffer, respondent waives his right to seek review of such damages decision. However,
respondent reserves his right, pursuant to 42 U.S.C. § 300aa-12(e), to seek review of the Chief
Special Master’s October 10, 2022, entitlement decision.

Case 1:20-vv-01553-UNJ Document 45 Filed 11/17/22 Page 4 of 4
These amounts represent all elements of compensation to which petitioner is entitled
under 42 U.S.C. § 300aa-15(a).2 Petitioner agrees.
II. Form of the Award
The parties recommend that compensation provided to petitioner should be made through
a lump sum payment of $89,235.85, in the form of a check payable to petitioner. Petitioner
agrees.
Petitioner is a competent adult. Evidence of guardianship is not required in this case.
Respectfully submitted,
BRIAN M. BOYNTON
Principal Deputy Assistant Attorney General
C. SALVATORE D’ALESSIO
Director
Torts Branch, Civil Division
HEATHER L. PEARLMAN
Deputy Director
Torts Branch, Civil Division
ALEXIS B. BABCOCK
Assistant Director
Torts Branch, Civil Division
/s/ ANDREW J. HENNING
ANDREW J. HENNING
Trial Attorney
Torts Branch, Civil Division
U.S. Department of Justice
P.O. Box 146
Benjamin Franklin Station
Washington, D.C. 20044-0146
Tel.: (202) 616-4405
Email: andrew.j.henning@usdoj.gov
DATED: October 13, 2022
2 Should petitioner die prior to the entry of judgment, the parties reserve the right to move
the Court for appropriate relief. In particular, respondent would oppose any award for future
medical expenses, future lost earnings, and future pain and suffering.
2