5th ama edition evaluation guide impairment permanent

Next Article. Article Navigation. Article July 01 This Site. Google Scholar. Guides Newsletter 6 4 : 1—4, 11, Cite Icon Cite. All Rights Reserved. You do not currently have access to this content. Required Medical Evidence. The ADL or equivalent information should be completed within the last 12 months before the impairment evaluation. If the employee is under nursing care, the CE provides all nursing notes from the past 30 days to the CMC for review. In addition to the ADL or its equivalent, some conditions require specific medical evidence before a CMC can complete the impairment evaluation, as outlined in Exhibit 5.

The CE also includes the information regarding the required medical evidence Exhibit 5 for the covered illness es. The letter includes instruction for the employee to return the required evidence within 30 days. If after 30 days, the claimant does not submit the required evidence, the CE makes a phone call to determine the status of the evidence. The CE advises the employee verbally of the need to obtain this evidence.

The CE explains that if the employee does not return the required evidence within 30 days, a recommended decision to deny the impairment claim may be issued.

After this phone call, the CE sends a second letter to the employee and includes a written summary of the phone call, blank ADL and information regarding the required medical evidence needed to conduct an impairment evaluation. If at the end of this total day period no evidence exists to show progress in obtaining the necessary impairment evidence and the employee has not provided a valid reason for the delay, the CE may issue a recommended decision to deny the impairment claim.

Insufficient Evidence. Unavailability of Records. The CE may proceed with a CMC referral to determine if the available records are sufficient to perform a rating. If the CMC is able to perform a rating based on the available medical evidence but states that additional testing could potentially increase the rating, the CE notifies the employee that additional testing may result in a higher rating and that the DEEOIC will pay for the additional testing.

The CE sends the employee a letter and gives the employee the option of obtaining the necessary testing paid by DEEOIC, or notifying the CE in writing that a decision may proceed based on the available medical evidence. If the employee does not respond, the CE proceeds with the impairment evaluation based on the available medical evidence. Outdated Evidence.

If the CE has provided the employee the opportunity to obtain current medical evidence but the claimant has not responded adequately, the CE may use medical evidence in the file that is older than 12 months to obtain an impairment rating from a CMC.

In some instances, the CMC may not be able to render an opinion with older or missing medical records. The CE explains this to the employee and provides the employee 30 days to submit documentation from a physician to establish a link between the exposure to a toxic substance at a covered facility and the development of a mental impairment. If the CE does not accept the prostate cancer due to a lack of a causative link and because prostate cancer is not an SEC-specified cancer, it is important that the CE ensure that a physician does not apply the non-covered prostate cancer in an impairment rating.

Receipt of the Impairment Evaluation. The CE reviews the impairment evaluation to determine the following: whether the opining physician possesses the requisite skills and requirements to provide a rating as set out in paragraph 4d 2 ; whether the evaluation was conducted within one year of receipt by the DEEOIC; whether the report addresses the covered illness or illnesses; whether the whole person percentage of impairment is explained with a clearly rationalized medical opinion as to its relationship to the covered illness or illnesses, and whether the medical opinion is supported by medical evidence in the case file.

Incomplete Ratings. If the impairment rating report is unclear or lacks rationalized medical analysis in support of the offered conclusion, additional clarification is required. In such instances, the CE returns the impairment rating evaluation to the rating physician with a request for clarification, explaining what areas are in need of remedy. If a response is not forthcoming, the CE may issue a recommended decision to deny the impairment claim for an insufficient impairment report.

Pre-Recommended Decision Challenges: Upon request, the CE may provide the employee with a copy of the impairment rating report.

However, any additional impairment evaluations must meet the criteria discussed above in Section 9 before the CE can consider it when making impairment determinations. If the additional evaluation differs from the existing rating, the CE must review and weigh See guidance provided in Procedure Manual Chapter , Developing and Weighing Medical Evidence the two reports to determine which report has more probative value.

Determining Probative Value. Impairment Award. Maximum Aggregate Compensation. If there are impairment benefits due to multiple covered illnesses, and at least one of those illnesses is subject to a tort offset or coordination of SWC award, the CE must determine the impairment award by following the steps in this section. Since DEEOIC does not apportion impairment within the same organ or body function, if there are several covered illnesses affecting the same organ or body function and one illness from the same organ or body function is subject to coordination or offset, the entire rating for that affected organ or body function is subject to coordination or offset.

Identify the combined impairment rating and calculate the dollar amount. Determine the percentage of the combined impairment rating that each separate impairment represents apportionment using these steps:. Calculate the dollar amount attributable for each organ or body function.

In the John Doe example case, the calculation is as follows:. For asbestosis — Multiply For skin cancer — Multiply His surplus due to asbestosis will not affect his entitlement to benefits for skin cancer. Calculate the Payable Impairment Award. The CE absorbs this surplus from medical benefits for asbestosis and future compensation benefits for asbestosis. Using the current impairment rating, follow the calculation in Section 12c to determine the relative percentage of impairment for each organ or body function and Section 12d to determine the dollar amount attributable for each organ or body function.

As such, the increased impairment calculation is as follows:. In any unique or challenging circumstance involving how best to apply SWC coordination or tort offset to a payable impairment, the CE consults with the National Office Policy Branch. Issuance of a Recommended Decision. Moreover, the CE must explain the sufficiency or insufficiency of the evidence justifying the decision outcome. For example, the CE discusses the qualification of the physician to perform an impairment rating.

For any lump-sum award, the CE explains clearly the calculation of the award, including subtractions due to prior lump sum impairment payments. If a decision recommends denial of an impairment claim based upon an insufficient evaluation, or if the CE relies on one evaluation over another evaluation s in the file, the CE provides a detailed discussion regarding the probative value of the evaluation s. This is necessary in the event that the employee submits additional impairment evidence to FAB, as any additional impairment evidence submitted has to overcome the weight of medical evidence as assigned by the CE.

FAB Development. Keep abreast of the latest developments in assessment, with authoritative guidance. It is authoritative and provides guidance on the assessment of impairment, causation, workability, and other critical issues. Published bi-monthly. Assess your knowledge and skills now with a item mini-assessment, at no cost. If not so well, we can assist you with online training and resources. Take action, take either or both mini-assessments now:.

Learn about certification. Most impairment assessments are performed by independent medical evaluators IMEs. Assessments should be unbiased and accurate.

Technology solutions such as ImpairmentCheck can help to ensure accuracy. With these products, the AMA aims to provide relevant training resources, user-friendly tools, and essential references for physicians and other health care workers with a professional investment in impairment and disability evaluation, particularly those who perform—or need to understand—independent medical examinations IMEs.

These tools are a collaboration of the latest scientific research and evolving medical opinions of nationally and internationally recognized physician and non-physician impairment and disability experts. This comprehensive collection is truly a one-stop-shop for all impairment, disability, and training needs.