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Steven D. Feinberg

Abstract

This article describes special aspects of addressing and defining substantial medical evidence, causation, and apportionment in the California Workers' Compensation system. Substantial medical evidence is framed in terms of reasonable medical probability, and the opinion must be based on fact and not be speculative. The issue of whether the injury occurred in the course of employment is left to the Trier of Fact (WCAB judge). The issue of arising out of employment is a medical issue left to the physician. Apportionment applies to both the industrial and nonindustrial cause of the disability.

in AMA Guides® Newsletter
Robert B. Snyder
and
James B. Talmage

Abstract

The decision about whether a case of documented COVID-19 illness is accepted as occupationally acquired and thus work compensable is made by insurers, or if contested, by judges or administrative bureaus. Causation for COVID-19 may be difficult to show because of the lack of accurate information and difficulty in meeting some of the criteria established by Bradford Hill. Nevertheless, physicians will be asked for medical records and documentation of illness. This article provides preliminary guidance to assist physicians in responding to insurers or workers compensation agencies' requests for information on the medial aspects of COVID-19.

in AMA Guides® Newsletter
Charles N. Brooks
,
Christopher R. Brigham
,
Marjorie Eskay-Auerbach
, and
James B. Talmage
in AMA Guides® Newsletter
Douglas W. Martin
,
J. Mark Melhorn
, and
James B. Talmage
in AMA Guides® Newsletter
James B. Talmage
,
Mark H. Hyman
, and
Robert B. Snyder

Abstract

The current pandemic of COVID-19 cases includes cases identified in emergency medical technicians, nurses, physicians, and others with occupational exposure to the SARS-CoV-2 virus. Many of these health care professionals have filed workers' compensation claims that have been accepted. Each accepted claim will eventually need a physician to declare the individual “at maximal medical improvement” or the equivalent phrase in the jurisdiction involved. The next step is for the physician to rate permanent impairment, if present, so the case can be administratively closed. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is used by many jurisdictions, but the AMA Guides does not mention COVID-19 or have guidance on how to assess individuals for impairment after recovery from this illness. This article provides preliminary guidance on rating permanent impairment within the respiratory, cardiac, vascular, neurologic, renal, gastrointestinal, and/or mental systems in COVID-19 survivors. Current references on the manifestations of COVID-19 illness in these body systems are included, which can be used as references to support documented impairment related to this illness.

in AMA Guides® Newsletter
Justin D. Beck
and
Judge David B. Torrey

Abstract

Medical evaluators must understand the context for the impairment assessments they perform. This article exemplifies issues that arise based on the role of impairment ratings and what edition of the AMA Guides to the Impairment of Permanent Impairment (AMA Guides) is used. This discussion also raises interesting legal questions related to retroactivity, applicability of prior precedent, and delegation. On June 20, 2017, the Supreme Court of Pennsylvania handed down its decision, Protz v. WCAB (Derry Area Sch. Dist.), which disallows use of the “most recent edition” of the AMA Guides when determining partial disability entitlement under the Pennsylvania Workers’ Compensation Act. An attempted solution was passed by the Pennsylvania General Assembly and was signed into law Act 111 on October 24, 2018. Although it affirms that the AMA Guides, Sixth Edition, must be used for impairment ratings, the law reduces the threshold for total disability benefits from 50% to 35% impairment. This legislative adjustment benefited injured workers but sparked additional litigation about whether, when, and how the adjustment should be applied (excerpts from the laws and decisions discussed by the authors are included at the end of the article). In using impairment as a threshold for permanent disability benefits, evaluators must distinguish between impairment and disability and determine an appropriate threshold; they also must be aware of the compensation and adjudication process and of the jurisdictions in which they practice.

in AMA Guides® Newsletter
Christopher R. Brigham
,
Helene Fearon
,
Steven Feinberg
,
Barry Gelinas
,
David Langham
, and
J. Mark Melhorn

Abstract

Virtual independent medical evaluations (IMEs) have become and are likely to remain common even after the coronavirus disease 2019 (COVID-19) pandemic ends, but virtual health care and virtual examinations are not simply a matter of moving to a new platform—rather, they require a transformation that affects all stakeholders. Innovative solutions necessitated by virtual IMEs potentially can improve both quality and efficiency. The American Medical Association (AMA) defines telemedicine as health-related services that are synchronous and asynchronous and include a variety of tools and platforms that allow clinicians to connect with one another and patients (a box provides information about AMA's ongoing telehealth initiative). Physicians who plan to perform virtual evaluations must have the appropriate policies, procedures, and security in place; resources are available from the AMA Guides series of publications. Each component of the virtual IME, including each data element, should be assessed to determine best practices and how to use virtual technologies successfully. The credibility of virtual IMEs may hinge on the examiner's ability to explain both what was done and why it was as efficacious as an in-person alternative or perhaps as useful as any other alternative under the circumstances. One challenge is to master the tools used in virtual IMEs and another is to obtain stakeholders' acceptance of the virtual process, but this will come with time, experience, and effective physician performance.

in AMA Guides® Newsletter