Extent of Injury (EOI)Taking the Medical History • Document a thorough medical history • Cover all items on DD’s checklist • Clinical course, including past medical history,
The material presented in this presentation is made available by the Texas Department of InsuranceDivision of Workersrsquo Compensation (TDI-DWC) for educational purposes only The material is not intended to represent the sole approach method procedure or opinion appropriate for the medical situations discussed
Material Disclaimer
3
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantial factor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
4
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantialfactor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
5
EOI Analysis Understanding the Questionbull Important medicallegal question in workersrsquo
compensationbull You give your opinion and rationale as to which
injuries are caused by accident and which are not bull Support your opinion from a medical perspective
within the legal frameworkbull You provide medical expertise to inform those
reading your report including an Administrative Law Judge
bull We will review legal standards for you to consider
6
DWC 32 Box 36C
7
EOI - DWC Form-032
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
The material presented in this presentation is made available by the Texas Department of InsuranceDivision of Workersrsquo Compensation (TDI-DWC) for educational purposes only The material is not intended to represent the sole approach method procedure or opinion appropriate for the medical situations discussed
Material Disclaimer
3
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantial factor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
4
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantialfactor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
5
EOI Analysis Understanding the Questionbull Important medicallegal question in workersrsquo
compensationbull You give your opinion and rationale as to which
injuries are caused by accident and which are not bull Support your opinion from a medical perspective
within the legal frameworkbull You provide medical expertise to inform those
reading your report including an Administrative Law Judge
bull We will review legal standards for you to consider
6
DWC 32 Box 36C
7
EOI - DWC Form-032
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantial factor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
4
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantialfactor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
5
EOI Analysis Understanding the Questionbull Important medicallegal question in workersrsquo
compensationbull You give your opinion and rationale as to which
injuries are caused by accident and which are not bull Support your opinion from a medical perspective
within the legal frameworkbull You provide medical expertise to inform those
reading your report including an Administrative Law Judge
bull We will review legal standards for you to consider
6
DWC 32 Box 36C
7
EOI - DWC Form-032
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated DoctorWas the accident or incident giving riseto the compensable injury a substantialfactor in bringing about the additional claimed injuries or conditions and without it the additional injuries or conditions would not have occurred
Include an explanation of the basis for your opinion
5
EOI Analysis Understanding the Questionbull Important medicallegal question in workersrsquo
compensationbull You give your opinion and rationale as to which
injuries are caused by accident and which are not bull Support your opinion from a medical perspective
within the legal frameworkbull You provide medical expertise to inform those
reading your report including an Administrative Law Judge
bull We will review legal standards for you to consider
6
DWC 32 Box 36C
7
EOI - DWC Form-032
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
EOI Analysis Understanding the Questionbull Important medicallegal question in workersrsquo
compensationbull You give your opinion and rationale as to which
injuries are caused by accident and which are not bull Support your opinion from a medical perspective
within the legal frameworkbull You provide medical expertise to inform those
reading your report including an Administrative Law Judge
bull We will review legal standards for you to consider
6
DWC 32 Box 36C
7
EOI - DWC Form-032
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Box 36Cbull Lists all injuries (diagnosesbody partsconditions)
in question bull Gives description of accidentincident that caused
claimed injury in questionin dispute
DD must address each injury (diagnosisbody partcondition) listed in Box 36C
8
EOI Process
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
1 Prepare for DD exam2 Conduct DD Exam3 Research and Literature Review4 Causation Analysis5 Drafting the Narrative Report6 Multiple Certifications of MMIIR7 Completing the DWC 68
9
1 Prepare for DD Exam
10
1 Prepare for DD Exam
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Review all materials includingbull DWC Form-032 (particularly Box 36C)
bull Or Presiding Officer Directive (POD)bull Medical recordsbull Insurance carriertreating doctor analysis
bull Put together an ldquoExam Checklistrdquo
11
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Review of Medical Recordsbull DD can receive injured employeersquos confidential
medical records and other records to assist in dispute resolution without signed release
bull Treating doctor and insurance carrier must provide all required medical records and may send analyses
bull Treating doctor and insurance carrier shall ensure required records are received by DD no later than 3 working days prior to exam
28 TAC sect12710(a)(3)
12
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Review of Medical Recordsbull If DD does not receive medical records or any
part thereof at least 3 working days prior to exam DD SHALLbull Report violation to DWC within one working day of not timely
receiving recordsbull IF DD has not received records within one working day of
exam or if DD does not have sufficient time to review late medical records before exam do NOT conduct exam until all records received
bull THEN DD shall reschedule exam to occur no later than21 days after receipt of records
bull Reportfile complaint regarding non-compliant carrier ortreating doctor
bull DWC shallbull Take action necessary to ensure DD receives records
13
Review of Medical Records
bull DD must review records prior to exam
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull As DD reviews submitted records prior to exam DD may discover additional required records existbull Obtain and review those required records
prior to conducting exam
bull DWC assistance with recordsbull DDRecordstditexasgov
14
Review Other Analyses Provided
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Both carrier and treating doctor can provide you with an analysis limited to the following topics for injured employeebull medical conditionbull functional abilitiesbull return to work opportunities
bull May include videotaped activities and marked copies of medical records
bull Consider the source Is it written by a doctor lawyer or adjuster
15
Review of Medical Records and Timeline
bull Date of injury
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Explain how accidentincident happened (mechanism of injury)
bull Condition beforeafter accidentincident
bull Timing of signssymptom onset
16
Review of Medical Records and Timeline
bull Clinical findings
bull Testing results
bull Response to prior treatment
bull Treatment plan-claimant compliance
bull Recommended future treatment or testing
17
Exam Checklist
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull A checklist for your exambull Will help ensure you do not miss anythingbull Will make you think through evidence and
issues prior to exam to ensure you get what you need during exam
bull You will need to ask more questions as you take your history and perform the physical exam but this is good place to start
1818
Questions About Preparing for EOI Exam
19
2 Conduct DD Exam
20
2 Conduct DD Exam
bull Medical History
bull Physical Exam
bull Additional TestingReferrals if needed
21
Taking the Medical History
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Document a thorough medical historybull Cover all items on DDrsquos checklistbull Clinical course including past medical history
signssymptoms prior treatment and testingbull Consider timeline
bull Are onset and timeline of signs and symptoms consistent with what happened (mechanism of injury) and conditioninjuryin question
22
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
How Did AccidentIncident Occurbull Document understanding of the mechanism of
injurybull Failure to do so may discredit report
bull Document each account bull Sourcesbull Are they consistentbull Document all findings in an objective way
bull If there are multiple accounts of accident in records and exam then describe which account used and why
23
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Typical Physical Exam Checklistbull Consider other potential injuries conditions or diagnoses
bull Some common musculoskeletal and neurological bulletsbull examination of gait and station bull ROM (measured active ROM)bull strengthbull sensationbull stabilitybull deep tendon reflexesbull spine - presence or absence of neural tension signs (ie SLR)bull other - non-organic signs comparison of observed vs measured
ROM etc
bull Examination of contralateral extremity
24
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Additional TestingReferrals bull DD determines the need for additional
testingreferralbull Not subject to preauthorization or retrospective
review for medical necessity extent of injury or compensability
bull If it is necessary to determination then it is DDrsquos obligation to order and review findings prior to completing DD report
bull Failure to base analysis on complete patient evaluation may discredit DD analysis
28 TAC sect 12710 (c)
2525
Questions About Conducting EOI Exam
26
3 Research and Literature Review
27
Evidence-Based Medicine (EBM)
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoEvidence-based medicinerdquo means useof current best quality scientific and medical evidence formulated from credible scientific studies including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines in making decisions about care of individual patientsTLC sect401011(18-a)
28
3 Research and Literature Review
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Obtain and review relevant medical literature if available
bull Many resources for EBMbull Consider relevant EBM that supports or
refutes your causation conclusion if available and when appropriate
29
Resource List
See Evidence-Based Medicine sources handouts
3030
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Questions About Research and Literature review for EOI Exam
31
4 Causation Analysis
32
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
4 Causation Analysis ndash Step by StepA Describe each injury or condition in
question from Box 36CB Explain the mechanism of injuryC Describe the clinical findings and timelineD Apply EBM if available and appropriateE Answer the question using appropriate
legal terms
33
Understand Legal Definition
ldquoInjuryrdquobull Damage or harm to the physical
structure of the body bull Disease or infection naturally resulting
from the damage or harm bull Includes occupational disease
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Claimed injury that causes additional damageor harm to the physical structure of the body
bull May include any naturally resulting diseaseor infection
bull Can include an enhancement accelerationor worsening of an underlying condition
Appeals Panel Decision 002967
35
Substantial Factor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull No legal definition in DWC systembull Substantial factor is relativebull Consider the mechanism of injurybull Co-morbiditiesbull Substantial factor is not the same as sole
causebull May be more than one substantial factor
36
ldquoEggshell Claimantrdquo
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Means DD takes injured employee as is bull With all pre-existing conditions and co-morbidities
DD finds in any patient
bull History and medical timeline factorinto DD analysis
bull Determine if accident was substantial factor in causing injury in question and without accident or incident additional injuries or conditions would not have occurred
37
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Describe Injury in Questionbull Refer to injury or condition using the same
terms as listed in Box 36C bull Keep in mind legal concepts of injury and
aggravationbull If referring to injury or condition by different
medical term or grade of condition than listed in Box 36C explain
bull Do you view these terms as synonymous bull If so state that these are same
38
Describe Injury in Question
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull If there are injuries that can be grouped together as same or part of same medical process explain such grouping
bull Do not assume reader has any medical knowledge
bull Give thorough explanation
bull Describe how the injury typically occurs
39
Describe Injury in Question
bull Explain injury using medical terminology
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull A list of diagnoses or codes from records is not sufficient
bull Address each injurybody partcondition in question
40
Explain Mechanism of Injury
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Explain the mechanism of injury that caused injury or condition in question
bull Explain accidentincident and how these forces if applicable caused claimed injury condition or an aggravation of preexisting injury or condition
bull An incorrect or incomplete account of this in your analysis may create doubt regarding your conclusion
41
Explain Mechanism of Injury
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Be as specific as possible as to details and where you found them Specific medical records claimantrsquos account carrierrsquos analysis etc
bull Objectively recount any contradictions regarding accidentincident you find
bull State how injury happenedbull Mechanism of injury that occurred and who
gave you that account
42
Explain Mechanism of Injury
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Not stating in report how injury happened implies you do not know what happened
bull If you do not know and state what happened then how can you render credible opinion on causation
bull Be objective in descriptions do not use inflammatory language
43
Clinical Findings and Timeline
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull What was medical condition of IE at time of accident incident
bull What about the condition and history of this particular IE was a substantial factor in causing the specific injurycondition or aggravation in question
44
Clinical Findings and Timeline
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull On the flip side what about the history or condition of this particular IE allowed you to rule out accident as a substantial factor in giving rise to injury or condition in question
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Clinical Findings and Timelinebull Pertinent positive and negative findings in
your review of medical records and your exam
bull How all these fit into timeline to assist you in determining whether this accident was substantial factor in causing injury
bull Resulted from something else related or unrelated
46
Apply Evidence-Based Medicine
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Both medicine and law are based on research and applicable precedent
bull Use EBM when available and if appropriate to inform and support your opinion
bull What supports your conclusion that injury was or was not the result of this accidentincident
47
Apply Evidence-Based Medicine
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull What studies would a doctor taking a contrary position cite and why did you render those inapplicable or unconvincing
bull Peer review journals articles and studiesbull If evidence or resources on subject matter
are limited indicate so in your reportbull See EBM resource list
48
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Answer Question Using Appropriate Legal Termsbull ldquoYESrdquo or ldquoNOrdquo and ldquoWHYrdquobull Regardless of conclusion you MUST explain
based on aforementioned factors how reachedbull Stating conditions in question were result of
accident is incompletebull Follow steps previously discussed and connect
dots for readerbull Keep in mind ldquoWHYrdquo as you work through this
analysis
49
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Answer Question Using Appropriate Legal Termsbull Reasonable medical minds will differ so
explain in ldquoreasonable medical probabilityrdquo to ensure reader understands why injury isis not result of accident
bull Avoid the following and similar termsphrasesbull ldquopossiblerdquobull ldquomight haverdquobull ldquocould haverdquobull ldquopotentiallyrdquo
50
Answer Question Using Appropriate Legal Terms
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Ensure your approach references relevant legal definitions and standards in reaching your conclusionbull Injurybull Aggravationbull Substantial factorbull Reasonable medical probability
51
Connect the Dots
Connect the Dots
52
Insufficient Causation Analysis
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Conclusions rather than explanationbull Only listing diagnosesbull General statements that condition was
not present until after accidentAll parties including Administrative Law Judge need explanation as to why you reached your conclusion not just a conclusion
53
Causation Analysis Examples
bull See printed material
54
Causation Not a Trivial Pursuit
Presenter
Presentation Notes
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Now wersquore going to put the audience to the test in this interactive exercise - wersquoll read a short causation analysis and get your take on why it is effective and why it is not Some of these will test you on concepts wersquove discussed so far in this presentation 1313Add a disclaimer that every case has its own facts and this game is being offered for entertainmenteducational purposes It is not a substitute for the important exercise of basing your determination of the extent of the injury on the physical examination and medical record
55
Disclaimer
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Every case has its own facts and this game is being offered for entertainment educational purposes It is not a substitute for the important exercise of basing your determination of the extent of injury on the physical examination and medical record
56
Sufficient or Not
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoIt is possible that the degenerative disc disease noted in the MRI was aggravated by the compensable lifting eventrdquo
Presenter
Presentation Notes
Assume this sentence and the ones in the slides that follow are all we have to go on 1313Not sufficient Why How could this be improved1313See Appeals Panel Decision 1220851313The Appeals Panel has previously held that proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection Appeals Panel Decision (APD) 022301 decided October 23 2002 See also Guevara v Ferrer 247 SW3d 662 (Tex 2007) To be probative expert testimony must be based on reasonable medical probability City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Insurance Company of North America v Myers 411 SW2d 710 713 (Tex 1966) 1313Reports which say ldquocould berdquo or ldquoit is possiblerdquo do not meet the standard of reasonable medical probability required by Guevara and City of Laredo
57
Sufficient or Not
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoSince the examinee was not symptomatic prior to the compensable injury event and developed symptoms right after the injury event it stands to reason that the MRI pathology identified post-injury are related to the compensable injury eventrdquo
Presenter
Presentation Notes
Post hoc ergo propter hoc Temporal proximity should be part of the analysis but it shouldnrsquot be the only thing relied upon1313From APD 1507391313The condition of an acute tear of the lateral meniscus is a condition that requires evidence to establish a causal connection with the compensable injury See City of Laredo v Garza 293 SW3d 625 (Tex App-San Antonio 2009 no pet) citing Guevara v Ferrer 247 SW3d 662 (Tex 2007) However the court in Guevara also noted that while temporal proximity alone does not by itself support an inference of medical causation ldquo[t]his is not to say that evidence of temporal proximity that is closeness in time between an event and subsequently manifested physical conditions is irrelevant to the causation issuerdquo Id at 668 The court further stated 1313Evidence of an event followed closely by manifestation of or treatment for conditions [that] did not appear before the event raises suspicion that the event at issue caused the conditions But suspicion has not been and is not legally sufficient to support a finding of legal causation When evidence is so weak as to do no more than create a surmise or suspicion of the matter to be proved the evidence is no more than a scintilla and in legal effect is no evidence Nevertheless when combined with other causation evidence evidence that conditions exhibited themselves or were diagnosed shortly after an event may be probative in determining causation 1313
58
Sufficient or Not
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoThe claimed condition of knee arthritis is an ordinary disease-of-life finding that pre-existed the injury eventrdquo
Presenter
Presentation Notes
An injury includes the aggravation of a preexisting condition or injury Cooper v St Paul Fire amp Marine Ins Co 985 SW2d 614 (Tex App-Amarillo 1999 no pet) Peterson v Continental Cas Co 997 SW2d 893 (Tex App-Houston [1st Dist] 1999 no pet) To prove an aggravation of a preexisting condition there must be some enhancement acceleration or worsening of the underlying condition from the injury APD 0029671313How can this be improved Just because itrsquos pre-existing doesnrsquot end the inquiry If the condition is pre-existing is there evidence of aggravation of the pre-existing injury
59
Sufficient or Not
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoI opine that the examineersquos injury caused within reasonable medical probability the claimed condition of carpal tunnel syndromerdquo
Presenter
Presentation Notes
APD 0114771313In Stodghill v Texas Employers Insurance Association 582 SW2d 102 (Tex 1979) the Supreme Court of Texas stated that the medical expert need not use the exact magic words reasonable medical probability but the testimony is sufficient if the circumstances show that this is the substance of what the expert is saying 13This opinion is conclusory notwithstanding the use of the ldquomagic wordsrdquo13Could the fact finder glean from this opinion what the mechanism of injury was and how within reasonable medical probability the condition is causally related to the mechanism of the injury
60
Sufficient or Not
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoIn my medical opinion and within a reasonable degree of medical probability stepping on a crack and rolling her ankle at work on [the date of injury] caused torqueing forces to the examineersquos left ankle joint which stressed the joint structures of her left ankle and exceeded the strength of the joint structures of her left ankle and produced the left ankle plantar fasciitisrdquo
Presenter
Presentation Notes
Changed a little from the original 1313This largely comes from APD 130723 The ALJ found that a causation letter very similar to this was ldquoconclusory and merely recites the MRI findings diagnosis and a statement that they are related in his opinion to the injuryrdquo The AP disagreed that the opinion was conclusory and remanded the case for the ALJ to give the opinion proper weight in making his determination The AP wrote ndash ldquoAlthough the [ALJ] could accept or reject in whole or in part the opinion of Dr W or any other evidence the [ALJ] misread Dr Wrsquos causation letter rdquo 1313What makes this opinion sufficient or at least non-conclusory Compare the more substantive use of ldquoreasonable medical probabilityrdquo in this slide to the previous one 1313Caveat ndash just because a causation opinion is sufficient does not necessarily mean it will be adopted
61
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Sufficient or NotldquoIn my opinion the right shoulder rotator cuff tear is not part of the compensable injury The MRI of the right shoulder approximately three months from the date of injury demonstrated no acute injury in the right shoulder but only chronic degenerative changes Also a review of the medical records does not document any history of impact to the right shoulder or blunt trauma by the 2 eyewitnesses to the injury nor does the medical record document any ecchymosis or swelling of the right shoulder in the emergency department on the date of injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
62
Sufficient or Not
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoThe mechanism of injury involved a rollover motor vehicle accident (MVA) The injury included jarring and jolting of the examineersquos cervical spine Due to the impact of the MVA there is a causal relationship between the impact involving jarring and jolting forces in the examineersquos cervical area resulting in a cervical sprainstrainrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
63
Sufficient or Not
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
ldquoNeuritis occurs when nerves become inflamed The inflammation results in pain and numbness wherever the affected nerve travels Nerves from the thoracic (middle) spine extend to the upper abdominal area as well as the back the neck and the area between the shoulder There is nothing in the physical examination or the medical records to indicate thoracic neuritis so that condition should not be included as part of the compensable injuryrdquo
Presenter
Presentation Notes
Is this opinion sufficient Why or why not Is it clear Logical13
6464
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Questions About Causation Analysis for the Extent of Injury Exam
65
5 Narrative Report
66
Extent of Injury Template
67
Extent of Injury Template
68
Extent of Injury Template
69
Extent of Injury Template
70
Extent of Injury Template
71
6 Multiple Certifications of MMIIR
72
Multiple Certifications of MMIIR
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Pursuant to 28 TAC sect12710(d) if a DD is simultaneously asked to address MMI andor IR and extent of injury in a single exam the DD shall provide multiple certifications for MMIIR that take into account each reasonable outcome for extent of injury
73
Multiple Certifications of MMIIR Best Practice
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
1 Injury accepted as compensable by insurance carrier
2 Injury accepted as compensable by insurance carrier plus all disputed injuries listed in Box 36C
3 Compensable injury as defined by DD if different from 1 or 2 above
74
Multiple Certifications of MMIIR
After certification you must
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
State which of your certifications you believe is the appropriate MMIIR and why based on your EOI opinion
75
When to Provide Multiple Certifications
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Only requests for DD to simultaneously address MMIIR and EOI in single exam provide for multiple certifications of MMIIR
bull Requests for multiple certifications when exam addresses EOI alone or MMIIR alone in a single exam do not require multiple certifications
76
Hearings An Exception
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
A DD must comply with a Presiding Officerrsquos Directive from a Benefit Review Officer or an Administrative Law Judge ordering multiple certifications of MMIIR
77
MMI IR and EOI Case
You are asked to simultaneously
address MMI IR and EOI in a
single exam
78
MMI IR and EOI Case
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
History of Injurybull 45-year-old male warehouse worker with
acute onset low back pain four months ago after lifting a 150-lb toolbox
79
MMI IR and EOI Case
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
History of Injury (contrsquod)bull Medical records and history document low
back pain for a week accompanied by left-sided radicular pain four days after DOI with pain and decreased sensation in S1 dermatome slightly decreased Achilles reflex and sciatic nerve root tension signs demonstrated by left SLR
80
MMI IR and EOI Case
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
History of Injury (contrsquod)bull Lumbar MRI scan shows L4L5 disc
degeneration 6 mm left posterolateral disc herniation at left L5-S1 with impingement on exiting left S1 nerve root
81
MMI IR and EOI Case
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
History of Injury (contrsquod)bull Signs and symptoms persist despite 10
visits of PT NSAIDS muscle relaxants and narcotic pain medication
bull ESI and surgery denied because EOI beyond a lumbar sprainstrain disputed
82
MMI IR and EOI Case
bull You see IE as a DD 4 months post injury
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Box 37 of DWC Form-032 completed by insurance carrier lists injury accepted as compensable by insurance carrier as ldquolumbar sprainstrainrdquo
83
VII Examination Injury Information
84
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
MMI IR and EOI CaseBox 36C of DWC Form-032 lists injuries (diagnosesbody partsconditions) in question claimed to be caused by or naturally resulting from accident or incident as
bull L4L5 disc degenerationbull Disc desiccation at L5S1 lumbar spinebull L5S1 disc herniation with impingement on
exiting left S1 nerve root
85
Purpose for Examination
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
L4L5 disc degenerationDisc desiccation at L5S1 lumbar spineL5S1 disc herniation with impingement on exiting left S1 nerve root
xxxxxxX
X
X
86
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
MMI IR and EOI Casebull In this case the DD defines compensable
injury for certifying MMI and IR asbull Lumbar sprainstrainbull Left S1 radiculopathy
(not included in Box 37 or 36C)bull L5-S1 disc herniation with impingement on
exiting left S1 nerve root (from 36C)
bull Explain in report the basis in medical records and certifying exam that led to conclusion
87
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
bull Address Extent of Injury with causation analysis as discussed previously that injury does not extend tobull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
88
MMI IR and EOI Case
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Multiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 1 MMIIR for injury accepted as compensable by the insurance carrier as ldquolumbar sprainstrainrdquo
89
Certification 1
S335XXA S39012A
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
90
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 2 Injury accepted as compensable by the insurance carrier plus all disputed injuries listed in Box 36C bull Lumbar sprainstrainbull L5-S1 disc herniation with impingement on
exiting left S1 nerve rootbull Disc degeneration at L4L5bull Disc desiccation at L5S1 lumbar spine
91
Certification 2
S335XXA S39012A M5417 M5127 M5137
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
92
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
MMI IR and EOI CaseMultiple certifications of MMIIR each withDWC-Form 69 all explained in report
bull Certification 3 MMIIR for what you define the injury to bebull Lumbar sprainstrainbull Left S1 radiculopathybull L5-S1 disc herniation with impingement on
exiting left S1 nerve root
93
Certification 3
S335XXA S39012A M5417 M5127
Presenter
Presentation Notes
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
Note to reviewer Codes in animation will be updated to ICD-10 codes1313Animation will complete this 69 with info from previous slide codes for13Lumbar sprainstrain
94
Not Yet at MMI
bull If one of possible combinations includes any injury where IE is not yet at MMI then you cannot do impairment rating for that combination
bull Present combination as possible alternate certification and explain why IE has not yet reached MMI as to that injurythose injuries
bull Address it by explaining why you cannot assign impairment rating as IE not at MMI for that injury
95
MMI IR and EOI Case
bull Address Extent of Injury with causation analysis as discussed previously that injury does extend tobull L5-S1 disc herniation with impingement
on exiting left S1 nerve root
9696
Questions About Multiple Certifications of MMIIR for EOI Exams
97
Complete DWC Form-068
98
Transfer Info from DWC Form-032
George Raley
Carrier One 03-02-2015
000-00-0000
E J McDermott MD
PO Box 7156 Austin TX 78777T4321 TXMD 512 804-512870 Medical Park Loop Austin TX 78647812016 300 PM
No
99
Transfer Info From DWC Form-032 Box 36C Add ICD Codes
L4L5 disc degeneration XDisc desiccation at L5S1 XL5S1 disc herniation with impingement on exiting left S1 nerve root
x
M5136M5137M5127
X
100
Document Referrals Testing Sign
Robert Payments E2234 01102016 X
E J McDermott MD 05232016
101101
QUESTIONS ABOUT EXTENT OF INJURY
Extent of Injury
Slide Number 2
Extent of Injury Question for the Designated Doctor
Extent of Injury Question for the Designated Doctor
