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Developed with the busy physician in mind, TeachCE.com’s publications are in a refreshing, periodical-style format (articles) and contain information valuable and beneficial to a Qualified Medical Examiner’s practice, report writing and knowledge of the CA Workers’ Compensation laws.

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***We are continually updating articles based on current regulations. Some outdated articles have been removed from the list.***

15. Self-Referrals/Cross Referrals – The Rules

In 1993, the legislature enacted the Workers’ Compensation Reform Act (AB 110) which contained sweeping changes that went to the heart of the way the compensation system functioned. One of the basic aims of the 1993 amendments in the fraud area was to curb potential abuses in the fee for direct service structure, which is built into physicians’ solo or group practices. In order to accomplish this, the legislature made disclosure a central component where a financial interest is involved in referrals for physician consultations, testing or treatment. As part of the new legislation, the legislature added far more specific prohibitions against self-referrals and cross-referrals than existed at that point and also added accompanying disclosure requirements to require the physician to declare under penalty of perjury that no such illicit actions were taking place. Unfortunately, these statutes, Labor Code sections 139.3 and 139.31, as written and rewritten by the legislature, are confusing to almost everyone and are often misinterpreted, even by attorneys. This article will clarify many of the confusing aspects of the legislation.

19. AMA Guides - Introduction

The AMA Guides are the most widely used basis for defining permanent impairment. They are used in most workers’ compensation jurisdictions in the United States, and often used in personal injury and automobile casualty cases to quantify the impact of an injury. Impairment and disability are not synonymous. The Guides only assess impairment. Impairment is defined as the “loss, loss of use, or derangement of any body part, organ system or organ function.” In this article, the concepts of impairment evaluation and the appropriate application of the Guides are reviewed. This article specifically addresses Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.

20. AMA Guides – Upper Extremity

The methods for upper extremity impairment assessment and specific ratings have been developed over a period of years, and are based in large part upon contributions from various specialty societies. In this article, the concepts of impairment evaluation and the appropriate application of the Guides in evaluating Upper Extremity impairment will be reviewed. In conjunction with this instruction, the reader will achieve the greatest learning by reviewing the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, Chapter 16.

21. AMA Guides – Spine

Spinal injuries are the most common reason for an impairment rating. There are two methods of evaluating the spine in the AMA Guides, 5th Edition: the Diagnosis Related Estimates (DRE) and the Range of Motion (ROM). The spine is divided into three regions: cervical, thoracic and lumbar. In this article, the concepts of impairment evaluation of the spine and the appropriate application of the Guides are reviewed. Practical guidance on the use of the Guides and avoiding common errors is offered.

22. AMA Guides – The Pain Patient

The basis of impairment rating is to evaluate pain in context to the underlying, objectively defined impairment In general, the percentages awarded in the AMA Guides for various permanent impairments allow “for the pain that may occur with those impairments.” While the AMA Guides and other authorities consider pain to be of secondary importance relative to objectively defined impairment, many patients present to the Qualified Medical Examiner or primary treating physician with subjective complaints but little or no objective findings. Moreover, efforts to standardize guidelines for disability evaluation have met with little success. There are few benchmarks available to the disability examiner against which to assess this difficult patient group. This article offers some guidelines that are of value in assessing pain patients more effectively.

23. AMA Guides – Lower Extremity

In Chapter 17 of The Guides, the lower extremities are divided into six anatomic sections for the purposes of calculating impairment ratings: the pelvis, the hips, the knees, the legs, the ankles and the hindfeet. Each of these anatomic sections has associated soft tissues, joints and neural and vascular structures. This article focuses on the principals and methods of assessing lower extremity impairment.

24. The Psychiatric Medical Legal Evaluation

A psychiatric medical-legal report provided for the purposes of the evaluation of a claim of industrially-related psychiatric injury is the product of a comprehensive clinical evaluation. A medical-legal report must address various issues such as Causation, Disability Status and Apportionment; whereas evaluations or consultations that are performed for purely clinical reasons do not typically address these issues. This article is written based upon the premise that the history, testing and examination findings should lead to unbiased conclusions.

Updated in 2013

25. Toxic Exposure Related Illness: Causation, Diagnosis and Disability

Within the framework of SB899, this paper discusses issues of causation, impairment, disability and apportionment of permanent disability with a particular focus on exposure-related illness. It provides a roadmap for physicians on how to communicate to the fact finders via medical and medical-legal reports, when evaluating and/or caring for a worker who has, or is suspected to have, toxic exposure-related medical conditions. For the purposes of this article, it is assumed that the establishment of permanent disability is based on the evaluating physician outlining permanent impairment per the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition with regard to occupational injuries/illness that reach a permanent and stationary status subsequent to January 1, 2005.

28. Substantial Evidence of Causation Apportionment

The issue of apportionment of permanent disability has always presented a problem in workers’ compensation. Then, SB 899 came along. Apportionment would no longer be measured by the disability that the injured worker would have had if he had not been injured at work. From now on the focus would be on causation of disability rather than disability itself. Labor Code sections 4750 and 4750.5, which had governed apportionment of disabilities that developed before or after the industrial injury, were repealed. Labor Code section 4663, the former “natural progression” statute, was re-enacted in a different form with the introductory statement that “Apportionment of permanent disability shall be based on causation.” New Labor Code section 4664 gave a conclusive presumption of the continued existence of disabilities that were the subject of prior awards. Determining the underlying causes of a disability can be a formidable task. In pre-SB 899 days, a physician’s inability to come up with a definitive answer was not crucial. The defendant had the burden of proof and if it did not carry that burden, the applicant was entitled to an unapportioned award. The Legislature eliminated this “escape clause” by providing that if the doctor doesn’t make an apportionment determination, the report can’t be used as evidence of permanent disability. This article addresses the intricacies of Causation Apportionment.

29. Cumulative Trauma Injuries (CTs)

Cumulative injury is one of the most difficult concepts for physicians in the workers’ compensation field. Physicians often must address the long term harmful effects of work exposure to the psyche, the back and internal organs and must do so while simultaneously explaining (to the satisfaction of a workers’ compensation judge) why some elements of the exposure contributed more to the overall snapshot of a worker’s disability while others did not. They also must deal with claims and denials over whether there were, in fact, any periods of harmful exposure or, where more than one cumulative injury may have occurred to the same individual over a lengthy period of time; or where the injury slowly occurred with different employers over a period of time. Cumulative injuries have been described as a series of “micro-traumas” and “degenerative conditions” that occur slowly through repetition of some physical or mental stress to the body. This article covers date of injury, multiple injury case and multiple employer case issues.

30. QME Sanction Guidelines

The purpose of these guidelines is to provide a framework of the Department of Worker’s Compensation-Medical Unit (DWC-MU) disciplinary process for those affected by it – Qualified Medical Evaluators, the DWC-MU administrative law judges with the Office of Administrative Hearings, licensing boards and other interested parties. These guidelines are not intended to be an exhaustive list of violations or disciplinary actions that the DWC-MU may consider against any QME. These guidelines set out the parameters for discipline for misconduct considered serious. This article is taken directly from the DWC-MU guidelines.

31. From The AMA Guides to California Permanent Disability Rating Pre 1/1/2013 DOI

There are significant differences between the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition (The Guides) and the Permanent Disability Rating Schedule (PDRS). Every evaluating physician should be aware of these differences when preparing a comprehensive MMI/P&S medical-legal report. This article will cover the MMI/P&S Report Requirements, Physician’s Report as Evidence, Imaging/Clinical Studies & Ancillary Testing, Substantial Medical Evidence of the Comprehensive MMI/P&S Report, and Causation Apportionment: the How & Why of Apportionment.

32. Obesity: Complications in Workers Compensation Claims

Obesity is one of the most common chronic medical problems in developed countries second only to hypertension, and more prevalent than ischemic heart disease. Obesity is no longer viewed as a difficult-to-treat inconvenient problem, but has become a common denominator to many life threatening diseases. The presence of obesity in a patient presenting with an industrial injury may complicate both the treatment of the industrial injury and confound the medical legal issues. The discussion in this article, deals with the identification of obesity, associated diseases, medical legal considerations, and very briefly with treatment issues.

35. Commonly Identified Areas of Deficiency in Med-Legal Reports

There are some areas in which med-legal reports are often found to be lacking in pertinent or relevant information. Typically this information is required by law or jurisdiction, or because it is integral to the support or calculation of an impairment rating or legal concepts, such as apportionment and causation. In California these reports are governed by the Permanent Disability Rating Schedule (PDRS), California Labor Codes, case law, and the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition (the Guides). This article, explores deficiencies in the history portion of the report, as it is the basis for formulating opinions on legal concepts such as causation and apportionment, as well as for calculating impairment ratings and determining work restrictions.

37. Top Ten Problems in Reports

The AMA Guides – often, physicians read only those few pages of the Guides that apply to their specialty. They don’t know what is in the rest of the book. To fully comply with the new rating standards, which focus on objective data, rather than subjective complaints, physicians must ask certain critical questions of injured workers, take additional measurements with specified tools and consider ramifications on other body parts that were never considered before. Set forth in this article are excerpts from medical reports that illustrate the ten most common errors physicians make in this regard and how these reports should be supplemented in order to constitute substantial evidence.

40. Privacy Compliance for Work Related Medical Issues

Privacy is one of our most important and fundamental freedoms, and yet we are watching its erosion like the sand on a fading beach. In addition to our unique and specific state constitutional provision on the right to privacy, the legislature has enacted various statutes to protect privacy in California which help afford a measure of protection against unwanted intrusions. Under current employment law, there is a great deal of uncertainty with respect to when disclosure of medical information is proper and when the disclosure or inquiry may result in a successful action against the physician. Obviously the physician is an integral part of the disclosure chain, and whether he or she makes disclosure is an area filled with potential ramifications for both the physician and his or her patient.

43. Personality Structure and The Evaluation and Treatment Of Industrially-Related Injuries - Severely Immature Personality Types

This paper presents a model for understanding the impact of personality structure – in simple language, differing levels of emotional maturity – upon the evaluation and treatment of industrially-related physical injuries. This article, #43 (Part I), will address Severely Immature Personality Types and the next article. The objective is to provide a very practical guide to aid medical providers of all specialties to conceptualize patients in a different context, free of psychiatric jargon or the need to accept or adopt any one specific school of psychological theory, so as to be able to identify, describe and effectively react to the complex interactions between physiological and psychological symptomatology which occur in a significant percentage of injured workers. Relying on basic concepts of personality development, the organization of the material is unique, and focused upon the practical needs of the clinician in dealing with difficult and complex cases.

44. Personality Structure and the Evaluation and Treatment of Industrially-Related Injuries - Pseudo-Mature and Mature Personality Types

This paper presents a model for understanding the impact of personality structure – in simple language, differing levels of emotional maturity – upon the evaluation and treatment of industrially-related physical injuries. This article, #44 (Part II), will address Pseudo-Mature and Mature Personality Types. The objective is to provide a very practical guide to aid medical providers of all specialties to conceptualize patients in a different context, free of psychiatric jargon or the need to accept or adopt any one specific school of psychological theory, so as to be able to identify, describe and effectively react to the complex interactions between physiological and psychological symptomatology which occur in a significant percentage of injured workers. Relying on basic concepts of personality development, the organization of the material is unique, and focused upon the practical needs of the clinician in dealing with difficult and complex cases.

45. A Tale of Two Injuries: The Benson Decision

Let’s say a worker’s back has been bothering him over the course of a year from repeatedly lifting heavy boxes at work. On December 25, he tries to lift an unusually heavy box on the job and his back finally “goes out.” He files claims for a cumulative trauma and for a specific injury. He treats with an orthopedic surgeon and eventually, due to unrelenting pain and diagnostic studies, undergoes a fusion. He missed a total of eight months from work. He is considered to have reached maximum medical improvement (MMI) and the case ends up in the QME panel system, due to a dispute regarding the level of impairment. The QME concurs that the patient has reached MMI and concludes that two separate injuries have occurred. He writes a QME report indicating that the patient has a 28% Whole Person Impairment (AMA Guides, 5th Edition.) He considers 50% of the residual impairment to have been caused by the cumulative effects of the job and approximately 50% of the impairment to have been caused by the specific injury. The worker is able to return to his usual and customary occupation and is given a provision for future medical care.

In this case, it had been admitted that the worker sustained both a cumulative injury and a specific injury. But how should the two injuries be rated; as one injury or two? Stated another way, should the two injuries be apportioned as two separate events or as one combined event? The answer to this query makes a huge difference because case law has established that, when the board makes an award of a combined disability under the rating system, the compensation paid to the worker is always higher (in many cases substantially so) than when the injuries are apportioned into two separate awards. This article discusses the details of this dilemma.

46. A Defensive Perspective on Almaraz/Guzman

The genesis of Almaraz/Guzman is not really in the level of PD ratings that are generated by the 2005 PDRS. The real issue is the amount of compensation for the injuries. When SB 899 adopted the AMA Guides as the basis for a new PDRS, the legislature also reduced PD benefits for the lower levels of permanent disability through 24%. Several studies have documented significantly reduced or even eliminated ratings for partial permanent disability for comparably injured employees, pre and post 2005 PDRS. The combination of lower PD ratings and reduced benefits provided a double hit for injured workers with many conditions that rated significantly lower under the AMA Guides based 2005 PDRS compared to similar conditions under the 1997 PDRS. In many other states, many of which use the AMA guides, smaller impairments receive larger amounts of compensation relative to similarly impaired employees in California.

49. The Dorsett Decision: Court of Appeals Closes Apportionment Loophole

The Court of Appeal closed what could have been an enormous loophole in Labor Code Section 4663 with a decision reversing a WCAB opinion on apportionment and then ordering publication of the decision. With the Dorsett decision, the 6th appellate district reversed a previous decision that had combined the effects of two injuries into a single PD rating in contravention to the decision of Benson. (See also our article # 45 The Benson Decision)

50, 51, 52. The Comprehensive Medical Legal Evaluation: Why and How - A Step-by Step Tool

Counts for 3 articles for 4.5 credits (must be taken together)

How can an AME or QME best fulfill the purpose of a medical-legal evaluation, and minimize the time required to bring a workers’ compensation claim to a proper resolution? The best way to do that is to not only perform a complete, thorough and excellent evaluation; but to prepare and issue a report that indicates how complete, thorough and excellent the evaluation actually was. This article contains a comprehensive outline and template, focusing on orthopedic injuries, but helpful with all specialties, ensuring that a physician fulfills the required elements of a medical-legal report. With a complete, thorough and excellent report, the parties will know what you concluded represents your best assessment of the issues, based on reasonable medical probability given the evidence that was available to you. Such a report will also assist in perceptions of the physician’s credibility; reduce the need for post-evaluation depositions; and assist all parties in resolving the disputed issues in a more-timely manner than might otherwise be possible with a less complete and thorough report.

53. Peripheral Nerve Disorders Impairment Protocols Under the AMA Guides

Chapter 16 of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, details a specific rating method in connection with a diagnosed peripheral nerve disorder. This article addresses two essential features in connection with impairment ratings related to peripheral nerve disorders, including the underlying prerequisites and methodology of assessing sensory loss impairment which results from peripheral neuropathies, as well as the more subtle considerations involved in the rating of peripheral nerve disorders, under the AMA Guides.

54. Evaluating Dental Injuries Using the AMA Guides

Dental injuries to workers are no different than most other injuries and can include three types: direct and cumulative trauma, compensable consequences of other medical conditions, or treatment for industrial injuries. Injuries to the teeth as a result of direct trauma are straightforward. Teeth are knocked out, broken, or fractured off at the gumline. Many of these teeth need to be extracted and replaced with costly implants or other prosthesis. Injuries to the temporomandibular joint and muscles of mastication are sometimes the result of traumas, such as a slip and fall or whiplash injuries, but are often caused by cumulative trauma and stress. The diagnosis of a TMJ injury consists of a careful history, an examination, and imaging.

55. First Aid: More Than a Band-Aid Explanation and How To Replace Panel Qualified Medical Evaluators

Two short articles together for 1.5 credits

First Aid: More Than a Band-Aid Explanation
Who would have ever thought that something as innocuous and simple as first aid would be so controversial and occasionally contentious between employers and workers compensation carriers? While some insurance carriers have developed their own definitions, compliance with existing state statutes and guidelines as outlined here is a far better policy for employers, carriers, and most importantly, the injured workers.

How To Replace Panel Qualified Medical Evaluators
As part of SB 899, reforms were enacted to establish a system of medical discovery. To that end, a selection process was implemented wherein panel qualified medical evaluators (“PQMEs”) are selected from a randomly generated three-name list provided by the Medical Unit. In those instances where parties cannot agree on an AME, participation in the PQME selection process can result in a loss of control over medical discovery, which could adversely affect case outcomes.

56. Senate Bill 863 – Highlights for Qualified Medical Examiners

SB 863, signed into law at the end of 2012 by Governor Jerry Brown, contained many sweeping changes to workers’ compensation law that will directly impact physicians in the California workers’ compensation system. This article is a breakdown of some of the rules and regulations impacting doctors relative to both treatment of injured workers and forensic evaluation of industrial injury claims.

57. From AMA Guides Impairment Ratings to California Permanent Disability Ratings Post 1/1/2013 DOI

Explores how the Labor Code and the Permanent Disability Rating Schedule (PDRS) compliments and strengthens the underpinning of the AMA Guides – rating the objective manifestation of impairment.

58. The Medical-Legal Evaluation Process under California Workers Compensation Law - After S.B. 863

The AME/QME process currently remains the method by which medical-legal evaluations are obtained and disputes are resolved under the California workers’ compensation system. Over the past decade, the legislature amended the relevant sections and the result has been a new system designed to limit the expenses of continued litigation under the process while keeping most of its unique characteristics. Nonetheless, Labor Code section 139.2 (appointment of QMEs) remains on the books as do several of the original QME statutes, albeit, in many respects, unrecognizable from their original form. With additional changes brought about to the AME/QME process first under SB 899, AB 749 and last year under SB 863, the current system, although still resembling the original QME process enacted in 1989, is vastly different. This article is intended to assist the physician in understanding his or her role within the larger context of the medical-legal process and will address this process as it now exists after the most recent legislative changes.

59. Evaluating Arthritic Conditions Impairment Protocols Under The AMA Guides Lower Extremity Impairment

Chapter 17 of the AMA Guides to the Evaluation of Permanent Impairment, 5 Edition, addresses impairments of the lower extremities. The chapter details specific rating methods in connection with many different conditions and diagnoses. Unfortunately, many practitioners are not familiar with all of these prescribed protocols. Further, even in cases where practitioners are familiar with the AMA Guides’ protocols, many are unaware of the special combining rules which pertain to the numerous lower extremity impairment methods. This article will address specific impairment rating protocols in connection with one common feature of the lower extremities, under the AMA Guides.

60. INDEPENDENT MEDICAL REVIEW: Navigating the New Industrial Medicine Matrix

As of July 1, 2013 all current medical treatment disputes in the workers’ compensation arena are subject to Independent Medical Review [IMR]. MAXIMUS Federal Services, Inc. [Maximus] has been given a two year contract as the sole entity in the State of California to oversee the implementation of this dispute resolution process, applying the evidence-based medicine protocols as delineated in the Labor Code and attendant regulations.

This article will describe the new treatment matrix implemented by the State and provide guidance on how to successfully navigate a patient’s care through the system. The changes necessary to successfully obtain medical care will not come easy; yet, once implemented into the medical practice, they will turn chronic UR denials into approvals.

Carriers, patients and attorneys are all looking for medical practitioners who can navigate the new system to get medical care approved. Using the techniques described in Article 60 will raise the effectiveness of the medical practice and provide opportunities for growth and expansion.

61, 62, 63. The Comprehensive Medical Legal Evaluation: Psychiatric/Psychological Injury Reporting

Counts for 3 articles for 4.5 credits (must be taken together)

What is a Comprehensive Medical-Legal Evaluation, and what is its purpose? And is the purpose in claims of psychiatric/psychological injury any different than it is in other types of injury claims? Second answer first: The purpose is the same in regard to psychiatric injuries as it is in regard to all other types of injury, but the process of a psychiatric evaluation is by nature different than that of all other medical specialties; and the basis for determining industrial compensability is entirely different than it is with regard to all other medical specialties, because causation in psychiatric injuries is governed by an entirely different Labor Code section than is causation in all other types of injuries. This article covers all major issues in preparing a medical-legal psychiatric/psychological injury report.

64. Medical Provider Networks After SB 863

Under the Reform Act passed in 2004, (SB 899) medical control under section 4600 was by and large returned to employers via the newly established Medical Provider Networks (MPNs) (Labor Code section 4613 – 4616.7) provided the insurance carriers elected to have their own MPN. The MPNs, as with any other change in the system, were criticized by some for unavailability of physicians, delays in treatment, and lack of sufficient specialists. Others pointed to the accessibility of medical care, successful return to work ratios and costs savings to the system. In a 2013 Reform Bill (SB 863) the legislature further refined the MPN networks. This article highlights changes to the MPN system as a result of SB 863.

65, 66. Evaluating Shoulder Impairment

Counts for 2 articles for 3 credits (must be taken together)

Chapter 16 of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, provides numerous methods for assessing impairment related to shoulder injuries. One of the most common consequences of a shoulder injury involves loss of motion, within the shoulder joint. The AMA Guides provide specific protocols for assessing impairment based upon motion loss. These protocols will be explored in detail, within this article. This article outlines the applicable protocols, related to the most common impairment assessment methods associated with shoulder injuries, under the AMA Guides, 5th edition.

67. Subsequent Injuries Benefits Trust Fund (SIBTF)

The Subsequent Injuries Benefits Trust Fund (SIBTF) is a source of additional compensation to injured workers who already had a disability or impairment at the time of injury. For benefits to be paid from the SIBTF, the combined effect of the injury and the previous disability or impairment must result in a permanent disability of at least 70 percent. The fund enables employers to hire disabled workers without fear of being held liable for the effects of previous disabilities or impairments. SIBTF benefit checks are issued to injured workers by the SIBTF Claims Unit after benefits are awarded by the Workers’ Compensation Appeals Board. Application for subsequent injuries fund benefits is the required application for SIBTF benefits.

68. Causation in California Workers’ Compensation

The intent of this article is to provide a common sense understanding of the issues associated with causation in California workers’ compensation. The article will review the following terms and the intent behind these terms in the medical legal context of CA Workers’ Compensation. Causation, AOE/COE, Aggravation, Exacerbation, Derivative effect, Compensable consequence, Specific injury, CT injury, Presumptive injury.

69, 70, 71. Controversies in California Workers Compensation Rating: Impairments Rated Under Two or More Chapters

Counts as 3 articles for 4.5 credits (must be taken together)

According to the Guides, “Whenever the same impairment is discussed in different chapters, the Guides
tries to use consistent impairment ratings across the different organ systems”. However, when impairment ratings are not consistent across the different organ systems, “Generally, the organ system where the problems originate or where the dysfunction is greatest is the chapter to be used for evaluating the impairment”. This article discusses how Chapter 15 uses the DRE and ROM methods. According to the Guides, if they do overlap, how to evaluate the instances in which the ROM and DRE methods can both be used.

72. Apportionment - An Update

Article #72 is an update of apportionment. Apportionment is defined for purposes of workers’ compensation as the separating out of the part or parts of a disability or condition that are the result of an industrial injury from the part or parts of the disability or condition that are the result of other industrial or non-industrial injuries, conditions, or diseases. When different body parts are injured at the same time, apportionment is termed “duplication.”

73. Appropriate Use Of Almaraz-Guzman Case Law and Analogy

This article addresses the appropriate use of the Almaraz-Guzman cases, as well as when an “analogy” can be used in the absence of that case law. In California, use of the 5th Edition of the AMA Guides to the Evaluation of Permanent Impairment is mandated by the 2005 Permanent Disability Rating Schedule. As such, this article addresses only this edition of the Guides. When a worker is injured in California and they are determined to have reached maximum medical improvement with treatment, it is at this point the issue of permanent impairment is to be addressed in a permanent and stationary report by the primary treating physician, or a Qualified Medical Evaluator.If there is residual impairment, an impairment rating is required. The physician is directed to provide a rating based on the direct application of the instructions in the Guides. There are times, however, when an evaluator may opine that the impairment rating is either an inaccurate reflection of the impact a particular condition has on an injured worker’s ability to perform activities of daily living, or that a particular condition is simply not addressed in the Guides.This article addresses how to appropriately address this situation.

74, 75. Chronic Pain Medical Treatment Guidelines

These Chronic Pain Medical Treatment Guidelines apply when a patient has pain that persists three (3) or more months from the initial onset of pain (i.e.,12 weeks or more) as determined by following the  relevant sections of the Medical Treatment Utilization Schedule (MTUS). In following the Clinical Topics section of the MTUS (8 CCR § 9792.23), the physician begins by assessing the presenting complaint and determining whether there is a “red flag for a potentially serious condition” that would trigger an immediate intervention. Upon ruling out a potentially serious condition, the physician should provide conservative management, that is, a treatment approach designed to avoid surgical and other medical and therapeutic measures with higher risk of harm compared to benefit.(Singh, 2013). If the  complaint persists, the physician needs to reconsider the diagnosis and decide whether a specialist evaluation is necessary. The Chronic Pain Medical Treatment Guidelines provide a framework to manage all chronic pain conditions, even when the injury is not addressed in the Clinical Topics section of the MTUS.

76. Apportionment Case Law, Hikida vs. WCABm City of Jackson v. WCAB (Rice)

City of Jackson v. WCAB (Rice)

Apportionment to cause of injury versus cause of disability

Apportionment to genetics

Apportionment to risk factors

Apportionment to impermissible immutable factors

Hikida v. WCAB

Is P.D. that was caused by unsuccessful medical treatment subject to apportionment?


Christopher Brigham, M.D.

Christopher Brigham, M.D., MMS, FACOEM, FAADEP, CIME, CEDIR, CIR is a consultant, author and trainer on impairment evaluation and disability assessment, medical aspects of workers’ compensation and disability management, and occupational medicine. His medical practice includes impairment evaluation reviews, medical file reviews, impairment and independent medical evaluations, consulting and clinical services.

John A. Don, Esq.

Areas of Practice: 100% Workers’ Compensation Law

Certified Legal Specialties: Certified Specialist, Workers’ Compensation, State Bar of California

Bar Admissions: California, 1986

McGeorge School of Law, University of the Pacific, Sacramento, California, J.D. – 1986
Columbia University, New York, New York, B.A. – 1979

Marjorie Eskay-Auerbach, MD, JD

Marjorie Eskay-Auerbach, MD, JD, is a board certified orthopedic surgeon, board certified spine surgeon and medical-legal consultant with a special interest in spine care. She practiced spine surgery and non-operative care of back and neck injuries in Phoenix for approximately 10 years. She attended University of Arizona Law School from 1996-2000, after which she resumed her medical practice with a focus on medical-legal issues. Her current clinical practice focuses on non-operative care and medical pain management of patients with neck and back problems. She performs medical-legal consultations, independent medical evaluations and record reviews, and provides expert opinions and testimony. Dr. Eskay-Auerbach is board-certified by the American Academy of Orthopedic Surgeons and the American College of Spine Surgery. She is an active member of the North American Spine Society, serving as a member of the Board of Directors and Chairperson of the Public Relations Council. She is also a member of the American Academy of Pain Management. She speaks nationally, is an educator for the AMA on the most recent edition of the AMA Guides to the Evaluation of Permanent Impairment, and teaches multiple CLE courses, including a course entitled, “Orthopedics for Lawyers”. She received her JD from U of A in 2001, and is a member of the Arizona bar.

Steven Feinberg, M.D.

Dr. Steven Feinberg is Board Certified by of the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is an Adjunct Clinical Professor in the Department of Anesthesia, Pain Division, at the Stanford University School of Medicine. Dr. Feinberg is a past president (1996) of the American Academy of Pain Medicine. He served as a longtime member of the Board of Directors of the California Society of Industrial Medicine and Surgery and served as President in 2001. He serves on the Board of Directors to the American Chronic Pain Association. He also serves as the Medical Director for Cedaron AMA Guides Software.

Judge Pamela Foust

Judge Pamela Foust practiced workers’ compensation law from 1978 to 1985, when she was appointed a Workers’ Compensation Judge. She currently sits at the Santa Monica WCAB.In 1991, Judge Foust was voted “Workers’ Compensation Judge of the Year” for Southern California by the attorney associations representing applicants and defendants. Judge Foust drafted amendments to Labor Code sections which were included in Senate Bill 31, enacted into law on April 3, 1993. Judge Foust contributed to California Workers’ Compensation Practice, 4th Edition, published in 2000 by CEB. She has written numerous articles on workers’ compensation issues, particularly those involving lien claims and other topics of interest to medical providers. She has been a frequent speaker at educational programs and is an adjunct professor at the University of West Los Angeles School of Law.

Frederick Fung, M.D., M.S.

Frederick Fung, M.D., M.S. is chief toxicologist and Occupational Medicine Medical Director, Sharp Rees-Stealy Medical Group, San Diego, and medical toxicology consultant, University of California, San Diego, School of Medicine.

Greg Goddard, DDS

Dr. Greg Goddard is a graduate of the University of California at San Francisco. He specializes in TMJ Disorders and Orofacial Pain. He has lectured both nationally and internationally, published over 25 journal articles, two books and several book chapters on temporomandibular disorders. He has done extensive research in acupuncture for orofacial pain. Dr. Goddard recently retired from UCSF as a Clinical Professor. He has lectured to both Defense and Applicant attorneys, as well as insurance adjusters, on dental injuries to California workers. He continues to work in private practice, evaluating TMJ injuries for California Workers Compensation as an AME through MedLink Scheduling Services in San Francisco.

Richard M. Jacobsmeyer

Richard M. Jacobsmeyer is a founding partner of Shaw, Jacobsmeyer, Crain & Claffey, LLP. His practice is limited to representation of employers and insurance carriers before the California Workers’ Compensation Appeals Board, and related matters.

Richard T. Katz, MD

Richard T. Katz, MD is Board Certified in Physical Medicine and rehabilitation, Electodiagnostic Medicine and is an Independent Medical Examiner. He is also an Associate Professor of Clinical Neurology at Washington University School of Medicine. He was a contributor and reviewer for the 5th edition, and is a section editor for the 6th edition of the AMA Guides to the Evaluation of Permanent Impairment.

Kenneth Kingdon, Esq.

Mr. Kingdon  specializes in rating medical reports under the AMA Guides to the Evaluation of Permanent Impairment. He is  available for doctor depositions, expert witness testimony, cross examinations of D.E.U. raters, training seminars and appearances at settlement conferences,  rating conferences and trials. He is the author of the AMA publication A Medical-Legal Companion to the AMA Guides Fifth. He was a reviewer for the AMA Guides Sixth Edition and a reviewer for the spine and lower extremities workbooks for the AMA Guides Sixth Edition. He was also a consultant to the AMA for continuing legal education programs for the Sixth Edition. He has taught beginning and advanced rating for the Insurance Educational Association, has spoken at numerous seminars, and has been an expert witness on the AMA Guides in Longshore and Harbor Workers Compensation litigation.

David Kizer, Esq.

David Kizer, Esq. has been in practice for 25 years. He is the former Lead counsel for the Industrial Medical Council (DWC Medical Unit) and is a former Administrative Law Judge for Unemployment Insurance Appeals Board. He is currently in private practice in Berkeley, CA.

Luis Pérez-Cordero and Craig Andrew Lange

Luis Pérez-Cordero and Craig Andrew Lange are both certified AMA Guides Impairment and California Disability Rating Specialists and are associated with the American College of Disability Medicine and the American Board of Independent Medical Examiners.

Allan Leno

Allan Leno is a consultant to insurers and self-insured employers on workers’ compensation, vocational rehabilitation, job modification, ADA, and FEHA issues. He frequently addresses employers, trade groups, and educational forums on ADA Title I and FEHA disability and employment issues as they impact public and private sector employers’ workers’ compensation obligations. A graduate of the University of Southern California, where he earned a Masters degree in Public Administration, Mr. Leno has more than 25 years experience dealing with rehabilitation issues, most recently as Vice-President of Rehabilitation Services at Zenith Insurance where he managed the Rehab Department, established corporate policies based on current statutes, developed and presented training programs for claims and rehab staff, and worked with marketing and underwriting staff on programs for agents and brokers. Mr. Leno is an ex officio member and former chair of California Workers’ Compensation Institute’s (CWCI) Rehabilitation Committee; Vice-President and Treasurer of the National Association of ADA Coordinators; and a member of the DWC Rehabilitation Advisory Committee.

Robert Neveln, MD

Robert Neveln, MD – is a medical graduate of the University of Arizona and was Board Certified in Internal Medicine in 1977. He moved to San Diego and began a solo practice in Internal Medicine at the prestigious Scripps Memorial Hospital in La Jolla, where he has practiced for over 20 years. Dr. Neveln held the position of Section Chief of Internal Medicine at Scripps Hospital from 1991-99. He is a member of both the La Jolla Academy of Medicine and the American Medical Association. He has performed industrial evaluations in Internal Medicine for over 20 years, and has been a Qualified Medical Evaluator for the State of California since 1993.

Donald M. Pilger, Esq.

Certified Impairment Rater (CIR)

Certified AMA Impairment Rater (CAMAG)

Robert G. Rassp, Esq.

Robert G. Rassp, Esq., Law Offices of Robert G. Rassp, Sherman Oaks, CA, received two undergraduate degrees from the University of California at Irvine in 1978 and his law degree from Loyola Law School in 1981. He has practiced workers’ compensation and Social Security disability since 1981. He was the Chair for the State Bar Workers’ Compensation Law Section Executive Committee in 2000-2001 and is currently active as a member of that committee. He is the author of The Lawyer’s Guide to the AMA Guides and California Workers’ Compensation (LexisNexis Matthew Bender). He has conducted workers’ compensation seminars on a variety of topics, including the AMA Guides, and is a frequent speaker at State Bar workers’ compensation seminars. Mr. Rassp also serves on the LexisNexis California Workers’ Compensation Editorial Board and the Larson’s National Workers’ Compensation Advisory Board.

David M. Reiss, M.D.

David M. Reiss, M.D. is a psychiatrist in private practice, with offices in San Diego and Fresno, California, specializing inthe performance of Medical-Legal Evaluations and the diagnosis and mental health treatment of Personality Disorders in the Borderline Spectrum.

Dr. Reiss is available for Medical-Legal Evaluations for Workers’ Compensation, Fitness for Duty, and Disability Evaluations. Dr. Reiss is available for treatment, including both psychotherapeutic intervention and psychopharmacological intervention.

Stacey Lee Smith, MD

Stacey Lee Smith, MD is an Assistant Professor of Clinical Psychiatry at Washington University School of Medicine. She is Board certified in psychiatry.

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