Coronavirus and Permanent Impairment
COVID-19 is an emerging, rapidly evolving situation. As the COVID-19 situation evolves, we should all expect and accept new information and ideas.
We cannot provide concrete information relative to this new condition, but if a COVID-19 disease claim is deemed work-related, we need to consider how best to assess potential benefits with what we know now.
This article will discuss what to consider when evaluating reserves and appropriate payment of any Permanent Disability benefits.
Compensability – AOE/COE
A recent CE Webinar (March 23, 24) from Don Barthel, John Kamin, and Louis Larres, discussed COVID-19, and reviewed AOE/COE issues.
“How do we determine aoe/coe when the infection’s source could be…literally: ANYWHERE!”
You can access that Webinar on the Bradford & Barthel website.
The takeaway: As a general rule, there must be some connection between injury and work. Deviation from job duties for personal benefit is generally not in the ‘course of employment’.
Maximum Medical Improvement (MMI)
Permanent Disability is assessed based on the condition at MMI. When does that happen?
Although World Health Organization (WHO) reports the median time from onset to clinical recovery from COVID-19 to take approximately 2-6 weeks, that might be an optimistic assessment for true Maximum Medical Improvement, and evaluation of permanent residuals.
The National Institute of Health (NIH) has reported:
“There is increasing evidence of the lung’s capacity to repair itself.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681355/
The AMA Guides indicates within Chapter 16 that MMI likely isn’t reached until approximately one year following injury or surgery.
The takeaway: We don’t know at this point how long it might take to achieve MMI status. It might be prudent to allow an additional 6 months after the initial recovery to follow for additional improvement of function. As improvement continues, and then plateaus, MMI can be determined.
From what is currently known, it seems likely that residual impairment will be assessed primarily from Chapter 5 of the AMA Guides 5th Edition – The Respiratory System.
In recent history with workers’ compensation in California, we do not have much experience with workplace respiratory injury. Specialists in Pulmonary Medicine would likely be better prepared to evaluate respiratory disorder from Chapter 5 of the AMA Guides than an Internist without that specific training. We may have a need for new QMEs.
Evaluating and Reporting WPI with The AMA Guides
The AMA Guides focuses on the evaluation of objective findings.
Medical Information and WPI
- Objective findings should lead to the correct Chapter, correct Table, and correct Class or Category
- Doctor has discretion for WPI within the selected Class or Category
Review WPI reporting
- Does the doctor explain the WPI? Objective or subjective findings?
- Multi-level fracture
- Check WPI:
- Read the relevant part of the Guides
- Introduction to that Chapter
- Applicable section
- Applicable Tables/Figures
- Read the relevant part of the Guides
Review of objective clinical findings should include X-rays and CT scans that identify and describe any organic abnormalities.
AMA Guides – 5th Edition – Chapter 5 – The Respiratory System
Table 5-12, page 107 of the AMA Guides, is used to evaluate impairment due to respiratory disorders.
It includes 4 separate measures that might support Classes 2-4 respiratory impairment. Class 1, and 0% WPI, considers function greater than the lower limit of normal. Class 4 provides a range of 51-100% WPI, corresponding to significantly reduced respiratory function.
The AMA Guides states (page 107):
“Table 5-12 lists criteria for estimating the permanent impairment rating due to respiratory disorders, using pulmonary function and exercise test results. Perform spirometry and Dco on each person being evaluated…Determine the predicted values for FVC, FEV₁, and Dco using Tables 5-2a through 5-7a, and calculate the percent predicted (observed/predicted value). Determine the lower limit of normal for FVC, FEV₁, and Dco using Tables 5-2b through 5-7b…”
Tables 5-2a through 5-7a provide “predicted” normal and lower limits of normal for FVC, FEV₁, and Dco. Accurate evaluation using these methods requires some care.
The takeaway: We recommend review for consistency of clinical findings regarding a respiratory disorder.
Exercise Testing – METS
Although VO2 maximum and METS are included within Table 5-12, these tests are less likely to provide an accurate indicator of organic injury and functional capacity.
On page 28 of the Guides (within Chapter 3), in the discussion of METS testing, it is noted:
“a major problem with the use of any exercise-testing technique to attempt to quantify an individual’s functional capacity is the marked variability in people’s efforts and abilities…”
We reviewed the AMA Guides for guidance in the evaluation of “deconditioning” as an impairment. We note that the 5th Edition contains 18 Chapters, 598 pages (plus glossary), 233 Tables, and 96 Figures, used to evaluate impairment. ‘Deconditioning’ is not included as an Impairment.
From Chapter 5, page 101 of the Guides
“…tests can help differentiate pulmonary impairment from cardiac impairment or physical deconditioning effects.”
The takeaway: Deconditioning should be considered a symptom of underlying injury, and time off work, rather than a separate, diagnosable impairment.
Impairment Evaluation Summary
- Is it reasonable to expect that the employee is still recuperating, and additional recovery would be expected?
- Look for diagnostic studies that confirm the extent and severity of residual scar tissue.
- There are potential variable elements with stress testing that can give inaccurate assessments. Look for consistency of findings of the extent of impairment. There are several measures that can be considered from which to evaluate Respiratory System function, and Table 5-12.
As we hear from the CDC, people ages 65 and older, and those with underlying medical conditions, are at higher risk.
From the CDC website:
Based on what we know now, those at high-risk for severe illness from COVID-19 are:
- People aged 65 years and older
- People who live in a nursing home or long-term care facility
People of all ages with underlying medical conditions, particularly if not well controlled, including:
- People with chronic lung disease or moderate to severe asthma
- People who have serious heart conditions
- People who are immunocompromised
- Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
- People with severe obesity (body mass index [BMI] of 40 or higher)
- People with diabetes
- People with chronic kidney disease undergoing dialysis
- People with liver disease
The above-referenced list from the CDC provides guidance for “other factors” apportionment review.
Tim Mussack has been in the workers’ compensation industry since 1988. His background includes training and auditing of claims handling in over 30 jurisdictions, with most of his experience in California. Tim has been an instructor of Permanent Disability rating since 1991, teaching rating using the 1988, 1997, and 2005 PD rating schedules. If you have any questions about rating PD, please feel free to reach out to Tim at firstname.lastname@example.org or 916.569.0790.
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