A recent Pennsylvania Commonwealth Court decision would allow the Impairment Rating Evaluator to alter/revise/expand the scope of the work-related injury
The Impairment Rating procedure remains a powerful remedy for the Employer and Insurer to attempt to limit future indemnity wage loss benefit exposure. On October 24, 2018, Act 111 replaced the constitutionally infirm Section 306(a.2) with revised language. One requirement of Section 306(a.3) is that an injured worker receive 104 weeks of total disability benefits before an employer may require one’s submission to an Impairment Rating Evaluation (IRE).
At this time - legal challenges to the constitutionality of Section 306(a.3) continue to course their way through the appellate courts.
Recently a Commonwealth Court panel decision impacts an important factor in an Impairment Rating Evaluation - the description of work-related injury under review.
In Sicilia v. WCAB (API Roofers Advantage Program) No. 747 C.D. 2021, filed: June 7, 2022, a WCJ decision granting an Employer petition to modify a Claimant’s benefit status from total to partial disability pursuant to a Section 306(a.3) Impairment Rating Evaluation (IRE) was reversed by a three Judge Panel of the Commonwealth Court. The case was remanded for reinstatement of ongoing total disability benefits.
The Commonwealth Court determined that a limitation of the scope of the IRE to the accepted/recognized work-related diagnoses was an error of law, based upon their interpretation of the prior Pennsylvania Supreme Court decision in Duffey v. WCAB (Trola-Dyne,Inc.), 152 A.3d 984 (Pa. 2017) (cited as Duffey II).
The Sicilia opinion reviewed the factual background reflecting the “rounds of litigation” involving a 1999 work injury which the Notice of Temporary Compensation Payable initially described as a “lumbar strain and left knee contusion”.
A 2003 WCJ decision expanded the work injury description, approving a stipulation which
added: chronic pain syndrome; chronic adjustment disorder; anxiety; depression.
A 2011 WCJ decision found that 2007 back surgery was related to the work injury. The injury description remained unchanged.
A 2014 WCJ decision approved a stipulation, resolving a Penalty petition for unpaid medical
bills. The injury description remained unchanged.
In 2019 Employer secured an IRE, in accord with the “new” IRE procedures at Section 306a(3). Based upon the accepted work injury descriptions, the IRE whole person impairment was 23% which would support a modification of claimant’s benefits to a partial disability status. A separate score for the chronic pain syndrome diagnosis was not added as there was a diagnosis that covered the pain generator. The addition of a separate pain score would increase the Impairment percentage to 25%.
Significantly - the IRE physician report, clinical summary section included diagnoses secondary to the 1999 work accident, which were beyond the diagnoses described in the prior WCJ decisions: “lumbar protrusion or spondylolisthesis with lumbar radiculopathy”. The IRE physician qualified her rating, stating that her rating was constrained to address only to the diagnoses accepted by the NTCP, NCP, Stipulations or WCJ decisions.
Importantly - to better understand the appellate court decision – the IRE evaluator stated that she was convinced that the additional diagnoses were in fact attributable to the work injury.
Employer requested an addendum IRE report to separately address the inclusion of Impairment scores for diagnoses beyond the accepted injury description - “lumbar protrusion or spondylolisthesis with lumbar radiculopathy”. With that inclusion, the whole person Impairment score was 43%. If one added a separate chronic pain score, the rate was 45%. As this addendum report Impairment rating score exceeded the 35% threshold, there would be a presumption of continuing total disability. Section 306(a.3) (2), (4), (5), (7)).
A 2014 WCJ decision approved a stipulation, resolving a Penalty petition for unpaid medical
bills. The injury description remained unchanged.
In 2019 Employer secured an IRE, in accord with the “new” IRE procedures at Section 306a(3). Based upon the accepted work injury descriptions, the IRE whole person impairment was 23% which would support a modification of claimant’s benefits to a partial disability status. A separate score for the chronic pain syndrome diagnosis was not added as there was a diagnosis that covered the pain generator. The addition of a separate pain score would increase the Impairment percentage to 25%.
Significantly - the IRE physician report, clinical summary section included diagnoses secondary to the 1999 work accident, which were beyond the diagnoses described in the prior WCJ decisions: “lumbar protrusion or spondylolisthesis with lumbar radiculopathy”. The IRE physician qualified her rating, stating that her rating was constrained to address only to the diagnoses accepted by the NTCP, NCP, Stipulations or WCJ decisions.
Importantly - to better understand the appellate court decision – the IRE evaluator stated that she was convinced that the additional diagnoses were in fact attributable to the work injury.
Employer requested an addendum IRE report to separately address the inclusion of Impairment scores for diagnoses beyond the accepted injury description - “lumbar protrusion or spondylolisthesis with lumbar radiculopathy”. With that inclusion, the whole person Impairment score was 43%. If one added a separate chronic pain score, the rate was 45%. As this addendum report Impairment rating score exceeded the 35% threshold, there would be a presumption of continuing total disability. Section 306(a.3) (2), (4), (5), (7)).
The WCJ decision found the IRE initial report of 25% impairment was credible. The WCJ found the portion of the IRE physician-evaluator testimony (and addendum report) that the 1999 work-related injury included the additional lumbar diagnoses, was not credible medical evidence.
The Court's opinion in Sicilia reversed the modification of claimant’s benefit status, commenting that the IRE physician-evaluator “misapprehended her responsibility as a physician-evaluator in her initial calculation of Claimant’s whole person impairment rating”, as she felt her initial rating was constrained to the accepted injury diagnoses.
The Sicilia Court exclusively relied upon the Supreme Court Duffy opinion in reciting:
- The IRE physician-evaluator is explicitly invested with the obligation to determine “the
degree of impairment due to the compensable injury,” (emphasis in original)
- “a physician-evaluator must consider and determine causality in terms of whether any
particular impairment is ‘due to’ the compensable injury”.
- Moreover, the required evaluation is of “the percentage of permanent impairment of the
whole body resulting from the compensable injury.”
The Sicilia Court acknowledged that the NCP (NTCP) should define “compensable injury” for purposes of this inquiry but the Court further stated that even under former Section 306(a.2) and the AMA Guides, “the physician-evaluator must exercise professional judgment to render appropriate decisions concerning both causality and apportionment.”
The Sicilia Court stated - the AMA Guides refer to an “event” rather than an “injury,” permitting the physician-evaluator to attribute a particular condition to the event in which the claimant was injured rather than the injury itself – “a physician-evaluator simply may not entirely disavow any and all responsibility to consider causality relative to a given condition.”
degree of impairment due to the compensable injury,” (emphasis in original)
- “a physician-evaluator must consider and determine causality in terms of whether any
particular impairment is ‘due to’ the compensable injury”.
- Moreover, the required evaluation is of “the percentage of permanent impairment of the
whole body resulting from the compensable injury.”
The Sicilia Court acknowledged that the NCP (NTCP) should define “compensable injury” for purposes of this inquiry but the Court further stated that even under former Section 306(a.2) and the AMA Guides, “the physician-evaluator must exercise professional judgment to render appropriate decisions concerning both causality and apportionment.”
The Sicilia Court stated - the AMA Guides refer to an “event” rather than an “injury,” permitting the physician-evaluator to attribute a particular condition to the event in which the claimant was injured rather than the injury itself – “a physician-evaluator simply may not entirely disavow any and all responsibility to consider causality relative to a given condition.”
The Commonwealth Court reasoning rejected the Employer arguments that:
1. res judicata controls and Claimant is bound by the stipulated injuries incorporated in the
2003, 2011 and 2014 WCJ decisions;
2. Claimant succeeded in obtaining payment of medical bills for lower back surgeries in the
2011 decision but did not amend or expand the injury description;
3. the WCJ was within her discretion to reject the expanded scope of the lumbar injuries
given the extensive case background. The WCJ is charged with assessing the credibility
of medical evidence. The WCJ rejected the credibility of the IRE addendum report.
4. Duffey ll is distinguishable as the procedural posture differs. There was
extensive litigation in this matter that addressed the compensable injuries, whereas in
Duffey II a review petition seeking to modify the injury description was not filed until
after the IRE.
1. res judicata controls and Claimant is bound by the stipulated injuries incorporated in the
2003, 2011 and 2014 WCJ decisions;
2. Claimant succeeded in obtaining payment of medical bills for lower back surgeries in the
2011 decision but did not amend or expand the injury description;
3. the WCJ was within her discretion to reject the expanded scope of the lumbar injuries
given the extensive case background. The WCJ is charged with assessing the credibility
of medical evidence. The WCJ rejected the credibility of the IRE addendum report.
4. Duffey ll is distinguishable as the procedural posture differs. There was
extensive litigation in this matter that addressed the compensable injuries, whereas in
Duffey II a review petition seeking to modify the injury description was not filed until
after the IRE.
The Commonwealth Court reasoned –
a. Employer’s arguments boil down to an assertion that the WCJ decision(s) description of
the work injury controls the IRE process.
b. “While no petition or other request for such change was made in this case, it is
disingenuous to assert that an injury description in one WCJ’s decision, or a string of
such decisions, binds subsequent WCJs later in the history of a claim. Even when an
injury description is not formally amended, a diagnosis may become an accepted injury
if a WCJ finds it was caused or aggravated by the work injury.
c. The WCJ’s reasoning for rejecting the IRE testimony concerning the additional
diagnoses, and the higher rating resulting from such inclusion, was not, in fact, a
credibility determination based on evaluation of the evidence, but rather a
misapprehension of the discretion accorded an IRE physician-evaluator. The only
reason proffered for discrediting the additional diagnoses was that they had not been
previously found by other WCJs. Simply put, the WCJ erred as a matter of law in
constraining the IRE review solely to the earlier accepted descriptions of Claimant’s
work injuries.
The Dissent opinion stated - Duffey II has muddled the law in this area. It takes the IRE into issues of liability and causation for a work injury when the sole purpose of an IRE is to determine the claimant’s disability status after maximum medical improvement from the adjudicated work-related injury.
See: Section 306(a.3)(8)(i) which defines “impairment” as “anatomic or functional abnormality or loss that results from the compensable injury and is reasonably presumed to be permanent.”
Dissent would affirm the WCAB and WCJ, as the WCJ simply rejected the credibility of the IRE evaluator’s addendum opinion that Claimant’s other symptoms were attributable to his work injury. Therefore, there was no credible evidence to support a finding that Claimant has a whole-body impairment greater than 35%.
PRACTICE RECOMMENDATIONS:
1. Continue to utilize the IRE remedy as a means of limiting the duration of work-related total disability status and the overall duration of future indemnity benefit liability.
2. Before filing the IRE physician designation request - Review the pre-IRE appointment records of medical treatment. Has there been a change or additional description of the diagnoses treated, when compared to the accepted injury description in the NTCP, NCP or prior WCJ decision?
If so, consider a pre-IRE medical document review to preliminarily assess the existence of additional diagnoses that would exceed the 35% threshold. Is there a diagnosed condition that is improving … or declining?
3. If there are additional diagnoses, beyond the accepted work-related injury, then consider an IME to attempt to secure a medical expert opinion that the additional diagnosis IS NOT work-related.
3. If there are additional diagnoses, beyond the accepted work-related injury, then consider an IME to attempt to secure a medical expert opinion that the additional diagnosis IS NOT work-related.
In recent discussions, at least one Impairment Rating physician evaluator welcomes additional pre-exam information when there are issues regarding the description or scope of the work-related injury. An example is the case where a WCJ has defined the work-related injury in a manner that may include a medical condition that clinically is not typically attributed to the accepted type of injury.
4. Also, one must consider the impact of a separate "chronic pain" diagnosis score - where the medical condition, that is the pain generator, is not considered in the IRE score.
Once again, the best practice in handling this workers compensation issues depends upon the specific facts presented. One must take the time to review the medical records of treatment in your case – before
you select an appropriate worker's compensation remedy.
As we always recommend, please discuss your case handling options with your workers compensation professionals.
