[Date]

 

 

                             [Claimant’s Name]

                             [Case File Number]                        

 

[Physician’s Name]

[Physician’s Address]

[City, State, Zip Code]

 

[Dear Physician:]

 

This letter is in reference to the workers’ compensation claim for the employee named above.  The employee has claimed impairment to the breast as a result of the accepted work related condition.

 

The Division of Energy Employee Occupational Compensation (DEEOIC) requires impairment determinations to be performed in accordance with the current edition of the American Medical Association’s Guide to the Evaluation of Permanent Impairment.  Moreover, to ensure that the employee’s impairment is fully rated, several factors must be considered and included in the evaluation report.  These factors include: (1) the unilateral or bilateral absence of the breast; (2) the loss of function of the upper extremity, including range of motion, neurological abnormalities and pain, etc; (3) skin disfigurement; and (4) other physical impairments affecting activities of daily living.

 

We would greatly appreciate a detailed narrative report from you, based on your examination that addresses the following:

 

1. Has maximum medical improvement been reached? If so what is the approximate date?

 

2. Is there surgical absence of the breast(s)? Surgical absence of a breast is rated in accordance with AMA Guides, section 10.9, p239 and is assigned a maximum of 5% of the whole person.

 

3. A description of the surgical site (if any) and mention of infections, ulcerations, grafts and any other factors that have affected the size and aspect of the scar and the presence of other skin abnormalities.  If a rating for skin disfigurement/abnormalities is needed please use Chapter 8 in the AMA Guides.

 

4. The effects of radiation or other therapies on any organ system represented by clinical findings and/or tests, as well as the ability to perform activities of daily living.

 

5. Other physical impairments related to the underlying condition including those mentioned under 4. These need to be well documented and ratable under the AMA Guides.

 

6. Your recommended percentage of impairment including a rationalized opinion as to how you arrived at the total impairment.  This includes how you arrived at the impairment figure, using applicable tables and sections of the AMA Guides.

 

It is important that you respond to each of these questions to ensure that the patient receives the maximum percentage of impairment allowed by the AMA Guides for his/her work-related condition.  The rating should be performed on the patient’s current level of impairment.  Please note that the DEEOIC allows for periodic re-evaluations for future increases in permanent impairment.

 

Thank you for your assistance.  Please bill us your usual fee for a report of this type using Form HCFA-1500.  If you have any questions or concerns regarding this matter, please contact me directly at (XXX) XXX-XXXX.

 

Sincerely,

 

 

 

 

[Claims Examiner’s Name]

[Title]