EEOICPA BULLETIN NO. 06-12           

 

Issue Date:  August 3, 2006

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Effective Date:  August 3, 2006

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Expiration Date:  August 3, 2007 

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Subject:  Evaluating Permanent Impairment to the Breast (Male or Female).

 

Background:  As a part of the adjudication process under Part E of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), impairment attributable to a covered illness is compensable under the provisions of 42 U.S.C. 7385s. Impairment is defined as a loss, loss of use, or derangement of any body part, organ system or organ functionality after having reached maximum medical improvement (MMI). MMI is reached when impairment is stabilized and unlikely to improve with or without medical treatment. 

 

The standard used to determine impairment is the American Medical Association (AMA) in its Guides the Evaluation of Permanent Partial Impairment 5th ed.  The Guides provide instruction needed for a physician to apply measures and other criteria for making a judgment on the total percentage of impairment due to injury or illness. 

 

The Division of Energy Employee Occupational Illness Compensation (DEEOIC) has received numerous claims from employees (male and female) who were diagnosed with breast cancer and are claiming impairment as a result of their illness.  Given the manner in which the American Medical Association (AMA) describes the methodology to calculate an impairment of the breast, it was determined that procedural clarification was required.

  

In any instance where an impairment of the breast due to cancer is claimed, several factors are to be addressed by the physician performing the impairment rating: (1) presence or absence of the organ; (2) loss of function of the upper extremity; (3) skin disfigurement; (4) other impairment(s) caused by the breast cancer or lack of the organ.

 

By itself, the anatomical absence of a mammary gland is rated according to the AMA Guides, Section 10.9 Mammary Glands, p239, and is assigned a maximum of 5% of the whole person.

 

Loss of function of the upper extremity can accompany the surgical treatment of breast cancer, causing range of motion problems, neurological abnormalities, lymphedema, and other complications that affect the activities of daily living (ADL).  The physician performing the evaluation should use the AMA Guides, Chapter 16. The Upper Extremity, p433-512 to assess these impairments.

 

Breast cancer and its surgical treatment can result in skin disfigurement which can be assessed using Sections 8.2 and 8.3 (p175 – 176) of the AMA Guides.

 

Other physical impairments identified by the physician performing the evaluation need to be well documented and related to the underlying accepted condition, or therapy such as radiation and chemotherapy.  They have to be ratable under the AMA Guides.

 

The completed evaluation must delineate all the factors present in the case, together with the individual whole person impairment assigned to each, and a mention of the supporting sections and tables of the Guides.  The individual impairment percentages need to be added into a total impairment percent.

 

The Guides do not define “child bearing age”.  Therefore, for the purposes of DEEOIC (when considering impairment due to breast cancer), “child bearing age” will not be a determining factor when issuing an impairment rating.

 

References:  EEOICPA Part E Procedure Manual Chapter 2-900 and the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.

 

Purpose:  To provide guidance on evaluating impairment for individuals (male or female) diagnosed with breast cancer.

 

Applicability: All staff. 

 

Actions:

 

1.  Upon receipt of a claim for impairment for the breast in either a male or female, the Claims Examiner (CE) will submit a request to the physician undertaking the evaluation for permanent impairment explaining all the criteria that must be considered and referenced in their final report. Attached to this bulletin is a sample letter that may be used for this purpose (Attachment 1).

 

2.  When the completed impairment evaluation is returned, the CE must review it to ensure that the physician has comprehensively addressed each of the factors necessary for an acceptable rating.  The report must show that the physician has considered:  (1) the presence or absence of the breast(s); (2) the loss of function of the upper extremity (or extremities if there is absence of both breasts due to cancer), including range of motion, neurological abnormalities and pain, lymphedema, etc.; (3) skin disfigurement; and (4) other physical impairments resulting from the breast cancer.  The total percentage of permanent impairment of the whole person must be supported by medical rationale and references to the appropriate sections and tables (with page numbers) of the AMA Guides.

 

3.  If the CE determines the physician has not provided a complete rating for a claimed impairment of the breast, a follow-up letter should be sent.  The CE should explain to the physician the noted deficiency in the assessment and that the purpose for obtaining a complete response is to ensure the employee received the maximum allowable rating provided by the Guides.  

 

4.  Upon receipt of an acceptable report pertaining to an assessment of permanent impairment of the breast, the CE should proceed with additional development of the claim, as necessary, and issuance of a recommended decision. 

 

Disposition:  Retain until incorporated in the Federal (EEOICPA) Procedure Manual.

 

 

 

 

PETER M. TURCIC

Director, Division of Energy Employees

Occupational Illness Compensation

 

Attachment

 

Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections