EEOICPA BULLETIN NO. 10-15
Issue Date: June 14, 2010
Effective Date: June 14, 2010
Expiration Date: June 14, 2011
Subject: SEM Quality Assurance Plan
Background: Changes in the SEM information about the work processes, labor categories, and toxic materials used at a DOE site can change the outcome of an eligibility determination and are typically the result of DOL’s research of previously un-reviewed site documentation. DOE does not maintain a central document repository or index of records applicable to each site, thereby inhibiting DOL’s research and data collection efforts. Records for most sites, especially those that are no longer operating, are typically spread among several Federal Records Centers and operating DOE sites. Furthermore, active DOE sites regularly generate new documentation. As a result, the DOL SEM research team constantly reviews site documentation as it is identified and adds it to the DOL SEM Library where appropriate (it’s worth noting that information is also obtained from the Haz-Map website).
Past adjudication results may have been different if adjudication had been performed using current SEM information. To ensure that such previously adjudicated cases are reviewed with the latest and most complete SEM information, this procedure has been developed. Using this procedure will result in the post-adjudication review of cases where changes in the SEM diseases and disease associations could affect the denial decision. As noted above, this procedure is also applicable to Part E claims that are still in the process of being reviewed.
On a quarterly basis, Paragon provides DEEOIC with a report that describes the changes made to the SEM database and the affected ICD-9 codes, by worksite, during the previous three months. The DEEOIC SEM Coordinator reviews this report and shares it with the Branch of ADP Systems (BAS) within 2 business days. The BAS then generates a “Post Adjudication Report” within 5-10 business days.
The Post Adjudication Report generated by BAS has two components: a SEM Summary Report and a SEM Detail Report. The SEM Summary Report gives the total number of Part E Denials, based on a medical condition (ICD-9 match) identified as a result of changes in the SEM. These numbers are broken up by District Office, including the FAB. The SEM Detail Report provides specific information on these cases by District Office, claimant name, affected worksite, file number and the assigned Claims Examiner. Using this information, the District Offices/FAB can ensure that each denial decision that could be affected by the SEM changes can be reevaluated. For example, the SEM may list a new relationship between a toxic material and an occupational disease (the procedure “Instruction for Compiling and Entering Toxic Substance Information into the Site Exposure Matrices (SEM) Database,” provides a detailed discussion of how toxic materials are added to the SEM). Using the ICD-9 code of that disease, District Office/FAB personnel can search its database of denied cases to identify those cases with the same ICD-9 disease code. At each District Office, those cases on the SEM Detail Report are assigned to a Claims Examiner (at the District Director’s discretion) for review to determine if its denial should be reevaluated. The Claims Examiner uses the SEM to reevaluate the case using current information. After reviewing the totality of evidence, this reevaluation may result in the case being reopened and approved or, alternatively, there may be no change in the existing denied status. Similarly, for cases that are in the process of being reviewed, this procedure will assist the current Claims Examiner with the most current information relative to the condition being evaluated. These actions are to be controlled by the District Director and the data are to be utilized at the discretion of the District Director and the FAB Manager.
DEEOIC believes the above process provides each claimant whose case has been denied a fair opportunity for reevaluation whenever new disease and disease-toxic material association information is added to the SEM database.
References: U.S. Department of Labor EEOICP Site Exposure Matrices Pre-adjudication Changes Report, National Office Post-Adjudication Report
Purpose: To provide a mechanism for ensuring that previously denied cases have a way to be reopened based upon new medical and toxicological data that have been added to the SEM database since the cases’ initial adjudication. This plan is also applicable to cases that have yet to be adjudicated that may be impacted by changes to the SEM. For example, if an additional causative agent link is added for bladder cancer, personnel will have a means of addressing this new piece of information. This plan is part of an overall effort to maintain the quality of the DEEOIC program and to be claimant-friendly in the review and ultimate adjudication of claims.
Applicability: All staff.
Using SEM Pre/Post-Adjudication Reports:
Sometimes changes are made in SEM that may affect the DOL adjudication decision of a closed or in-process claim. Specifically, a denied case may need to be reevaluated because of a disease or disease/toxic material association change in the SEM. The SEM changes affecting an adjudication decision include the recognition of an occupational disease not previously listed in the SEM, deletion of a previously accepted occupational disease, or new toxic substance associations with existing occupational diseases.
Two methods have been established to facilitate the District Office/FAB’s review of cases, the first for denied adjudicated cases where the ICD-9 is impacted by a change in the SEM and the second for pre-adjudication (in-progress) cases:
1. Using the Post-Adjudication Report: As noted above, this report has two parts, the SEM Summary Report (covers all the District Offices and the FAB) and the SEM Detail Report (provides detailed information, including case number, work location, claims examiner, district office, etc.). The Post-Adjudication Report is issued periodically by the National Office to identify those denied Part E cases that may be affected by a change in the SEM health effect information (by ICD-9) during the prior quarter. Please see Figures 1 through 16 (attachments) to assist in visualizing these steps. It’s important to note that the District Directors, FAB managers and National Office management will ultimately review and prioritize possible post-adjudication file review by trends in the data fields.
a. Using the SEM Detail Report, Select the “All” tab or a District Office to display those cases of interest. Delete the first row of the spreadsheet, and then enable the Excel Auto Filter feature for all remaining columns and rows of the spreadsheet.
b. In the “ICD-9 CD” column click on the drop-down arrow and select the ICD-9 Code of interest. The list of those cases potentially affected by a change in the SEM is returned.
c. In the “Worksite ID” column, click on the drop-down arrow and select the number of the site of interest. The resulting list indicates those cases for the selected site that potentially need to be reevaluated using current SEM information.
d. Using information in the “Case Number” and “LOC” (case location) retrieve the case file for the case of interest (for Privacy Act reasons, the case numbers have been suppressed in the attached figures).
e. For only the health effect in Step 2, repeat the applicable SEM searches. Section 4 of chapter E-500 of the procedure manual provides guidance on using the SEM to evaluate a claim.
(1) If the SEM indicates that none of the claimant’s potential exposures is related to the health effect then the Claims Examiner documents this information, inserts this documentation in the case file, and returns the case file to storage.
(2) If the SEM indicates that the worker may have been exposed to one or more substances linked to the health effect, then the claim should be carefully reviewed to determine whether, based upon the claimant’s documented job title and work activities, there should be an industrial hygiene review to determine whether any significant exposures to the material(s) in question may have occurred.
Example: The Cleveland District Office receives the SEM Detail Report covering the period of April through June 2008 (see Figure 1).
a. Using the SEM Detail Report, select the “CLE” tab to display those cases that may need reevaluation at the Cleveland District Office (see Figure 2). Delete the first row of the spreadsheet and then enable the Excel Auto Filter feature for all remaining columns and rows (see Figure 3).
b. Suppose the District Office is interested in reviewing denied cases with the ICD-9 code of 173.3, Skin Cancer. In the “ICD-9 CD” column, click on the drop-down arrow and select “173.3”. The list of those denied cases linked to ICD-9 code 173.3 is returned (see Figure 4).
c. Suppose the District Office is interested in reviewing the denied ICD-9 code 173.3 at cases at [SITE NAME], Worksite ID 242. In the “Worksite ID” column, select “242”. The list of those denied cases linked to ICD-9 code 173.3 at the [SITE NAME] is returned. Nine cases are listed (see Figure 5).
d. If the District Office is interested in reviewing case #111111111, that number should be highlighted off the spreadsheet (See Figure 6) and assigned to a Claims Examiner who would then retrieve the case file. Using information from the case file, the Claims Examiner repeats the SEM searches for case 111111111 that are applicable to Skin Cancer.
(1) If the SEM indicates that none of the claimant’s potential exposures is related to skin cancer, then document this information and return the case file.
(2) If the SEM indicates that the worker may have been exposed to one or more substances linked to skin cancer, then the claim should be carefully reviewed to determine whether, based upon the claimant’s documented job title and work activities, there should be an industrial hygiene review to determine whether any significant exposures to the material(s) in question may have occurred.
2. Using the Pre-Adjudication SEM Changes Report (in the SEM database): On the SEM Main Menu, clicking on the link “Adjudication-Related Change Report” on the lower task bar takes authorized users to a search page. That page allows the user to search SEM for recent changes in the SEM diseases and disease associations that could affect the recommended decision of a case that has been evaluated, but where a final adjudication decision has not yet been made. The following search filters are available:
· Site name
· Health effect
· Reporting period
In addition, the user can select what features of the search are displayed:
· Show sites (shows all the sites affected by a change in a health effect during the selected reporting period)
· Show toxics (shows all the toxic substances associated with the health effect and any changes - additions and deletions - in disease associations during the selected reporting period)
· Show dates (shows the date that a disease was added to SEM and the date(s) of any disease association changes during the selected reporting period)
Because the SEM contains large amounts of data, the user will find that search times are shorter if use of the above features is limited to just those necessary. Selecting all the features will result in thousands of rows of information being returned and will slow response time.
a. Select “Adjudication-Related Change Report” on the SEM Main Menu lower task bar.
b. On the returned page, select the DOE site of interest.
c. On the returned page, select the health effect of interest.
d. Select a start date just after the SEM searches in the case file were completed, and select an end date of yesterday. For example, if a case was researched in the SEM on June 28, 2008, and today’s date is December 5, 2008, then the reporting period should be June 29, 2008 to December 4, 2008.
e. Click “Run Report.” Within the designated reporting period, the returned report tells the user whether the selected disease was added, deleted, or had disease association changes.
f. If changes are reported, then the case may need to be reevaluated using current SEM data before it is adjudicated.
Example 1: “Worker C” worked at the Pinellas Plant from 1970 to 1990. He filed a COPD claim in July 2008. Case research was completed on August 15, 2008, and a recommended “denial” decision made. However, a final adjudication decision has not been made. The user wants to know, “Have changes been made in the SEM information for COPD that could affect the adjudication decision?” Assume that today’s date is December 5, 2008.
a. Select “Adjudication-Related Report” on the SEM Main Menu lower task bar (see Figure 7).
b. On the returned page, select “Pinellas Plant” as the site (see Figure 8).
d. Select “Pulmonary disease, chronic obstructive” as the health effect (see Figure 9).
d. In the Reporting Period blocks enter “8/16/2008” (start date of search) and yesterday’s date, e.g. “12/4/2008” (end date of search).
e. Click “Run Report.” Results: The returned information shows that no changes have been made in the SEM COPD information at Pinellas since the denial recommendation was made on August 15, 2008 (see Figure 11). The SEM page with this information is printed and inserted in the file and is processed for adjudication.
f. Since there were no changes in COPD from the time the case was previously researched in the SEM, there is no need for case reevaluation.
Example 2: “Worker D” worked at Hanford from 1975 to 2001. He filed an “occupational asthma” claim in July 2008. Case research was completed on August 15, 2008, and a recommended “denial” decision was made. However, a final adjudication decision has not yet been rendered. The user wants to know, “Have changes been made in the SEM information for occupational asthma that could affect the adjudication decision?” Assume that today’s date is December 5, 2008.
a. Select “Changes Report” on the SEM Main Menu lower task bar.
b. On the returned page, select “Hanford” as the site (see Figure 12).
c. Select “Occupational asthma” as the health effect (see Figure 13).
d. Enter the reporting period “8/16/2008” (start date of search) and yesterday’s date, e.g. “12/4/2008” (end date of search). See Figure 14.
e. Click “Run Report”. Results: two rows of data are returned (see Figure 15). This alerts the user that since August 15, 2008, changes (additions, deletions, or both) have occurred in the occupational asthma toxic material associations.
f. Because there were changes in occupational asthma associations since the time that the case was previously researched in the SEM, there is a need for reevaluation.
Note that this generated report can be used by authority granted at the discretion of District Directors/FAB Managers or other management; ad hoc reports can also be run as needed.
Disposition: Retain until incorporated in the Federal EEOICPA Procedure Manual.
RACHEL P. LEITON
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution List No. 1: (Claims Examiners, Supervisory Claims Examiners, Technical Assistants, FAB District Managers, Operation Chiefs, Hearing Representatives)