Sample Questions for Physician

 

Questions:

CE:  Choose from options below or add your own

  1. Impairment:  Refer to PM Ch. 2-1300, Impairment Ratings for questions and instructions for CMC’s conducting impairment evaluations.

 

  1. Impairment:  If it is not possible to complete an impairment rating based on the medical evidence we provided, please advise us what medical records and/or testing is required to complete the rating.

 

  1. Diagnosis:  In your opinion, do the medical records support a diagnosis of a medical condition?  If so, please provide the first date of diagnosis, diagnosis, and the ICD code.

 

  1. Causation:  If a medical condition was diagnosed, in your opinion is it at least as likely as not that exposure to toxic substances during the course of employment at covered facility was a significant factor in aggravating, contributing to, or causing the employee’s medical condition?

 

  1. Causation:  If so, please provide the earliest date of diagnosis(es) and ICD code of the condition you believe is related.  Please provide the rationale and objective findings to support your conclusion that the condition(s) are related to exposure in the workplace.

 

 

 

Claims Examiner

Claims Examiner

 

 

 

(Printed Name)

 

 

 

 

 

Date

 

(Signature)

 

(Date)