TABLE OF CONTENTS
Paragraph and Subject Page Date Trans. No.
Chapter 2-1500 Consequential Conditions
Table of Contents. . . . . . . . i 01/10 10-07
1 Purpose and Scope. . . . . . . . 1 01/10 10-07
2 Defining a Consequential
Condition. . . . . . . . . . . 1 01/10 10-07
3 Consequential Condition Claims . 1 01/10 10-07
4 Claim Development. . . . . . . . 1 01/10 10-07
5 Metastasized Cancer(s) . . . . . 2 01/10 10-07
6 Conditions Resulting from
Medical Treatment. . . . . . . 3 01/10 10-07
7 Independent Intervening
Causes . . . . . . . . . . . . 4 01/10 10-07
8 Natural Progression/Development
(Pathogenesis). . . . . . . . . 5 01/10 10-07
9 Psychological Factors. . . . . . 6 01/10 10-07
10 Accepting or Denying the
Consequential Condition. . . . 7 01/10 10-07
11 Impairment and Wage-Loss . . . . 7 01/10 10-07
12 State Workers’ Compensation (SWC)
Claims, Lawsuits and Fraud . . 8 01/10 10-07
1 Medical Conditions with Likely
Secondary Disorders . . . . . 01/10 10-07
2 Conditions that Require
Additional Development . . . . 01/10 10-07
1. Purpose and Scope. This chapter discusses the Claims Examiner’s (CE) role when developing claims for consequential conditions. It also provides examples of the types of injuries, illnesses, impairments, or diseases that may be accepted as consequential conditions under EEOICPA.
2. Defining a Consequential Condition. A consequential condition covered by EEOICPA is any diagnosed injury, illness, impairment or disease that has occurred as a result of an accepted occupational illness under Part B and/or covered illness under Part E. Consequential conditions also include independent incidents related to an accepted condition.
Any illness, injury, impairment, or disease shown by medical evidence to be a consequence of an accepted Part B or Part E condition is covered for medical benefits under the Act. Additionally, under Part E, any illness, injury, impairment, or disease shown by medical evidence to be a consequence of a covered Part E condition may affect the calculation of an impairment rating and/or wage-loss.
3. Consequential Condition Claims. The claimant must make a claim for a consequential condition in writing. He or she may use any method of written notification, including a Form EE-1/2. Additionally, in some situations the CE develops a potential consequential condition upon receipt of medical evidence that discusses medical conditions other than the accepted condition that may be consequential.
4. Claim Development. Consequential condition(s) must be developed factually and medically in accordance with 20 C.F.R. 30.114(b)(3) of the EEOICPA regulations and DEEOIC procedures relating to weighing medical evidence.
There are four types of consequential conditions:
a. Metastasized Cancer(s);
b. Conditions resulting from medical treatment of the accepted condition/s;
c. Independent incidents related to an accepted condition/s;
d. Natural progression and/or development (pathogenesis).
5. Metastasized Cancer(s). Metastasized cancer(s) is a secondary cancer that originates from the primary cancer site.
a. Assessing and Developing Medical Evidence in Metastasized Cancer Claims. The CE can accept a metastatic cancer claim, if the claimant provides medical evidence, including a rationalized medical report from a physician that identifies the metastatic cancer and links the cancer to a primary site that had previously been accepted. The evidence must also establish:
(1) The diagnosis of a secondary cancer; and
(2) The date of diagnosis for the secondary cancer.
The date of diagnosis for the secondary cancer will be: a) subsequent to the date of diagnosis for the primary cancer; b) the same diagnosis date for the primary cancer; or c) before the date of diagnosis for the primary cancer if the primary site is not obvious.
If the medical evidence is inconclusive and the CE is unable to determine if the cancer is a metastasis, the CE seeks clarification from the treating physician and/or a District Medical Consultant (DMC).
b. Examples of Metastasized Cancers. It is widely accepted that certain carcinomas and/or sarcomas metastasize from the primary site. For example:
(1) Carcinomas of the lung, breast, kidney, thyroid, and prostate tend to metastasize to the lungs, bone, and brain.
(2) Carcinomas of the gastrointestinal tract, reproductive system, and abdomen tend to metastasize to the abdominal lymph nodes, liver, and lungs. Later in their course, these carcinomas can metastasize to the brain and other organs.
(3) Sarcomas often first metastasize to the lungs and brain.
(4) Primary malignant tumors of the brain seldom metastasize to other organs, but they can spread to the spinal cord.
6. Conditions Resulting from Medical Treatment. These conditions require a fully rationalized medical report by a physician that shows the relationship between the injury, illness, impairment or disease and the compensable illness.
a. Examples of Common Consequential Conditions Resulting from Medical Treatment for Accepted Conditions. As part of a patient’s medical treatment or protocol, a patient may undergo treatment and/or other drug therapy that will produce side effects that can be considered common consequential conditions.
Examples of such conditions are:
(1) Radiation pneumonitis as a result of radiation treatment;
(2) Skin rashes and radiation burns because of radiation treatment;
(3) Osteoporosis (which causes weakening of the bones and injuries such as spontaneous hip fractures) as a result of steroid treatment;
(4) Chronic Pain, extreme fatigue, anemia, and gastrointestinal conditions such as nausea, vomiting, constipation, diarrhea, and weight loss are additional examples of side effects of medical treatment.
b. Developing evidence for conditions resulting from medical treatment. When a claim is made for a consequential condition caused by medical treatment of the accepted condition, the CE investigates the submitted documentation to ensure the medical evidence supports the claim. The CE obtains the following supporting documentation from the claimant:
(1) Medical Evidence that establishes a causal connection between the claimed consequential condition and the accepted condition. The physician discusses the causal relationship between the consequential condition and the accepted condition, and establishes that the prescribed treatment is a recognized medical response to the accepted condition.
c. Assessing the medical evidence. The CE must use reasonable judgment when assessing the medical evidence required for a claim for a consequential condition.
7. Independent Intervening Causes.
a. Condition(s) resulting from an accident during travel to a medical appointment. If the employee sustains an injury in transit to or from a medical appointment or other necessary travel, it is considered a consequential condition. The CE must obtain the following factual and medical evidence:
(1) A Personal Statement that describes the circumstances of the event that resulted in an injury during travel to or from a medical appointment.
Examples of personal statements include: The employee trips down the stairs when exiting the doctor’s office and breaks an arm or leg.
The employee is assaulted in the parking lot of the doctor’s office, and obtained bruises, cuts, possible concussion, etc.
The employee is involved in a motor vehicle accident while en route to the doctor’s office and has whiplash. In this event, reasonable assessment of the situation is needed. If the employee’s accident occurred at 8 am and the doctor’s appointment was scheduled for 1 pm, the CE must determine the distance between the employee’s residence and his or her doctor’s office.
(2) Medical Evidence must include a diagnosis of the condition being claimed as a consequence of a travel-related injury and confirmation that the scheduled appointment was for treatment or care of a previously accepted covered illness.
b. An independent intervening incident caused by, or attributed to the employee’s own conduct. Injuries, illnesses, impairments or diseases suffered as a result of the employee’s own actions will not be accepted as consequential conditions.
8. Natural Progression/Development (Pathogenesis). There are medical conditions that are expected to develop due to the natural progression of the accepted illness. Natural progression is an expected measurable change in the illness that occurs with the passage of time.
The CE may accept certain conditions arising as a natural progression of accepted condition(s) when he or she is notified of the existence of these secondary medical conditions. Exhibit 1 outlines secondary conditions that are known to result from Chronic Beryllium Disease and Silicosis, and can be accepted upon the receipt of notification. Notification must be in the form of a well-rationalized medical report diagnosing a secondary condition that progressed/developed from the accepted condition. When notified of such a condition listed in Exhibit 1, the CE updates ECMS and sends an appropriate letter to the employee.
However, some medical conditions could develop as a result of either the natural progression of the accepted condition or the natural aging process (see Exhibit 2). Hypertension, gout, and heart disease are examples of medical conditions that potentially result from either the aging process or natural progression of the accepted condition. When a claimant presents evidence of such a medical condition, the CE assesses the medical evidence as described below.
a. Assessing the medical evidence. The CE must use reasonable judgment when assessing the medical evidence required for a claim of consequential condition. In some instances, the CE may accept conditions caused by the natural progression upon receipt of the medical evidence describing the conditions listed in Exhibit 1.
In other situations where the relationship is questionable, more medical evidence (e.g., DMC review, clarification from treating physician, or second opinion) may be required.
Given that these conditions have not yet been accepted, any bills that are initially submitted to the medical bill processing agent relating to the non-accepted condition will suspend and/or reject until ECMS is updated.
9. Psychological Conditions. Psychological conditions can arise as a consequence of the accepted condition and/or treatment of that condition. They can also arise with no physiological basis. Depression, anxiety, or chemical imbalance are a few examples of psychological conditions that have no physiological basis. In addition to a specific diagnosis, these conditions may be described as “psychogenic pain disorder,” “conversion disorder,” or “psychological syndrome.”
However described, the symptom or pain is quite real to the individual involved although there is no demonstrable physical disorder.
Unless expressly claimed by a claimant, the CE develops for psychological conditions only if the attending physician indicates that such a component is present and that it is directly related to the accepted physiological condition. In such cases, the CE refers the claimant to a Board-certified psychiatrist for evaluation and opinion concerning causal relationship.
10. Accepting or Denying the Consequential Condition. The CE is responsible for taking the appropriate steps in developing any claimed consequential condition. This includes notifying the claimant of any deficiencies in the evidence and allowing him or her an opportunity to respond and submit additional evidence.
a. Acceptances. If the consequential condition is accepted, the CE notifies the claimant in a letter decision. However, if the decision is to deny the consequential condition, the CE advises the claimant of his/her determination by issuing a recommended decision. The recommended decision affords the claimant the opportunity to object to the determination, and present new evidence.
b. Issuing the Decision. When the case is in posture for the CE to accept a primary covered condition and a potential consequential condition exists, the CE proceeds with the immediate release of a recommended decision for the primary condition. A recommended decision accepting a primary covered condition must not be delayed while developing a consequential condition. However, if the case is in posture to also accept the consequential condition, this acceptance is included in the recommended decision. While the case file is at the Final Adjudication Branch (FAB), the FAB hearing representative (HR) or CE2 Unit staff pursues all development regarding consequential conditions. A letter accepting a consequential condition or a recommended decision denying a consequential condition cannot be issued before FAB issues a final decision on the primary covered condition. Decisions of this nature can be issued concurrently. Once the case file is returned to the District Office, the CE can continue development on the consequential condition and/or issue the letter accepting the consequential condition or the recommended decision denying it.
11. Impairment and Wage-Loss. Consequential conditions may cause additional impairment or wage-loss under Part E, but do not result in an additional lump sum award under Part B.
a. Impairment rating. An impairment rating assesses the functionality of the whole organ or system. DEEOIC does not apportion impairment by disease (see EEOICP PM 2-1300 for further discussion of impairment ratings). If the accepted condition and consequential condition affect the same organ or system, a rating for impairment to that organ or system should proceed. However, if the accepted condition affects one organ/system and the consequential condition involves another, the impairment rating on the organ/system affected by the consequential condition could be developed either concurrently with the impairment for the primary system (if the consequential condition has been accepted), or later. Ideally, the CE develops the primary and consequential conditions concurrently; however, this may not be possible if, for example, the system affected by the consequential condition has not reached maximum medical improvement (see EEOICPA PM 2-1300). As soon as an impairment rating is completed for the primary affected system an impairment decision should proceed. There would be nothing to preclude a later decision on the impairment due to the consequential condition as long as the organ or system affected by the consequential condition was not rated within the past two years. After passage of two years, the claimant can receive an impairment rating based on the consequential condition affecting the same organ system as the accepted condition.
b. Wage-Loss. The acceptance of a consequential condition may affect the claimant’s entitlement to wage-loss. Wage-loss is calculated using the first day that the employee lost wages due to the covered illness (see EEOICPA PM 2-1400 for further discussion of wage-loss).
In certain instances, the consequential condition may be the initial cause of the employee’s wage-loss. For example, a claimant submits medical evidence showing that pulmonary hypertension caused his or her wage-loss, and shows a diagnosis of Chronic Beryllium Disease (CBD) three years thereafter. In this instance, CBD is accepted under Parts B and E as the primary condition and pulmonary hypertension is accepted as the consequential condition under Parts B and E. Also, the claimant may receive wage-loss benefits under Part E dating from the time that the he or she first lost wages due to the pulmonary hypertension.
12. State Workers’ Compensation (SWC) Claims, Lawsuits and Fraud. Prior to accepting a consequential condition, the CE collects information to determine if a claimant has filed an SWC claim, lawsuit, or if the claimant has been convicted of fraud in connection with the consequential condition.