Date CASE ID#:


Med Provider

street address

City, State, zip

Dear Medical Provider;

The above-named employee filed a claim for whole body impairment as a result of breast cancer under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) requires impairment determinations to be performed in accordance with the 5th Edition of the American Medical Association’s Guide to the Evaluation of Permanent Impairment (AMA’s Guides). 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? DEEOIC defines maximum medical improvement as when the claimant’s condition is unlikely to improve substantially with or without medical treatment.

2. Is there surgical absence of the breast(s)? Surgical absence of a breast is rated in accordance with AMA’s Guides, section 10.9, page 239 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’s 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 number 4 above. These need to be well documented and ratable under the AMA’s 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, referencing applicable tables and sections of the AMA’s 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’s 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.

Payment for the impairment evaluation and required diagnostic tests are covered by the DEEOIC. Physicians may bill impairment evaluation using CPT Code 99455 or 99456 with ICD-9 code V70.9. Diagnostic services related to impairment evaluations must be billed with the appropriate CPT codes. Supporting documentation (e.g. medical reports, evaluation reports, assessment reports and diagnostic testing results) must be submitted with the completed Office of Workers’ Compensation Program (OWCP) Health Insurance 1500 Form (OWCP 1500). Reimbursement for these services will be in accordance with the OWCP fee schedule.

If you have any questions or concerns regarding this letter or impairment ratings in general, please contact me directly at (XXX) XXX-XXXX.

Thank you for your assistance.


Examiner name

Claims Examiner