Attention: This bulletin has been superseded and is inactive.
EEOICPA BULLETIN NO. 08-15
Issue Date: May 30, 2008
Effective Date: May 30, 2008
Expiration Date: May 30, 2009
Subject: Adjudication of Part E claims for the conditions of parkinsonism and Parkinson’s disease (PD).
Background: “Parkinsonism” is a neurological disorder or syndrome that can arise from a number of sources, including toxic exposure, drugs, and PD. There is no clinical test or method for distinguishing parkinsonism from PD and the two terms are often used interchangeably since the symptoms are the same. According to the New England Journal of Medicine a misdiagnosis occurs about 25% of the time because of the inability to distinguish the one from the other. This is problematic for the EEOICPA Claims Examiner (CE) when adjudicating toxic exposure claims, because the Site Exposure Matrices (SEM) shows a causal link between certain toxic substances and parkinsonism, but no substances are linked to PD. Claims Examiners need to be aware of this potential for misdiagnosis and must know how to treat either condition when developing claims for toxic exposure under Part E.
References: Federal EEOICPA Procedure Manual 2-300 and E-500 (4, 19); U.S. Department of Labor EEOICP Site Exposure Matrices (NIH HazMap Disease List); The New England Journal of Medicine; and The Centers for Disease Control and Prevention.
Purpose: To clarify the policies and procedures for adjudicating claims involving the conditions of parkinsonism and PD.
Applicability: All staff.
1. For the purpose of claim adjudication under Part E of the EEOICPA, the CE is to consider the medical conditions of PD, parkinsonism, or any reasonable alias as synonymous. In other words, in any instance where an individual has claimed any one of these conditions, the CE will proceed to adjudicate the claim in the same manner.
2. Upon receipt of a claim for PD, parkinsonism, or any reasonable alias, the CE is to access SEM and perform an appropriate site/area/facility/building/process/labor category/job description/incident/exposure search using the “Toxic substance by health effect” query. The CE selects the entry for “parkinsonism” from the list box of health effects. At present, the SEM database contains the following substances with a known link between exposure and development of the condition of parkinsonism:
a. Carbon disulfide
b. Carbon monoxide
c. Diesel exhaust
e. Manganese II chloride
f. Potassium permanganate
g. Steel, cold drawn
h. Steel, tool
i. Steel, galvanized
k. Hastelloy ®
l. MPTP (1-Methyl-4-phenyl-1,2,3,6-tetahydropyridine)
3. In cases where SEM identifies the presence of carbon monoxide (CO) at the worksite, or where the employee claims CO exposure, there must be evidence of an acute occupational exposure that precedes the onset of parkinsonism. If the claimant does not produce documentation substantiating such an exposure, the CE must request that the claimant, treating doctors, the employer, or others, provide contemporaneous evidence (e.g. emergency room records, hospital records, industrial accident reports, industrial hygienist reports, witness statements, etc.), of an incident requiring medical intervention that fits one of the following criteria:
a. An incident involving acute occupational CO exposure that caused the claimant to lose consciousness at the time of the exposure.
b. A documented incident involving significant CO levels and/or exposure sufficient to either cause loss of consciousness or a reduction in oxygen to levels which could result in brain injury. (NIOSH and OSHA consider a CO level of 1200PPM to be “immediately dangerous to life and health,” and this level would be considered evidence of a toxic level sufficient to cause loss of consciousness in an adult.)
c. Documentation such as laboratory test results or other clinical records demonstrating blood gas levels consistent with a reduction of oxygen sufficient to cause injury to the brain; or records documenting admission to an acute care facility or hospital for treatment or observation arising from an occupational CO exposure. (A carboxyhemoglobin level of 20% or higher would be evidence of a blood gas level sufficient to cause brain injury.)
Acceptance of parkinsonism from CO exposure is contingent upon the claimant exhibiting symptoms of, or being diagnosed with parkinsonism, following an incident of acute occupational CO exposure as described above.
4. With the exception of the above guidelines for CO exposure, the CE is to evaluate toxic exposure claims for parkinsonism in accordance with Federal EEOICPA Procedure Manual Chapter E-500, 2(c), which states that the CE must review all evidence of record. If after review the CE is uncertain as to the potential for an employee to develop parkinsonism resulting from exposure to any of the above-listed toxic substances, a referral may be made to an industrial hygienist (IH) or toxicologist. Most importantly, the CE should not rely exclusively on SEM to ascertain whether an employee had contact with a known toxic substance linked to parkinsonism. All evidence of record must be evaluated including: DAR records, occupational health questionnaires, former worker screening documents, EE-3/4 forms, or any other documents which may provide information on toxic substance exposure. Attachment 1 provides additional information on work processes and routes of exposure, to aid the CE in identifying possible sources of toxic exposure to the substances listed therein. This attachment is not inclusive of all routes of exposure and the CE should not rely exclusively on this document when evaluating a claim for toxic exposure. In addition, since the SEM database is regularly updated with new exposure information, the CE should conduct a separate exposure search for each new claim.
5. If the evidence of record clearly establishes that exposure to a toxic substance known to be associated with parkinsonism is evident, and if the medical evidence satisfies the Part E causation standard, then the CE can accept the claim for parkinsonism, PD, or any reasonable alias. However, if there is evidence of an exposure to toxic substances, but the medical rationale linking the exposure to the patient’s condition is lacking, or not clear, the CE must follow up with the claimant’s treating doctor, or refer the case to a DMC for a medical opinion on causation.
6. As with all medical referrals, the CE must prepare a clearly written Statement of Accepted Facts (SOAF) and a list of questions for the medical expert to consider. The SOAF must identify all relevant toxic exposure data. In the referring memorandum accompanying the SOAF, the CE must clearly explain the issue(s) to be addressed and must make it very clear that: a) the purpose of the medical review is to establish or rule out causation on the basis that it is at least as likely as not that exposure to a toxic substance at a Department of Energy facility was a significant factor in aggravating, contributing to, or causing the employee’s illness or death; and b) the doctor is not to differentiate between parkinsonism and PD when making this determination. The conditions of parkinsonism, PD, or any reasonable alias, are to be considered synonymous.
7. In the exercise of the Director’s discretion over the reopening process, the Director is delegating limited authority to the District Directors to sign reopening orders. This delegated authority is limited to reopenings for those cases affected by this bulletin. The Director is retaining sole signature authority for all other types of reopenings not otherwise delegated.
8. Prior to reopening, the medical evidence must be reviewed in all targeted cases. For all cases that have a final decision to deny, where:
· the denial was based on a diagnosis of Parkinson’s disease(PD);
· the denial was based on a diagnosis of an alias for parkinsonism or PD; or
· the initial diagnosis was parkinsonism but the case was denied because the medical evidence supported a finding of Parkinson’s disease;
reopening of the case is warranted, and the case should be reviewed in accordance with the instructions provided in this bulletin.
The Director’s Order should state that the case is being reopened as a result of new guidelines for evaluating cases involving a diagnosis of parkinsonism, PD, or any alias of this disease or syndrome.
The District Director should code the case as “MN” (NO Initiates Review for Reopening) with a status effective date as the effective date of this bulletin. Upon reopening the claim, the District Director should code the case as “MD” (Claim Reopened – File Returned to DO) to reflect that the case has been reopened and is in the district office’s jurisdiction. (The “MZ” status code is not used.) The status effective date of the “MD” code is the date of the Director’s Order.
Please note that while the “MD” code is generally input by National Office staff, entry of this code has been delegated to the District Director, just as the authority to grant reopenings has been delegated in this specific circumstance.
District Offices will be provided with a list of cases affected by this bulletin, under separate cover.
Disposition: Retain until incorporated in the Federal EEOICPA Procedure Manual.
PETER M. TURCIC
Director, Division of Energy Employees
Occupational Illness Compensation
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)
[A1]David – revise this and go through a instruction with regard to a DMC referral. The CE will need to send a SOAF and referral, but how do we notify the DMC or treating that our program treats all the illnesses synonymously