AMA guides allow a physician's 'exercise of clinical judgment'

According to California law, impairment ratings are calculated with an allowance for a physician's clinical judgment in cases that do not fit neatly into the diagnostic criteria and descriptions laid out in the AMA Guides.

Case name: Milpitas Unified School District v. Workers' Compensation Appeals Board, No. H034853 (Cal. Ct. App. 08/19/10).

Ruling: The California Court of Appeal held that California law permits reliance on the entire American Medical Association Guides to the Evaluation of Permanent Impairment for determining an employee's impairment rating. This includes allowing a physician's "exercise of clinical judgment."

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What it means: According to California law, impairment ratings are calculated with an allowance for a physician's clinical judgment in cases that do not fit neatly into the diagnostic criteria and descriptions laid out in the AMA Guides.

Summary: A secretary was injured when her foot became entangled in computer wires, causing her to fall. She sought treatment for pain in various parts of her body and for psychiatric symptoms. Her physician assigned her an impairment rating of 100 percent, which was higher than a rating assigned using the AMA Guides. The California Court of Appeal held that the guides allow a physician's "exercise of clinical judgment" to evaluate the impairment accurately.

California statutes state that the impairment rating determination must "incorporate" the descriptions and measurements of physical impairments and the corresponding percentages published in the AMA Guides. The court stated that it could not expand the statute to change the word "incorporate" to "apply exclusively." The court also refused to conclude that the guides are always accurate. The court mentioned that "the guides itself recognizes that it cannot anticipate and describe every impairment that may be experienced by injured employees." The guides call for a physician's use of judgment in complex or extraordinary cases.

The court mentioned that a physician's opinion that departs from an application of the guides can be challenged, and if a physician's explanation for his medical conclusion fails to convince the workers' compensation judge or Workers' Compensation Appeals Board, it will properly be rejected.

Read more at the WorkersComp Forum homepage.

October 25, 2010

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