We have recently seen a dramatic decrease from designated doctor’s impairment ratings for sprain/strain spinal injuries in Texas Workers Compensation claims. The Fourth Edition of the AMA Guides generally uses Diagnosis Related Estimate (DRE) Categories to provide for spinal injuries. Most sprain/strain injuries result in either a DRE Category I or a DRE Category II.
To find a DRE Category I, it must fit under the following description and verification:
The patient has no significant clinical findings, no muscle guarding or history of guarding, no documentable neurologic impairment, no significant loss of structural integrity on lateral flexion and extension roentgenograms, and no indication of impairment related to injury or illness.
The description and verification for a DRE Category II are:
The clinical history and examination findings are compatible with a specific injury or illness. The findings may include significant intermittent or continuous muscle guarding that has been observed and documented by a physician…
The doctors state that upon examination they found no neurological impairment and no loss of range of motion. However, they seem to ignore the inclusion of intermittent muscle guarding documented by a physician.
The Appeals Panel finally has provided support for our position that the impairment rating must properly use the AMA Guides. In Appeals Panel Decision No. 120897, they found that the designated doctor improperly applied the AMA Guides in finding a DRE Category I for a cervical sprain/strain injury. The Appeals Panel found that to meet the requirements of a DRE Category II, the injury worker need to only meet one of the three differentiators (muscle guarding, muscle spasms or non-uniform loss if ROM). The differentiator may be present at the time of examination or have been documented by a physician to be used.
This helps to clarify for the doctors that only one differentiator is necessary to find a DRE Category II. This provides a 5% greater impairment rating than a DRC Category I, which calculates to 15 additional weeks of impairment income benefits.
Daniel L Morris, email@example.com (214)357-1782