OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Aggravation and Substantial Aggravation of a Pre-Existing Condition

Policy #:

CP-01-09

Code/Rule Reference:

R.C. 4123.01(C)(4); R.C. 4123.54(G)

Effective Date:

09/04/20

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

Policy # CP-01-09, effective 06/30/16 and Procedure # CP-01-09.PR1, effective 06/30/16

History:

Previous versions of this policy are available upon request

 

 

 

 

 

 Aggravation and Substantial Aggravation of a Pre-existing Condition Table of Contents

 

I. POLICY PURPOSE

II. APPLICABILITY

III. DEFINITIONS

Aggravation

Substantial Aggravation

Date of Disease

IV. POLICY

V. PROCEDURE

A.         General Claim Note and Documentation Requirements

B.         General Procedures

C.         Date of Injury or Occupational Disease Before 8/25/2006

D.         Date of Injury or Occupational Disease On or After 8/25/2006

E.         Pre-Existing Condition Returned to a Level That Would have Existed Without the Injury or Occupational Disease

F.         Requests After a Final Decision That the Pre-Existing Condition Has Returned to the Level That Would Have Existed Without the Injury or Occupational Disease

G.        Payment Status

 

 


 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that claims services staff recognizes what constitutes aggravation or substantial aggravation of a pre-existing condition and when each may be compensable, dependent upon the date of injury/date of disease. 

 

II. APPLICABILITY

 

This policy applies to claims services staff. 

 

III. DEFINITIONS

 

Aggravation:  A medical filing that a condition that pre-existed an injury or occupational disease is worsened by the injury or occupational disease and has an adverse impact, no matter how slight.

 

Substantial Aggravation:  A medical finding that a condition that pre-existed an injury or occupational disease is worsened considerably in amount, value, or extent solely because of the injury or occupational disease. 

 

Date of Disease: The latest event of one of the following:

·        Date injured worker first became aware;

·        Date injured worker first received medical treatment;

·        Date injured worker first quit work because of the occupational disease. 

 

IV. POLICY

 

It is the policy of BWC to provide compensation and benefits for an aggravation or substantial aggravation of a pre-existing condition (based upon the date of injury/disease) when the injury or occupational disease causing the aggravation is sustained or contracted in the course of and arises out of employment.

 

V. PROCEDURE

 

A.     General Claim Note and Documentation Requirements

1.     Claims services staff shall refer to the Standard Claim File Documentation and Altered Documents policy and procedure for claim note and documentation requirements; and

2.     Shall follow any other specific instructions for claim notes and documentation included in this procedure.

 

B.     General Procedures

1.     In addition to determining if any injury meets the requirements of the Compensable Injuries policy and procedure, claims services staff shall review a Motion (C-86) or other written request for allowance of an aggravated or substantially aggravated pre-existing condition for sufficient evidence to support:

a.     Existence of the pre-existing condition; and

b.     Aggravation or substantial aggravation of the pre-existing condition, consistent with the applicable standard based on the date of injury or date of disease in an occupational disease claim.  See section C. below.  

2.     Claims services staff shall contact the injured worker (IW) and the managed care organization (MCO) to request additional medical evidence, as needed.  If medical evidence prior to the date of injury is specifically requested, claims services staff shall obtain an Authorization to Release Medical Information (C-101) from the IW.     

a.     Types of medical evidence that support a request for allowance of an aggravated or substantially aggravated pre-existing condition include, but are not limited to:

1.     Lab reports, x-rays, magnetic resonance imaging (MRI), computerized tomography (CT) reports or any other diagnostic tests that may document the current status of the aggravated or substantially aggravated pre-existing condition;

2.     Lab reports, x-rays, MRI, CT reports or other diagnostic tests pertaining to the condition prior to the injury or occupational disease;

3.     Documentation of current medication, including dosage and frequency for the aggravated or substantially aggravated pre-existing condition;

4.     Documentation of medication, including dosage and frequency for the aggravated or substantially aggravated pre-existing condition the IW was receiving prior to the date of injury of occupational disease;

5.     Any objective physician examination findings of the aggravated or substantially aggravated pre-existing condition prior to and subsequent to the injury or occupational disease;

6.     Physical therapy or occupational therapy records prior to and subsequent to the injury or occupational disease;

7.     Emergency room reports;

8.     Accident reports; and

9.     Operative reports. 

b.     It is not necessary that the pre-existing condition was diagnosed and/or documented prior to the injury, only that the medical evidence supports that it was pre-existing to the injury or occupational disease. 

c.      Claims services staff may refer the C-86 or other written request to the medical services specialist (MSS) to determine if an independent medical examination (IME) or a physician file review is appropriate pursuant to the Additional Allowance or Initial Claim Determination policies and procedures and the Independent Medical Exams and Physician File Reviews policy and procedure. 

3.     Previous Claim with a Same or Similar Condition

a.     Claims services staff shall not automatically characterize the current condition as an aggravation or substantial aggravation of a pre-existing condition solely because the IW has a previous claim with the same or similar condition. 

b.     Claims services staff shall carefully scrutinize the facts and supporting documentation to determine if: 

1.     The prior condition was resolved and the current condition is a new and distinct condition; or

2.     The prior condition was not resolved and is aggravated or substantially aggravated by the new injury or occupational disease.

c.      Example 1:

1.     The IW has a prior claim allowed for ankle sprain.

2.     The condition resolved and the IW returned to work with no restrictions.

3.     Now, a new claim has been filed with a new accident description and a diagnosis of ankle sprain.

4.     There is no medical documentation to indicate the current sprain is in any way related to the previous sprain.

5.     This claim would not be considered for substantial aggravation of a pre-existing ankle sprain.  The previous ankle sprain was resolved; therefore, this claim would be considered for allowance of a new ankle sprain. 

d.     Example 2:

1.     The IW has a prior claim allowed for herniation at L4-5.

2.     The IW received conservative treatment and was able to continue working without on-going treatment. 

3.     Now, the IW suffers a new injury and the herniation at L4-5 is substantially aggravated.

4.     The prior claim would be considered for allowance of the substantial aggravation of the pre-existing condition.  The IW had stopped being treated for the condition in the prior claim, but the condition was not technically resolved.  The herniation continued to exist but was not symptomatic until the new injury. 

e.     Previously allowed occupational disease:  A resolved occupational disease in a previously allowed claim may be subsequently aggravated by a new injury.  In that situation, the aggravation of the occupational disease may be allowed as part of the new injury claim.  Staffing with a BWC attorney and/or a physician file review may be necessary.  See the Occupational Disease policy and procedure for additional information.

4.     Psychiatric Allowance:  Claims services staff may find that there is an aggravation or substantial aggravation of a pre-existing psychiatric condition if the alleged condition is supported by sufficient evidence and proof of causal relationship.  See the Psychiatric Conditions policy for further information.

5.     If the condition meets the criteria for an aggravation or substantial aggravation of a pre-existing condition, claims services staff shall:

a.     Ensure the narrative description of the physical injury ICD code is modified to reflect “aggravation of pre-existing (identify the condition)” or “substantial aggravation of pre-existing (identify the condition)”; and

b.     Update the claims management system to reflect an aggravated or substantially aggravated pre-existing condition.

6.     When an IW requests allowance of substantial aggravation of a pre-existing condition in an initial claim:

a.     Claims services staff shall follow the Initial Claim Determination policy and procedure; and

b.     If the IW is requesting multiple conditions, including substantial aggravation of a pre-existing condition, but insufficient evidence is provided for the substantial aggravation of a pre-existing condition, claims services staff may:

1.     Address the other condition(s); and

2.     State in the BWC order that the alleged substantially aggravated pre-existing condition will be considered upon submission of supporting medical documentation.

3.     Example:

a.     An initial request is filed asking for allowance of:

i)       Substantial aggravation of pre-existing arthritis of the knee:

ii)      Knee sprain/strain; and

iii)    Contusion of the knee.

b.     Evidence on file supports allowance of the knee sprain/strain and contusion, but there is no evidence on file to support allowance of substantial aggravation of pre-existing arthritis of the knee.

c.      Objective medical evidence is requested, but none is received.

d.     Claims services staff may issue a BWC order to allow the knee sprain/strain and contusion and state that substantial aggravation of pre-existing arthritis of the knee will be considered upon submission of supporting medical documentation.

7.     When the IW requests an additional allowance of an aggravation or substantial aggravation of a pre-existing condition, claims services staff shall follow the Additional Allowance and Motions policies and procedures, and the Psychiatric Conditions policy and procedure if applicable. 

8.     If the IW requests the additional allowance of a condition as direct causation, but it may be more appropriately allowed as aggravation or substantial aggravation of a pre-existing condition:

a.     Claims services staff shall request an IME or physician file review to clarify the status of the condition (i.e., determine if is it an aggravated or substantially aggravated pre-existing condition, or a condition directly caused by the injury or occupational disease).

b.     If the opinion in the IME or physician file review states the condition was aggravated or substantially aggravated by the injury or occupational disease, claims services staff shall:

1.     Contact the IW to determine if the IW agrees to modify the requested condition to an aggravation or substantial aggravation of a pre-existing condition.

a.     If the IW agrees, allow the aggravation or substantial aggravation of a pre-existing condition; or

b.     If the IW does not agree to modify the requested condition, refer the matter to the IC.

2.     If the opinion in the IME or physician file review states that the condition was directly caused by the injury or occupational disease, claims services staff shall simply allow the condition.

3.     Example:

a.     The IW files a request asking for allowance of degenerative disc disease.

b.     Claims services staff obtains a physician file review that states the degenerative disc disease was a pre-existing condition that was substantially aggravated by the injury.

c.      Claims services staff contacts the IW and the IW agrees to the degenerative disc disease being allowed as a condition substantially aggravated by the injury. 

d.     Claims services staff allows substantial aggravation of pre-existing degenerative disc disease.  

e.     If the physician file review stated that the degenerative disc disease was directly caused by the injury, claims services staff would allow the condition of degenerative disc disease.     

 

C.    Date of Injury or Occupational Disease Before 8/25/2006

1.     Claims services staff may determine that a condition that pre-existed an injury or occupational disease occurring before 8/25/2006 is compensable if:

a.     Evidence is presented to support the pre-existing condition is aggravated by the injury or occupational disease; and

b.     The aggravation is shown to have some real adverse effect, even if the effect is slight.

2.     Claims services staff may review and discuss these claims with a BWC attorney.

 

D.    Date of Injury or Occupational Disease On or After 8/25/2006

1.     Claims services staff may determine a condition that pre-existed an injury or occupational disease occurring on or after 8/25/2006 is compensable if the pre-existing condition is substantially aggravated by the injury or occupational disease and supported by objective:

a.     Diagnostic findings;

b.     Clinical findings; or

c.      Test results. 

2.     Subjective complaints may be included as evidence of a substantial aggravation of a pre-existing condition, but subjective complaints alone, without objective findings, are insufficient to support a substantial aggravation.

3.     Claims services staff shall ensure the evidence shows the condition is substantially aggravated by the injury or occupational disease; i.e., the aggravation is considerable in amount, value, or extent.   

4.     Example

a.     A claim is allowed for lumbosacral sprain.

b.     The IW is now requesting allowance of substantial aggravation of pre-existing degenerative arthritis.

c.      The IW must submit medical evidence that supports the degenerative arthritis pre-existed the injury or occupational disease; and

d.     The injury or occupational disease has caused the degenerative arthritis to become significantly worse.

 

E.     Pre-Existing Condition Returned to a Level That Would have Existed Without the Injury or Occupational Disease

1.     When a request is received, or there is other reason for claims services staff to question whether a substantially aggravated pre-existing condition may have returned to the level that would have existed without the injury or occupational disease, claims services staff shall:

a.     Review any medical documentation contained in the claim and/or submitted with the request;

b.     Contact the MCO to notify them of the possibility the condition has returned to a level that would have existed without the injury or occupational disease and request assistance, as necessary, in gathering appropriate medical evidence; and

c.      Review the issue with an Injury Management Supervisor (IMS) and BWC attorney to determine next steps based on the evidence on file and the circumstances of the claim. 

d.     Continue compensation and benefits for the substantially aggravated pre-existing condition until a final decision is rendered.

2.     If medical evidence is gathered that indicates the substantially aggravated condition has returned to the level that would have existed without the injury or occupational disease, claims services staff shall:

a.     If no conflict exists and the issue has been staffed with a BWC attorney, send a Miscellaneous Order to all parties to the claim stating compensation and benefits are no longer payable for the substantially aggravated pre-existing condition; or

b.     Refer the issue to the IC if a conflict exists.

3.     If the final decision is that the condition has returned to a level that would have existed without the injury or occupational disease, claims services staff shall:

a.     Retain the substantially aggravated pre-existing condition as an allowed condition in the claim;

b.     Provide no further compensation or benefits for that condition; and

c.      Continue providing compensation and benefits, as appropriate, for any remaining condition(s) allowed in the claim.

4.     If the final decision is that the condition has not returned to a level that would have existed without the injury or occupational disease, claims services staff shall continue providing compensation and benefits, as appropriate, for the substantially aggravated pre-existing condition and any other condition(s) allowed in the claim. 

5.     Claims services staff shall notify the MCO of the final BWC or IC decision via e-mail after all appeal periods have expired. 

 

F.     Requests After a Final Decision That the Pre-Existing Condition Has Returned to the Level That Would Have Existed Without the Injury or Occupational Disease

1.     If a written request is received to “reopen” a period of substantial aggravation for a pre-existing condition, claims services staff shall process the request consistent with the Motions policy and procedure.

2.     Claims services staff shall refer the request to the IC when:

a.     The IC issued a previous decision stating the condition has returned to a level that would have existed without the injury or occupational disease;

b.     The IC issued a previous decision stating the condition has resolved; or

c.      The request is not supported and should be disallowed. 

 

G.    Payment Status

1.     Claims services staff shall refer to Substantial Aggravation Payment Statuses and Definitions on the Aggravation and Substantial Aggravation Policy Page on COR under “Tips and Tools;” and

2.     Update the payable status of the substantially aggravated pre-existing condition accordingly in the claims management system.