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Policy and Procedure Name:
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Aggravation and Substantial Aggravation of a Pre-Existing
Condition
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Policy #:
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CP-01-09
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Code/Rule Reference:
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R.C. 4123.01(C)(4);
R.C. 4123.54(G)
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Effective Date:
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09/04/20
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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Policy # CP-01-09, effective 06/30/16 and Procedure # CP-01-09.PR1,
effective 06/30/16
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History:
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Previous versions of this policy are available upon
request
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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
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.
This policy applies to claims services staff.
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.
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.
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.
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.
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.
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.
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.
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.
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.