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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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Industrial Commission (IC) Resolution/Memo
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None
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Effective Date:
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06/04/2025
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Approved:
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Shawn Crosby, Chief Operating Officer
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Origin:
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Operational Policy and Support
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Supersedes:
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Policy # CP-01-09, effective 09/04/2020
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History:
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Previous versions of this policy are available upon
request
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Table of Contents
I. POLICY PURPOSE
II. APPLICABILITY
III. DEFINITIONS
Aggravation
Substantial Aggravation
IV. POLICY
A. Consideration of Aggravation
and Substantial Aggravation of Pre-Existing Conditions
B. General Evidentiary
Requirements
C. Burden of Proof for
Aggravation of Pre-Existing Conditions (DOI/DOD before 08/25/2006)
D. Burden of Proof for
Substantial Aggravation of Pre-Existing Conditions (DOI/DOD on or after
08/25/2006)
E. Pre-existing condition
status
V. PROCEDURE
A. General Claim Note and
Documentation Requirements
B. Identifying Pre-Existing
Conditions: Gathering and Assessing Evidence
C. Medical Referral and Review
D. Decision
E. Return of a Substantially
Aggravated Pre-Existing Condition to a Level That Existed Before the Injury or
OD
F. Related Policies and
Procedures
This policy's purpose 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 (DOI) or date of disease (DOD) in occupational disease (OD)
claims.
This policy applies to Claims Services staff.
Aggravation:
A medical finding that a condition that pre-existed an injury or OD is worsened
by the injury or OD and has an adverse impact, no matter how slight. This
definition applies to claims with a DOI before Aug. 25, 2006.
Substantial Aggravation:
A medical finding that a condition that pre-existed an injury or OD is worsened
considerably in amount, value, or extent solely because of the injury or OD.
This definition applies to claims with a DOI on or after Aug. 25, 2006.
1. It
is BWC’s policy to provide compensation and benefits for an aggravation or
substantial aggravation of a pre-existing condition when the injury or OD
causing the aggravation is sustained or contracted in the course of and arises
out of employment.
2. BWC
will consider both pre-existing physical and pre-existing psychiatric or
psychological conditions for aggravation or substantial aggravation.
3. A
resolved OD in a previously allowed claim may be aggravated by a new injury,
but not by a new OD.
4. BWC
will consider a request for aggravation or substantial aggravation of a pre-existing
condition submitted on a:
a. Motion
(C-86) or equivalent;
b. Request
for Medical Service Reimbursement or Recommendation for Additional Conditions
for Industrial Injury or Occupational Disease (C-9) or equivalent; or
c.
First Report of an Injury,
Occupational Disease or Death (FROI) or
equivalent, when the substantial aggravation is part of the initial filing of a
claim.
5. BWC
will use the DOI, or DOD in OD claims when determining whether a request will
be considered and processed as an aggravation or a substantial aggravation of a
pre-existing condition.
6. BWC
will not automatically assume that a pre-existing condition has been aggravated
or substantially aggravated only because the injured worker (IW) has a previous
claim with the same or similar condition.
1. For
an aggravation or substantial aggravation of a pre-existing condition to be
allowed in the claim, BWC requires sufficient evidence to support:
a. The
existence of the pre-existing condition; and
b. Proof
that this pre-existing condition was aggravated or substantially aggravated,
depending on the DOI, or DOD in OD claims.
2. Evidence
documenting the existence of the condition before the injury or OD, or the
current status of the pre-existing condition alleged to have been aggravated or
substantially aggravated may include, but is not limited to:
a. Objective
physician findings of the condition, both before and after the injury or OD;
b. Lab
reports;
c. X-rays;
d. Magnetic
resonance imaging (MRI);
e. Computerized
tomography (CT) reports;
f.
Other diagnostic tests;
g. Documentation
of medication, including dosage and frequency, used to treat the pre-existing
condition, both before and after the injury or OD;
h. Physical
therapy (PT) or occupational therapy (OT) records, both before and after the
injury or OD;
i.
Emergency room reports; and
j.
Operative reports.
3. The
pre-existing condition does not need to have been diagnosed and/or documented before
the injury or OD, but medical evidence must support that the condition existed
before the injury or OD.
1. A
pre-existing condition is considered to have been aggravated by the injury or
OD when evidence supports that the pre-existing condition worsened after the
DOI or DOD.
2. Evidence
must show that the aggravation had an adverse effect on the pre-existing
condition, even if the effect is slight.
1.
A pre-existing condition is considered to have been substantially
aggravated by the injury or OD when objective diagnostic or clinical findings
or test results show that the IW’s condition is significantly worse than it was
prior to the injury or OD.
2. The
aggravation must be considerable in amount, value, or extent.
3. BWC
may also consider subjective complaints 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.
1. Aggravation
of Pre-Existing Conditions (DOI/DOD before Aug. 25, 2006)
a. When
a condition is allowed as an aggravation of a pre-existing condition, it will remain
an allowed condition in “Accepted” status.
b. When
supported, compensation and benefits will be payable for the pre-existing
condition.
2. Substantial
Aggravation of Pre-Existing Conditions (DOI/DOD on or after Aug. 25, 2006)
a. While
a condition allowed as a substantial aggravation of a pre-existing condition
will remain an allowed condition, compensation and benefits will no longer be
payable if BWC receives medical evidence and formally determines that the
pre-existing condition has returned to a level that existed before the injury
or OD.
b. The
substantially aggravated condition will only remain payable as long as the pre-existing
condition remains aggravated.
c. When
BWC receives medical evidence that suggests the condition has returned to the
level that existed before the injury or OD, and then formally determines this
to be the case:
i.
No further compensation or benefits will be paid for that condition.
ii. Compensation
and benefits will continue, as appropriate, for any remaining condition(s)
allowed in the claim.
1. BWC
staff will refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Must
follow any other specific instructions for claim notes and documentation
included in this procedure.
1. Investigating
Requests for Aggravation or Substantial Aggravation
a. If
the request specifically states the requested condition is an aggravation or
substantial aggravation, the claims service specialist (CSS) or medical claims specialist
(MCS) will:
i.
Confirm that the medical evidence on file demonstrates:
a) How
the requested condition was aggravated or substantially aggravated, depending
on the DOI or DOD; and
b) That the
requested condition pre-existed the injury.
ii. Contact
the managed care organization (MCO) to obtain any missing medical documentation
iii. Contact the IW
to obtain the missing information if the MCO is unsuccessful. The CSS or MCS
will:
a) Request
any medical documentation related to the pre-existing condition if it is not
already on file; and
b) If
necessary, obtain an Authorization to Release Medical Information
(C-101) from the IW to allow BWC and the MCO to receive prior medical records
related to the requested pre-existing condition.
b. If
the request does not specifically state that it is for an aggravation or
substantial aggravation of the condition, but the condition likely pre-existed
the injury (e.g., arthritis requested when the injury is only three months old),
the CSS or MCS must contact the MCO to request that they:
i.
Ask the treating physician if the requested condition pre-existed the
injury; and
ii. If
yes, obtain medical evidence that demonstrates how the condition was aggravated
or substantially aggravated, depending on the DOI or DOD.
c. If
the CSS or MCS determines that the requested condition did not pre-exist the
injury, they will process the request in the same manner as any other initial
claim determination or additional allowance (AA) request.
2. Previous
Claim with the Same or Similar Condition
a. If, while
initially investigating the claim, the CSS or MCS discovers that the IW has a
previous claim with the same or similar condition, they must not automatically
assume that the condition in the previous claim has been aggravated or
substantially aggravated by the new injury or OD.
b. The
CSS or MCS will investigate and determine whether the prior
condition:
i.
Has resolved, and the current condition is new and distinct; or
ii. Has
not resolved and is aggravated or substantially aggravated by the new injury or
OD.
3. If,
after reviewing the request and the medical evidence on file, the CSS or MCS
believes that the requested condition appears to be an aggravation or
substantial aggravation, they must:
a. Use
the DOI or DOD to determine whether the request should be processed as an aggravation
or a substantial aggravation of a pre-existing condition.
i.
Aggravation if the DOI or DOD is before Aug. 25, 2006;
ii. Substantial
Aggravation if the DOI or DOD on or after Aug. 25, 2006.
b. Enter
the requested ICD codes into the ICD Status screen with a status of “Pending;”
c. Send
a request to the ICD Modification Team asking that the narrative description of
the ICD codes be modified to reflect either “aggravation of pre-existing
(identify the condition)”, or “substantial aggravation of pre-existing
(identify the condition)” depending on the DOI or DOD; and
d. Send
the claim for a medical review following the procedures outlined below.
4. The
CSS or MCS must staff all requests for aggravation or substantial aggravation
of an OD with BWC Legal.
1. Once
the required medical evidence has been received, the CSS or MCS will refer
requests for aggravation or substantial aggravation of a pre-existing condition
to the medical service specialist (MSS).
2. The
MSS will review the medical evidence on file.
a. If
there is sufficient and clear medical evidence to conclude that the
pre-existing condition was aggravated or substantially aggravated, the MSS may recommend
allowance without an additional medical review.
b. If
the medical evidence does not clearly support the aggravation or substantial
aggravation, the MSS will:
i.
Determine whether an independent medical examination (IME) or physician
file review is more appropriate to make that decision;
ii. Send
the claim for medical review using the proper questions for either aggravation
or substantial aggravation, depending on DOI or DOD; and
iii. Summarize their
findings and actions in a claim note.
3. When
the medical review is complete:
a. If
the review supports the requested condition as an aggravation or substantial
aggravation, the MSS will:
i.
Ensure that the aggravation or substantial aggravation finding is
appropriate based on the DOI or DOD (e.g., a physician should not say that an
injury is substantially aggravated with a DOI before Aug. 25, 2006); and
ii. If
the finding does not appropriately match the DOI or DOD, seek an addendum to
correct the aggravation or substantial aggravation finding.
b. The
MSS must:
i.
Document the recommendation for allowance or denial based on the medical
review in a claim note; and
ii. Send
the claim back to the CSS or MCS for determination.
4. If
the review supports the requested condition as an aggravation or substantial
aggravation, prior to making a decision, the CSS or MCS must:
a. Confirm
that the aggravation or substantial aggravation is appropriate based on the DOI
or DOD; and
b. Send
the claim back to the MSS for an addendum if necessary.
1. If
the initial request for an AA did not specifically state that it was for an
aggravation or substantial aggravation of the condition, but the medical review
finds that to be the case, the CSS or MCS must contact the IW or their
representative to obtain their agreement to modify the condition prior to
making a decision on the claim.
a. If
the IW agrees, the CSS or MCS will allow the aggravation or substantial
aggravation, following the procedures detailed below.
b. If
the IW disagrees, the CSS or MCS will:
i.
Update the status of the ICD code(s) to “Hearing;” and
ii. Complete
a Notice of Referral (NOR) to the Ohio Industrial Commission (IC).
2. After
reviewing all available evidence, the CSS or MCS will complete the following
steps prior to making a decision:
a. Ensure
the narrative description of the ICD code(s) in question have been properly
modified; and
b. If
not, send a request to the ICD Modification Team to do so.
3. Aggravation
(DOI or DOD prior to Aug. 25, 2006)
a. If
the decision is to grant the AA request the CSS or MCS will:
i.
Update the status of the ICD code(s) to “Accept/Appeal” in the claims
management system; and
ii. Publish
a Subsequent Decision Order for AA.
b. If
no appeal is filed, the CSS or MCS will update the status of the ICD code(s) to
“Accepted” in the claims management system.
c. If
an appeal is filed to the order published, the CSS or MCS will:
i.
Update the status of the ICD code(s) to “Hearing;” and
ii. Once
the IC order is final, update the status of the ICD code(s) based on the IC’s
decision (Accepted, Denied, or Dismissed).
d. If
the decision is to deny the AA request the CSS or MCS will:
i.
Complete a NOR to the IC for AA; and
ii. Update
the status of the ICD code(s) to “Hearing;”
iii. Once the IC
order is final, update the status of the ICD code(s) based on the IC’s decision
(“Accepted,” “Denied,” or “Dismissed”).
4.
Substantial Aggravation (DOI or DOD on or after Aug. 25, 2006)
a.
If the decision is to grant the request:
i.
The CSS or MCS will:
a) Update
the status of the ICD code(s) to “SubAgg Accept/Appeal” in the claims
management system; and
b) Publish:
i) An
appropriate Initial Determination Order based on whether this is the
only condition being addressed or if there are multiple conditions requested
that will otherwise be allowed or denied; or
ii) A Subsequent
Decision Order for an AA.
ii. If
no appeal is filed, the CSS or MCS will update the status of the substantially
aggravated ICD code(s) to “SubAgg Payable” in the claims management system.
iii. If an appeal is
filed, the CSS or MCS will:
a) Update
the status of the ICD code(s) to “Hearing;” and
b) Once the
IC order is final, update the status of the substantially aggravated ICD
code(s) based on the IC’s decision (“SubAgg Payable,” “Denied,” or “Dismissed”).
b. If
the decision is to deny the request:
i.
For an initial claim determination, the CSS or MCS will:
a) Update
the status of the substantially aggravated ICD code(s) to “Deny/Appeal” in the
claims management system; and
b) Publish an
appropriate Initial Determination Order based on whether this is the
only condition being addressed or if there are multiple conditions requested
that will otherwise be allowed or denied
c) Once
the order is final, update the ICD statuses as appropriate.
ii. For
AA, the CSS or MCS will:
a) Complete
a NOR to the IC;
b) Update the
status of the ICD code(s), to “Hearing;” and
c) Once
the IC order is final, update the status of the substantially aggravated ICD
code(s) based on the IC’s decision (“SubAgg Payable,” “Denied,” or “Dismissed”).
1. If
the CSS or MCS receives medical evidence that indicates an allowed, substantially
aggravated condition has returned to the level that existed without the injury
or OD, they must:
a. Review
all medical documentation on file; and
b. If
the medical evidence came from someone other than the IW’s provider of record
(POR), request that the MCO contact the POR to seek agreement on whether the
substantially aggravated condition has returned to its pre-injury state.
2. If the
POR agrees that the substantially aggravated condition has returned to the
level that would have existed without the injury or OD, the CSS or MCS will:
a. Place
the substantially aggravated condition in “SubAgg Pending Abatement;” and
b. Publish
a Miscellaneous Order stating compensation and/or benefits are no longer
payable for the substantially aggravated pre-existing condition.
3. If
the POR does not agree that the substantially aggravated condition has returned
to the level that would have existed without the injury or OD, the CSS or MCS
will staff the claim with BWC Legal to determine if a physician file review is
appropriate.
a. If a
physician file review is not appropriate, the CSS or MCS does not need to take
any further action.
b. If a
physician file review is appropriate, the CSS or MCS will complete a MSS
referral.
i.
If the result of the medical review is that the substantially aggravated
condition has not returned to its pre-injury state, the CSS or MCS does not
need to take any further action.
ii. If
the result of the medical review is that the substantially aggravated condition
has returned to its pre-injury state, the CSS or MCS will:
a) Refer
the issue to the IC; and
b) Update the
status of the substantially aggravated condition to “Hearing”.
4. The
CSS must continue to pay compensation and benefits for the substantially
aggravated pre-existing condition until a final decision is
rendered.
a. If
the final decision is that the condition has returned to a level that would
have existed without the injury or OD, the CSS or MCS must update the ICD code
status to “SubAgg Not Payable”.
i.
No further compensation or benefits are payable for the substantially
aggravated condition once the ICD code is placed in “SubAgg Not Payable”
status.
ii. The
ICD code for the substantially aggravated pre-existing condition must not be
deleted.
b. If
the final decision is that the condition has not returned to a level that would
have existed without the injury or OD, the CSS or MCS will continue providing
compensation and benefits for the substantially aggravated pre-existing
condition.
5. The
CSS or MCS will notify the MCO of the final BWC or IC decision via email after
all appeal periods have expired.
6. If a
substantially aggravated pre-existing condition has been deemed non-payable,
the CSS or MCS must staff any request to return that condition to payable
status with BWC Legal.
1. Claims
Services staff will follow the directions detailed throughout this procedure.
2. Claims
Services staff must also follow the Initial
Claim Determination, Additional
Allowance, Independent
Medical Examinations (IMEs) and Physician File Reviews (PFRs),
and Notice
of Referral to the Industrial Commission policies and procedures, as
applicable.