Evidence for Diagnosis Determinations (MEDD)
RC 4123.53; O.A.C.
Rick Percy, Chief
of Operational Policy, Analytics & Compliance (Signature on File)
All Injury Management
policies, directives and memos regarding MEDD that predate the effective date
of this policy.
I. POLICY PURPOSE
The purpose of this
policy is to ensure that BWC considers and makes determinations based on the
sufficiency of medical evidence required to support allowances in the claim,
and that staff use the Disability Determination Guidelines (DDG) to improve the
quality of referrals to the Medical Service Specialist or the physician
This policy applies
to field staff and Managed Care Organizations (MCO).
purposes of this policy and related procedure, a reasoned medical determination
with legal implications that determines if the condition the injured worker
(IW) is requesting is compatible with or could result from the mechanism or
mode of injury, or could be the result (e.g., flow-through) of a previously
allowed condition in the claim.
medical evidence: For
purposes of this policy and related procedure, medical evidence that does not
support the allowance of a claim or condition, and may derive from the medical
opinion of a BWC physician review/exam or from medical documentation that
conflicts with the medical documentation submitted to support the allowance of
Determination Guidelines (DDG): Tool used by BWC to identify the appropriate medical
information needed to support field staff’s processing a requested condition in
the claim without needing to seek additional medical input; also used to
improve the quality of referrals to the Medical Service Specialist and the
information that may prove or disprove whether a requested condition is
medically supported in a claim; one criterion that BWC must consider when
determining compensability of a claim or allowance of a condition.
type, as specifically identified by BWC, that requires no medical evidence for
staff to allow the condition in the claim and permits staff to make a claim
allowance or condition allowance decision based on the description of the
of the evidence: A
standard of proof which is met when a party’s evidence on a fact indicates that
it is “more likely than not” that the fact is as the party alleges it to be.
A. It is the policy of BWC to:
1. Use the DDG as a tool to assess
the sufficiency of medical evidence;
2. Weigh the medical evidence as
one criterion with other required legal factors such as jurisdiction, coverage,
compensability and causality;
3. Make claim and condition determinations
based on the totality of the evidence.
B. BWC shall not use the DDG as the exclusive criteria to
either allow or deny a claim or new condition.
C. BWC staff will consider the causal relationship between
the requested condition and the mode or method of injury.
1. Causality shall be
established in one of the following ways:
a. Direct causation (i.e., proximately
b. Substantial aggravation/exacerbation
of a pre-existing condition (i.e., a worsening);
c. Acceleration (i.e., hastened progression);
d. Flow-through (i.e., new condition
that develops as a result of an allowed condition).
2. MCOs must make and document at
least two efforts to contact the provider. The MCO must try to obtain causality
information. The MCOs must submit causality indicators, as indicated below, to BWC
and identify the documentation the MCO is relying upon to support the indicator.
The MCOs must submit one of three values:
a. “Y” – indicates yes; the provider
indicates the injury is causally related to the IW’s employment;
b. “N” – indicates no; the provider
does not indicate that the injury is causally related to the IW’s employment;
c. “U” – indicates that the causality
is undetermined and that BWC must seek additional information. Examples include:
to respond to whether a causal connection existed.
worker did not seek medical treatment and the injury is not a minor injury.
D. Medical documentation, except as noted in Section IV.E,
below, is required and must establish that the condition probably occurred as a
result of the injury or as a flow-through to already allowed conditions.
E. It is the policy of BWC to permit
field staff to allow, without the submission of medical evidence, a claim or
condition classified as a minor injury.
1. Minor injuries include only the
a. First degree burns to less than
10% of the body
b. Superficial lacerations (e.g.,
cut, open wound)
c. Superficial contusions (e.g.,
d. Insect stings
e. Minor animal or human bites
foreign body in the eye
g. Corneal abrasions
h. Conjunctivitis (also known as
k. Superficial injury/abrasion
2. Staff shall not delay the investigation
and processing of a minor-injury claim because BWC has not received medical
3. Field staff shall consider whether
a causal relationship between the minor injury and the mode or mechanism of
injury is established by a preponderance of the evidence (i.e., more likely
4. Field staff will consider the
description of the accident to determine if the circumstances of the accident could
produce the injury the IW is requesting.
5. Staff may identify and code the
diagnosis consistent with the mechanism of injury for these types of injures if
there is no medical evidence on file.
F. For non-minor injuries, if field
staff obtain the appropriate medical evidence in accordance with the DDG and
determine that all other legal factors are met:
1. Field staff will either:
a. Code the condition using the ICD
code provided by the treating physician; or,
b. Code the diagnosis using the narrative
diagnosis the treating physician has provided, whether or not the treating
physician has provided an ICD code; or,
c. If the physician has provided
both an ICD code and a narrative diagnosis and the two do not match, field staff
will seek clarification from the BWC ICD Modification Unit.
2. Field staff will verify the site/location
a. If field staff cannot verify the
site or location:
i. Field staff will select a site/location.
ii. If it is discovered, even after
expiration of the appeal period, that the site/location is different, BWC will
consider such a clerical error and will issue a corrected order.
b. Field staff shall refer to the
ICD Modification policy and procedure, if needed.
G. If field staff cannot obtain appropriate or sufficient
medical evidence in accordance with the DDG for initial allowance of the
claim, staff may make a referral to the local nurse and/or request a physician
review for an opinion.
1. Field staff may allow the claim
or condition for the diagnosis(es) the physician reviewer provides.
2. If a physician reviewer recommends
allowance of a diagnosis different than what the IW requested, BWC will notify
the parties via an order that the requested condition will be considered when
the IW submits supporting medical evidence for that particular condition.
a. Treating physician diagnoses rotator
cuff syndrome but no MRI was performed.
b. Per the DDG, staff cannot allow
the condition without a physician review.
c. The physician reviewer recommends
allowance of sprain/strain of the shoulder based on the medical evidence in the
d. Staff will issue an order allowing
the sprain/strain of the shoulder and noting that the rotator cuff syndrome
will be considered when the IW submits supporting medical evidence.
H. For subsequent allowance requests, if field staff cannot
1. Any medical evidence, the subsequent
allowance request will be dismissed;
2. Appropriate or sufficient medical
evidence in accordance with the DDG, field staff shall seek a physician review
and refer the issue to the IC.
1. It is the policy of BWC to accept
original or stamped signatures on physician reports.
2. It is the policy of BWC to accept
electronic data interface (EDI) transmissions of medical evidence to make
medical determinations. However, if a
claim is contested, BWC must obtain the hard copy medical report with a provider’s
signature from the MCO.
3. It is the policy of BWC to accept
a healthcare provider’s authorized representative’s signature on medical reports.
The physician of record (POR) or treating
physician’s authorized representative/designee will sign for the POR or treating physician and initial.
4. It is the policy of BWC to accept
the signature of a nurse practitioner or a physician assistant to diagnose
conditions for claim allowance decisions, additional conditions, and medical
treatment decisions within the scope of their practice.
5. Please refer to the
“Physician Signature on Medical Evidence” Chart, located on COR for BWC staff.
BWC staff may refer to the corresponding
procedure for this policy entitled “Medical Evidence for Diagnosis
Determinations (MEDD)” for further guidance.
EVIDENCE FOR DIAGNOSIS DETERMINATIONS (MEDD)
Policy # Reference:
Rick Percy, Chief
of Operational Policy, Analytics & Compliance (Signature on File)
All Injury Management
procedures, directives and memos regarding MEDD that predate the effective
date of this procedure.
II. BWC staff shall refer to the Standard
Claim File Documentation policy and procedure for claim-note requirements, and
BWC staff and Managed Care Organization (MCO) staff shall follow any other specific
instructions included in this procedure.
III. Staff shall ensure a claim is
compensable for initial determination
A. Staff shall refer to the following
policies and procedures to evaluate a claim, in addition to using the Disability
Determination Guidelines (DDG) detailed in this procedure and corresponding
1. Interstate Jurisdiction
3. Compensability and Coverage.
1. BWC shall consider the relationship
between the requested condition and the mode or method of injury to determine
the specific theory of causation, which is one of the following:
a. Direct causation (i.e., the injury
or employment proximately caused the condition);
aggravation/exacerbation of a pre-existing condition (i.e., the injury or
employment worsened a condition the injured worker [IW] already had);
c. Acceleration (i.e., the injury
or employment hastened the progression of a condition);
d. Flow-through (i.e., a new condition
that develops as a result of an allowed condition);
e. A non-work related injury or illness.
2. Staff shall rely on medical documentation,
except as noted in Section IV, below, to establish the condition probably
resulted from the injury or employment.
C. The MCO is primarily responsible for gathering the documentation
that establishes causality and shall submit the causality indicators to BWC via
the Electronic Data Interchange (EDI) 148 for initial determinations (for
subsequent decision requests, the MCO shall include this information in a
1. The MCOs shall choose one of the
following indicator values:
a. “Y” – Yes, the provider has indicated
that the injury is causally related to the IW’s injury or employment;
b. “N” – No, the provider has indicated
that the injury is not causally related to the IW’s injury or employment;
c. “U” – Undetermined. Reasons the
MCO submits a “U” causality factor include, but are not limited to, the following
would not provide an opinion as to whether or not the injury was causally
related to the IW’s employment. The MCO shall enter a note indicating the
provider declined to establish a causal connection.
The provider did
not provide an opinion as to whether or not the injury was causally related to
the IW’s employment and the MCO has documented at least two attempts to obtain
iii) The injured worker did not seek
2. The MCO shall identify the documentation
that supports the causality indicator.
3. The MCOs shall not submit the
initial EDI 148 until the MCO has:
a. Obtained and provided the causality
b. Documented a failure to obtain
the information after at least two attempts to contact the provider and secure
the causality information.
D. Field staff shall determine if the medical evidence the
MCO gathered, including consideration of the causality factor, supports the subjective/objective
exam findings for the diagnosis(es) being requested.
IV. Staff Shall Use the DDG
A. Field staff shall refer to the
DDG to ensure that the appropriate medical evidence required for the requested
diagnosis(es) is submitted, and if all required evidence is in the claim, field
staff may issue a decision without sending the claim for Medical Service
Specialist (MSS) or physician review.
B. If supporting evidence is submitted and field staff determines
the requested condition(s) is related to the employment/injury, field staff
shall follow the process in the ICD Modification policy and procedure.
C. If the supporting evidence is submitted but field staff
is not sure the diagnosis is related to the employment/injury, field staff
1. Refer the claim to the MSS to
clarify and verify the medical documentation and assist in determining if the information
in the submitted medical evidence meets the requirements of the DDG.
2. Then, the MSS may request a physician
review to opine on a diagnosis.
D. If the IW’s request for a condition is not supported by
the medical evidence, field staff shall send for a physician review, and:
1. If the decision is an initial
determination and the physician reviewer recommends allowance of a diagnosis different
from the requested condition(s), field staff shall allow the claim for the
physician reviewer’s recommended allowed conditions and include in the order
the following statement: “The specific condition requested will be considered
upon submission of appropriate medical evidence.”
2. If the decision is subsequent
to the initial determination period, field staff shall:
a. Seek clarification of the request;
b. Ask the IW to modify the request;
If the IW agrees
to modify, process the request; or
If the IW will
not agree to modify, refer the claim to the Industrial Commission (IC).
E. If the supporting evidence is not submitted after attempts
to secure it have been made (except for a minor injury, covered in Section IV
below), field staff shall:
1. Check to verify if a diagnostic
test is planned, and if field staff does not yet have results, field staff may
set a task in the claim to follow-up with the MCO to obtain the test results
prior to sending the claim for physician review.
a. For an initial determination:
If the evidence
is not obtained before the determination date arrives and the IW is requesting
only one condition, field staff shall deny the claim;
If the IW is
requesting more than one condition and evidence is obtained on some but not all
of the conditions, field staff shall indicate that the condition for which no
evidence was obtained is neither allowed nor disallowed.
b. For a subsequent
determination, if the evidence is not obtained before the determination date
arrives, field staff shall process the claim with the evidence on file.
diagnostics are received or planned, send the issue to the Virtual Medical
group so that an MSS may request a physician review to opine on the appropriate
diagnosis, if any, for the claim allowance; and,
Code and process
the claim based on the physician reviewer’s diagnosis, if one is supplied.
V. Minor Injuries
A. Field staff shall rely on the description of the accident
to determine if the mode or mechanism of injury could produce the requested
B. Staff shall not require medical
evidence to determine the compensability of minor injuries. Minor injuries only
1. First degree burns to less than
10% of the body
2. Superficial lacerations (e.g.,
cut, open wound)
3. Superficial contusions (e.g.,
4. Insect stings
5. Minor animal or human bites
6. Superficial foreign body in the
7. Corneal abrasions
8. Conjunctivitis (also known as
11. Superficial injury/abrasion.
C. Field staff shall, if determining the claim is compensable,
identify a diagnosis code consistent with the mode/mechanism of injury.
D. Field staff shall not allow a minor injury if there is
contrary evidence on file, but shall:
1. If it is an initial determination,
issue an order based on the evidence; or,
2. If it is a subsequent decision,
refer the claim to the IC for hearing. Field staff may refer to the Notice of
Referral policy and procedure.
VI. How to Gather Medical Evidence
or Additional Medical Evidence
A. Field Staff shall work and coordinate
with the MCO, who is primarily responsible, to gather medical evidence, as
B. Field staff shall follow up with the MCO if the MCO does
not send medical evidence within three (3) days of BWC’s receipt of the initial
EDI 148. If the MCO does not submit the medical evidence within four (4) days
of the BWC’s receipt of the initial EDI 148, field staff shall coordinate
efforts with the MCO and may contact the treating physician directly for
C. Lost-time field staff shall call the MCO or provider to
obtain information, and if that is unsuccessful, may send the “Request for Additional
Information” letter to the treating provider, as needed, to obtain additional
or sufficient medical evidence.
D. Medical Claims staff may call the MCO or provider to obtain
information, and shall send the “Request for Additional Information”
letter to the treating provider, as needed, to obtain additional or sufficient
VII. Physician Signature
A. Field staff shall ensure that
physician reports are signed.
B. Staff may accept electronic data interface (EDI) transmissions
as medical evidence in making claim determinations.
However, if a claim is contested, BWC must obtain the hard copy medical report
with a provider’s signature from the MCO.
C. Staff shall ensure that the person signing the report
has authority to do so. Staff shall refer to chart entitled “Physician Signature
on Medical Evidence” for details on signatory authorization.
D. Staff shall accept a healthcare provider’s authorized
representative’s signature, pursuant to IC Resolution R97-1-06. The POR or treating physician’s authorized
representative (designee) will sign for the
POR or treating physician and initial.
E. Staff shall accept the signature of a nurse practitioner
and/or physician assistant as valid medical evidence for claim allowance
decisions and medical treatment decisions with the scope of practice, but not
for disability certification.