UNITED STATES DEPARTMENT OF LABOR

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ADVISORY BOARD ON TOXIC SUBSTANCES AND WORKER HEALTH

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SUBCOMMITTEE ON MEDICAL ADVICE FOR CEs REGARDING WEIGHING 

MEDICAL EVIDENCE (AREA #2)

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MEETING MINUTES

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TUESDAY

SEPTEMBER 13, 2016

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The Subcommittee met telephonically at 1:00 p.m. 

Eastern Time, Victoria A. Cassano, Subcommittee Chair, 

presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

KENNETH Z. SILVER

LESLIE I. BODEN

MEDICAL COMMUNITY:

STEVEN MARKOWITZ, Board Chair

VICTORIA A. CASSANO, Subcommittee Chair
CLAIMANT COMMUNITY:

DURONDA M. POPE

FAYE VLIEGER

DEPARTMENT STAFF:

CARRIE RHOADS, Designated Federal Official

JOHN VANCE, Policy Branch Chief, DEEOIC
Introduction

Ms. Rhoads called the meeting to order at 1:00 p.m. Chair 

Cassano recapped the first meeting of the subcommittee and 

restated the specific questions asked by the DOL program to the 

Advisory Board: 1) Clarify and make recommendations regarding 

the assessment of medical opinions; 2) Develop methodologies for 

physician responsiveness; 3) Develop training resources for 

improving the quality of medical review of the medical evidence 

and guidance regarding assessing contribution or aggravation to 

a preexisting disease. 

Review questions from last subcommittee meeting and DOL’s 

responses

The first question that the subcommittee asked was, “Who has the 

responsibility for gathering information that would support a 

medical opinion?” The department responded by saying that it is 

the claimant’s responsibility. The underlying issue is housing 

the expertise that’s needed on the causation and diagnosis side. 

How does this underlying issue impact the process of claims, 

review, and determinations?

Something that the subcommittee should think about is developing 

procedures that would make the claims examiners’ job easier and 

more transparent. For specific covered illnesses there should be 

some kind of manual that describes the content contained in the

consensus documents from expert bodies. Examiners could pull 

together consensus documents on the relationships between 

occupational exposure and disease outcomes. This resource should 

be publicly releasable. 

The department said that only medical evidence goes to the CMCs. 

The department also said that there is no regulatory duty to 

assist the claimant, but they do assist anyway. It is routine 

for the claims examiners to assist claimants. The procedure 

manual has directions for the claims examiners about assisting 

claimants. But the department does help with phone calls and 

talking to treating physicians. In regards to sufficient

evidence and historical wages, it is difficult to see how a 

doctor would address those issues by himself. 
On unavailable records, the question from the subcommittee to 

the department was whether they receive a blanket of medical 

records so that the claims examiners can go and talk to whatever 

physician is on the list. Mr. Vance from DOL said that the cases 

can identify sources of information that might not necessarily 

be medical from the onset. If the department has no information 

then there are no avenues of development and the claim is not 

going to have a positive outcome. Cases are extremely disparate 

and have all kinds of assemblies of information and data that 

can lead a CE in different directions. If the claimant is 

living, he could go to a doctor and get a diagnosis. Some of the 

toughest cases are the individuals who worked at facilities in 

the forties and fifties and passed away in the seventies. 

Weighing medical evidence is the trickiest issue that the 

subcommittee will encounter. The department said that CEs are 

trained to evaluate all the evidence that is submitted in the 

case file. The subcommittee still does not have a good grasp of 

how the CEs are trained. There are some training documents 

available but the basic process is that the senior CEs train 

newer CEs. There is no standardized training manual.

Member Vlieger said that the 2015 audit found that there was 

more than a 10 percent error going around in the way claims were 

developed and processed by CEs. Member Silver said that a longterm solution requires a curriculum with advancement and 

recognition for people who have acquired real expertise within 

the Office of Workers Compensation.

The department said that the treating physician isn’t 

compensated unless the claim is accepted, as nothing can be paid 

without an acceptance. A claimant could go out and spend $2,000 

for a nexus opinion and lose that $2,000 if the claim is not 

accepted. Mr. Vance said that the department would pay based on 

a coding structure in the billing services being provided by a 

physician, if there is an ICD-10 classification for a reporting 

of that nature that can be billed to the government. Member 

Boden wanted to get more information on exactly how physicians 

can bill for their work with the DOL program. Member Silver 

asked if there are physicians working on a contingency basis 

writing fully rationalized causation reports. Member Markowitz 
said that subcommittee should look at individual claims to see 

how medical evidence is interpreted and moved.

Member Vlieger said that it’s very stultifying to not be able to 

discuss anything with people in-between meetings. Ms. Rhoads 

said that the subcommittee can use email to communicate with 

each other as long as they copy her on the email. The 

subcommittee can also break into working groups if they wish.

Discussion of how to proceed

Ms. Rhoads said that it might take the program a couple of weeks 

to gather the training materials and training letters. Ms. 

Rhoads said that she would need to speak to someone about a 

timeframe for speaking with CEs. Chair Cassano said that the 

subcommittee needs to see cases from Part E cases because there 

are so many different types of information. Member Vlieger said 

that the subcommittee needs to look at Part E patients not just 

beryllium patients. 

The subcommittee wanted to look at some actual cases prior to 

the full board meeting. Chair Cassano suggested that the 

subcommittee look at 28 cases. Before the October 16 

subcommittee meeting it would be nice to have a discussion about 

the cases. The goal is for the subcommittee to have the cases by 

October 1. After the full meeting the subcommittee can discuss 

the training materials and the development of letters. There 

isn’t time to do a deep dive before the October full board 

meeting. 

Chair Cassano said that the subcommittee is going to look at the 

preliminary cases and then set up some standardized template to 

look at the cases. PII will be scrubbed from the summaries of 

the case reviews. The subcommittee also needs to put out some 

synthesized document on what they found out about the procedure 

manual. 

In the future the subcommittee can have a discussion on whether 

the board is going to develop training materials or try to 

develop disease presumptions. 

Member Markowitz wanted to make sure that the issue of 

operationalizing the legal requirements under the statute