FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0100 

Part 2 - Claims Introduction 

________________________________________________________________ 

EEOICPA Tr. No. 16-05 

March 2016 

i

TABLE OF CONTENTS 

Paragraph and Subject Date Trans. No. 

Chapter 2-0100 Introduction 

 Table of Contents . . . . . . . 03/16 16-05 

 1 Purpose and Scope . . . . . . . 03/16 16-05 

 2 Staff Responsibilities . . . . 03/16 16-05 

 3 Reference Materials for 

 Claims Examiners . . . . . . . 03/16 16-05 

 

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FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0100 

Part 2 - Claims Introduction 

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1. Purpose and Scope. Part 2 of the Federal (EEOICPA) 

Procedure Manual (PM) outlines the policies, guidelines and 

procedures for developing, adjudicating and managing claims 

under the Energy Employees Occupational Illness Compensation 

Program Act (EEOICPA). Topics included in Part 2 relate to 

claim intake, eligibility criteria, developing evidence, 

application of program policy, and issuing decisions. 

2. Staff Responsibilities. District Office and Final 

Adjudication Branch (FAB) staff within the Division of Energy 

Employees Occupational Illness Compensation (DEEOIC) develop and 

adjudicate claims, provide courteous and timely responses to 

requests for information, comply with program policy to reach 

fair and consistent claim outcomes, initiate compensation 

payments, and monitor assigned caseloads. 

a. Processing Claims. The mission of a DEEOIC Claims 

Examiner (CE), FAB Hearing representative (HR), and FAB CE 

is to exercise keen judgment, derived from experience, 

background, and acquired knowledge, tempered with 

compassion and common sense. This involves the ability to 

assess evidence, consider pertinent issues, and make wellrationalized judgments. DEEOIC claims staff are to 

evaluate each case comprehensively based on the unique 

characteristics of the information present. Moreover, 

staff are to apply an objective analysis of the evidence 

that comports with the legal, regulatory and procedural 

guidance in guiding claim adjudication. Decisions issued 

by DEEOIC staff are to include a description of evidence 

considered; analysis and interpretation of information 

supporting factual findings; and provide a clear, 

understandable decision. 

3. Reference Materials for Claims Examiners. DEEOIC district 

and FAB offices have full access to a range of reference 

materials and programmatic resources that are available through 

a publically accessible website. In addition, DEEOIC makes 

locally available other material that assists its staff in 

adjudicating claims. Reference materials available to staff 

include: 

a. Energy Employees Occupational Illness Compensation 

Program Act (EEOICPA) of 2000, as amended, 42 U.S.C. § 

7384 et seq. 

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Part 2 - Claims Introduction 

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b. 20 CFR Parts 1 and 30 (Regulations) – Claims for 

Compensation Under the Energy Employees Occupational 

Illness Compensation Program Act, issued December 29, 

2006. 

c. Executive Order 13179, signed December 7, 2000. 

d. Federal EEOICPA PM. 

e. Bulletins, Circulars and Program Memoranda. 

f. Guides to the Evaluation of Permanent Impairment, 5th

Edition, American Medical Association. 

g. ICD9/10 coding manuals or online resources. 

h. NIOSH Regulations on dose reconstruction and 

probability of causation (42 CFR Parts 81 and 82, 

Guidelines for Determining the Probability of 

Causation and Methods for Radiation Dose 

Reconstruction Under the Employees Occupational 

Illness Compensation Program Act of 2000; Final 

Rules). 

i. The Federal Register publications listing covered 

facilities. 

j. User’s Guide for the Interactive RadioEpidemiological 

Program (NIOSH-IREP). 

k. Interagency contacts or website links 

 l. Shared Drive maintained by the NO. 

 m. Site Exposure Matrix (SEM). 

n. Energy Compensation System (ECS) user guidance and 

procedures 

o. OWCP Imaging System (OIS) User Guide and indexing 

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guidance 
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0800 

 Developing And Weighing 

Part 2 – Claims Medical Evidence 

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EEOICPA Tr. No. 16-05 i 

 March 2016 

TABLE OF CONTENTS 

Paragraph and Subject Date Trans. No. 

Chapter 2-0800 Developing and Weighing Medical Evidence 

 Table of Contents. . . . . . . 03/16 16-05 

1 Purpose and Scope. . . . . . . 03/16 16-05 

2 Sources of Medical Evidence. . 03/16 16-05 

3 Types of Medical Evidence. . . 03/16 16-05 

4 Contents of a Medical Report . 03/16 16-05 

5 Developing Medical Evidence. . 03/16 16-05 

6 Weighing Medical Evidence. . . 03/16 16-05 

7 Using Death Certificate to 

 Establish Diagnosis. . . . . 03/16 16-05 

8 Using Affidavits to 

 Establish Date of Diagnosis. 03/16 16-05 

9 Reviews by a CMC . . . . . . . 03/16 16-05 

10 Deciding on Need for a CMC 

 Referral . . . . . . . . . . 03/16 16-05 

11 Referral to CMC . . . . . . . 03/16 16-05 

12 Role of Medical Scheduler in 

 CMC Referrals. . . . . . . . 03/16 16-05 

13 Post Referral to CMC . . . . . 03/16 16-05 

14 Second Opinion Examinations. . 03/16 16-05 

15 Referee Specialist 

 Examinations . . . . . . . . 03/16 16-05 

16 Failure to Undergo Second 

 Opinion or Referee Specialist 

 Examination. . . . . . . . . 03/16 16-05 

Exhibits 

1 Statement of Accepted Facts 

 (SOAF). . . . . . . . . . . . 03/16 16-05 

2 Sample Questions for Physician. . 03/16 16-05 

3 ICD Codes and Corresponding 

 Procedure Codes . . . . . . . . 03/16 16-05 

4 Sample Letter to Claimant 

 Regarding Second Opinion/ 

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 Referee Physician. . . . . . . 03/16 16-05
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0800 

 Developing And Weighing 

Part 2 – Claims Medical Evidence 

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1. Purpose and Scope. Proper development and weighing of 

medical evidence is essential to the sound adjudication of 

claims for benefits and to the comprehensive management of 

Energy Employees Occupational Illness Compensation Program Act 

(EEOICPA) claims. This chapter discusses the function of a 

Claims Examiner in developing and evaluating medical evidence 

and weighing conflicting medical opinions. 

2. Sources of Medical Evidence. Most medical reports come 

from one of these sources: 

a. Claimant's health care provider, which includes the 

attending physician, consulting experts, and medical 

facilities. The CE may consider treatment records from a 

clinic operated at an employing facility as medical 

evidence. 

b. Department of Energy (DOE). Medical Monitoring 

Programs, administered by certain DOE facilities, maintain 

medical examination records and exposure data on their 

employees. For example, the DOE Former Worker Medical 

Screening Program (FWP) began in 1996 and functions to 

evaluate the effect of the DOE's past operations on the 

health of former workers at DOE facilities, and to offer 

medical screening to former workers. 

c. Oak Ridge Institute for Science and Education (ORISE) 

administers the beryllium screening program by providing 

beryllium-related testing at locations across the country. 

ORISE offers extensive testing for chronic beryllium 

disease (CBD) and medical monitoring to individuals testing 

positive for beryllium sensitivity. 

d. Contract Medical Consultant (CMC). Furnishes medical 

opinions, guidance, and advice based upon review of the 

case file. Moreover, the physician provides independent 

and rationalized responses to CE questions regarding 

various medical issues that may arise during case 

adjudication, such as causation, impairment, wage-loss, or 

medical necessity of care. 

e. Second Opinion Physicians are physicians contracted by 

the Division of Energy Employees Occupational Illness 

Compensation (DEEOIC) to provide a narrative report 

describing the findings from physical examination of a 

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patient and review of diagnostic testing or other medical 

records. 

f. Referee Specialists are physicians of an appropriate 

specialty, chosen randomly, to examine the employee or a 

case file and furnish a rationalized medical opinion, to 

resolve a conflict of medical opinion in a case between the 

employee’s physician and a CMC, Second Opinion Physician, 

or other medical specialist. 

3. Types of Medical Evidence. Medical evidence in EEOICPA 

cases consists of the following major categories: 

a. Treatment records are the most prevalent form of 

medical evidence. They consist of any record made during 

the evaluation, diagnosis and treatment of a patient by his 

or her health care providers. They include: 

(1) Attending physician records (e.g., chart notes, 

reports, etc.) which include records from medical 

consultants assisting the attending physician. 

(2) Records of physicians consulted by the patient 

for an independent medical opinion. 

(3) Evidence of diagnostic testing (e.g., X-ray 

films, electrocardiogram (EKG) tracing, etc.) and the 

reports of medical providers interpreting the tests. 

For the purposes of interpreting tests, medical 

providers include physicians as defined in Section 

30.5(dd) of the regulations. 

(4) Treatment records from hospitals, hospices, inhome health or residential health care facilities. 

b. Medical evaluations may occur for a variety of reasons 

other than to further the diagnosis and treatment of the 

patient. The purpose of the examination distinguishes 

medical evaluations from treatment records. Medical 

evaluations include: 

(1) Evidence from the DOE’s FWP (e.g., former worker 

screening records, pre-employment physicals, 

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(2) Examinations required under state or federal 

compensation programs (e.g., evaluations for state 

workers’ compensation (SWC) claims, Social Security 

disability examination, Veterans’ Administration (VA) 

programs, etc.) 

(3) Medical reports or opinions obtained for 

litigation under state or federal rules of evidence. 

c. Reports produced in response to a DEEOIC referral to a 

CMC, Second Opinion physician, or Referee Specialist. 

d. Other types of evidence include: 

(1) Cancer Registry records may be used in some cases 

to establish a diagnosis of cancer and date of 

diagnosis. 

(2) Death certificates which contain information 

about the cause of death or date of diagnosis. (See 

Section 7 of this chapter for additional information 

regarding death certificates.) 

(3) Secondary evidence relied upon by a physician in 

forming an opinion. For example, a doctor may rely 

upon the information provided by a medical specialist 

in determining the cause of an illness. 

(4) Affidavits containing facts based on the 

knowledge of the affiant regarding the date of 

diagnosis. 

4. Contents of a Medical Report. The value of findings and 

conclusions contained in medical records varies. 

a. Treatment Records. 

(1) A doctor’s report of examination usually contains 

a description of subjective complaints, objective 

findings, assessment, and a plan for follow up or 

treatment. The Subjective, Objective, Assessment and 

Plan format is often shown in the medical records by 

the letters S, O, A and P. Even where the “SOAP” 

abbreviation is not used, the records tend to follow 

this pattern. 

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(a) The subjective section records information 

obtained from the patient. It generally contains 

information about why he or she is seeking 

treatment, complaints, medical history and 

current treatment. A subjective section might 

state, for example, “Patient comes in today to 

have us look at a lump on his neck that has 

gotten larger over the last month.” 

(b) The objective section records the 

physician’s findings based on his or her 

observation, examination and testing. An 

objective section might state, for example, “The 

patient’s breathing is labored and his X-ray 

shows a spot on his left lung.” The three 

general classes of objective findings are: 

 

 (i) Laboratory findings such as complete 

blood count (CBC), tissue biopsy, bone 

marrow smear or biopsy, beryllium lymphocyte 

proliferation test (BeLPT), etc. 

(ii) Diagnostic procedures such as X-rays, 

ultrasound, computerized axial tomography 

(CAT)scans, magnetic resonance imaging 

(MRI), electromyelogram (EMG) and similar 

techniques of visualizing or recording 

physiological conditions. Some objective 

tests are subject to greater interpretation 

by the physician. 

(iii) Physical findings that are noted by 

the physician’s visual inspection, palpation 

and manipulation of the body. They include 

description of demeanor, readings of 

temperature or pulse, description of 

respiration, observation of affect, etc. 

(c) The assessment section contains the 

physician’s opinions, suspicions and diagnoses. 

In most cases, the value of a medical report is 

determined by the quality and detail of the 

narrative describing the physician’s assessment. 

The scope of the assessment will vary with the 

type of medical condition and its complexity. 

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The assessment section may contain statements 

such as, “The pathology report was reviewed and 

showed the presence of small cell carcinoma of 

the lung.” or “Based on the patient’s rest 

tremor, balance problems and rigidity of muscles, 

he has Parkinson’s disease.” 

(d) The plan section describes the treatment 

plan and prognosis. The physician may, for 

example, prescribe medication, refer the patient 

to a specialist, or suggest additional testing. 

(2) Reports of tests and procedures should contain 

the employee’s name, date of the test, the objective 

data obtained, and the signature of the person 

responsible for conducting the test or procedure. 

Where appropriate, reports should include a 

physician’s interpretation of laboratory tests or 

diagnostic procedures. 

Tests for which interpretation is necessary include, 

but are not limited to, pathology reports, BeLPT, Xrays, MRI, CAT scans, Pulmonary Function Tests (PFT), 

Minnesota Multiphasic Personality Inventories (MMPIs), 

and the Beck Depression Inventory. In cases where the 

physician offers insufficient interpretation of 

medical evidence, the CE must seek clarification 

either from the source of the report, or a CMC 

referral, as appropriate. The CE is not to interpret 

test results, as that is a medical judgment to be made 

by a medical professional. 

(3) Hospital, hospice and clinic records will contain 

the same type of physicians’ records and diagnostic 

testing as outlined above. Also, the CE should review 

the admission summary, surgery reports, nursing notes, 

the discharge summary, autopsy reports, etc. 

b. Medical Evaluations. Generally, medical evaluation 

reports contain the following types of information: 

 

(1) An explanation as to why the physician is 

conducting an examination of the patient. The report 

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may state, for example, “Mr. Smith is referred by the 
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0800 

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Department of Labor (DOL) for an independent medical 

evaluation regarding his claim for asbestosis.” 

(2) A description of the information the physician 

has reviewed and relied upon in reaching his or her 

conclusions. This often includes a discussion of the 

course of treatment, which describes past treatment 

undergone by the patient, and the physician’s 

recommendation for present and future care. 

References to studies and other medical or scientific 

data that supports the analysis may also be included. 

(3) A description of any examination and tests 

performed during the evaluation. 

(4) The opinion(s) of the evaluating physician with 

an explanation of the rationale supporting his or her 

conclusion. 

 c. DEEOIC Referrals. The CMC, Second Opinion physician, 

or Referee Specialist reports should contain the same 

general information as any other medical assessment. In 

addition, the report should contain a well-reasoned 

response to questions presented by the CE, including a 

summary of the evidence and medical references used. 

5. Developing Medical Evidence. Although it is ultimately 

the responsibility of the claimant to submit medical evidence in 

support of his or her claim, the CE is to assist the claimant in 

collecting evidence necessary to establish a compensable medical 

illness. This includes communicating with the claimant to 

explain deficiencies in case evidence, requesting supportive 

documentation, and allowing reasonable time for the claimant to 

provide a response. The CE also assists by taking affirmative 

action to obtain medical evidence through communications with 

treating physicians and/or other medical providers. Assistance 

can also be achieved with the use of Program resources to obtain 

clarifying medical evidence including the use of a CMC, Second 

Opinion physician, or Referee Specialist. The development of 

medical evidence is performed in various aspects of case 

adjudication: to establish diagnosis, to establish causation, 

to determine a percentage of impairment in impairment claims, to 

establish a causal relationship between a covered illness and 

wage-loss, and to resolve inconsistencies and conflicts in 

medical opinions. 

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a. Physicians and chiropractors. Medical evidence must 

be from a physician. The definition of a physician 

includes surgeons, podiatrists, dentists, clinical 

psychologists, psychiatrists, occupational medicine 

practitioners, optometrists, and osteopathic practitioners 

within the scope of their practice as defined by state law. 

Chiropractors may only be considered physicians in EEOICPA 

cases for treatment of manual manipulation of the spine to 

correct a subluxation that is demonstrated to exist by 

X-ray (usually relevant only in consequential injuries.) 

However, chiropractic care may be authorized as treatment 

for an accepted condition. Any such treatment must be 

prescribed by the authorized treating physician, and the 

physician must provide rationale as to how the treatment in 

question relates to the covered condition. 

b. Deficient Evidence. During adjudication of a claim, 

there are many topics that require evaluation of medical 

evidence including: medical diagnosis, interpretation of 

diagnostic evidence, causal relationship between illness 

and occupational toxic substance exposure, permanent 

partial impairment, effect of illness on historical wages, 

and medical necessity of care or other service needs. In 

each of these matters, legal, regulatory, or procedural 

guidance exists through on-line Programmatic resources 

(Bulletins, Circulars, EEOICPA Regulations, etc.) to 

instruct the CE on evaluating the sufficiency of evidence 

submitted in support of a claim. The CE is to adhere to 

these guidelines and to direct development in a manner that 

will best overcome evidence omissions or deficiencies. 

c. Telephone Requests. In many situations, a minor 

deficiency in the medical evidence can be easily overcome 

with a telephone call to the physician’s office to request 

specific documents. If, however, a phone call does not 

produce an immediate result (i.e., a fax of the required 

documentation) the CE should send a written request. If 

the physician’s office indicates that the medical evidence 

will be mailed, the CE will follow-up with written 

correspondence memorializing the telephone call and noting 

the specific documents that are being requested. 

(1) The CE must document the call in the Energy 

Compensation System (ECS). 

 

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(2) Statements made by the physician over the 

telephone do not constitute valid medical evidence. 

d. Written Requests. The CE may decide that the best 

method of collecting the evidence is to submit a written 

inquiry directly to the physician (with a copy to the 

claimant). However, the CE has the authority to submit 

written requests for information to any possible source 

that may reasonably be able to provide a substantive 

response to a need for medical documentation. A written 

request for information is to communicate the identified 

defect, in a clear and concise fashion, and the various 

options available for presenting information or 

documentation that will best overcome the defect. 

(1) If records are requested from a treating 

physician or other sources, the Form EE-1/EE-2 

submitted by the claimant serves as a medical release 

to obtain the requested medical information. 

(2) If a reply is not received within 30 days or 

the response does not resolve the deficiency, the CE 

considers other options for obtaining the required 

medical evidence (e.g., a CMC referral, cancer 

registry or death certificate). Reasonable time 

extensions may be granted by the CE. It may be 

helpful to initiate telephone contact with the 

recipient to gauge the likelihood for response, or to 

respond to questions or other concerns. 

e. Unavailable Medical Records. If the CE obtains 

information that pertinent medical records have been 

 destroyed or are otherwise unavailable, the CE should 

attempt to obtain from the physician written confirmation 

which contains the following information: 

(1) An affirmation that the physician treated the 

employee for the claimed condition(s). 

(2) A statement that the requested medical records 

 are no longer available. 

(3) A discussion that includes the diagnosis and date 

of diagnosis. 

 

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(4) The physician’s signature and the date signed. 

6. Weighing Medical Evidence. When the CE receives medical 

evidence from more than one source, he or she must evaluate the 

relative value, or merit, of each piece of medical evidence. 

This is particularly important in cases where there is a 

conflict between the medical evidence received from a CMC and a 

treating physician. A thorough understanding of how to weigh 

medical evidence will assist the CE in determining when and how 

further medical development should be undertaken. The CE should 

also understand how to assign weight to the medical evidence 

received. 

a. How to Evaluate Evidence. In evaluating the merits of 

medical reports, the CE evaluates the probative value of 

the report and assigns greater value to: 

 

(1) An opinion based on complete factual and medical 

information over an opinion based on incomplete, 

subjective or inaccurate information. Generally, a 

physician who has physically examined a patient, is 

knowledgeable of his or her medical history, and has 

based the opinion on an accurate factual basis, has 

weight over a physician conducting a file review. 

For example, a physician who opines that his patient’s 

lung cancer is related to exposure to diesel engine 

exhaust has less probative value if the opinion 

demonstrates no knowledge of the frequency or levels 

of exposure to diesel engine exhaust. 

 (2) An opinion based on a definitive test(s) and 

includes the physician’s findings. Some medical 

conditions can be established by objective testing. A 

positive pathology report from a physician is 

sufficient evidence of the diagnosis of cancer. 

However, a physician’s opinion that a patient has 

cancer is of little probative value if the pathology 

report shows no malignancy. A physician’s report of a 

positive beryllium lymphocyte proliferation test or 

lung lavage cells showing abnormal findings is 

sufficient evidence of the diagnosis of beryllium 

sensitivity. 

It is important for the CE to undertake appropriate 

steps to work with a treating physician in the 

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collection of evidence, before referring the case to a 

CMC. 

(3) A well-rationalized opinion over one that is 

unsupported by affirmative evidence. The term 

“rationalized” means that the statements of the 

physician are supported by an explanation of how his 

or her conclusions are reached, including appropriate 

citations or studies. An opinion that is wellrationalized provides a convincing argument for a 

stated conclusion that is supported by the physician’s 

reasonably justified analysis of relevant evidence. 

For example, an opinion which is supported by the 

interpretation of diagnostic evidence and relevant 

medical or scientific literature is well-rationalized. 

Conversely, an opinion which states a conclusion 

without explaining the interpretation of evidence and 

reasoning that led to the conclusion is not wellrationalized. 

(4) The opinion of an expert over the opinion of a 

general practitioner or an expert in an unrelated 

field. For example, if a general practitioner has a 

patient with rest tremors, balance problems, and 

muscle rigidity, a diagnosis of alcohol abuse with 

dehydration may seem reasonable. However, if a 

conflicting report is received from a Board-Certified 

neurologist diagnosing Parkinson’s disease based on 

the same symptoms, it would carry greater weight 

because a neurologist is an expert on neurological 

disorders. This is particularly true for an illness 

like Parkinson’s disease that cannot be confirmed by 

an objective laboratory test. Conclusive statements 

of an expert without any underlying justification, 

other than affirmation of the physician’s expertise, 

are not to be viewed as carrying significant probative 

value. 

(5) An unequivocal opinion over one that is vague 

or speculative. A physician offering a clear, 

 unequivocal opinion on a medical matter is to be 

 viewed as more probative compared to an opinion that 

waivers or hesitates in its presentation or, contains 

vague and speculative language. An opinion which 

contains verbiage such as “possibly could have” or 

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“may have been” or provides a guess or estimation 

indicates speculation on the part of the physician. 

7. Using Death Certificate to Establish Diagnosis. Prior to 

considering the use of a death certificate to establish a 

diagnosis, the following actions must be undertaken: 

a. Claimant Advised. The CE must advise the claimant, in 

writing, of the medical evidence necessary to establish a 

diagnosis and grant him or her the opportunity to submit 

available medical records (See PM Ch. 2-0300.6 Advising the 

Claimant of Deficient Evidence). The letter sent to the 

claimant is to include a statement describing the need to 

obtain medical evidence of a diagnosed condition. Medical 

evidence with the potential to identify a diagnosed illness 

include any hospital admission/discharge reports or reports 

describing an illness; inconclusive diagnostic testing 

results, or other medical records alluding to the existence 

of a potential illness. The function of this development 

is to ensure that the CE receives all available medical 

records for consideration. 

b. Diagnosis listed on death certificate. Once 

development is completed and it is unlikely any other 

affirmative medical evidence is available for review, a CE 

may use a death certificate acknowledged by a physician or 

recognized by a state medical authority to establish a 

diagnosed illness. 

 

Nothing in this section should be interpreted as limiting the 

use of a death certificate for other purposes, such as evidence 

of the cause of death under Part E. 

8. Using Affidavits to Establish Date of Diagnosis. While an 

affidavit cannot be used to establish a medical diagnosis, it 

can be used to establish a date of diagnosis after the CE has 

made a reasonable effort to establish the date of diagnosis from 

the medical records. CE actions should include the following: 

a. Advice to Claimant. The claimant must be advised, in 

writing, that medical evidence (i.e., pathology report, 

autopsy report, physician’s reports) should be submitted to 

establish a date of diagnosis. 

c. Additional Medical Development. If the claimant and 

the CE cannot obtain medical evidence to establish the date 

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of diagnosis, the CE must notify the claimant of the need 

to submit copies of affidavits from those in a position to 

know the former worker’s condition during the illness. For 

example, a home health nurse or relative who provided care 

to the employee may provide an affidavit. 

d. Death Certificate. If reliable affidavits are not 

received, then the CE may use the date of diagnosis (if 

shown) or date of death from the death certificate. The CE 

should not guess at a diagnosis date based on a death 

certificate’s “approximate interval between onset and 

death” as the date of onset is not necessarily the date of 

diagnosis. 

e. Medical Review. If an affidavit reveals evidence of a 

medical condition, but no physician’s diagnosis is 

contained in the file, the case may be forwarded to a CMC 

for review and confirmation of a diagnosis. 

 

9. Reviews by a CMC. DEEOIC uses the services of a 

contractor to coordinate referrals of cases to qualified medical 

specialists. A CMC is a contracted physician who conducts a 

review of case records to render opinions on medical questions. 

Medical opinions from a CMC are essential to the resolution of 

claims due to ambiguous causation, lack of medical evidence, 

unique exposures or other medical questions. The function of a 

CMC is to provide clarity to claims situations in the absence of 

pertinent or relevant medical evidence from other sources that 

support the claim. The function of a CMC is not to validate 

probative input by the claimant’s chosen treating physician. 

The description of appropriate reasons for CMC referral includes 

the following: 

a. Diagnosis. Clarification and confirmation of 

diagnosis. 

b. Causation. Assessment of exposure and medical 

documentation for the purpose of rendering an opinion on 

causation. 

c. Impairment. Percentage of permanent impairment to the 

whole person as a result of an accepted illness or 

illnesses. 

d. Onset Date. Onset and period of illness relating to 

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reported wage-loss. 

e. Consequential Injuries. Determination of 

consequential illness/injury due to accepted illness or 

treatment of that illness. 

f. Treatment. Medical necessity of medical care, durable 

medical equipment or home/auto modification. 

 

g. Clarification. Interpretation of medical reports, 

test results or other medical evidence. 

h. Conflict. Resolve conflict of medical opinions. 

10. Deciding on Need for a CMC Referral. The decision to refer 

a case to a CMC for review is at the discretion of the assigned 

CE. An obvious defect in case evidence must exist, including 

the absence of affirmative medical evidence or other diagnostic 

evidence, for which a medical opinion is necessary. A CMC 

referral may also be necessary for review of impairment or wageloss issues. The CE should not view a medical referral as an 

automatic requirement for each claim, but an option available in 

situations where no other reasonable option exists to obtain a 

resolution to an outstanding medical question. 

a. Review Not Necessary. The following are examples of 

when a CMC referral may not be necessary: 

 (1) The CE determines that other action, such as 

 requesting additional records from the claimant or 

 treating physician, may be more appropriate. In most 

cases, the CE does not need to refer a claim to a CMC 

when a treating physician has provided a substantive, 

well-rationalized opinion in response to a claim 

question. Moreover, the CE should view the existence 

of a treating physician as the primary source of 

medical evidence before consideration of a CMC 

referral. Accordingly, the CE should typically give 

the treating physician the first opportunity to review 

medical evidence from the file, such as a SOAF and 

other documents, for the purpose of responding to 

claim questions. If the treating physician does not 

provide substantive responses to claim questions, the 

CE may consider the claim in posture for a CMC review. 

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(2) The claim evidence renders a CMC opinion 

unnecessary, such as instances where a presumption of 

causation exists, or the circumstances of case 

development does not necessitate a medical opinion, 

such as when there is no evidence of exposure to a 

toxic substance or no plausible scientific association 

between a toxin and a diagnosed illness. 

b. Appropriateness of Review. The following are some 

examples of when a CMC referral may be required: 

(1) The CE is unable to conclude whether pre-1993 

medical evidence is sufficient to diagnose CBD. 

(2) Medical tests are submitted which do not provide 

clear diagnosis or interpretation (e.g., a BeLPT that 

does not clearly state that the test is positive or 

negative). 

(3) It is unclear whether a medical condition, 

unlisted on a death certificate, was a significant 

factor in causing, contributing to or aggravating an 

employee's death. For example, an employee dies of a 

heart condition, but the covered condition is 

asbestosis. 

(4) It is unclear whether the confirmed exposure to a 

toxic substance is linked to the illness claimed by 

the employee. 

 (5) A treating physician has offered a speculative, 

 or vague opinion, or one that is not substantiated by 

 reasonable medical rationale, and the CE has 

 undertaken reasonable steps identifying the defects 

 to the physician, but he or she has not responded or 

 responded unsatisfactorily. 

11. Referral to CMC. It is ultimately the responsibility of 

the jurisdictional DO to ensure that all the necessary 

components of a CMC referral are prepared accurately, the 

content of the referral is appropriate and specific to the issue 

under determination, and sufficient factual documentation 

is prepared to allow the CMC a clear understanding of the 

medical question(s) to be addressed. When guidance requires 

that email communication be prepared, a copy of the email is to 

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scanned/bronzed into the case file in the OWCP Imaging System 

(OIS). 

Interactions between DEEOIC staff and the CMC contractor occur 

through a secure internet portal, referred to as the Client 

Portal. All DEEOIC staff are to reference the “Client Portal 

User Guide” for additional information about using the Client 

Portal and referring cases to CMCs. Coordination of information 

between DEEOIC staff and the CMC contractor, including 

transmission of referral packages, is the responsibility of 

designated staff (i.e., Medical Scheduler). The CE, however, 

initiates the CMC referral process. 

a. Preparation of referral email. The CE sends an email 

to the Medical Scheduler indicating that a CMC review is 

required, and requesting referral to the CMC contractor. 

The body of the email should contain: 

(1) Claimant name. 

(2) Claim number. 

(3) Type of review requested. 

(4) Medical Specialty requested. The “Client Portal 

User Guide” contains a list of medical specialty types 

available for claims review. It is crucial that the 

CE selects the most appropriate preferred medical 

specialty to perform the review. The CE considers the 

following in determining the preferred medical 

specialty. 

 (a) Causation questions are best handled by 

occupational medicine specialists. Occupational 

medicine specialists can also evaluate the 

diagnosis and treatment of occupational lung 

conditions; such as asbestosis, silicosis, CBD, 

pneumoconiosis, and chronic obstructive pulmonary 

disease (COPD). 

(b) Diagnosis or treatment questions are best 

handled by medical specialists for the condition 

or procedure under evaluation. Selecting 

generalist/internal medicine/family practice is 

appropriate if the condition involves a medical 

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specialty not listed in the ”Client Portal User 

Guide.” 

(c) Impairment questions are best performed by 

specialists with experience in treating the 

particular organ system affected by the accepted 

work-related illness. 

b. Scanning. The CE creates an electronic image of the 

following items as a single PDF file, and attaches the file 

to the referral email. A copy of the completed Statement 

of Accepted Facts (SOAF) is to be scanned/bronzed to the 

case file in OIS. 

(1) A SOAF (See Exhibit 1 for example) is a narrative 

summary of the factual framework of the case record. 

The SOAF logically conveys factual findings that have 

been decided by the CE upon examination of the case 

record, or application of Programmatic resources, such 

as the Site Exposure Matrices (SEM). The CE makes 

factual findings derived from a reasonable 

interpretation of evidence contained in the case 

record, and not from undocumented sources. 

Factual findings presented in the SOAF are to be 

clearly stated. Simple words and direct statements 

reduce the potential for ambiguity or 

misinterpretation. The CE is to avoid using legal 

terms and Program jargon. Moreover, the CE must 

ensure that factual findings are presented in a 

logical order, and grouped chronologically within 

subject-specific sections relating to medical, 

employment, exposure, etc. The SOAF is to include the 

following information: 

(a) Identifying demographics, including the 

employee’s name, case file number and relevant 

personal information (e.g., employee’s date of 

birth, date of employee’s death, etc). 

 (b) Description of any accepted conditions or 

other diagnosed medical conditions. Medical 

information in the case file that is not relevant 

to the referral need not be reiterated in the 

 SOAF. 

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(c) Detailed description of the employee’s 

employment history. This includes information 

about where the employee worked, dates of 

employment, and his or her job title and duties, 

if relevant to the referral. The CE will review 

Form EE-3 to assess the employee’s claimed 

employment; however, in preparing the SOAF, the 

CE should only include employment that has been 

verified by the DEEOIC and determined to be 

covered employment (See PM Ch. 2-0500, 

Establishing Covered Employment). 

The CE refers to the OHQ for more detailed 

descriptions of work processes and must be 

diligent to identify all relevant employment data 

that has been determined to be factually 

established from the case evidence. This is 

particularly true in referral situations 

involving causation, as there is a need to 

clearly understand job descriptions, duties 

performed, working conditions, etc. 

(d) For causation determinations, identification 

of the occupational toxic substance exposures 

encountered by the employee. The CE makes 

findings of toxic substance exposure based on a 

careful analysis of case evidence, and reference 

to Program resources such as researching the SEM, 

or seeking guidance from the Industrial 

Hygienists (IH) or Toxicologists (TOX) when 

appropriate (See PM Ch. 2-0700, Establishing 

Toxic Substance Exposure). Toxic substance 

exposures, reasonably established by available 

evidence, and shown to have a potential health 

effect to the diagnosed condition, are listed in 

the SOAF. When possible, the CE is also to 

provide relevant information on the nature, 

extent and duration of such exposures. 

Quantification might include levels of exposure, 

concentrations of asbestos fibers in the air, 

levels of noxious substances, the (approximate) 

number of times exposed, etc. The CE is to avoid 

the use of terms such as light, heavy, undue, 

severe, and abnormal because they are subject to 

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great differences of interpretation. In certain 

situations, where the CE must provide an 

explanation as to how certain exposure findings 

are achieved, he or she is to document such 

analysis in the case file with a memorandum to 

the file. 

(e) The CE should include a brief history of the 

significant events that have transpired in the 

case (i.e., date of filing of Part B and/or Part 

E, date submitted to the National Institute for 

Occupational Safety and Health (NIOSH) for dose 

reconstruction, date of denial/acceptance, etc.) 

if determined to be relevant to the referral. 

 

(2) List of Questions for the CMC to address. (See 

Exhibit 2 for example). The questions put to the CMC 

must relate to a particular informational need that a 

physician is to address. The questions to a CMC 

should clearly communicate the information required. 

To this end, the questions should be straightforward 

and objectively stated. Avoid questions that are 

overly broad, or contain numerous subcomponents. In 

addition, questions that are leading or biased to a 

particular outcome are not appropriate. The CE is to 

limit the questions to the CMC to the relevant 

information necessary to address the particular claim 

for which a decision is required. A copy of the list 

of questions is to be scanned/bronzed to the case file 

in OIS. 

(a) For referrals under Part B, questions should 

be specific to a statutory requirement for any of 

the compensable occupational illnesses. 

Questions must be specific to a medical 

determination, rather than an adjudicatory 

standard. 

For example, in a pre-1993 CBD claim, a specific 

medical question is, “Does any X-ray show 

characteristic abnormalities consistent with 

CBD?” rather than, “Do the medical records 

support an acceptance of CBD under our Program 

requirements?” 

(b) For referrals under Part E, questions should 

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identify the standard of proof required. For 

example, the CE asks, “Is it at least as likely 

as not that asbestos was a significant factor in 

causing, contributing to or aggravating the 

employee’s diagnosed illness?” 

In some instances, there may be two unrelated 

conditions that the CE determines require a review by 

two separate specialists. The CE will need to prepare 

one SOAF and specify the two specialists required for 

review. The CE will prepare separate questions for 

each specialist to address. 

(3) Medical Records relevant to the issues for which 

the CMC is to render an opinion are to be imaged into 

a PDF formatted to the file and attached to the CMC 

referral email. For cases where an impairment rating 

is being sought, the CE may image the most pertinent 

or recent (two or three years old) medical records. 

For Second Opinion, Referee Specialist examination, or 

other case reviews, comprehensive medical records may 

need to be imaged. In some instances, the CE or 

designated staff person may need to divide the 

electronic images into several files to allow for 

electronic submission. The designated staff person 

should label each file clearly to allow for 

chronological or other categorical identification. 

12. Role of Medical Scheduler in CMC Referrals. Each District 

Director (DD) designates a Medical Scheduler who processes and 

tracks CMC referrals. The Medical Scheduler is also responsible 

for coordinating communication between DO staff and 

the CMC contractor. When guidance requires that email 

communication be prepared, a copy of the email is to be printed 

and placed in the case file. Upon receipt of a CMC referral 

submission from a CE, the Medical Scheduler is to take the 

following actions: 

a. Review of Referral. Conducts a thorough review of the 

referral package to ensure all required documentation is 

present, questions to the CMC are clear, and imaged records 

are legible. The SOAF should also be inspected to ensure 

that relevant factual findings have been reached that will 

allow for a comprehensive and reliable CMC analysis. Upon 

inspection, any referral package that is deemed to be 

incomplete or defective is returned to the CE for 

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corrective action. The Medical Scheduler is to return the 

referral package to the originating CE with a memo 

describing the problem to be addressed before a referral 

can be initiated. 

 

b. Submission of Referral. Once the Medical Scheduler 

has determined that a referral is complete and ready for 

submission to the CMC contractor, he or she is to log onto 

the CMC contractor’s internet portal, and follow the steps 

in the “Client Portal User Guide” for creating a claimant 

referral. Using the referral tab on the Client Portal, the 

Medical Scheduler inputs the claimant’s information as 

needed, and uploads all relevant electronic documents to 

complete the transaction. 

c. Confirmation. Upon receipt of submission confirmation 

from the CMC contractor, the Medical Scheduler is to notify 

the originating CE via email that the referral is complete. 

d. Processing for Payment. When the Medical Scheduler 

receives confirmation from the CE that the report is 

complete and accurate (see Section 13 of this Chapter), the 

Medical Scheduler compares the referral sheet to the 

billing form submitted by the contractor to validate that 

the charged amount corresponds to the service request. The 

Medical Scheduler must ensure that the billing codes/units 

identified on the OWCP-1500 correspond appropriately to 

what the CE requested be performed by the contractor. The 

Medical Scheduler must be aware of the following when 

reviewing billing for CMC reports completed through the 

contractor process: 

(1) For cases with multiple questions regarding the 

same or related conditions requiring the services of 

one specialist, (e.g., occupational medicine) one 

billable charge is permitted. 

(2) For cases with one or more unrelated conditions, 

requiring the services of a single specialist, (e.g., 

pulmonary or occupational medicine) one billable 

charge is permitted. 

(3) For cases with unrelated conditions requiring the 

services of multiple specialists, (e.g., oncology, 

pulmonary, dermatology) separate charges are 

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appropriate for each referral to a different 

specialist. 

e. If the OWCP-1500 is correct, the Medical Scheduler 

prints the OWCP-1500 and stamps the document “Prompt Pay” 

in black ink, with a signature and date in black ink, in 

the top right hand corner of the OWCP-1500. The “Prompt 

Pay” date (date received in the district office (DO) plus 7 

days) must be entered in block 11 of the OWCP-1500. The 

Medical Scheduler scans the stamped document, titles the 

bill using the last four digits of the employee’s Social 

Security Number (SSN) and the employee’s last name (e.g., 

1234Smith). 

The Medical Scheduler does not attach the CMC report or 

other documents to the bill. The Medical Scheduler then 

submits the approved OWCP-1500 to the Contracting Officer 

Representative (COR) or alternate COR designee via email at 

the email group “DEEOIC-CMC-INVOICES.” The COR 

coordinates, communicates, and ensures cooperation among 

the contractor and associated Government personnel, for the 

purpose of anticipating and resolving difficulties, and 

ensuring satisfactory completion of contracts. For 

efficiency and management purposes, payable bills should be 

collected throughout each business day and electronically 

transmitted by batch in one email at the end of each work 

day. The Medical Scheduler should include in the body of 

the email a list of the bills that should be included as 

attachments to ensure that the COR or alternate COR 

designee receives an accurate listing of bills. The case 

file should contain a copy of the OWCP-1500 and the 

original medical report. 

f. The Medical Scheduler will enter the following dates 

in ECS to ensure prompt payment of all physician referral 

bills : 1) Status Effective Date (enter the date listed in 

block 24A of the OWCP-1500); and 2) Eligibility End Date 

(enter the date of the physician’s response, i.e., the date 

 of the report). 

g. Once the COR or alternate COR designee receives the 

batch, the bills are to be certified by the designated COR 

by placing a signature stamp on each invoice. The office 

Administrative Assistant will then mail the bills to the 

Bill Pay Agent (BPA) for processing and payment. 

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h. If a problem with the billing is identified, the 

Medical Scheduler communicates the issue with the 

contractor and copies the COR and alternate COR designee 

via e-mail. 

i. Problems with Reports. The Medical Scheduler notifies 

the District Director of any problems dealing with the CMC 

 contractor. 

13. Post Referral to CMC. Upon submission of a referral to the 

CMC contractor, the contractor will then assign a particular CMC 

to respond. The CMC selection is the function of the CMC 

contractor, and DEEOIC has no input in the selection of the 

physician chosen to review the case, other than the preferred 

specialty of the physician. Once assigned, the CMC is to assess 

all submitted documentation, and prepare a comprehensive and 

responsive medical narrative to the questions posed by the 

referring CE. The CMC then submits his or her report back to 

the contractor. The contractor then undertakes a quality 

control review to ensure that the report is complete, 

rationalized, and fully responsive to the questions posed by the 

CE. Upon clearance for release, the CMC contractor will then 

post the completed report along with a completed Form OWCP-1500 

on the Client Portal. 

To access the reports, the Medical Scheduler or designated staff 

logs into the Client Portal using the steps listed in the 

“Client Portal User Guide” and accesses the status for the 

relevant claim. The Medical Scheduler or designated staff 

downloads the CMC report and completed Form OWCP-1500 from the 

Client Portal. 

a. Completed Reports. Once the medical report is 

downloaded, the CE reviews it for accuracy and 

completeness. The review should include the CMC’s 

interpretation of test results, evaluation of medical 

reports submitted for review, answers to each question 

posed, and the CMC’s rationale showing how his or her 

opinion is supported by the evidence in the file. 

(1) If the medical report is accurate, appropriate 

and complete, the CE sends approval to the Medical 

Scheduler, via email, to authorize payment of the 

medical bill no later than the next business day. The 

CE indicates in the text of the email that the review 

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completed by the CMC is acceptable. The email is 

scanned/bronzed to the case file in OIS.

(2) If the medical report is incomplete or incorrect, 

or not properly responsive to the questions posed, the 

CE notifies the Medical Scheduler, via email, of the 

issues with the medical report. The email is 

scanned/bronzed to the case file in OIS. The District 

Director or designated staff will return the medical 

report to the contractor and request the contractor 

provide an additional report to correct the situation. 

The CMC shall provide the additional report within 

(14) days of receipt of the request without additional 

charge. The District Director will notify the 

contractor in writing of the request for the 

additional report. A copy of the notification should 

be scanned/bronzed to the case file in OIS. 

To ensure prompt payment of all physician referral 

bills to the BPA, (i.e., CMC, Second Opinion, Referee 

Specialist bills) the Medical Scheduler or designated 

staff records the referral and receipt of the medical 

report/billing in ECS. 

b. Request for Report. If the claimant requests a copy 

of the CMC’s report, the CE provides a copy of the report 

with a cover letter, which includes the following 

disclaimer paragraph: 

Attached is a copy of the medical report 

that you requested. Please be advised 

that {Enter the CMC’s name} is a medical 

consultant for the Department of Labor. The 

Department of Labor will make the final 

decision in this claim. Please do not contact 

{Enter the CMC’s name} regarding this report. 

If you have additional evidence to submit in 

support of your claim or if you have any 

questions or concerns regarding this report, 

please contact me at {Enter the DO’s 

toll-free number}. 

Staff may redact the CMC’s personal address, personal 

telephone number, and personal email address, but must give 

the CMC’s business telephone number, business address, and 

business email information. 

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A copy of the CMC’s IH/Toxicologist report will be sent 

with all Recommended Decisions denying a claim based on 

causation. 

c. Contract Compliance. Upon the identification of any 

systematic deficiencies or other problematic situations 

involving the CMC referral process, immediate action is to 

be taken to advise the District Director or a designee and 

the National Office COR. This would include situations 

involving consistently poor or low quality CMC reports, 

timeliness problems, or unresponsiveness to questions. 

14. Second Opinion Examinations. A Second Opinion examination 

is a type of medical referral arranged by the DEEOIC that 

requires the employee to undergo a physical examination. The 

results of that examination, along with the physician’s review 

of pertinent medical documentation, facilitate the production of 

a narrative medical report describing the physician’s 

independent medical opinion in response to questions raised by 

the assigned CE. 

To schedule Second Opinion examinations, the DEEOIC utilizes the 

CMC contractor with access to a database of physicians capable 

of performing in-person physical examinations by geographical 

location. Much like the CMC referral process, the decision to 

initiate a Second Opinion examination and the appropriate 

specialist falls to the CE assigned to the claim, but selection 

of the physician is the sole responsibility of the scheduling 

contractor. 

a. Role of the CE. The CE is responsible for deciding 

when a Second Opinion examination is necessary in lieu of 

obtaining information from other sources, such as inquiry 

to a treating physician or CMC referral. A Second Opinion 

 examination should be reserved for situations for which an 

 actual physical examination of the patient will assist with 

 the resolution of an outstanding claim, such as those 

 involving issues of medical necessity or in situations 

where claimants have difficulty obtaining information 

necessary for completion of an impairment rating. 

b. Referral for Second Opinion Examination. As discussed 

in Section 11 of this Chapter, interactions between the 

DEEOIC staff, the CMC, and physicians selected for Second 

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Opinion examinations occur through the Client Portal. The 

Medical Scheduler or designated staff is responsible for 

the coordination of information between DEEOIC staff and 

the contractor, including transmission of referral 

packages. The CE initiates the process for obtaining a 

Second Opinion examination and ensures all necessary 

referral and medical documentation is sent to the Medical 

Scheduler or designated staff. Arranging for a Second 

Opinion examination follows the same basic referral steps 

listed as when making a CMC referral. 

(1) Preparation of referral email. The CE sends an 

email to the Medical Scheduler indicating that a 

Second Opinion examination is needed, and requesting 

referral to the CMC contractor. The body of the email 

should contain: 

a. Claimant name. 

b. Claim number. 

c. Second Opinion review request. 

d. Medical Specialty requested. Refer to 

Section 11.a(4)of this chapter for further 

discussion of medical specialty. 

e. Previous physicians involved in the case. 

f. SOAF (Exhibit 1). 

g. List of Questions for the Second Opinion 

physician to address. (Exhibit 2) 

h. Medical Records. 

 i. Cover Letter to the claimant. (Exhibit 4) 

A copy of the referral email is scanned/bronzed to the 

case file in OIS. 

(2) Role of the Medical Scheduler. The Medical 

Scheduler follows the steps listed in Sections 11 and 

12 of this chapter to transmit the Second Opinion 

examination request to the CMC contractor and perform 

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follow-up actions. As is the case with the CMC 

referral process, the identification of any systematic 

deficiencies or other problematic situations involving 

the Second Opinion examination referral process, 

should be brought to the attention of the DD. 

Once the contractor has selected a physician to perform the 

Second Opinion examination, the contractor will notify the 

claimant, in writing, of the specialist’s name, address and 

telephone number, and date and time of the appointment. The 

contractor will also send the claimant a copy of the cover 

letter (See Exhibit 4 for example). The contractor will followup with the claimant to ensure that the claimant attended the 

appointment. 

In the event the claimant requests to reschedule the Second 

Opinion examination, the CE will determine whether the 

appointment should be changed, as outlined in Section 16 of this 

chapter. If the claimant does not attend the Second Opinion 

examination, the CE may suspend action on any open claims and 

administratively close the case until such time as the employee 

agrees to and attends the examination as outlined in Section 16. 

15. Referee Specialist Examinations. A conflict of medical 

opinion can arise between a physician selected by a claimant, 

and that of a CMC or Second Opinion physician. In most 

instances, the CE’s careful weighing of the medical evidence 

should permit the resolution of the conflict. However, where 

the weight of medical evidence is equal between the opinion of 

the treating doctor and that of the CMC or Second Opinion 

physician, a Referee Specialist opinion is necessary. The CE 

obtains a Referee Specialist opinion by requesting a third, 

impartial physician review the competing opinions presented. 

The assigned physician then evaluates both sides of the 

competing argument, and makes the deciding conclusion. 

a. Value of Referee’s Opinion. The probative value of a 

Referee’s opinion, if sufficiently rationalized and derived 

from careful examination of evidence from the competing 

physicians, is granted special weight. This means that 

once the Referee has fully considered the argument 

presented by both sides engaged in a conflict in medical 

opinion, and reached a rationalized conclusion regarding 

the matter, the CE is to consider the opinion of the 

Referee as the conclusive answer to the issue to be 

resolved. 

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 b. File review or physical examination. A Referee 

Specialist examination will consist of either a review of 

the case record or an actual physical examination of the 

employee. If a conflict exists between the medical opinion 

of the employee’s treating physician and the 

 medical opinion of a CMC, a Referee referral file review is 

 needed. However, if a conflict exists between the medical 

 opinion of employee’s treating physician and the medical 

 opinion of the Second Opinion physician, a Referee 

 referral physical examination should be scheduled. 

c. Assignment of the Referee. The CE will utilize the 

same basic referral process for referral to a Referee 

examiner as is used for a Second Opinion, except for some 

notable differences. 

(1) In the referring email to the Medical Scheduler, 

the CE is to denote the type of review as a Referee 

Specialist examination. A copy of the email is to be 

scanned/bronzed to the case file in OIS. 

(2) The CE’s questions to the Referee Specialist are 

to be sufficiently detailed and narrow to resolve the 

conflict of medical evidence. The questions should 

not introduce new or unique topics for the physician 

to address. The purpose of the Referee Specialist 

examination is limited to that which is necessary to 

resolve an existing conflict of medical opinion. 

16. Failure to Undergo Second Opinion or Referee Specialist 

Examination. The employee assigned to undergo either a Second 

Opinion or Referee Specialist examination is obligated to attend 

the examination. Moreover, the CE is responsible for evaluating 

any request to change the date or time of an appointment to 

determine if sufficient reasons exist to allow for such a 

change. The employee and/or claimant will not be authorized to 

change a scheduled Second Opinion or Referee Specialist 

examination without providing a substantive and documented 

cause. The determination of whether an appointment should be 

changed is at the discretion of the CE who is responsible for 

initiating the referral. Generally, appointment changes should 

only be permitted in emergency situations, or when the employee 

has given a sufficiently convincing rationale for a need to 

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change the appointment. Appointment changes that are necessary 

merely for the general convenience of the employee are usually 

not permitted. Once authorization for an appointment change is 

granted, the CE, through the Medical Scheduler, must notify the 

designated contractor. 

Once a Second Opinion or Referee Specialist examination has been 

scheduled, it is expected that the employee attend. Failure to 

attend a scheduled examination may result in suspension of 

action on any open claims and administrative closure until such 

time as the employee agrees to and attends the necessary 

examination. 

a. Follow-up Action. If the employee was examined, the 

CE should expect a report within 21 days. This guideline 

also applies if a case is referred for a file review. 

b. Failure to Appear. If the physician’s office reports 

that the employee did not appear for his or her scheduled 

appointment, the employee and any representative should be 

contacted by a documented phone call or in writing to 

request an explanation. If a reasonable explanation is 

provided, the CE re-schedules the examination, through the 

CMC Contractor. 

If the employee does not respond to the CE’s request for an 

explanation or if an explanation is provided and the CE 

determines good cause is not established, or if the 

employee fails to appear for the re-scheduled examination 

without good cause, the CE issues a letter advising the 

employee and representative that the issue to be resolved 

(i.e., adjudication of a consequential injury, request for 

surgery, medical supply, etc.) cannot be further 

adjudicated until the medical examination is completed. 

The CE suspends any further action to adjudicate the 

outstanding issue and administratively closes the claim. 

Development may resume if the employee agrees to undergo a 

medical examination and undergoes it. 

c. Disruptions at the Medical Examination. If a medical 

examination cannot be completed due to disruptions caused 

by someone accompanying the employee, the medical 

examination must be rescheduled with a different qualified 

physician. The employee will not be entitled to have 

anyone else present at this subsequent examination unless 

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the CE determines that exceptional circumstances exist, for 

example, if a hearing impaired employee requires a sign 

language interpreter.

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Exhibit 1 

Statement of Accepted Facts (SOAF) 

1. Employee Information

a. Name:

b. Case File Number:

c. Date of Birth:

d. Date of Death:

i. If deceased, list Cause(s) of Death from Death Certificate

2. Medical Information 

a. Has an Occupational Health Questionnaire (OHQ) been completed? (Provide date)

b. Diagnosed Condition(s): (Provide date of diagnosis for each, if possible; if diagnosed 

 condition is skin cancer, provide body location) 

c. List any accepted conditions (if applicable). 

d. Other medical information/conditions available for review by referral personnel (if 

 appropriate): (Provide dates of Former Worker Protection (FWPP) Interview, authorized

home health care periods, etc.)

3. Employment Information - If Relevant - (Provide a detailed description of the employee’s 

verified and covered employment history – include where employee worked, date(s) of 

employment, job title(s), job duty(ies)) 

4. Occupational Toxic Exposure - If Relevant - (Provide the occupational toxic substance 

exposures encountered by the employee and shown to have a potential health effect to the 

diagnosed condition; provide relevant information on the nature, extent and duration of such 

exposures) 

5. Claim History – If Relevant - (Provide significant events such as date of filing of Part B and/or 

Part E, date submitted to NIOSH for dose reconstruction, Probability of Causation %, date of 

denial/acceptance, date of remanded claim, etc.)

6. Other Information - (Include any other information that may be useful to those conducting the 

referral evaluation) 

7. Claims Examiner Information 

a. Submitting District Office:

b. Claims Manager:

c. Unit designation:

d. Telephone Number: 

e. E-mail address:

f. Date of referral:

8. Verification of Review – (Should be signed by District Office Director, or designee, indicating 

SUPERSEDED

that the referral information has been reviewed and meets minimum criteria for submittal)
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Exhibit 2 

Sample Questions for Physician 

Questions:

CE: Choose from options below or add your own 

1. Impairment: Refer to PM Ch. 2-1300, Impairment Ratings for questions and instructions for 

CMC’s conducting impairment evaluations. 

2. Impairment: If it is not possible to complete an impairment rating based on the medical evidence 

we provided, please advise us what medical records and/or testing is required to complete the 

rating. 

3. Diagnosis: In your opinion, do the medical records support a diagnosis of a medical condition? 

If so, please provide the first date of diagnosis, diagnosis, and the ICD code. 

4. Causation: If a medical condition was diagnosed, in your opinion is it at least as likely as not that 

exposure to toxic substances during the course of employment at covered facility was a 

significant factor in aggravating, contributing to, or causing the employee’s medical condition? 

5. Causation: If so, please provide the earliest date of diagnosis(es) and ICD code of the condition 

you believe is related. Please provide the rationale and objective findings to support your 

conclusion that the condition(s) are related to exposure in the workplace. 

Claims Examiner Claims Examiner

(Printed Name)

Date

(Signature) (Date)

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 Exhibit 3 

ICD Codes and Corresponding Procedure Codes

V49.8 File Reviews 

FR001 File Review 

FR002 Supplemental File Review 

FR003 Clarification of Diagnosis, Treatment,

 Tests 

V49.8 Impairment Ratings

FR004 Impairment Evaluation 

V68.89 Wage Loss

WL001 Assessing Ability to Work/Wage-Loss

V68.2 Second Medical Opinions 

SEP02 Second Medical Opinion (includes

 physical exam and file review) 

FR002 Supplemental File Review 

Cancl Appointment Cancellation 

V65.8 Referee Referrals (Physical Exam 

or Written Exam)

REFER Physical examination which includes file 

review 

REF01 File review only

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Page 1 of 2 Exhibit 4 

Sample Letter to Claimant Regarding Second Opinion/Referee Physician

DEEOIC Case ID: (Case ID # 

Employee Name: (Employee Name)

(Claimant Name)

(Street Address)

(City, State, Zip)

Dear (Mr/Ms Claimant): 

 

This letter is in reference to your claim under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA).

Under our regulations, the Division of Energy Employees Occupational Illness Compensation 

(DEEOIC) has the authority to refer an employee for a physical examination by a second 

opinion physician when it considers such a referral to be reasonably necessary.

Because it considers such a referral to be reasonably necessary for the proper adjudication 

of your claim, DEEOIC has arranged for you to be examined by a second opinion physician. 

Please review the attached letter for the time, date, and location of your scheduled 

appointment. DEEOIC will pay the out-of-pocket costs you incur in connection with the 

examination or any diagnostic testing. Travel costs to attend the examination are 

reimbursable upon submission of Form OWCP-957 (Attached).

DEEOIC recommends that you call the physician’s office ahead of time to confirm your 

appointment. Providing the physician with your name, case ID #, and contact information, 

when you call, will help ensure that the process works as smoothly as possible.

Rescheduling the appointment is strongly discouraged and you should only do so in 

emergencies. Altering an appointment schedule can hinder our ability to take substantive 

action on your claim and promptly deliver services to you. If you are unavoidably 

prevented from keeping your appointment, you must immediately call your assigned claims 

examiner at the district office at Your Phone #. DEEOIC will evaluate any request to 

reschedule your appointment to determine whether you have submitted proof of one or 

more legitimate reasons to change the appointment. 

If you do not attend the scheduled appointment, or cannot establish good cause for your 

failure to appear, DEEOIC will suspend claim adjudication and administratively close your 

claim. Reopening of the claim record will not occur until you agree to and attend a 

DEEOIC scheduled medical examination.

DEEOIC strongly encourages physicians to limit persons in attendance during the actual 

examination to one or two individuals. This would include a family member or designated 

authorized representative, and/or a health care professional, such as a RN/LPN, or 

CNA/HHA who is currently providing care to the patient. Ultimately, it is the examining 

physician’s decision as to who can be present during the examination.

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Page 2 of 2 Exhibit 4 

If you have a disability (a substantially limiting physical or mental impairment), please contact our 

office/claims examiner for information about the kinds of help available, such as communication 

assistance (alternate formats or sign language interpretation), accommodations and modifications. 

Should someone accompanying you disrupt the scheduled medical examination, DEEOIC 

will reschedule the exam with a different qualified physician. You will not be entitled to 

have that individual accompany you during the subsequent examination unless DEEOIC 

determines that exceptional circumstances exist.

We appreciate your cooperation in this matter. If you have any questions regarding the 

scheduled examination, please contact me at the address listed above or call Your Phone 

#.

 

Sincerely,

(YOUR NAME)

Enc: OWCP-957 

Copy of Authorization Letter 

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EEOICPA Tr. No. 16-05 i 

March 2016 

TABLE OF CONTENTS 

Paragraph and Subject Date Trans. No. 

Chapter 2-1500 Consequential Conditions 

 Table of Contents. . . . . . . . . . 03/16 16-05 

1 Purpose and Scope. . . . . . . . . . 03/16 16-05 

2 Defining a Consequential 

Condition . . . . . . . . . . . . 03/16 16-05 

3 Claims for Consequential 

Conditions. . . . . . . . . . . . 03/16 16-05 

 4 Claim Development. . . . . . . . . . 03/16 16-05 

 5 Metastasized Cancer(s) . . . . . . . 03/16 16-05 

 6 Conditions Resulting from Medical 

 Treatment . . . . . . . . . . . . 03/16 16-05 

 7 Independent Intervening Causes . . . 03/16 16-05 

 8 Pre-existing Conditions. . . . . . . 03/16 16-05 

 9 Psychological Conditions . . . . . . 03/16 16-05 

 10 Accepting or Denying the 

 Consequential Condition . . . . . 03/16 16-05 

 11 Impairment and Wage-Loss . . . . . . 03/16 16-05 

 12 State Workers’ Compensation (SWC) 

 Claims, Lawsuits and Fraud. . . . 03/16 16-05 

Exhibits 

1 Sample Listing of Consequential 

Illnesses 03/16 16-05 

2 Sample Letter Decision 03/16 16-05 

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1. Purpose and Scope. This chapter discusses the Claims 

Examiner’s (CE) role when developing claims for consequential 

conditions. It also discusses the types of injuries, illnesses, 

impairments, or diseases that may be considered as consequential 

conditions. 

a. OWCP Imaging System (OIS). Anyone undertaking development 

action with regard to a claim for consequential conditions is 

to ensure that documents generated or received during the 

evaluation process for consequential conditions are properly 

bronzed/scanned into the OIS. This guidance applies to any of 

the procedures described throughout this chapter. 

2. Defining a Consequential Condition. The effect of an 

accepted occupational illness under Part B and/or covered 

illness under Part E in causing, contributing to or aggravating 

an injury, illness, impairment, or disease is considered a 

consequential condition. A CE is to accept as compensable any 

claimed consequential condition(s) that is documented properly 

by substantive, well-rationalized medical evidence. 

Consequential conditions can arise for any reason established as 

being medically linked to a previously accepted work-related 

illness. In some instances, a “chain of causation” can result in 

a series of injuries, illnesses, impairments, or diseases, which 

are a direct consequence of an accepted work-related illness. 

When medical evidence is present to establish such a scenario, 

the resulting consequential condition(s) in the causal chain are 

all compensable under the EEOICPA. The acceptance of a 

consequential condition(s) results in medical coverage for that 

condition(s) under Part B and/or Part E as appropriate. 

Additionally, under Part E, any diagnosed illness, injury, 

impairment, or disease shown by medical evidence to be a 

consequence of a covered Part E condition may affect the 

calculation of an impairment rating and/or wage-loss. 

3. Claims for Consequential Conditions. The claimant must file 

a claim for all consequential condition(s) in writing and may 

use any method of written notification. However, while documents 

containing written words of claim for a consequential 

condition(s) are acceptable to begin the adjudication process, 

the CE is to obtain a completed and signed Form EE-1/2 

associated with the consequential claim before issuing a 

decision. A signed claim form is also required for all 

metastatic cancers. Ideally, the claimant should concurrently 

send a written statement identifying the specific nature of the 

consequential condition claimed, along with a signed EE-1/2. A 

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signed EE-1/2 is required because it provides notice to the 

claimant of his or her responsibilities in filing for benefits 

under the Act. 

a. For each distinct medical condition claimed as a 

consequence of a previously accepted condition, the CE 

undertakes a careful examination of the evidence presented in 

support of the claim. If the evidence demonstrates the 

existence of a diagnosed consequential illness and the CE 

decides that the medical justification is sufficient to link 

reasonably the condition to a previously accepted condition, 

he or she proceeds with issuing a letter decision of 

acceptance (refer to 10a on acceptances). In those claims 

situations where insufficient evidence exists, after 

development, to establish a consequential claim, the CE issues 

a recommended decision of denial. 

There may be instances where a claimant files words of claim 

or an EE-1/2 for a condition but it is not clear whether the 

claimant’s intent was to file the condition as resulting from 

toxic substance exposure or as a consequential condition. In 

most cases, the condition will be processed as a primary 

diagnosed condition resulting from toxic substance exposure. 

However, if the medical or factual information provided with 

the words of claim or the EE-1/2 alludes to the fact that the 

condition may be a consequence of a previously approved 

condition, the CE is to contact the claimant to obtain 

clarification on whether he or she wants the claim to be 

processed as a primary condition or as a consequential 

condition. Once the CE obtains clarification, he or she 

documents the claimant’s intent in ECS and begins appropriate 

development for that condition. 

In those cases where only words of claim was filed, the CE 

requests that the claimant submit a completed and signed EE1/2 clearly indicating that the condition is consequential, 

prior to issuing any decision. (Note: if a completed and 

signed EE-1/2 was already submitted and the CE just needed to 

seek clarification of the claimant’s intent, a new updated EE1/2 is not needed). 

(1) For any consequential condition(s) where the CE has 

requested a completed and signed Form EE-1/2, the CE allows 

a period of 30 days for the claimant to submit the required 

documentation. After 30 days, the CE administratively 

closes the claim if the claimant has not submitted a signed 

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EE-1/2 claim form. The CE is to mail a notice to the 

claimant(s) that no further action will occur on the claim 

for that medical condition until receipt of a completed and 

signed claim form. 

b. In some situations, the CE may find evidence contained in 

a case record that suggests that an unclaimed medical 

condition is consequential to an accepted condition. If there 

is sufficient reason to discern that the evidence of record 

communicates the existence of a likely consequential 

condition, the CE is to contact the claimant to ascertain 

whether he or she wants to claim that condition as 

consequential to a previously accepted illness. If the 

claimant states that he or she wants to file a claim for that 

condition, the CE instructs the claimant to submit a completed 

and signed EE-1/2 form. The mere fact that the CE identifies 

an unclaimed condition in the medical evidence is not 

sufficient reason to seek a new claim. Evidence has to be 

present in the case record to lead the CE to a reasonable 

conclusion that the condition is consequential to an approved 

primary condition. 

c. Where a claimant previously filed Form EE-1/2 for a 

condition due to toxic substance exposure that was denied, but 

later claims that the denied condition is consequential to an 

accepted condition, the claimant is to file a new Form EE-1/2 

claiming the condition as a consequential illness. In this 

scenario, the CE treats it as new claim filed under the 

EEOICPA. As this is a new claim filed under the EEOICPA, a 

Director’s Order vacating the prior denial of the same 

condition based on toxic substance exposure is unnecessary. 

4. Claim Development. When assessing a claim for a consequential 

condition, medical evidence is required to document clearly the 

relationship that creates the nexus between a consequential 

condition and an accepted work related illness. The medical 

documentation is to contain information identifying the 

diagnosis of the consequential condition. In addition, the 

medical evidence is to include a physician’s opinion that 

presents a convincing and well-rationalized conclusion linking 

the consequential condition to a previously accepted illness. 

The opinion of the physician regarding a consequential condition 

is to be sufficiently probative and compelling to allow the CE 

to assign the weight of medical evidence to the conclusion 

offered. Physicians offering vague, equivocal, speculative 

positions on the relationship between a consequential condition 

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and a work-related illness require additional investigation by 

the CE. Additional development is also required when a 

physician offers opinions that the CE considers to be 

unsupported by any reasonable medical justification. 

a. Exhibit 1 provides a sample listing of secondary medical 

conditions that are known to result from Chronic Beryllium 

Disease (and treatment), silicosis, prednisone treatment, and 

other conditions. This list is not all-inclusive but serves as 

a guide for identifying some commonly known consequential 

illnesses. While the Exhibit serves as a guide and lists 

potential secondary illnesses, the CE is to exercise 

discretion when developing for these conditions. The fact that 

a condition appears as “secondary” on the Exhibit in no way 

establishes that the condition truly resulted from the 

claimant’s approved underlying condition. The CE is to ensure 

that the claimant submits sufficient medical evidence to 

substantiate the relationship between the underlying condition 

and the claimed consequential condition. 

5. Metastasized Cancer(s). Metastasized cancer(s) is a type of 

cancer that originates from a primary cancer site but spreads or 

invades other organ systems. Metastatic cancer has the same name 

and the same type of cancer cells as the original, or primary, 

cancer (Under a microscope metastatic cancer cells generally 

look the same as cells of the original cancer). For example, 

breast cancer that spreads to the lung and forms a tumor is 

metastatic breast cancer, not lung cancer. In many situations, 

there will be evidence in the form of pathology or other 

diagnostic evidence that identifies a cancer as “metastatic” or 

“secondary” to a primary cancer type. A CE may accept a claimed 

metastatic cancer as a consequential condition if the diagnostic 

or other medical evidence is sufficiently descriptive to 

identify it as being caused by another primary cancer accepted 

as work-related. If the evidence is unclear or does not 

establish a relationship between the cancers, the CE undertakes 

additional development to include collecting the opinion of a 

treating physician or an assessment of the record by a Contract 

Medical Consultant (CMC). 

a. The evidence relating to a metastatic cancer is to include 

the following: 

(1) The diagnosis of each secondary cancer; and 

(2) The date of diagnosis for each secondary cancer(s). 

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If the medical evidence is inconclusive and the CE is unable 

to determine if the cancer is a metastasis, the CE seeks 

clarification from the treating physician and/or a CMC. 

b. Examples of Metastasized Cancers. It is widely accepted 

that certain carcinomas and/or sarcomas metastasize from a 

primary site. For example: 

(1) Carcinomas of the lung, breast, kidney, thyroid, and 

prostate tend to metastasize to the lungs, bone, and brain. 

(2) Carcinomas of the gastrointestinal tract, reproductive 

system, and abdomen tend to metastasize to the abdominal 

lymph nodes, liver, and lungs. Later in their course, these 

carcinomas can metastasize to the brain and other organs. 

(3) Sarcomas often first metastasize to the lungs and 

brain. 

(4) Primary malignant tumors of the brain seldom 

metastasize to other organs, but they can spread to the 

spinal cord. 

6. Conditions Resulting from Medical Treatment. Consequential 

conditions can arise from treatment modalities imposed on an 

employee because of an accepted work-related illness. This can 

include any injury, illness, impairment or disease arising from 

any form of medical treatment, including effects from 

prescription medication. 

a. Consequential Conditions Resulting from Medical Treatment 

for Accepted Conditions. As part of a patient’s medical 

treatment or protocol, a patient may undergo treatment and/or 

other drug therapy that will produce side effects that can be 

considered as common consequential conditions. 

Examples of such conditions are: 

(1) Radiation pneumonitis as a result of radiation 

treatment; 

(2) Skin rashes and radiation burns because of radiation 

treatment; 

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(3) Osteoporosis (which causes weakening of the bones and 

injuries such as spontaneous hip fractures) as a result of 

steroid treatment. 

b. Developing evidence for conditions resulting from medical 

treatment. When the CE receives a claim for a consequential 

condition caused by medical treatment of the accepted 

condition (also known as iatrogenic), the CE investigates the 

submitted documentation to ensure that the medical evidence 

supports the claim. 

(1) Medical evidence is to identify the medical diagnosis 

of an illness or injury that is due to the treatment of an 

accepted work-related illness. 

(2) A physician opinion or narrative is to be present that 

discusses the causal relationship between the consequential 

condition and a treatment modality made necessary because 

of the accepted condition. The physician’s opinion should 

present a reasonable chronology of the onset of a 

consequential condition following a treatment regimen. In 

addition, the physician is to offer a well-rationalized 

position on the relationship that exists between a newly 

diagnosed problem and the treatment of an accepted illness. 

Vague, speculative or unsubstantiated positions taken by a 

physician require additional development including a review 

of the situation by a CMC, if necessary. 

7. Independent Intervening Causes. Consequential conditions can 

arise from an injury arising from an action or event that is 

reasonably linked to the accepted work-related illness. An 

example would be an injury sustained by the claimant as a result 

of a slip and fall on his or her way to or from a medical 

appointment for the accepted work-related illness. Other 

examples include injuries to the claimant resulting from 

accidents involving wheelchairs or scooters, improper Durable 

Medical Equipment (DME) use, medical transport, etc. When 

assessing claims of this sort, the CE is to collect 

documentation that describes the circumstances of the injury, 

along with the medical evidence that diagnoses a medical 

condition linked to the event. 

a. The CE is to obtain a signed written statement from the 

claimant that describes the circumstances of the event that 

resulted in an injury. For example, “I tripped down the stairs 

when exiting the doctor’s office and broke my arm.” The 

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claimant’s statement is to be sufficiently descriptive to 

explain the circumstances of the event or accident, along with 

an explanation as to how it is linked to the accepted workrelated illness. 

b. A physician opinion or narrative is to be present that 

discusses the causal relationship between the event or 

accident that is somehow linked to the accepted work-related 

illness and the onset of a new diagnosed medical condition. 

The physician is to explain the sequence of events that led to 

the consequential condition, along with his or her explanation 

as to how the event or accident is related to the accepted 

work-related illness. If the physician is unable to provide a 

rational explanation, or there are other contradictions in the 

evidence that lead the CE to question the sufficiency of the 

claim, additional development should occur, including a review 

of the situation by a CMC. In situations where the claimant 

sustains an injury on his or her way to a medical appointment, 

it may be necessary to confirm the date, time and location of 

the appointment to assist with determining that the claimant 

was in fact on his or her way to an appointment related to the 

accepted condition. 

(1) An independent intervening incident caused by, or 

attributed to, the employee’s own conduct. Injuries, 

illnesses, impairments or diseases suffered as a result of 

the employee’s own actions will not be accepted as 

consequential conditions. For example, if an employee is 

involved in an automobile accident on his or her way to a 

doctor’s appointment for treatment of an accepted 

condition, but it is determined through medical 

evidence/police report that the claimant was under the 

influence of drugs or alcohol at the time of the accident, 

then the results of the accident could not be considered as 

a consequential illness or injury. 

8. Pre-existing Conditions. Pre-existing conditions are 

conditions that pre-exist the diagnosis date of an accepted 

work-related condition. If medical evidence supports that the 

pre-existing condition became aggravated or worsened by the 

accepted condition, it is considered a consequential condition. 

To accept a claimed pre-existing condition as a consequential 

illness, a medical report is required that includes the 

diagnosis of the pre-existing condition and a well-rationalized 

explanation of how the condition was worsened or aggravated by 

the accepted condition. The medical evidence has to support an 

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increase in the symptoms or disability that would not have 

otherwise occurred, or treatment that would not have been 

necessary, but for the accepted condition. An example of a preexisting condition affected by a covered condition includes 

Chronic Obstructive Pulmonary Disease (COPD) that aggravates a 

pre-existing heart disease such as Coronary Artery Disease. The 

“Eligibility Begin” date is the filing date of the underlying 

accepted condition. 

9. Psychological Conditions. Psychological conditions can arise 

as a consequence of the accepted illness and/or treatment of 

that condition. They can also arise with no physiological basis. 

Depression, anxiety, and/or chemical imbalance are a few 

examples of psychological conditions that may have no 

physiological basis. In addition to a specific diagnosis, these 

conditions may be described as “psychogenic pain disorder,” 

“conversion disorder,” or “psychological syndrome.” However 

described, the symptom or pain is quite real to the individual 

involved although there is no demonstrable physical disorder. 

To accept a claimed psychological condition, the claimant must 

provide diagnostic evidence and a well-rationalized medical 

opinion from a qualified physician supporting a causal 

connection between the psychological condition and the covered 

condition. A qualified physician must be a clinical psychologist 

or psychiatrist. In situations where clarification on the causal 

relationship between the psychological condition and an accepted 

condition cannot be obtained from a qualified physician, the CE 

forwards the claimant’s case file to a CMC or refers the 

claimant to a qualified second opinion physician for evaluation 

and opinion concerning causal relationship. 

A CE may authorize social worker services for the treatment of a 

consequential psychological condition when prescribed under the 

supervision of a qualified physician. However, the physician is 

to specify the justification for such services, along with the 

submission of a narrative report that describes the plan of care 

with regard to the extent and duration of social services. 

10. Accepting or Denying the Consequential Condition. The CE 

is responsible for taking the appropriate steps in developing 

any claimed consequential condition. This includes notifying the 

claimant of any deficiencies in the evidence and allowing him or 

her the opportunity to respond and submit additional evidence. 

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a. Acceptances. If the consequential condition is going to 

be accepted, the CE accepts the consequential condition under 

Parts B and E, if the primary underlying condition is also 

accepted under both Parts. The CE notifies the claimant in a 

letter decision. All letter decisions should contain two 

signature blocks; one for the CE who drafted the letter, and 

one for his or her supervisor (or another management official 

designated by the district director), who will certify the 

sufficiency of the decisional outcome. Exhibit 2 provides a 

sample decision letter for approvals of consequential 

conditions. 

The CE should be aware that once he or she accepts a 

consequential condition by letter decision, any pending claim 

for that same condition being affiliated with a toxic 

substance exposure can be administratively closed. For 

example, when a letter accepting glaucoma as a consequential 

condition occurs, there is no need to then issue a 

recommended accept/deny for glaucoma based on toxic substance 

exposure. The “Eligibility Begin” date for consequential 

conditions is the filing date of the underlying accepted 

condition. 

b. Denials. If the CE has determined that insufficient 

medical evidence exists to accept a claim for consequential 

condition, and the CE provided the claimant the opportunity to 

submit supportive evidence, he or she issues a recommended 

decision specifically denying the claim for a consequential 

illness. The CE does not issue a letter decision denying a 

consequential condition. A recommended decision issued to deny 

a consequential condition must contain a clear explanation to 

the claimant of the deficiencies in the medical evidence, 

including any interpretation of medical opinion from a 

physician, that is not considered sufficiently wellrationalized to support the claim. 

c. Issuing the Decision. A CE cannot issue a letter decision 

accepting a consequential condition or a recommended decision 

denying a consequential condition without a preceding final 

decision accepting a primary covered condition. In those 

situations where a case is in posture for the CE to accept a 

primary covered condition and a potential consequential 

condition exists, the CE proceeds with the immediate release 

of a recommended decision for the primary condition. A CE does 

not delay issuance of a recommended decision accepting a 

primary covered condition while development occurs for a 

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consequential condition. However, if the case is in posture 

for concurrent acceptance of both a primary and a 

consequential illness, the CE includes both in the recommended 

decision. 

11. Impairment and Wage-Loss. Consequential conditions may 

cause additional impairment or wage-loss under Part E, but do 

not result in an additional lump-sum award under Part B. 

a. Impairment rating. An impairment rating assesses the 

functionality of the whole organ or system. The DEEOIC does 

not apportion impairment by disease (see EEOICPA PM 2-1300 for 

further discussion of impairment ratings). The effect of this 

methodology means that an impairment rating encompasses all 

illnesses causing damage to an organ system, so long as one is 

an accepted work-related illness. For conditions accepted as 

consequential, the CE determines if the acceptance of a new 

consequential illness requires action to initiate an 

impairment rating under Part E. If the CE is reviewing case 

evidence to make a decision on an initial claim for 

impairment, he or she includes all accepted primary or 

consequential claims in the assessment of impairment. 

(1) The acceptance of a consequential illness that 

involves an organ system previously included in an 

impairment rating will not trigger a new impairment 

evaluation if it is less than two years from the date of 

the final decision awarding impairment benefits. 

(2) For situations where a new consequential illness is 

accepted after an initial impairment rating has occurred, 

the CE proceeds with a new impairment rating if the 

consequential condition affects an organ system that was 

not previously evaluated for impairment. For example, the 

primary accepted condition is lung cancer. FAB issued a 

final decision one year ago to award a 50% impairment due 

to whole person impairment rating to the pulmonary system. 

A consequential illness is accepted for stomach ulcers as 

a result of medication required to treat the cancer. The 

CE may immediately proceed with a new impairment 

assessment because the consequential illness effects an 

organ system (digestive) that was not included in the 

prior impairment assessment. 

If the claimant’s treating physician or a CMC identifies a 

consequential illness during an impairment evaluation that is 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-1500 

 

Part 2 - Claims Consequential Conditions 

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not included in the SOAF as an accepted condition (regardless 

of whether or not it is included in the impairment), the CE 

contacts the claimant and asks if he or she wants to file a 

claim for the condition (refer to paragraph 3). If the 

claimant answers in the affirmative, the CE instructs him/her 

to submit a completed and signed Form EE-1/2. The processing 

of the impairment claim should not be delayed if the condition 

is for the same organ/body system. 

b. Wage-Loss. With the acceptance of a new consequential 

illness, the CE has to determine if sufficient evidence is 

present to undertake development for wage-loss. CEs calculate 

wage-loss using the first day that the employee lost wages due 

to the covered illness and/or consequential illness (see 

EEOICPA PM 2-1400 for further discussion of wage-loss). 

In certain instances, the consequential condition may be the 

initial cause of the employee’s wage-loss. For example, a 

claimant is approved for CBD due to beryllium exposure under 

Parts B and E. A year later, the claimant files a claim for 

pulmonary hypertension as a result of CBD. The medical 

evidence supports this finding and the assigned CE accepts the 

pulmonary hypertension as a consequential condition to the 

approved condition of CBD. The CE obtains evidence showing 

that the employee has had to stop work due to breathing and 

cardiac difficulties. The claimant is now entitled to wageloss benefits under Part E for any lost wages due to pulmonary 

hypertension. 

12. State Workers’ Compensation (SWC) Claims, Lawsuits and 

Fraud. For each consequential injury that is to be accepted, 

the CE may need to obtain a newly signed Form EN-16 

SWC/Tort/Fraud affidavit from the claimant. The EN-16 is valid 

for one year from the date of claimant signature for all future 

claims related to that consequential condition, including claims 

for impairment and wage-loss. 

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Part 2 - Claims Consequential Conditions 

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 Exhibit 1 

Page 1 of 2

Sample Listing of Medical Conditions 

with Likely Secondary Disorders 

Disorders secondary to Chronic Beryllium Disease (CBD) or its 

treatment due to steroid use (such as Prednisone) 

• Hypoxemia (low oxygen levels at exercise, rest or with 

sleep) 

• Airflow obstruction/wheezing (asthma-like presentation of 

CBD) 

• Right heart failure, Cor pulmonale 

• Pulmonary hypertension 

• Respiratory infections (Pneumonia, Acute Bronchitis) 

• Spontaneous Pneumothorax 

• Deconditioning secondary to chronic lung disease 

• Joint Aches (this is a symptom) 

• Hyperuricemia, Gout 

• Hypercalcemia/hypercalciuria 

• Granulomatous Hepatitis 

• Skin Nodules/Ulceration 

• Aggravation of sleep apnea due to hypoxemia of CBD 

• Weight gain 

• Elevated blood pressure 

• Elevated Cholesterol and abnormal lipids 

• Liver function abnormalities 

• Blood sugar change 

• Diabetes 

• Eye/vision problems such as cataracts, glaucoma, and visual 

acuity changes 

• Gastrointestinal conditions such as gastric reflux or 

peptic ulcers 

• Psychiatric or psychological conditions such as depression 

or anxiety 

• Skin problems such as thrush or other fungal infections 

• Metabolic changes such as folic acid depletion 

• Decreased immune response leading to infections and viruses 

SUPERSEDED • Decreased bone density leading to osteoporosis/osteopenia 
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-1500 

 

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 Exhibit 1 

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Disorders secondary to Silicosis 

• Hypoxemia 

• Right heart failure, Cor pulmonale 

• Pulmonary Hypertension 

• Deconditioning secondary to chronic lung disease 

• Progressive Massive Fibrosis 

• Silicotuberculosis 

Disorders secondary to prednisone treatment 

• Cataracts 

• Glaucoma 

• Visual acuity changes 

• Diabetes Mellitus 

• Osteoporosis 

• Osteopenia 

• Gastric reflux 

• Peptic ulcers 

• Elevated blood pressure 

• Elevated cholesterol 

• Abnormal lipid profiles 

• Sleep disorders 

• Weight gain 

• Myopathy, dermal atrophy 

• Increased intracranial pressure 

Other disorders 

• Oral thrush and other fungal infections secondary to 

inhaled steroids, immunosuppression 

• Folic acid depletion secondary to Methotrexate 

• Infections due to immunosuppression (bacterial and viral) 

• Post-herpetic neuralgia secondary to Herpes Zoster 

• Flare due to immunosuppression 

• Tinnitus – this condition is typically synonymous with 

sensorineural hearing loss. Tinnitus can be considered as a 

separate, stand alone condition or as consequential to 

SUPERSEDED

sensorineural hearing loss. 
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 Exhibit 2 

Page 1 of 3

Date Case ID: 

Employee:

 

Name

Address

City, State, Zip Code

Dear XXXXX:

This letter is in reference to your claim to receive medical benefits to treat your 

Lymphedema as a consequential illness resulting from the treatment for your accepted 

condition of breast cancer, under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA). 

Medical evidence includes a letter dated January 1, 2015, in which Dr. John Smith 

stated that you have been diagnosed with breast cancer and had to undergo a radical 

mastectomy. As such, you developed lymphedema as a result of your radical 

mastectomy. 

Based on Dr. Smith’s statement, the medical evidence is sufficient to establish that your 

lymphedema is a result of treatment for your covered illness, breast cancer and is 

accepted as a covered consequential illness under Parts B and E of the EEOICPA 

guidelines. Medical benefits are approved for the treatment of your lymphedema (ICD-9 

Code 457.1) retroactive to July 1, 2013, the date of filing for your breast cancer.

Covered medical services are payable in accordance with fee schedules and medical 

policy of the EEOICPA. The policy includes coverage of medical appointments, 

hospitalizations, appliances, supplies and drugs that are prescribed by a qualified 

physician and approved by the EEOICPA.

When you receive medical treatment you should show this letter to the medical provider 

you wish to designate as your treating physician and any other authorized medical 

U.S. DEPARTMENT OF LABOR Office of Workers’ Compensation Programs

Division of Energy Employees Occupational 

Illness Compensation – Jacksonville Office

DOL DEEOIC Central Mail Room

P.O. Box 8306

London, KY 40742-8306

Tel: XXX-XXX-XXXX 

SUPERSEDED
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 Exhibit 2 

Page 2 of 3

provider who may treat you for your covered illnesses. Most physicians, hospitals, 

durable medical equipment providers, and other health care providers will bill the 

EEOICPA directly so that you will not have to pay for medical treatment covered under 

the Program. To bill directly, providers must be enrolled in the program. For information 

about enrollment and billing procedures, providers may contact the Program at the 

address and telephone number listed at the end of this letter.

Note: If the EEOICPA pays less than the billed amount (in accordance with the fee 

schedule), you are not responsible for payment of the difference to a provider. 

Providers (and claimants) may submit requests for reconsideration of fee 

determinations in writing, with accompanying documentation to the address supplied at 

the end of this letter.

The EEOICPA will reimburse you for the cost of covered services/items that you have 

personally paid, providing that you submit appropriate documentation to the Program’s 

billing address. However, bills and requests for reimbursement must be sent to 

EEOICPA within one year after the end of the calendar year in which the service or 

supply was provided, or within a year after the end of the calendar year in which the 

condition was accepted, whichever is later.

To request reimbursement of medical expenses associated with treatment of your 

accepted illnesses you are required to complete and submit the OWCP-915 form, 

Claim for Medical Reimbursement. You should also complete and submit the OWCP957, Medical Travel Refund Request form with appropriate receipts when seeking 

reimbursement for travel expenses covered under the program. Both OWCP-915 and 

OWCP-957 forms (copies enclosed for convenience) include instructions for when you 

should complete these forms and the documentation required to process your request 

for reimbursement. 

All requests for reimbursement of covered treatment related expenses including travel 

are to be mailed to:

 Division of Energy Employees Occupational 

Illness Compensation

P.O. Box 8304

London, KY 40742-8304

If providers have questions regarding submission or payment of bills, or require any 

other medical bill program assistance, they may contact a representative at toll free 1-

XXX

SUPERSEDED -XXX-XXXX.
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-1500 

 

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 Exhibit 2 

Page 3 of 3

Sincerely,

_______________________ _____________

(Name) Date

Claims Examiner

_______________________ ______________

(Name) Date

Supervisor 

Enclosures:

SUPERSEDED