UNITED STATES DEPARTMENT OF LABOR

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ADVISORY BOARD ON TOXIC SUBSTANCES AND WORKER

HEALTH

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SUBCOMMITTEE ON WEIGHING THE MEDICAL EVIDENCE (AREA #2)

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MEETING MINUTES

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MONDAY,

DECEMBER 12, 2016

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

Eastern Time, Victoria A. Cassano, Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

LESLIE I. BODEN

KENNETH Z. SILVER

MEDICAL COMMUNITY:

VICTORIA A. CASSANO, Chair

STEVEN MARKOWITZ

CLAIMANT COMMUNITY:

DURONDA M. POPE

FAYE VLIEGER

OTHER ADVISORY BOARD MEMBERS PRESENT:
CARRIE A. REDLICH

DESIGNATED FEDERAL OFFICIAL:

CARRIE RHOADS
Introduction and discussion of findings of 14 Part E cases

Ms. Rhoads called the meeting to order at 1:06 pm. The members 

took turns discussing their Part E cases in detail and gave 

their general impressions. Member Markowitz began with a hearing 

loss case. It was clear from the EE1, the claim form and the CE

(claims examiner) form which acknowledges what the claim is, 

that the claim was about hearing loss. The industrial hygienist 

was asked to weigh in on the issue of solvents exposure and 

noise exposure, and the industrial hygienist produced a report 

in which he confirmed that there was exposure to solvents and 

noise for the requisite period of time, and ultimately the claim 

was then accepted. It never went to a CMC (contract medical 

consultant), presumably because it wasn't necessary. It wasn’t 

clear where the information for the solvents came from in the 

case file. The solvent-related hearing loss issue is that a 

person has to conform to one of the 20 job titles in order to 

have a claim be accepted. Member Markowitz said his only real 

question was how this particular job title ended up being 

compensated. It doesn't appear to conform with any of the listed 

job titles under the EEOICPA. 

Member Vlieger’s first claim centered around breast cancer with 

metastatic sentinel lymph nodes with a subsequent claim made for 

hypothyroidism and a consequential condition of a hysterectomy 

and diabetes. They did not discuss an alternative diagnosis. 

The three diagnoses were accepted by the claims examiner. 

Member Vlieger considered that reasonable because no evidence 

was provided for the other two. Member Vlieger thought not all 

the exposures and causes of conditions were evaluated, because 

they didn't actually look at chemotherapy as the cause of the 

diabetes or that it contributed to the hypothyroidism. Member 

Vlieger thought that some of the claim was done properly and 

some of it could have been done better. There were some claimed 

medical conditions that did not make it to the CMC and no one

knew why. In a lot of the documents the thinking wasn’t 

entirely clear. 

Member Pope’s first case was congestive heart failure and 

rheumatoid arthritis. The case was denied. The stopping point in 

the case was the slim amount of information. It appears the 

department used the SEM to try to make the connection to the 
health concerns which did not prove to be connected to the 

health concern and the claim stopped there. Chair Cassano said

it’s troubling to see that the ball sometimes gets dropped and 

nobody knows why. 

Chair Cassano’s first case was on ischemic heart disease and 

rheumatoid arthritis. The claim was remanded and then denied. 

The claimant did not initially provide medical documentation, so 

the department had to go back and ask for more medical 

documentation. The question is, were all exposures that might 

have caused the claimed condition evaluated? The claim was not 

sent to an industrial hygienist. It doesn’t seem like claims 

examiners are following the guidance because the guidance 

specifically says that the SEM is never to be used by itself to 

deny a claim. On cases that are uncertain, the claim should be 

reviewed by a CMC before denial. There could have been a little 

bit more involvement in the evaluation process in this case.

Member Silver’s first case was kidney cancer and TCE

(trichloroethylene). The claimant did not have an opinion from a 

treating physician or any other outside expert. But when DOL 

received the claim, they got a hit in the SEM for this person's 

job title and a renal carcinogen, TCE, being in the matrix in 

that period of time at the site. The claim was referred to an 

industrial hygienist who concluded that the employee had 

significant exposure at low levels. The claim was paid exactly a 

year from the time it was filed. So this is a success story for 

the SEM supporting a cancer claim. This was essentially a 

trainee who was at a gaseous diffusion plant for three months, 

judged to have low level exposure to TCE, but causation was 

found and it was compensated. Member Silver noted that this is 

like the way NIOSH handles Part B radiation claims. NIOSH talks 

about efficiency processes where if they can get to a decision 

on the basis of some of the facts, they close the claim and pay 

it.

Member Vlieger had a case on lymphoma and breast cancer. This 

particular one is from a facility that does not have a SEM, and 

in the documents from the Department of Labor, they stated that 

they searched the SEM and could find no toxins that the claimant 

could have been exposed to for the site. There was a definitive 

diagnosis by biopsy of the lymph nodes. Member Vlieger could
not find the biopsy for the breast cancer, but it was accepted 

in the statement of accepted facts that there was a biopsy and 

that the claimant did have these diagnoses. There was nothing 

in contention because the claims examiner did not find any 

toxins that could have caused either breast cancer or lymphoma.

This was an obvious case where the CE stopped at the SEM, went 

no further and the claim was denied.

Member Boden did one of his cases on diabetes, among numerous 

other conditions. This person claimed diabetes as well as 

multiple out conditions theclaimant contended they suffered: : 

colon cancer, lung cancer, cardiomyopathy, obstructive sleep 

apnea, hypertension, chronic beryllium disease and dyslipidemia.

There were no medical opinions regarding causation from any of 

the treating physicians involved. There was also no evidence 

that the claim was referred to an industrial hygienist, although 

the question of causation for the COPD might well have used an 

industrial hygiene evaluation. The colon cancer was never 

developed for this case. In reference to the claim for COPD, the 

district office in this case determined that the claimant’s 

exposure to nitrogen dioxide was heavy and extended and 

according to the SEM, nitrogen dioxide is a substance linked to 

COPD. But that exposure was not part of the charge to the CMC, 

and therefore wasn't considered. The claim was denied.

Member Markowitz had two more claims, one for Parkinson’s 

disease and sleep apnea. There’s no question that the person had 

Parkinson’s disease and sleep apnea. The claims examiner 

obtained a coworker affidavit, which is very useful because the

job title didn't necessarily translate to manganese exposure. 

The affidavit was relied upon by the claims examiner to confirm 

the exposure. The only question Member Markowitz had here was 

not one of process, but of outcome. He thought the sleep apnea 

was a stretch to link to either Parkinson's or the chemical

exposures. However, the toxicologist said that there was no 

epidemiological evidence that TCE causes Parkinson's disease, 

though that's not quite where the literature is at this point.

Member Pope talked about a bladder cancer case. The case was 

approved with the support of medical documentation. The claimant 

used a district medical consultant. Member Pope also noted that 
it seems the more support claimants have the better off they 

are.

Chair Cassano presented a colon cancer, breast cancer, and skin 

cancer (basal and squamous cell) claim. The claimant was a 

computer analyst and security escort to nuclear areas. The 

department only looked at radiation. She was not considered a

member of a Special Exposure Cohort. The department used IREP 

and found 11 percent probability of causation, but they did each 

individual cancer, and then they did them from multiple cancers. 

They did not look at any other exposures because the computer 

analyst job description is not listed in any SEM, and that was 

the end of the case. It was sent to NIOSH for a dose 

reconstruction, then for evaluations at IREP. It was not 

referred to a contract medical consultant. The reason for that 

was that the claimant was considered not to have been exposed to 

radiation. Again, all possible exposures present at a work site 

need to be evaluated, regardless of whether SEM is silent. In 

many cases, collateral exposure is experienced when individuals, 

work in, around or are traversing an area with known exposures.

Member Boden also had a meningioma and skin cancer case. The 

person was an explosives handler and machine operator from 1958 

to 1966. The diagnoses for both the skin cancer and the 

meningioma were supported by objective medical evidence. But as 

in all the other cases the committee talked about, there was no 

treating physician statement of relationship between the disease 

and occupational exposures. The CMC gave what seemed to be a 

reasonable report based on the questions that were given to him. 

He said that he did not think that there would've been enough 

exposure, and that some of the cellular changes that one might 

have expected were unrelated to machining oil exposure. Given 

the fact that the person had spent 50 years as a farmer it was 

unlikely that he could meet the more likely than not standard 

for the skin cancer. The meningioma was not developed. Why the 

meningioma was dropped at the point of the claims examiner is a 

mystery. 

Member Markowitz talked about a prostate cancer case. Prostate 

cancer was accepted under Part B. It met the threshold for 

probability of causation which means it was automatically 
accepted under Part E. The only issue was heart disease and a 

long-term chemical exposure; there was no question about the 

diagnosis. The medical records were nicely assembled. The whole 

issue of heart disease was not developed at all. There was

nothing from the treating physician. It wasn't sent to an 

industrial hygienist or a CMC. The SEM was explored and 

probably came up with nothing.

Chair Cassano reviewed a case on multiple immune disorders. The 

person was a lab technician. There was no other delineation of 

what kind of lab tech this person was. She did say in an 

occupational history questionnaire that she would take 

contaminated materials and laundry back and forth from the sites 

and do testing on various liquids to see if there was 

contamination. It was not clear exactly what process the 

claimant was talking about. Her other contention was anemia.

The only one that was evaluated was the anemia because the SEM 

was silent on all the others. It is unknown if she was working 

with organic solvents. Some autoimmune disorders, like

scleroderma, are associated with some organic solvents, but they 

only looked at anemia. The claim was therefore not referred to 

an industrial hygienist, but it was referred to a CMC only for 

the anemia. It turns out that her anemia was an iron deficiency 

anemia, so the CMC opined that it could not have been due to a 

toxic exposure, which is probably correct. The entire claim was 

denied for no evidence.

Member Boden said there seems to be some slippage in documents 

getting into the claims files and that many of the people who 

are filing claims are not really in a very good position to 

advocate for themselves. 

Discussion of training documents

Chair Cassano asked the committee to look at whether the 

training documents are complete, whether they have clarity, 

whether they are based on current scientific evidence and 

current policy, and also whether or not they have any gaps. The 

department does have basic framework training, and this training 

is put up on the document library. This training material

demonstrates the overall application of the process guidance. 

The department does have a huge volume of case-specific training 
because the training itself has to be applied. The committee 

thought that the claims process document was excellent. The 

documents were carefully put together and make it clear that 

when in doubt, one should lean toward the claimant. There is a 

document on the issue of causation that addresses aggravation, 

contribution and causation that should make its way into the 

training materials. The information that is initially collected 

by the claims examiner needs to go to the CMCs.

One of the frustrating things for claimants is when something is 

prescribed, the department requires that it be prescribed by a 

doctor. If a PA or a nurse practitioner does something, for 

example, home health or a medically necessary piece of 

equipment, the department defers back and requires that a doctor 

prescribe it. It was noted that the statute itself requires a 

qualified physician’s opinion. 

Member Vlieger asked if there was a list of diseases that the 

claims examiners have or some sort of play book that they're 

using so that they question some diseases and don't question 

others. Where are they making these decisions from? The 

committee expressed its desire that the CMC see the broader set 

of records to ensure that that person can capably answer the

questions that are being posed. It’s a safety net in case the 

claims examiner doesn’t provide everything that is needed. 

Member Markowitz said the question, “If the SEM is no longer 

going to be updated or even looked at for new data from Haz-Map, 

where are they going to get their occupational disease list from 

if they don't allow them to go outside the department?” would be 

a good one for the SEM committee. He said that from the cases 

reviewed by the committee, there was a clear use of the 

occupational health questionnaire and consultation with the 

industrial hygienists – not just an exclusive reliance upon the 

SEM. For Part E cases, there is an occupational questionnaire 

for every single case. 

Development of logistics and format for focus groups with Claims 

Examiners

The committee reiterated its desire to talk to people intimately 

involved in the claims examination process. It would be good to 

speak with actual claims examiners. Speaking to individual