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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES

AND WORKER HEALTH

+ + + + +

MEETING

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WEDNESDAY

SEPTEMBER 4, 2019

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The Board convened by teleconference 

at 1:00 p.m., Steven Markowitz, Chair, presiding.

PRESENT

STEVEN MARKOWITZ, Chair

MANIJEH BERENJI

JOHN DEMENT

KIRK DOMINA

GEORGE FRIEDMAN-JIMENEZ

RON MAHS

MAREK MIKULSKI

CARRIE REDLICH

KENNETH SILVER

CALIN TEBAY

ALSO PRESENT

DOUG FITZGERALD, Designated Federal Official

CARRIE RHOADS, Alternate Designated Federal 

Official

RACHEL LEITON, Director, DEEOIC

JOHN VANCE, Department of Labor
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CONTENTS

Review and follow-up on Advisory Board

Action Items from April 2019 Meeting .......... 7

Status of replacement of Dr. Cassano ......... 36

Follow-up on previous Board

recommendations .............................. 36

Review of Claims Data Provided by DOL ........ 38

Review of Claims Board ....................... 72

Consideration of any new issues

November Board meeting ...................... 140

Adjourn ..................................... 143
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P-R-O-C-E-E-D-I-N-G-S

1:11 p.m.

MR. FITZGERALD: Good afternoon, 

everyone, and thank you for your patience as we 

assembled the Board, we had some technical 

difficulties.

My name is Doug Fitzgerald, and I'd like 

to welcome you to today's meeting at the Department 

of Labor's Advisory Board on Toxic Substances and 

Worker Health. I'm the Board's Designated Federal 

Officer, or DFO. 

On behalf of the Department of Labor, 

I'd like to express my appreciation to the diligent 

work of our Board members over the past several 

months in preparation for this public meeting and 

for their forthcoming deliberations.

I also want to thank my colleagues here 

at Department of Labor for all their efforts in 

preparing for today's meeting, in particular 

Carrie Rhoads and the staff and Alternate CFO. 

And Kevin Bird and our SIDEM contract staff, who 

always do a great job putting these meetings 
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together.

As the DFO, I serve as the liaison to 

the Board in the Department. I'm responsible for 

ensuring all provisions of the Federal Advisory 

Committee Act, or the FACA, are met regarding 

operations of the Board. 

I work closely with the Board's Chair, 

Dr. Markowitz, and I'm responsible for approving 

the meeting agenda and opening and adjourning these 

meetings. I also work with the appropriate Agency 

officials to ensure that all relevant ethics 

regulations are satisfied.

We have a full agenda this afternoon, 

and it should be noted that agenda times are 

approximate. So we'll try as hard as we can to 

keep to those times, but we can't always promise 

to adhere to them exactly. Copies of all meeting 

materials and public comments are or will be 

available on the Board's website under the heading 

Meetings. 

The Board's website can be found at 

dol.gov/owcp/energy/reg/compliance/advisoryboar
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d.htm. Or you can simply Google the Advisory Board 

and FACA substances and worker health.

If you haven't already visited the 

Board's website, I encourage you to do so. You'll 

see there a page dedicated entirely to today's 

meeting. That page contains all materials 

submitted to us in advance of the meeting. And 

you'll also find today's agenda, as well as 

instructions for participating remotely. It 

should be noted that there is no public comment 

period scheduled for this full Board meeting today.

If you are joining by Webex, please note 

that the session is for viewing only and will not 

be interactive. During the meeting, I would 

request members be mindful of background noise in 

their locations, and to place their phones on mute 

when possible if you are not presenting or engaged 

in discussions with other members, since we're 

recording this meeting to produce transcripts.

I also want to remind Board members to 

exercise caution in discussing or referencing 

case-specific information and refrain from 
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divulging any personally identifiable 

information. That would also include names, 

injury sites, birth dates, and age. Please refer 

to any ages as a range, like late 40s rather than 

48 years old.

The FACA requires that this, the 

minutes off this meeting be prepared to include 

a description of the matters discussed and the 

conclusions reached by the Board. As the DFO, I 

ensure that the meetings are prepared and certified 

by the Board's Chair. 

The minutes of today's meeting will be 

available on the Board's website no later than 90 

calendar days from today, per FACA regulations. 

If they're available sooner, they'll be published 

before the 90th day.

Also, although formal minutes will be 

prepared because they are required by FACA 

regulations, we'll be publishing verbatim 

transcripts, which are obviously more detailed in 

nature. We will work to see that those transcripts 

are available on the Board's website within the 
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next several weeks.

And with that, Mr. Chairman, I convene 

this meeting of the Advisory Board on Toxic 

Substances and Worker Health.

Dr. Markowitz.

CHAIR MARKOWITZ: Thank you, Mr. 

Fitzgerald. This is Steven Markowitz, the Chair. 

I want to echo Mr. Fitzgerald's thank-yous to 

various people who have worked with us from DOL 

and otherwise to support the Board and to make this 

and our other meetings happen.

I want to welcome Board members, I hope 

you had a good summer. I want to welcome the 

public, whoever's participating. We're going to 

try, it's a little awkward, a teleconference. We 

prefer the face-to-face Board meetings, but we only 

have those twice per year, and we do this at other 

periods between, these face-to-face meetings, so 

that we can make progress.

We try through Webex to make as much 

as what we're discussing available for viewing. 

If you don't have access to Webex, it's also on 
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Board site, our website. But we'll try in speaking 

actually to be as clear as we can with reference 

to what we're discussing or the terms that we're 

using.

We will take a break for a few minutes 

roughly between 2:30 and well, anyway, between 2:30 

and 3:00. I should say that there are several 

Board members who are not here. Calin Tebay, just 

yesterday, not due to his own efforts, had some 

sort of hearing scheduled today, so he's going to 

be late to this meeting. 

And I got a recent text from Duronda 

Pope, who was called away to investigate a crush 

injury at the workplace of one of her union members, 

and so she mostly likely will not be here 

participating.

I also want to just recognize and thank 

George Friedman-Jimenez for participating today. 

I know there's been a serious illness in his 

family, and so we appreciate your efforts, George. 

Maybe you didn't have all that much time to 

prepare, but we always welcome your comments now 
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or in the future. So that will be good.

Unless there are any other comments by 

Board members, I just want to spend a minute on 

the agenda, and then we'll look over the items of 

the agenda, and then we'll start in on the agenda 

items. Any comments?

Okay, so you have access to the agenda. 

Anything that is omitted or anything you think 

that we should add? I'll, I'm going to actually 

add right at the beginning of the agenda just a 

very quick review of the public comments that have 

been submitted. 

Sometimes we, there is no public 

comment session at this Board meeting, and 

sometimes we don't get a chance to discuss or review 

the public comments. So I wanted to spend just 

a couple of minutes going over the few comments 

that we have at this time, and then we'll get into 

the other areas.

Okay, the public comments, there were 

just a few. All were, all but one is on our Board 

website, and the other one I will explain. It was 
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late in coming in. By the way, let me just say 

that DOL has done an excellent job posting 

materials for this Board meeting. Any slowness 

or lateness in getting the agenda or any of the 

materials for the meeting was due to me, not to 

the Department of Labor.

But in any case, so Ms. Vina Colley 

submitted several comments related to each other 

in June of this year, raising concern about 

exposure to neptunium at the Paducah Gaseous 

Diffusion Plant. Part of the concern was about 

the environmental exposure, which is not really 

the domain of the Board. But she also mentioned 

that there was perhaps unrecognized worker 

exposure at Paducah.

That relates to Task 1 of the Board, 

which is attention to the site exposure matrices. 

I did inspect the SEM for neptunium at Paducah, 

and I did find that there were a number of 

buildings, jobs and work processes associated with 

neptunium. I was last updated in June of 2018. 
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So my request to DOL is if any 

additional information that DOE might have since 

June 2018 is available, that DOL acquire that 

information and update the SEM if necessary. I 

should also think that DOL might suggest to Ms. 

Colley that she go through the normal route of 

submitting additional information to the SEM, as 

is on the DOL website.

Second comment came from someone named 

Robert Rothe. I'm not sure I'm pronouncing his 

name right. This had to do with Rocky Flats and 

a particular laboratory at Rocky Flats. And the 

comment was that there were some toxins missing 

from the SEM for Rocky Flats, and he listed a number 

of them.

I looked at some of them. I did find 

some information about those particular toxins in 

the SEM, so I'm not sure whether the SEM is complete 

or not. And I would make the same request of DOL, 

that they obtain any information from DOE or Mr. 

Rothe since their last update, which was in June 

2018, to update the SEM if it's needed.
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DOL might also write directly to Mr. 

Rothe, inform him of the, or remind him of the 

standard method of requesting information be added 

to the SEM.

Finally, there was a comment from Cody 

Wetier, I think it came in a just couple days, which 

had to do with removing a certain presumption from 

the procedure manual that DOL uses for the program 

between version 2.3 and version 3.0. 

The Board has discussed this issue, and 

I think it's going to be subject to the next agenda 

item, which is a followup on our action items. 

Because we have the, we made the same observations 

and requested an explanation background impact of 

this change in the procedure manual. So I'm not 

going to say more about that comment, other than 

I think that we'll return to it.

So that's it for the public comments. 

Let's move on -- any comments so far? Okay, so 

let's move on to the agenda item, the review and 

followup on our action items from our last meeting. 

And Ms. Leiton is going to lead much of this. 
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But the first item had to do with the, 

this issue on asbestos, which is that the previous 

versions of the procedure manual briefly stated 

that between 1957 and 1996, that it was assumed 

that certain job titles had significant but low 

exposure to asbestos. And secondly, the 

assumption was that everyone else at the facility 

also had some exposure during that time period.

I may not have entirely summarized that 

properly, that's from memory. But that section 

was struck in the more recent version of the 

procedure manual. So, Ms. Leiton.

MS. LEITON: Yes, I'm here, this is 

Rachel Leiton. We've been through these, so I'm 

just going to start with the, basically I'll 

probably go through the highlighted ones. We can 

take them order of, I've got an email from you with 

regard to these action items. That's from Carrie, 

actually.

And the first one is related to this 

asbestos presumption and the fact that we had taken 

off the one section. I believe the thinking was 
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that there are some that would need, for that period 

of time it would be better to have those evaluated 

by an IH on a case-by-case basis. But we realized 

that it did have this impact on the presumption 

because of the lack of the significant exposure 

which used to place those people into the 

presumption.

So we are actually looking at revising 

that language to clarify the matter, and that will 

be published in our next publication of the 

procedure manual that should be out by the end of 

this month.

CHAIR MARKOWITZ: And do you think 

you'll restore most of the old language?

MS. LEITON: I don't know that it will 

be restored exactly, but I think that we will, 

because I think there's a certain, we believe that 

after a certain date, and we've discussed this date 

many times, that it's going to vary depending on 

case. 

So the language about the presumptions 

is being evaluated to determine if that whole 
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period for all those should be exactly as it was, 

or should some of those be referred for an IH. 

So that's what we're deliberating on now.

CHAIR MARKOWITZ: Okay.

MS. LEITON: All right. The second 

question here I think we already answered. This 

was about the process for the Board to refer issues. 

It finds while reading over cases, you had 

indicated in the last meeting that you wanted to 

be able to let us know if you saw specific things.

And I think, Dr. Markowitz, you were 

going to work out a process for that?

CHAIR MARKOWITZ: Yes, I have some 

ideas. But later in this meeting I want to share 

them with the Board, and we can come to a decision 

about that.

MS. LEITON: Okay, great. So number 

three, the question is regarding the EEOICPA claims 

that may have been reopened as a result of the Board 

recommendations, could DOL provide a description 

by specific condition, personal diagnosis instead 

of doing three broad categories.
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So we did submit to you the chart that 

we had, well, so it was a chart that we had 

originally submitted to you about these cases that 

we had a list of. I think you probably have them 

now on your website. But it's been updated. 

We originally had grouped it into three 

groups. One was mesothelioma, ovarian cancer, and 

pleural plaques. Group two was hearing loss, 

bladder cancer. And Group three was lung cancer.

So what we have done is we provided you 

a list, and this was something that we gave you 

separately than anything that would be online, 

because it had PII. But we gave you a breakout 

of all those. They haven't been summarized by 

specific conditions, but they're all in there in 

terms of which conditions are which in our detailed 

summary.

We have completed since that time, 

we've completed all of them. I can get you the 

details behind our latest report, which is the one 

that shows that we have 100% review. But the one 

that we already submitted I believe was the 
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original list from when we submitted that to you, 

4/20/18. And we'll make sure that you get any 

details behind our most recent updates.

That, again, is going to be the detailed 

listing. We grouped them this way for ease. They 

can be broken out, I think if you look at those 

Excel spreadsheets, in more detail, as much detail 

as you want.

CHAIR MARKOWITZ: This is Steven 

Markowitz. So Kevin, can you put up the two tables 

that have been recently provided that do not have 

PII that we can share. Because I just want to see 

if we're talking about the, you know, same thing. 

There were two in particular.

MS. LEITON: The one I'm talking about 

right now is the one with those conditions. It 

says at the top illness and group on the lefthand 

corner. That's the other one. That's the right 

one.

CHAIR MARKOWITZ: Okay, so this is, 

this was the one with broader groups that was 

supplied some time ago that, after which we 
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requested breakdown by the individual diagnoses. 

Is that what you said, you were saying?

MS. LEITON: Yes, yeah. But this one 

we've updated, the numbers have been updated 

because we reviewed all those cases. We had not 

reviewed them all when we last submitted this 

chart. So that when we submitted it back at the 

last Board meeting, we'd only done a certain 

percentage of them. 

Now we've done all of them, so it shows 

100% reviewed and the actual numbers that have been 

reopened by district office. This is not broken 

out further, but the detailed spreadsheet that I 

provided does break them down. All I need 

to do with that spreadsheet is update it to match 

these figures in terms of it gives you the breakout 

of all the cases that we reviewed by condition, 

but it doesn't, I don't believe it has been updated 

to reflect which cases were reopened on that list. 

We can do that. But it does provide the breakout.

CHAIR MARKOWITZ: So the other tables 

are listings of individual cases, right?
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MS. LEITON: Yes.

CHAIR MARKOWITZ: Okay. So is, have 

you aggregated those individual cases by 

diagnosis? So for instance, between the table 

which shows the individual cases and what we're 

looking at now, one might aggregate the ovarian 

cancer cases. One might aggregate the 

mesothelioma cases and present those, the six 

different illness categories.

MS. LEITON: Yeah. I mean, that can 

be done from the detailed list. We have not done 

that at this point. We provided the background 

list that can be sorted however you want to sort 

it. I think I have, I think we could add to it. 

The most updated numbers in terms of 

what's been reopened and what hasn't I'll have to, 

you know, we can look into breaking it out. But 

it can be, again, if you have, since you have the 

detailed list you can break it out however you want.

CHAIR MARKOWITZ: Sure.

MS. LEITON: Using the spreadsheet.

CHAIR MARKOWITZ: Okay, and then just, 
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this is Steven, just to make sure we understand 

this. In the orange, all district offices, the 

total, total reopened for the various groups is 

26 plus 19 plus 50, which is, it's 95 out of a total 

number which is in the first orange column, which 

is close to 2000. So about, looks like by my eye, 

about five percent of cases in these various 

categories have been reopened.

MS. LEITON: Yeah.

CHAIR MARKOWITZ: Actually, that's not 

a question.

MS. LEITON: Okay.

CHAIR MARKOWITZ: It's just 

interpretation, that's all.

MS. LEITON: Yup.

CHAIR MARKOWITZ: Are there any --

yeah, go ahead.

MS. LEITON: Just keep in mind that, 

you know, we reviewed them all, any cases with these 

conditions. So some, you know, may have been 

denied for other reasons, and that may be why it 

wouldn't have been reopened, based on the 
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presumptions. But we did review them all for that 

reason. That's probably why the percentage is 

low.

CHAIR MARKOWITZ: Right. Any 

comments from the Board members? Okay, you sent 

us some other, at least one other table that I know 

we can share. I'm not sure it's with reference 

to this section.

MS. LEITON: It's the reference to the 

next question.

CHAIR MARKOWITZ: Okay.

MS. LEITON: So the next, are we ready 

for the next response?

CHAIR MARKOWITZ: Sure.

MS. LEITON: Okay. So the next one was 

how many cases are referred to an IH. And in my, 

in our last meeting I had indicated we had a new 

report on this. I'm providing that report. This 

report is from 2018. It is for all of 2018. And 

it shows, I had indicated last time that it was 

26%, I was going to double check it. That is still 

the correct amount.
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These breakouts are what we looked at, 

accepted only, denied only, and accepted and 

denied, which could be it was partially accepted, 

partially denied. And so basically it shows this 

percentage of 26%. 

It is kind of low, but then when we went 

back to look at these, I mean, a lot of them could 

have been denied because of a, they didn't have 

enough medical evidence, there wasn't, you know, 

insufficient evidence to support employment. So 

they could have been denied for a number of other 

reasons besides the causation or exposures 

elements. 

And for acceptances, you'll see that 

acceptance only without a prior IH, there were like 

89% of them that were accepted without that, which 

just meant that we had enough evidence already. 

So these are the chart we have. 

I would expect that in 2019, that will 

go up a little bit, because we did have training. 

John Vance and his team went out and did some 

training in all the district offices face to face 
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this year, just to go over, you know, what should 

be referred to an industrial hygienist, what kinds 

of things they should look at when they are not 

referring it to an IH, like, you know, anything 

submitted by the claimant. Going back to the 

training, position, things were that where all 

discussion is training.

But there was, you know, emphasis on 

make sure you refer to an IH if believe you need 

to. So this might uptick a little bit, but it's 

generally, it's accurate. And we could probably 

at the end of this fiscal year, I would think we 

could easily update this for fiscal year 2019 

figures.

CHAIR MARKOWITZ: This is Steven, I had 

a question. What does accepted and denied mean?

MS. LEITON: It means that we accepted 

a portion of the case but not another portion of

it. So for example, they filed for three 

conditions, we accepted two of them, we did not 

accept the other.

CHAIR MARKOWITZ: Okay. So my 
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interpretation of this is that among a very large 

number of accepted cases, almost 7000, only 12% 

were, of the claims was there a need to refer to 

an IH. And among the denied cases, over 5000, 

about 15% of the time there was need to refer to 

the IH. In other words, use of IH actually was 

similar between accepted and denied cases. 

One thing of interest, we'll have to 

figure out whether we, the Board wants this 

information, but since you mentioned that there 

are so many reasons for denial --

MS. LEITON: Yup.

CHAIR MARKOWITZ: That the issue of 

whether referral to an IH is appropriate or whether 

it's happening often enough, as you alluded to, 

the cases in which there's denial on the basis of 

not covered employment or some other 

non-causation, non-exposure issue, if you remove 

those and just looked at the cases in which the 

issue was that of questions about exposure or 

question of causation, and then looked at the 

proportion of times that IHs get involved with 
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those cases, that would be more informative to you, 

I think, in terms of the information value that 

the referral process, if that, if I'm 

understandable.

MS. LEITON: Yeah, I understand what 

you're saying. It's not always that easy for us 

to do that. We can't always attach a -- because 

we have multiple decisions per case in some 

instances. So determining which decision was 

impacted by -- so at one point it might have not 

enough medical evidence. Later, it might have not 

enough employment. Or then it has both and it's 

causation. 

Our data is not clean enough for us to 

maybe break it down that far. I'm not a data 

connoisseur, so I would have to check. But I 

understand your point, I'm just not sure we are 

able to break it down that way.

CHAIR MARKOWITZ: Right I --

MS. LEITON: Because -- yeah.

CHAIR MARKOWITZ: Claims, if we looked 

at some claims, we understand the complexity.
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MS. LEITON: Yeah, sure.

CHAIR MARKOWITZ: So any Board, any 

comments or questions? Okay, then let's move on.

MS. LEITON: Okay, so the next 

question, number five, is there was some discussion 

last time about the industrial hygienist being able 

to speak to the claimant -- speak to a CE at least, 

or speak to the claimant. We indicated we would 

be able to allow that with CE involvement. 

I unfortunately thought that that had 

been incorporated in our procedures, but it has 

not yet. It will be incorporated into our latest 

update, which is due out the end of this month.

CHAIR MARKOWITZ: And when will it 

start?

MS. LEITON: As soon as those 

procedures come out.

CHAIR MARKOWITZ: Okay.

MS. LEITON: But I don't think there's 

ever been any prohibition on it. I mean, there's 

been a prohibition against talking to contractors, 

but if an IH had ever wanted to have a claimant 
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on the line and had requested it, the only 

restriction would be we'd probably have to a fed, 

the IH federal person ask the question or be on 

the line. And we'd need the CE on the line, which 

is something we've talked about or put in our 

responses in the past.

So you know, if an IH really wanted to 

talk to a claimant, they could make it happen. 

But just we haven't gotten that kind of request 

as of yet. But we will definitely put it in our 

procedure manual make it so that it's very clear.

CHAIR MARKOWITZ: And the contract 

with Banda, the contractor who does the IH 

evaluations is able to accommodate this?

MS. LEITON: Again, I would have to, 

we have to need, we need to work out the whether 

they have to ask the question of our industrial 

hygienist to ask it, or whether the industrial 

federal hygienist has to be on the line. Those 

are things that we're trying to clarify on the 

contract. I do know that it can be IH to claimant 

with a CE involvement. It may have to be 
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contractually the federal IH that asks it.

CHAIR MARKOWITZ: The IH evaluations 

or the text of those is mostly written by a 

contractor industrial hygienist, right?

MS. LEITON: They write them and our 

federal employee's IHs review them before they are 

sent out.

CHAIR MARKOWITZ: So it's a little bit 

uncertain whether it's the federal IH who will be 

permitted to speak with the claimant or whether 

it could involve the contractor IH.

MS. LEITON: Yes.

CHAIR MARKOWITZ: You know, my only, 

the only reason I focus on that is I'm concerned 

the contractor IH is essentially, you know, doing 

the sort of the initial work of the exposure 

evaluation, and I understand it's reviewed and 

approved by the federal IH. But it's that assembly 

of the original pictures in the evaluation that's 

probably the most important, meaning the 

contractor IH. And so permitting that person to 

do that would probably be very valuable.
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MS. LEITON: I understand. But yeah, 

I can't, we have certain contractual obligations, 

and I'm not really sure that that's something that 

would be allowed. But again, if they have a 

question, they can talk to our IH and get that IH, 

federal IH, to get the person on the line and ask 

that question.

I know the back and forth is what you're 

saying would be more valuable. Again, we have 

certain contractual obligations and laws that we 

have to follow, so I'm not sure we can allow that. 

But I will find and make sure that you're aware 

of exactly which direction it goes.

CHAIR MARKOWITZ: Okay, great. 

Actually, I'm not referring to back and forth, I'm 

referring to the fact that the person who's 

actually sitting with the occupational health 

interview, with the EEIII , with the SEM, with all 

the original data and writing up that IH report, 

it looks like it's the contractor IH. 

And that's the person who would be in 

the best position to, and have the most motivation, 
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to actually tease out the exposure, and 

particularly with reference to intensity and 

duration. And so it would be very helpful if the 

contractor IH could be included in the process. 

But I think I've made my point.

MS. LEITON: Understood.

MEMBER DEMENT: This is John. I have 

a question as a followup. Given, you know, given 

the potential for just the federal IH to ask 

questions --

MS. LEITON: Yes?

CHAIR MARKOWITZ: John, if you're 

still speaking, we can't hear you. 

MEMBER DEMENT: Okay, I just don't know 

how many IHs are on the federal side of DOL.

MS. LEITON: We have two.

MEMBER DEMENT: They could be very busy 

if there's many questions.

MS. LEITON: It could be if there are, 

yes.

CHAIR MARKOWITZ: Well, you know, when

we discuss claims, we're going to talk about the 
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IH evaluations. So I think we'll probably get back 

to this point and why it's important to us. Any 

other comments from the Board? Okay, any other 

comments, Ms. Leiton, from, on this issue?

MS. LEITON: Well there's -- no.

CHAIR MARKOWITZ: Okay, okay.

MS. LEITON: So there are two, three 

-- numbers six and seven are, I'm just going to 

stick to the ones that are actually questions for 

us. 

CHAIR MARKOWITZ: Sure.

MS. LEITON: So that's number eight. 

And this is a question about the, he says, Dr. 

Markowitz requests clarification on the new CMC 

policy that was only given to DOH CMCs and not to 

private practice specialists, as discussed in the 

comments from Terrie Barrie.

So given that we have a contract with 

CMC, there are certain guidelines they must follow 

regarding receiving referrals, writing their 

reports, sending in their reports, and billing DOL. 

So these guidelines are appropriate for us to send 
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to the contractors in compliance, to gain 

compliance with the contract.

It wouldn't be appropriate for us to 

send those same guidelines out to treating doctors, 

claimants' treating doctors. You know, the 

procedures and the guidelines that are followed 

in terms of what is causation, all of those 

definitions are the same ones that we apply for, 

that are in our procedure manual. Any guidelines 

that are given to the contractor regarding our 

procedures are not outside of the scope of what 

we already have out there to the publically 

available.

When we deal with treating physicians 

of claimants, we will deal with them on an 

individual basis. So we would ask certain 

questions of a doctor who's treating a claimant 

of ours, certain questions that are related in that 

claim. The guidelines we're giving CMC, they're 

like, some of them are procedurally related to like 

the administrative side that I discussed. 

The rest is it's, if the contractor 
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itself rewords any of our procedure manual, it's 

reviewed by us but it's the same content. There's 

no separate, new, different kind of content that's 

given to the CMC that is not given out to the public.

CHAIR MARKOWITZ: Okay, thank you.

MS. LEITON: Okay. And I think that's 

the last of the questions I had on this followup 

action from the last meeting.

CHAIR MARKOWITZ: Yes, it's true. So 

just for the rest of the call, will you or Mr. Vance 

be on the call just in case questions arise?

MS. LEITON: Yes.

CHAIR MARKOWITZ: Okay, great. Let me 

then go over the other items. Number six, which 

is that Dr. Berenji helped with assembling a 

summary of recommendations. She'll be happy to 

know that that was done, that Ms. Rhoads and Mr. 

Fitzgerald's going to review the followup on the 

previous recommendations.

But here I got a question for Ms. 

Rhoads. Did we post or can we post that 

recommendation status on our website?
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MS. RHOADS: I haven't. I can see if 

I can.

CHAIR MARKOWITZ: I'm sorry, I 

couldn't hear you.

MS. RHOADS: Sorry, it has not been 

posted on the website yet. I can see if I can do 

that.

CHAIR MARKOWITZ: Okay. Yeah, I mean, 

it's our preference to do that.

MS. RHOADS: Okay.

CHAIR MARKOWITZ: Because then we can 

all look at it and see where we're at, and the public 

can access that as well. So that would be a 

request. I understand they require some 

modification from what it was, but on the list.

Item seven was we requested claims for 

four lung conditions, and DOL has provided those 

with, us with those claims. We're going to review 

some of those later.

Item nine was the Board requested that 

there be someone from DOL at all of our meetings 

going forward, which is the, is being complied 
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with.

And item ten is we're getting to the 

next meetings. And we're going to discuss that 

later for the next meeting later in the agenda.

So let's move on. What is the status, 

Mr. Fitzgerald, of the replacement of the Board 

member who dropped out, Dr. Cassano?

MR. FITZGERALD: I can probably 

address the two items that I'm on the agenda to 

speak. That would be the replacement of Dr. 

Cassano, as well as the Board recommendations.

Well, these two issues are pending, as 

you probably realize, due to circumstances beyond 

our control with the departure of Secretary Acosta. 

So those are kind of caught up in the transition 

process here in the Office of the Secretary right 

now. 

So nomination has been made, a 

recommendation has been made to fill that position. 

And I believe the program has responded to the 

recommendations, and those comments are pending 

review in the Office of the Secretary right now.
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CHAIR MARKOWITZ: I'm sorry, our prior 

recommendations are pending a response from the 

Department, in the Secretary's Office, is that what 

you said?

MR. FITZGERALD: That is correct.

CHAIR MARKOWITZ: Okay. So it's hard 

to predict the timetable, I guess.

MR. FITZGERALD: It is, and it's really 

I think at the discretion of the Office of the 

Secretary. I think that the desire is to give a 

new, incoming Secretary an opportunity to make an 

appointment or to certify those recommendations. 

I think everyone's expectation and hope is that 

that replacement of the new Secretary will happen 

expeditiously, and then we can move forward.

CHAIR MARKOWITZ: Okay. Comments, 

questions from the Board? Okay, so let's move on. 

We're going to talk about the data 

tables that have been provided by DOL. And Kevin, 

if you could bring up the first one. These are, 

by the way, these are available on our website and 
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were sent around to the Board members over the last 

few days. 

The first one we want to look at is 

called the major disease data request, that is 

tables from DOL. The first one on our list. By 

way of background, and while Kevin is bringing this 

up, we requested data from DOL on the 20 most common 

accepted conditions overall. And then the ten 

most common accepted cancers, neurologic 

conditions, renal conditions, and respiratory 

conditions.

We also requested similar data on 

denied claims, and then a table we'll look at in 

which I took the data from the other tables and 

calculated the proportion of claims that were 

accepted. So we've, okay. Now, this is -- oh. 

Okay, sorry about that.

So we're looking at initially the top 

ten cancer codes. And on the lefthand you see the 

ICD, the International Classification of Disease, 

-9 codes. And on the righthand of the table, you 

see the ICD-10 codes, and the dates that were for 
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these are approved claims under Part E, and the 

dates are 2013-2019.

Let me explain that I guess there was 

some question on my part how these ICD-9 and ICD-10 

claims related to each other. The ICD-9 claims 

are from a period of 2013 until near the end of 

2015. And then at the end of 2015, you should keep 

that table up if you could, near the end of 2015, 

DOL started using ICD-10 to code the illnesses.

So these are mutually exclusive claims 

from two adjoining time periods, 2013 to most of 

2015, and then 2016 to the present. On the, I only 

learned that recently. I mostly focused on the 

ICD-10 codes. But in fact if you go back and forth 

and look at 9 versus 10, the tables of ICD-9 versus 

ICD-10, you see they're very similar. And so 

focusing just on ICD-10, for our purposes, probably 

suffices.

The, what you need to remember on the 

cancer Part E claims is that when a cancer claim 

is rated under Part B, it is automatically, and 

it's accepted under Part B, it is automatically 
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accepted under Part E. So those numbers we're 

looking at here, there's like Part E cancer claims, 

some of which were inherited from a successful Part 

B claim, and some of which were Part E only claims. 

And one of those things that I suggest 

we request is a replication of this table with Part 

E only claims. Because those claims would be made 

in relation to supposed toxic exposures, and that 

would fall within the domain of this board, not 

the Radiation Advisory Board. Does that make 

sense?

And so when we look at cancer claims 

here in the top ten and then when we look at the 

top 20 health conditions, you'll see there are a 

number of cancers that make that list. You have 

to keep in mind that that's really a mix of Part 

B and Part E claims.

On the ICD-10 cancers, this is from the 

data that DOL gave us. You'll see under the text 

description a few oddities, like the number two 

item is malignant neoplasm of the left main 
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bronchus. And then you don't find anywhere the 

right main bronchus. 

So I think what happened was that 

someone who uses the text for the code took a very, 

very specific ICD code as opposed to a, more of 

a broader range. What should have happened, I 

think, is that the second column, in the table on 

the right, the ICD-10 category code, broader code, 

B-34, C-34, etc., probably is more appropriate than 

the code range which is shown in the fourth columns 

on the right.

So that said, Kevin, let's move to the 

next table, because what I did was, and this is 

the one that says ICD-10 updated, is I took the 

text description of these categories and made it 

more sensible. And if we could go -- is there a 

tab with the ten cancers? 

Okay, in any event, you couldn't get 

there. Okay, well, yeah, maybe in a moment. 

Yeah, that's good, we can work with this one. 

Okay, yeah, we can work with this one.

So before, we were looking at the top 
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ten cancers, and here we're looking at the top 20 

health conditions overall, Part E, same time 

period, 2013-2019, focus on ICD-10, which is where 

I made the text more recognizable. And you see 

in these top 20 health conditions, about eight of 

them are cancers. For some people on the phone, 

where it says malignant neoplasm, that means 

cancer. 

So then almost half of the top 20 health 

conditions are cancers. Again, those are, some 

of those came under Part B and others came only 

under Part E. But they're now all under Part E. 

But I want to focus on the non-cancers.

This is information that we've been 

wondering about for some time, which is what 

constitutes much or most of the work of the claims 

examiners. And we can see by the number of, 

setting aside the cancers, COPD is the leading 

approved condition, 2013-2019, 811 cases. 

Now, silicosis is a Part B and Part E disease. 

So it's similar to cancers in the sense of if it 

was accepted under B, Part B, it would be accepted 
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under Part E for a couple of DOE sites in 

particular. So you have to remember that whenever 

you see silicosis in this table.

And then we get to other interstitial 

lung diseases, 468 cases. And then the only 

condition which is not a lung disease or a cancer 

in the top 20 is the bilateral hearing loss.

Moving on down, we see asthma. And 

then we see asbestosis. So one thing of interest 

to me is that we have silicosis above, we have a 

line for asbestosis. But we have a lot of, quote, 

other interstitial lung diseases, end of quote. 

A lot of those cases, which is interesting because 

a priori I would have thought that many of the 

interstitial lung disease cases would have shown 

up in the rubrics of silicosis and asbestosis. 

But that's fine.

We also, if you go down the list 

skipping over the cancers for the moment and we 

go to encounter for a screening for respiratory 

disorders, a sizable number of claims. This looks 

like a, kind of a catch-all category, which 
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probably is not COPD, probably is not emphysema, 

probably is not asbestosis or silicosis. So it 

would be interesting actually to know about that.

And then pleural plaques, which of 

course is specific to asbestos exposure. And 

then, again, a sizable number of unspecified 

pneumoconioses. And that could be I guess mixed 

pneumoconiosis or the like.

Any comments? I mean, we were going 

to go down to the next table, the top ten 

respiratory, where we see much of the same thing. 

But any comments at this point?

MEMBER FRIEDMAN-JIMENEZ: Hi, this is 

George, I have a question. Can you hear me?

CHAIR MARKOWITZ: Yeah.

MEMBER FRIEDMAN-JIMENEZ: Okay. I'm 

looking at the hearing loss. I know there's a 

change from ICD-9 to -10, but there were 726 hearing 

loss NEC in ICD-9, and 444 conductive hearing loss 

bilateral in ICD-10. 

Now, those are approved conditions, and 

typically occupational hearing loss is sensory 
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neural, not conductive. And I'm wondering how, 

what's going on with the changing of categories 

and the naming of these categories?

CHAIR MARKOWITZ: Yeah, this is 

Steven. I don't have any insight other than, you 

know, we kind of have to actually look at the 

specific ICD codes. Both in 9 and 10 they give 

a code range, and so the text descriptions tend 

to be kind of -- well, we should be aggregated, 

encompassing the entire code range. 

But I don't know whether the text 

description actually represents the entire code 

range, or one specific code within that range. 

That's what I'm saying.

MS. LEITON: Dr. Markowitz, I don't 

think that you should rely on the description, but 

I think you need to rely on the range, as you had 

indicated, I believe that's where you're going. 

You know, since there is a range and we went by 

a range, they probably picked one and put it in 

there. The data people aren't always aware of so 

much of -- it's like we don't accept conductive 
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hearing loss.

As Dr. Jimenez said, that's not 

something, because it would be sensorineural 

hearing loss. And so this description in and of 

itself, they probably picked one and put it in there 

because there's a range. But it should be 

sensorineural hearing loss.

CHAIR MARKOWITZ: Okay, thanks, yeah 

that makes sense. If we work with these table 

further, I think we should probably ask DOL to 

confirm when we translate the text into what we 

think is, you know, the correct categories, just 

to confirm that that's what they had in mind.

MS. LEITON: Yeah, I mean it's very 

challenging, yeah. That's fine.

CHAIR MARKOWITZ: Other comments on 

the top 20? So let's go down to top ten 

respiratory. Now, I made no attempt to aggregate 

the apparently related categories in the top ten 

respiratory. In fact, I also did not change the 

ICD tag, code at all. I mean the text description. 

Because these are recognizable enough. 
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Some of us want, would want to take the 

first listing, COPD unspecified, and take the last 

listing, emphysema unspecified, and they represent 

pretty much the same condition. We probably want 

to aggregate them. Similarly, with other asthma 

and with unspecified asthma, we want to do the same 

thing.

But in any event, I just left it as it 

is, just so we could look at what DOL produced and 

understand sort of the magnitude of the issues 

here. A lot of COPD and emphysema claims accepted. 

There were numbers denied, you know, there were 

all numbers for accepted. And a fair number of 

dust-related diseases accepted as well.

In the top ten, it looks like there are 

about 250 asthma cases. There may be additional 

asthma cases, and they'll be on the top ten and 

have other ICD codes, I don't really know. But 

this gives us some sense of what the claims 

examiners are approving.

I'm going to show another table where 

we look at approved and denied and we can make more 
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sense of it. Comments? Okay, let's continue to 

neurologic ICD-10 codes.

You know, the top one is obstructive 

sleep apnea, which raises the issue of is the, we're 

not distinguishing in these tables between what 

is a primary claim, meaning a claimant is saying 

that their obstructive sleep apnea is due to some 

toxic exposures at DOE, from secondary claims to 

like, who are saying that I have obstructive sleep 

apnea, it may be related to some other condition 

which has been approved by DOL as part of the claims 

process. 

That would be a secondary condition. 

So we didn't ask them to separate that out. I'm 

guessing that this is more secondary than primary, 

but we could ask.

MS. LEITON: Sleep apnea definitely 

would be, just by the way.

CHAIR MARKOWITZ: What's that?

MS. LEITON: We've accepted a lot of 

sleep apnea cases based on, because they're kind 

of consequential to something else.
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CHAIR MARKOWITZ: Okay, 

consequential, right. Otherwise, what you see 

mostly is Parkinson's disease and neuropathy. 

Many different synonyms for various neuropathies. 

You know, and if you add them up, you'd probably 

get over 100, meaning that it's probably second 

to sleep apnea versus Parkinson's disease. 

But not clear whether some of these 

neuropathies might be secondary or consequential 

conditions, or whether most of them are primary. 

From an occupational medicine point of view, it's 

not surprising to see neuropathy from toxic 

exposures.

Comments? And then to renal is the 

last one I think we have. And here, we're just 

getting synonyms from chronic kidney disease. 

Almost nothing specific, broken down by stages. 

I don't really understand that. Is, are the 

claims categorized by stage, Ms. Leiton, in the 

claims?

MS. LEITON: We normally will take 

diagnosis code. I mean, sometimes we'll have a 
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diagnosis code from the treating and/or in other 

cases, with the ICD-10 it's so specific that it 

makes you break it down by this. 

So I think the claims examiners can 

either get that information directly from the bills 

or from the doctors themselves who were providing 

these diagnoses, or they'll look at the medical 

evidence and they'll put one of these in there based 

on what they see in the medical evidence. 

But again, since ICD, ICD-9 was a little 

bit more flexible. You just put in kidney disease. 

Now, it says you have to put in the, to the stage 

of what it is. So it's a little bit challenging.

CHAIR MARKOWITZ: Okay. I mean, from 

a causation point of view, we're looking at 160 

or so cases of chronic kidney disease.

MS. LEITON: Right.

CHAIR MARKOWITZ: Comments, 

questions? Otherwise we'll go on to the ICD-10 

updated approval percentages.

MEMBER SILVER: Ken Silver. Some of 

those renal cases will be uranium mill and 
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transport workers approved under RECA and now 

getting Part E benefits under this law I think.

CHAIR MARKOWITZ: That's interesting. 

So Ms. Leiton, these numbers would include RECA 

claims?

MS. LEITON: Yes, we did not exclude 

them.

CHAIR MARKOWITZ: Okay, okay, good 

point. So hopefully, okay, Kevin is putting up 

the approved percentage. If we could go back to 

the first set at the top, warning conditions or 

the cancer or respiratory, that would be good.

MR. BIRD: Dr. Markowitz, sorry, what 

are you looking for? Or are you looking for the 

new document?

CHAIR MARKOWITZ: So what I'm looking 

at it says top ten renal, right, approve/deny. 

Is that what you're seeing, Kevin?

MR. BIRD: At the bottom of that

document we were just looking at, or are we opening 

a new document?

CHAIR MARKOWITZ: Well, okay. The --
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MR. BIRD: What we're looking at now 

is a new document.

CHAIR MARKOWITZ: What does your 

screen show? I'm seeing top ten renal 

approve/deny federal claims.

MR. BIRD: Yes.

CHAIR MARKOWITZ: Okay, so I do want 

the approve/deny table, but not the renal, I want 

-- that's the original table. The file says at 

the end approval percentage, that's what we want 

to look at.

MR. BIRD: Yes, that's the document 

we're in currently. There are several tabs within 

that document.

CHAIR MARKOWITZ: Right, okay, that's 

good. Okay, well, we can stop there.

MR. BIRD: Okay.

CHAIR MARKOWITZ: Okay, so here I 

combined a couple tables, and I excluded cancer 

claims for the moment because of the Part B, Part 

E issue. And so we can look here, what's new is 

that we're looking at approved and denied at the 
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same time from the same time period, 2013-2019. 

And we can look at the percentages approved for 

selected conditions.

Now, you'll see there are a bunch of 

non-available in the A on this. And if it's on 

this, that means that that condition was not in 

the top ten approved or denied, so that we don't 

have those numbers. I think the next data request 

will be to have those numbers. So what that means 

is for instance, for silicosis, there are 546 

approved. 

There was a number presumably denied, 

we don't have that number. If it's below the top 

ten, that means it was probably less than 100. 

But that's, you know, conjecture, so we're just 

going to ignore that for the moment and just look 

at the percentage approved for those conditions 

that we have numbers of both approved and denied.

And so we say 50% of COPD was approved. 

And three-quarters of other interstitial lung 

diseases approved and 60% of asthma. And these 

are sizable numbers of claims during this period, 
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1600 or so COPD and close to 1000 hearing loss, 

and 600 or so both asthma and interstitial lung 

diseases.

Comments or questions here? We're 

going to get into more specifics of the -- could 

you go to the next one, the respiratory. It'd be 

just a tab, a tab, Kevin.

MR. BIRD: Yeah, I think I'm on the next 

tab, the top ten respiratory ICD.

CHAIR MARKOWITZ: So I'm still seeing 

the top 20 health conditions.

MR. BIRD: Can you refresh your Webex 

at all? I'm looking at, I'm seeing the correct 

one I think.

CHAIR MARKOWITZ: Okay, is everybody 

else seeing the correct one? Got to switch on.

MS. LEITON: Yes.

CHAIR MARKOWITZ: So my computer is 

frozen. Does somebody want to, while I fix --

okay, yeah, they just appeared. So here actually 

we have more information on denied and so that we 

can, for some of the conditions the same data as 
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before, COPD about 50%, almost all the silicosis 

cases were approved. 

Some of them, some portion of them are 

Part B cases, we don't know. And the 80% of 

pulmonary fibrosis, asbestosis, and unspecified 

pneumoconiosis were approved. Pleural plaques 

probably a high percentage, but we don't really 

know about not -- on asthma it's lower, somewhere 

between 50-70% of asthma was approved.

And I had one thought about this and 

then people can chime in. These are, in my view, 

fairly high rates of approval. That doesn't 

necessarily mean that DOL is correctly or not 

correctly approving them. 

It simply means to me that what I'm 

surprised by is that the cases that are coming into 

DOL on these diseases are, must be pretty well 

documented cases on the outside, outside of the 

DOL claims process. 

That is to say that the physicians or 

whomever are working with the claimants to help 

them submit these claims are doing a pretty good 
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job documenting the health condition. And 

someone, and ditto for the exposure. I don't think 

that's an over-interpretation, but anyway other 

thoughts?

MEMBER REDLICH: This is Carrie 

Redlich. I had --

MEMBER SILVER: Ken Silver. Go ahead, 

Carrie.

MEMBER REDLICH: Go ahead, Ken.

MEMBER SILVER: Just this simple idea 

that we looked at a bunch of cases within -- most 

of the cases, there were several diseases claimed. 

So what we're looking at here are the claims for 

a given disease. These are not unique individuals 

as far as people.

CHAIR MARKOWITZ: That's correct.

MEMBER SILVER: Okay.

CHAIR MARKOWITZ: Meaning some people 

could have multiple claims and would appear in 

multiple cells on this table, right?

MEMBER SILVER: Yes.

CHAIR MARKOWITZ: Okay. Dr. Redlich.
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MEMBER REDLICH: Actually, that was 

the same sort of question I had which -- in terms 

of, you know, someone -- clearly there are 

sometimes multiple respiratory claims at the same 

time, but I found that the same person could be 

in more than one category.

CHAIR MARKOWITZ: This is Steven, but 

those claims are processed or at least evaluated 

as separate claims.

MEMBER REDLICH: But if they were --

sometimes they're -- it seems that sometimes more 

than one disease is processed at the same time. 

But if it was two times within that --- this period 

of time from 2013 and 2019, I think this could --

you know, these are not all unique individuals. 

That's my understanding. Maybe we could get 

clarification.

MS. LEITON: That's correct. This is 

Rachel. These are not unique individuals. These 

are by condition claims, because like you said, 

if there's multiple claims filed for multiple 

different conditions, there would be no way to pick 
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which one to choose for our one case. So we just 

-- if it was listed as a condition claim, we put 

it on the chart.

In addition, Dr. Markowitz, a lot of 

times people will file for like three different 

conditions on the same claim form, so we'll 

evaluate them all at the same time.

CHAIR MARKOWITZ: Other comments, 

questions?

MEMBER BERENJI: Yes, this is Mani 

Berenji. I was curious about the COPD with acute 

exacerbation which I know it's hard to get some 

of these numbers, especially in the columns that 

have N/A. I'm just curious to see, you know, if 

they're having acute exacerbation while they were 

working or was this an acute exacerbation during 

the time they were working. I'm just a little 

curious about that particular item.

MS. LEITON: I, unfortunately, can't 

answer that question without looking at the case 

file. I mean it could have just been that we 

accepted an aggravation of COPD and it was put in 
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as an acute exacerbation. It could be that, you 

know, we got this diagnosis after a period of time 

and the doctor was saying the COPD that they had 

was exacerbated. It's hard to tell why they would 

put this particular ICD 10 code in here, but again, 

without looking at each of those cases, I wouldn't 

be able to give that answer, unfortunately.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I have a related 

question. Has the standard of causation always 

been caused, contributed to, or aggravated? Or 

has that changed and could that explain why maybe 

some of the 2016, 2017 cases may have been denied 

for exacerbation. Because I did see a comment in 

one asthma case that the only asthma that is 

compensated is occupational asthma which is not 

consistent with the current procedure manual.

MS. LEITON: So the standard has not 

changed under Part E. It says we suspect this is 

not a significant factor in causing to an 

individual aggravating. It's always been that. 

But the different tier might be due to the fact 
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of the ICD 10 code being as specific as it is. 

And if you saw there was a time when we required 

or thought we had to require that it had to be 

occupational asthma, but after more recent 

clarification, partially due to board 

recommendation, that's become a little bit --

that's changed a lot in terms of asthma. And we've 

been accepting a lot more asthma cases that do not 

require the word occupational. We've clarified 

that in procedures since. I'm not sure exactly 

when that changed.

MEMBER FRIEDMAN-JIMENEZ: Okay, that 

would cover the COPD exacerbation also and they're 

now all consistent with the OSHA definition of 

work-related disease.

MEMBER REDLICH: This is Carrie. I 

compared the ICD 9 data with the ICD 10 and I think 

as was mentioned because of the greater specificity 

and more options for diagnoses, there wasn't like 

an acute exacerbation of COPD in the old category 

and the old categories tended to all have more 

cases, so I think what's just happened is and anyone 
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who has used the ICD 10 coding system, it just keeps 

dividing things into smaller buckets that really 

may not be clinically for our purposes that 

different. Because if -- you don't have an 

exacerbation of COPD unless you have underlying 

COPD.

MEMBER FRIEDMAN-JIMENEZ: Right.

MEMBER REDLICH: And for causation 

purposes, it would probably not matter.

MEMBER FRIEDMAN-JIMENEZ: Well, in a 

60 pack a year smoker, they may have underlying 

COPD from smoking and an exacerbation due to an 

acute exposure to dust or fumes irritants that 

caused the exacerbation. That would be one.

MEMBER REDLICH: Yes, but those 

exposures could have contributed to their 

underlying COPD, too, in addition to the 

exacerbation.

CHAIR MARKOWITZ: If we wanted to 

really look at aggregate numbers, aggregating some 

of these columns that are kind of -- rows that are 

kind of artificially separated, we would request, 
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I think, the top 20 respiratory codes and then look 

at all the asthma, look at all the COPD and put 

them together to get a better overall 

understanding. We should consider that.

Kevin, can you bring up the next slide. 

I think it's the neurologic.

MR. BIRD: Do you see it?

CHAIR MARKOWITZ: No, I don't see it, 

but if everybody else sees it. Okay, it showed 

up now.

So again, the N/As are because they 

didn't appear in the top ten so that's why we have 

a lot of N/As, especially on -- both on the denied 

and the approval side. You can see about 40 to 

50 percent of the neurologic conditions were 

approved, 42 percent Parkinson's, probably 45 on 

average among the neuropathy, and close to half 

of the sleep apneas.

And the next is renal. It's not 

showing up for me, but if everyone else can see 

it. Does anybody want to walk through this, the 

way I'm walking through this?
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Okay, fine, the neurologic showed up. 

No, that's neuro -- we wanted the renal. You have 

the renal up, right?

MR. BIRD: Yes, correct.

CHAIR MARKOWITZ: Okay. I'm just 

going to go back to my own files here and -- what 

does it show on average acceptance for chronic 

renal?

Okay, Kevin, if we can move on to the 

last table, the reasons for denial, lung diseases, 

reasons for denial.

MR. BIRD: Okay. There are a few 

separate tables in this document.

CHAIR MARKOWITZ: Right.

MR. BIRD: Is that what you want?

CHAIR MARKOWITZ: Yes, Table 1 should 

say Table 1, overall approval --

MR. BIRD: Yes.

CHAIR MARKOWITZ: Okay. I'm working 

off my hard drive, the tables I have because the 

web access is not working. So if I -- okay, we're 

back to this.
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We're looking for the reasons for 

denial. 

MR. BIRD: So right now I have the Excel 

document open, data request lung diseases reasons 

for denial. And I'm on the first tab which is Table 

1.

CHAIR MARKOWITZ: Okay. 

MR. BIRD: Is that what you're looking 

for or are you looking for --

CHAIR MARKOWITZ: Yes, that's --

MR. BIRD: Table 3 gives reasons for 

denial.

CHAIR MARKOWITZ: Okay, yes. Table 3. 

Thank you. Okay. So just eyeballing this, there 

are really two major reasons throughout all these 

lung diseases and beryllium-related disorders, 

either the medical information was insufficient 

or negative causation result. And there's 

occasional other. And there's some pattern here. 

You can see under chronic beryllium disease, three 

quarters of the medical information wasn't there. 

For beryllium sensitivity, 80 percent, medical 
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information not present. It's really the dominant 

reason for denial rather than causation.

That begins to change somewhat for some 

of the other conditions, chronic silicosis, about 

in half the cases it was medically insufficient 

information. And then by the time you get to 

asthma, it's now negative causation is the dominant 

reason. COPD, negative causation, almost 70 

percent of the time. Same for interstitial lung 

disease, closer to 60 percent, as well as 

sarcoidosis. Asbestosis and asbestos pleural 

placques, the medical information is frequently 

not there. So there's some variation among the 

chronic lung diseases that are outside of asthma 

and beryllium.

Any comments? Okay. 

So in terms of the data and I do think 

there's some additional data we probably want and 

I propose that we form a working group that can 

have a discussion after this call in the near 

future, because it takes a while for DOL to produce 

data, in which we drill in a little bit on some 
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of the things that we didn't get to this time.

They did comply with all of our 

requests for data. It's just that we want the next 

round. Is that all right with people to have a 

working group? And I propose actually that when 

this group comes up with a plan to request 

additional data that we send it among the board 

members for comments or additions if that's 

permissible by the rule.

MR. FITZGERALD: Yes, I would just ask 

that we -- we had established a process for 

submitting requests for data, so try to use that 

form and really be kind of deliberate and specific 

about what you're requesting and the reason for 

its use. That's right out on the form that we 

produced. Thank you.

MS. LEITON: Doug, this is Rachel. We 

might want to have another conversation about the 

best way to request data specifically just because 

the data is complicated and I really would kind 

of -- I don't want to see the board members get 

together, come up with what they think they can 
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get in the allotted time to try to put together 

how to get it and then, say we can't do that. 

So I don't know if we have maybe some 

preliminary discussion with, once you guys, once 

the board members know what they -- kind of have 

an idea what they want before giving us that formal 

request, maybe a conversation somewhere in there.

MR. FITZGERALD: There's nothing 

prohibiting a working group from having a 

conversation with a designated program person to 

kind of clarify what you're --

MS. LEITON: -- yes, I'm just think it 

might be easier.

MR. FITZGERALD: Yes.

MS. LEITON: Yes, it might be easier 

than you guys trying to formulate something that 

when we get it we're like well, we can't do it that 

way. We're not exactly sure what it means, et 

cetera.

So once you guys have formulated kind 

of an idea of what you want, maybe we can have one 

of our data people talk to you about it, ask you 
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follow-up questions, and then formulate the exact 

request. And then that would probably make it go 

faster and easier for us to process them because 

we'll have that initial conversation before the 

formal request comes in.

MR. FITZGERALD: There's nothing in 

the FACA that would prohibit that process from 

taking place.

MS. LEITON: Dr. Markowitz, does that 

sound reasonable?

CHAIR MARKOWITZ: That would be ideal.

MS. LEITON: Okay.

CHAIR MARKOWITZ: Who wants to be on 

this working group by the way? Besides myself.

MEMBER DEMENT: This is John. I'd be 

happy to be on it.

CHAIR MARKOWITZ: Okay. Thank you. 

Well, the rest can think about it and --

MEMBER SILVER: This is Ken. I have 

a question about kind of a sleeper row in one of 

these spreadsheets. Among the top 20 health 

conditions excluding cancer claims is encounter 
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for screening for respiratory disorder. And Dr. 

Markowitz made the point that there's a rather high 

rate of approval of claims for respiratory 

conditions.

Then we looked at the reasons for denial 

often being insufficient medical evidence. Could 

more be done at those encounters for screening for 

respiratory disorders to improve the sufficiency 

of medical evidence? What do those encounters 

represent? If not an impairment evaluation.

CHAIR MARKOWITZ: Is the question 

--this is Steven. Is the question whether claims 

examiners, are they getting all the medical 

information that's out there and that should be 

used in a case or is it some other question?

MEMBER SILVER: DOL is keen for 

encounters for screening for respiratory 

disorders. What is going on in that screening 

process to develop the medical evidence?

MS. LEITON: I think we'd have to look 

at the codes you're looking at. I don't see it 

here. Maybe it's here.
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MEMBER SILVER: Top 20 non-cancer 

claims.

MS. LEITON: Encounters for that. I 

don't have the answer to that myself. I would 

imagine it probably is paying for some sort of 

impairment because a lot of times the claimant 

decides to get impairment ratings done by their 

own doctor or by one of our doctors, especially 

if it's a CMC. So we say you've got a bunch of 

these. You need to go get those tests and we'll 

pay for those tests. They go get those tests, 

submit them to us. We send them to our CMCs to 

review for impairment. So that's likely it. I 

can't guarantee you that's it, but that's the most 

likely possibility that I can think of right now.

MEMBER SILVER: So those are people for 

whom causation has already been established.

MS. LEITON: Probably yes.

CHAIR MARKOWITZ: Okay, anything else 

on the claims data?

MEMBER BERENJI: Yes. This is Mani 

Berenji. I think we should definitely pay 
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attention to the sarcoid items. I feel that --

we get them through the case reviews, but I feel 

that if we can try to pay attention to those 

particular cases, they do have a higher than 

average denial rate.

CHAIR MARKOWITZ: Okay.

MEMBER REDLICH: This is Carrie. I 

would second that.

CHAIR MARKOWITZ: Okay, good. Okay, 

so no other comments on claims data.

It's 2:35. We're going to take a 

five-minute break. Don't hang up. And we'll 

resume in about five minutes and we'll start on 

with the review of claims.

(Whereupon, the above-entitled matter 

went off the record at 2:35 p.m. and resumed at 

2:44 p.m.)

CHAIR MARKOWITZ: Okay, so we're 

moving on to discuss some claims. As a reminder, 

we do this under the second and fourth tasks 

assigned to the Board. One is to evaluate medical 

guidance, claims examiners when they evaluate 
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claims; and secondly, to look at the work of 

industrial hygienists and physicians to ensure 

objectivity, quality, and consistency of their 

work.

So before we actually get into these 

claims, we need to discuss what's going to happen 

with our comments. We're looking at claims for 

several reasons. One is we want to understand the 

claims process better. Secondly, we want to be 

in a position to structure a systematic look at 

claims so that we can make some recommendations 

if needed to improve the claims process. 

But we also, in looking at individual 

claims, come up with either disagreements about 

the decisions or significant questions about the 

decisions. And we need to transmit those concerns 

to the Department of Labor. So I want to just 

briefly figure out a system for doing that. 

We have some -- we were given some --

I think 80 claims or so to look at, sarcoidosis, 

interstitial lung, chronic beryllium disease, and 

asthma, and most of the claims had been looked at 
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by at least one person among us and we're going 

to discuss at least some of these, but each of us 

has their own, has their own look. We may agree 

with the claims decision or we may disagree.

And we have a few options here. One 

option is that if we have significant questions 

about the decision or frankly disagree with the 

decision with specific reasons, and that is decided 

by one board member. If that board member writes 

up those concerns and questions and disagreements 

and we submit that to DOL as an outcome of the 

evaluation of the claims. 

The alternative is that we somehow 

orchestrate two board members to look at the same 

claim and come to agreement as to whether they 

disagree with the decision or have major concerns 

and then submit those combined comments, if 

necessary to DOL.

The second approach is a lot of work. 

I'm not sure we have the person power to do it, 

frankly, and this is sort of leaning me towards 

the first approach which is that a single board 
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member looks at a claim, evaluates it, provides 

written comments about disagreements or major 

questions and that is submitted to DOL.

I wanted people's ideas about this and 

I want to arrive on a method of how we're going 

to do this so that we can do this going forward. 

Comments?

MEMBER DEMENT: Hi. This is John 

Dement. I think the single write up with details 

about the issues and concerns and keeping the chair 

informed, in the loop, would be an appropriate way 

to go.

MEMBER REDLICH: This is Carrie. I 

agree.

MEMBER BERENJI: This is Mani. I 

agree as well.

MEMBER MIKULSKI: This is Marek, and 

I think it's a good idea. I assume that there 

would be at least another person at the DOL looking 

at the claim again to confirm or disagree with those 

disagreements. So -- is that correct?

MR. FITZGERALD: This is Rachel. I 
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think I would like to have a conversation with Doug 

about how it will be handled in terms of -- I think 

it's -- you guys, if you come across things that 

you see that you want to bring to our attention, 

we can review them, but going into case by case, 

back and forth rebuttal, I don't think that -- I 

think that's a little bit beyond -- that's more 

like an auditor role. So we can look at them, but 

I mean I'll talk to Doug about the scope and all 

that, but in terms of us responding to all of these 

cases about whether we agree with you or not, we're 

not going to get into a, you know, we agree, you 

disagree. Because there's an appeals process for 

that. 

There's a line between case 

adjudication and what we have to do and the 

processes we have to go through and your role in 

advising on general topics. So if we start getting 

into case by case, oh, we think you should have 

done it this way. First of all, that will have 

to be totally something that would be not public. 

And second of all, we'll take the information and 
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review our cases, but we can't get into a debate 

with you guys about it, going back to you with all 

that.

MR. FITZGERALD: Rachel, I want to more 

fully understand what it is that the board wants 

to do here and I think we should have a conversation 

about it. I think the information or the 

perceptions you discover in review of these cases 

should be looking at what actions or systems or 

processes have led to what you might have some 

concerns or disagreements with, not individual 

decisions on cases because I do think that's kind 

of post-adjudication issues.

MS. LEITON: Yes.

MR. FITZGERALD: And we need to kind 

of make sure we separate that piece out from what 

the board's role is in terms of looking at overall 

processes and systems and policy and those sorts 

of things. So to the extent you identify 

problematic issues with cases, they should be 

categorized as something that would be within their 

purview of the board to address from a procedural 
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or policy standpoint.

CHAIR MARKOWITZ: Sure, this is 

Steven. Our obligation, I think, is just to give 

you feedback on individual cases that we look at 

where we think there were major concerns or errors. 

What you do with that information is up to you 

in terms of the individual claims, recognizing that 

there is a -- you have a well-established process 

for examining claims, reexamining claims, and the 

like.

MS. LEITON: Okay. That should work. 

Thank you.

CHAIR MARKOWITZ: I don't think any of 

us are interested in debates, not debates that we 

lose anyway.

MEMBER REDLICH: But I think that some 

of the cases illustrate sort of the rationale for 

some of our prior recommendations and I think some 

of them sort of highlight, you know, if it's 

unclear, whether -- what actually has been 

implemented. And I think maybe will lead us to 

sort of restate some prior recommendations.
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MEMBER DOMINA: This is Kirk Domina. 

I just got a text from Calin Tebay. He's on. 

And also the subject we're talking about here, one 

of these cases and it has to do with how they did 

the SEM. There's a glaring issue -- I'm not saying 

that it may change the way the claim was 

adjudicated, but there's a huge problem with 

categorizing somebody in the wrong job title and 

it could have an outcome on how the SEM changed 

in an eight or nine month period from 100 and some 

chemicals to almost 3,000.

MR. FITZGERALD: Kirk, if you're in 

touch with Mr. Tebay, could you tell him to press 

*0 and the operator can --

MEMBER TEBAY: I just talked to her.

MR. FITZGERALD: Okay, great. 

Welcome.

MEMBER TEBAY: Thank you.

CHAIR MARKOWITZ: I think we should now 

discuss individual claims because that's where 

some of this will get real. 

Any volunteers? I remind you we don't 
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-- give general ages. We obviously don't mention 

names, mention the last four digits of the claim 

number.

MEMBER DEMENT: This is John. I'll be 

glad to kick it off and see where we go.

CHAIR MARKOWITZ: Great.

MEMBER DEMENT: Ready?

CHAIR MARKOWITZ: Sure.

MEMBER DEMENT: This is an ILD case. 

The case number is 6115. I think the case sort 

of reflects many of the recommendations the board 

has made over the last two or three years.

This is an individual who was born in 

the 1930s. He worked as a sheet metal worker, for 

various periods of time between 1967 and 1998. 

So he had about 24 years of verified employment. 

He worked himself from journeyman to foreman to 

general foreman and then superintendent, so over 

the years, he moved away from working with the tools 

to being in a supervisory role, but nonetheless, 

in and out of many different work sites at Rocky 

Flats.
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This individual had only a brief smoking 

history. His OHQ suggested he started at 16 and 

stopped by the age of 20, but his medical records 

suggest that it was not at the minimal smoking.

In 2017, the claimant developed dyspnea 

and nonproductive cough. He was seen by his 

healthcare provider and also a pulmonary consult. 

The PFT said he showed a restrictive disease and 

a low diffusing capacity and a CT showed 

interstitial lung disease.

The person reading the CT said just in 

a passing comment in a pattern most commonly related 

to idiopathic pulmonary fibrosis. In that 

particular consult, there's no evidence that the 

physician or the radiologist took into 

consideration occupational exposures in his 

determination. The worker filed a claim for 

interstitial fibrosis in 2017 based on the CT 

findings and restrictive lung function. 

Looking at the OHQ it listed exposure 

to asbestos and sheet metal work, of course, and 

the OHQ specifically said work in and around pipe 
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cutting for at least two years. He also had many 

periods of work within buildings whereas you look 

at the buildings themselves, the SEM shows presence 

of asbestos, particularly in building materials.

The claims examiner looked apparently 

only at the SEM statement of accepted facts which 

was sent to the industrial hygienist and the CMC. 

The statement of accepted facts based on the SEM

listed aluminum, welding carbon steel, and 

synthetic vitreous fibrous and silicon carbide, 

but did not mention asbestos.

In his referral, the referral sheet 

indicated that the OHQ was, in fact, sent with a 

package to the IH. The industrial hygienist 

evaluated only those specific listed compounds that 

were just mentioned in the review of the case. 

There's no evidence in the IH report that he looked 

at all at the OHQ.

The industrial hygienist concluded this 

individual had low to moderate exposures, very low 

to moderate exposures through the mid-1990s to the 

compounds and materials that I just mentioned and 
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didn't mention asbestos at all.

He also included this phrase that we've 

seen repeatedly in the IH report and it says 

however, there's no available evidence, i.e., 

personal or area industrial hygiene monitoring data 

to support that after the mid-1990s his exposures 

would exceed existing regulatory standards. This 

phrase is apparently something that's from a high 

level decided to put in because I've seen it worded 

almost identically in many different industrial 

hygienists reports. So it's something that's from 

a program perspective that's being put in.

The CMC issued a report also in 2017. 

He accepted the IH's assessment of exposures. 

He also looked, interestingly, the individual 

during the work up had some medical tests for 

anti-nuclear antibodies and SEL-70 for possible 

autoimmune response. There's no diagnosis of an 

autoimmune disease in the medical records that I 

could find.

The CMC also further noted that the IH 

exposure evaluation showed all exposures were below 
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currently accepted standards and never looked also 

at asbestos. The CMC says given the relatively 

low level of exposures to toxic substances, his 

likelihood of autoimmune disease and the often 

slash always used respiratory protection. The 

evidence is not adequate to infer an association 

of employment with his condition.

Again, there's no evidence that I could 

find from a diagnosis of autoimmune disease and 

I considered this comment of the CMC pretty much 

speculation. Also, I see the CMC is also using 

from the OHQ the checkoff of having used respiratory 

protection to infer that it actually provided 

protection for this worker which I really don't 

think is an appropriate use of that information 

out of the occupational health questionnaire.

The notice of final decision denying 

compensation for pulmonary fibrosis was sent in 

March of 2018. 

Unfortunately, for this worker, the 

story doesn't end here. The worker had a 

(telephonic interference) worker medical programs 
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at National Jewish in August of 2017. He didn't 

get the report later, but (telephonic interference) 

program diagnosed this individual with 

asbestos-related disease which they attributed to 

his work as a sheet metal worker and exposure to 

asbestos at Rocky Flats.

The worker then filed another claim for 

asbestosis specifically in November of 2018. This 

time to look at the SEM looked at the labor category 

sheet metal worker, but looked at it across all 

sites and concluded that there was, in fact, 

potential for exposure to asbestos and the claim 

was awarded under the current asbestos assumption 

and the asbestosis assumption based on 250 days 

of aggregate work days, 10 years of latency.

I guess this case illustrates a couple 

of issues that I think are important. One is the 

occupational health questionnaire was not used on 

the first round of this worker. And I think that's 

really an oversight. It should have been looked 

at. It's also an instance where neither IH or the 

CMC were thorough as they looked at the information 
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available. They should have, first of all, looked 

at the OHQ and they would have seen this worker, 

in fact, had asbestos exposure.

The other issue is a simple look at 

PubMed and related to asbestos diseases in sheet 

metal workers. They could have found that there's 

a strong association with that type of work.

I think this is fortunate for this 

worker, they had a follow-up exam done by a former 

worker program that made the connection, one with 

sheet metal work and asbestos exposure and asbestos 

exposure and his lung disease based on chest x-ray 

alone for the worker program.

So that's my comments. Any discussion?

CHAIR MARKOWITZ: This is Steven. So 

John, the first claim was not -- did not mention 

asbestos in the claim, right?

MEMBER DEMENT: No, it did not -- well, 

it didn't mention asbestos in the claim. It's 

merely mentioned fibrotic lung disease I think is 

the term that was used on the EE-1.

CHAIR MARKOWITZ: So the claims 
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examiner, the industrial hygienist, and the CMC, 

all of them did not raise the issue of asbestos?

MEMBER DEMENT: No, at no point during 

that review was asbestos raised as an exposure or 

the exposure potential related to his condition.

CHAIR MARKOWITZ: Just a comment, for 

those of you who don't know, sheet metal work in 

the last 30 years is synonymous with asbestos 

exposure, more than 30 years. It's the only group 

that had regular periodic testing for 

asbestos-related disease since the mid-1980s and 

it's been documented in people who are still alive 

and sheet metal workers who have died and it's 

remarkable that the industrial hygienist and the 

CMC did not think pulmonary fibrosis in a sheet 

metal worker might represent asbestos.

Other comments?

Does someone else have another ILD claim 

while we're on interstitial lung disease?

MEMBER REDLICH: Yes. Let me just find 

it. 

CHAIR MARKOWITZ: I'm sorry, is someone 
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looking for a case?

MEMBER REDLICH: Yes, it's Carrie 

again. I'm taking a second look.

CHAIR MARKOWITZ: No problem.

MEMBER REDLICH: Well, actually, I'll 

pass on that. I don't want to waste time.

CHAIR MARKOWITZ: I have a quick ILD 

case. I was thinking about it. This is Steven. 

Claim 1504, this is a Mound worker for decades 

who worked in decontamination for two years. Was 

a machinist for six months and then as a 

draftsmen/designer for 26 years. On his 

occupational health questionnaire he described 

himself as a tool and die worker. 

And the claims examiner identifies from 

the SEM certain toxins related to pulmonary 

fibrosis, namely some cerium compounds and 

polyvinyl chloride and appropriately provides the 

SEM, the occupational health questionnaire, and 

the EE-3 to the industrial hygienist. The 

industrial hygienist looks at the exposures and 

says that they were unlikely to be significant and 
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ranks them as low to very low. And the CMC who 

did an excellent job, actually, in the report, 

particularly on the medical side, relies entirely 

on the industrial hygienist who declared that the 

exposures were insignificant and the claim was 

denied.

I have no problem with the CMC report 

except the fact that they relied exclusively on 

the industrial hygienist. The only question I have 

on this is I'm not entirely confident that the 

exposures have been fully characterized. I don't 

know what a tool and die worker does for 26 years 

at Mound and what the exposures might be. And I 

don't know that the decontamination work for two 

years was well characterized. 

I think it's a really good example where 

an intensive industrial hygiene interview with the 

person would have addressed those exposures and 

either made them real in terms of the claim 

situation or put them to rest as contributing to 

it. So that's my only comment on that piece.

MEMBER DEMENT: This is John again. 
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I wonder on the industrial hygiene exposure 

assessment and I have been looking for this as I've 

gone through these. The hygienist in looking at 

each of these exposures that are on the questions 

that are addressed to him or her needs to state 

the basis for their determination of that exposure. 

And I would think minimally they would have to 

express some understanding of the work that was 

done that would result in exposure to that 

particular material.

A tool and die worker does a lot of 

different things and it's probably pretty difficult 

to summarize that based on a simple job description 

alone. And I agree with you. I think that's the 

situation where a 15-minute discussion with the 

worker would have clarified a lot of issues.

MEMBER MAHS: I have one comment. This 

is Ron. Along with what you were saying, John and 

Steve. It's a short one, but it raises a lot of 

questions -- (telephonic interference) -- brick 

mason or a mason, he was working around asbestos 

and silica for years. If you've ever worked around 
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a mason, they look like a ghost by the break in 

the morning because most of them still to this day 

don't like to use water when cutting, which is their 

own fault. The IH determined the exposure was 

minimal and the doctor agreed. And they used these 

statements at the time that they had significant 

exposure but a low to very low levels. I don't 

understand how they could have significant exposure 

but at low level.

And this question I've had, because 

there were several of them that had this. What 

is the standard, the current exposure standard 

after 1998 had to do with something that people 

were exposed in the '70s and '80s? We didn't have 

that standard at that time. So like you were saying 

I like the idea of we going to have the IH contact 

to find it in a case like this or any other. How 

does he know what the exposure is? How does he 

know myself and guys at Oak Ridge for all these 

years, he didn't know my daily exposure. A lot 

of it's not monitored. I don't have any monitoring 

results or any exposure results. I think talking 
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to the claimant would help a lot on all of these 

cases and other things that I've looked at.

MEMBER DEMENT: This is John again. 

One of the other issues that I think for the IH 

exposure is substance and I think you've touched 

on it, too, is what does low to moderate mean without 

some anchor, something to relate it to, it has no 

real meaning from an exposure perspective. Is it 

related to current OSHA standards? Is it low 

relative to those standards? Is it low relative 

to historical OSHA standards or even periods of 

time where there were no OSHA standards.

In some ways, use of these terms low 

and very and moderate need to have some anchors 

and consistent anchors across the IH report that 

would at least provide some relative exposure 

context. Otherwise, I think it's being used by 

-- and sometimes appropriate and sometimes 

inappropriate by the CMCs and others to infer that 

low to moderate means de minimis which I don't think 

is a correct interpretation.

MEMBER FRIEDMAN-JIMENEZ: This is 
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George. John, I agree with you with regard to the 

concentration or the intensity of the exposure.

In this case, I didn't read the whole 

case, I'm just looking at the very beginning 

summary, his exposure was characterized as being 

two years and five months as a decontamination 

worker in the '60s, six months as a machinist and 

then 26 years as a draftsman designer.

So it may be that they're characterizing 

his exposure as low to moderate based on duration 

rather than intensity of the exposure. It's not, 

I haven't looked at the details of the case, but 

I just noticed that that's how they characterized 

his exposure in terms of the timing.

MEMBER DEMENT: George, most of the 

time the IH reports will take his job and determine 

what the exposure concentration or level was.

So for the draftsman it would probably, 

I assume the IH report, based on what I've seen 

on all the others, would have said incidental 

exposures only, if any.

CHAIR MARKOWITZ: You know the -- this 
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is Steven -- the IH reports have these rankings 

of intensity of this, what Ron points out, this 

contradiction between something being significant 

and something being low to very low. And they also 

raise the frequency.

I know that some of these industrial 

hygienists work within the Department of Energy, 

and that's better than not, I'm sure it helps a 

lot, but if you worked at Paducah it doesn't mean 

that you know Y-12 or Hanford. You just use a very 

diverse workplace.

The IH reports refer to data or data 

not being available. But ultimately, frankly, it 

just gets down to use of their own experience and 

professional judgment on whether the, what level 

of exposure there was.

And I just don't find that trustworthy 

in a vacuum. From a vacuum of not having spoken 

or gotten some detailed information from the 

claimants.

That's what we do in an occupational 

medicine evaluation. That's how we make our 
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judgements about causation, getting that level of 

detail. And I've had it, it sucks.

MEMBER DEMENT: I agree with you 

completely. This is John. I agree with you 

completely.

Lacking the ability to talk with this 

individual, the IH is totally relying on his or 

her personal knowledge. Which, in some cases, may 

be very complete. But given the diversity of sites 

and jobs and circumstances at these sites, most 

of the time it's very incomplete.

And it's the reason I said that the 

hygienist needs to state the basis of exposure 

determination. Does he or she in fact know this 

work?

What is the work of that tool and dye 

maker that we discussed? You know, what are the 

tasks that would have resulted in exposures? If 

they don't know, then it's purely a guestimate.

CHAIR MARKOWITZ: This is Steven. As 

you point out, the CMC, in some cases with some 

justification, just points to whatever exposure 
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the IH writes up and relies on that for their opinion 

for their assessment, so.

Let's move on, I think, to other, is 

there another ILD case that people want to discuss?

I would have in passing, I did look at 

5318 and I had no disagreement with either the 

medical assessment or the exposure assessment. 

I thought it was the right decision. It was a 

denial and I thought it was a denial for a good 

reason, so.

There is one case I just want to mention 

briefly actually. It's ILD 0021. And the, and 

I can just very briefly discuss. It was a denial. 

And it relates to this question of contribution. 

And it's the reason why I want to just discuss 

it briefly.

This person was a miner, I think under 

RECA, who had ten years exposure but only six months 

of covered employment. It was six months exposure 

in 1970 out of total ten years exposure.

And everybody acknowledges that he had 

silicosis. The issue was whether six months of 
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representative of sufficient exposure for 

contribution.

And the outside physicians who were Dr. 

Sood from New Mexico and Dr. Kesler from also the 

University of New Mexico said, yes, six months meets 

a contributory standard. And the first CMC said, 

no, he doesn't even have silicosis.

But they sent it to a referee CMC. I 

think that's the proper term, who did an excellent 

job in the case. Except for the fact that he said, 

no, six months isn't enough to cause this disease. 

Not addressing the issue of contribution.

So, they went to an oral hearing. Was 

very involved, very long claim. But the problem 

is that if doctors can disagree on issues of 

contribution, but with some guidance from DOL, 

perhaps they might have agreed in this case.

Is six months out of ten years of silica 

exposure, did that contribute to his silicosis.

And it's a question that we could 

probably have a long discussion. But it's 

something that if DOL provided guidance on then 
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there could have been, I think, a more rational 

answer to this question.

By the way, my own personal opinion is 

yes, it beats the contributory standard. But in 

any case.

Let's go on to some other claims.

MS. LEITON: Dr. Markowitz, this is 

Rachel. Can we avoid using specific doctor's 

names, please?

CHAIR MARKOWITZ: Sure. Okay.

MS. LEITON: Thank you.

CHAIR MARKOWITZ: Yes. I did, to my 

credit, I did avoid the CMC names.

MS. LEITON: Yes, you did. I 

appreciate that.

(Laughter.)

CHAIR MARKOWITZ: But okay, fair 

enough.

MS. LEITON: Okay.

MEMBER REDLICH: This is Carrie. I 

have one quick ILD case. If it's a --

CHAIR MARKOWITZ: Go ahead. Go ahead.
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MEMBER REDLICH: Okay. So it's 

basically someone who had a prior RECA claim for 

pulmonary fibrosis silicosis that had been 

accepted.

And it's -- the purpose of this was an 

impairment rating. And the records note a 

diagnosis of COPD on multiple medications, cough, 

shortness of breath, symptoms. And the oxygen at 

night for de-saturation.

And the pulmonary function tests are 

on the low end of normal. And so, the physician 

performing the rating says that there is no 

respiratory impairment based on the patient's 

spirometry.

There had been spirometry because this 

person had participated in prior surveillance back 

in 2004. Which showed them to be at, you know, 

the 120 percent predicted.

And now we're down to the low 80 percent. 

Which really is a substantial decline in lung 

function that's consistent with their 

symptomatology.
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So, I understand that DOE was with the, 

in this case it was a, the rating, the impairment 

rating performed by the physician was problematic. 

And it looked like the claim, there was some 

comments that they were not going to appeal it at 

this time.

Anyway, I just, there wasn't full PFTs, 

and I'm surprised actually that the physician rated 

the person as such. But that's all.

CHAIR MARKOWITZ: Oh, okay. Any other 

ILD claims?

MEMBER REDLICH: It's just a, I think 

they just unfortunately went to someone who worked 

to doctor an accurate rating.

CHAIR MARKOWITZ: Okay. So let's move 

on.

MEMBER REDLICH: That's it.

CHAIR MARKOWITZ: Another, any other 

-- we can go on to other illnesses because it's 

3:20. Yes.

MEMBER MIKULSKI: This is Marek. 

Well, I have a, unfortunately I have to leave in 
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literally like two minutes.

CHAIR MARKOWITZ: Okay.

MEMBER MIKULSKI: And I have a 

sarcoidosis case that I wanted to discuss so I was 

wondering if --

CHAIR MARKOWITZ: Go ahead.

MEMBER MIKULSKI: -- I should submit 

my observations through email or? Just briefly.

This is case 3580, D-9, sarcoidosis 

cases case for former chemical operator, custodian 

and utilities and special projects coordinator who 

worked for various subcontractors between Y-12 and 

K-25 Oak Ridge plants from 1970 all the way through 

2014.

In 1978 they were diagnosed with 

pulmonary sarcoidosis in 2016 with prostate cancer. 

Subsequent to which the claimant filed Part B and 

Part E claim for prostate cancer. And Part E claim 

for sarcoidosis.

Both claims were denied in 2018. 

Prostate cancer based on insufficient probability 

of causation.
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The claim examiner, however, did 

forward the sarcoidosis claim to the CMC and asked 

if the medical evidence on file supports the 

pre-1993 diagnosis of CBD.

And the CMC opined that the claimant 

meets two out of three pre-1993 criteria with 2016 

CAT scan positive for interstitial fibrosis but 

normal PSPs with a FEV of 79 percent, an FEV1 of 

72 percent. There was also a borderline lymphocyte 

proliferation test that was not confirmed in any 

further testing.

Well, there is really no record of what 

records were shared with the CMC. But in the files 

that we have received, there is evidence of all 

three pre-1993 criteria. This clinical course.

This worker was hospitalized for six 

days in a pulmonary hospital in the early 1980s. 

Had numerous abnormal chest x-rays between 1981 

and 1991 showing diffuse reticulonodular pattern.

And this was all in the absence of any 

infectious disease. And multiple PFTs. Abnormal 

PFTs between 1976 and 1981 that showed an 
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obstructive airways defect.

So, the question would be whether all 

this information was available to CMC and what was 

the basis of this opinion.

CHAIR MARKOWITZ: This is Steven. So 

in other words, he meet all three --

MEMBER MIKULSKI: Yes.

CHAIR MARKOWITZ: -- 1993 criteria. 

Clinical, radiologic, physiologic, PFT.

MEMBER MIKULSKI: Exactly.

CHAIR MARKOWITZ: Yes, you should write 

up it.

MEMBER MIKULSKI: Okay. I'll share 

it. Rachel, do I send it to you or share it with 

you, Steven?

CHAIR MARKOWITZ: Yes, I think you 

should send it to me.

MEMBER MIKULSKI: Okay.

CHAIR MARKOWITZ: Keep all that, the 

last four digits, but otherwise all identifiers 

out.

MEMBER MIKULSKI: Sure.
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MEMBER REDLICH: On the topic of 

sarcoids --

MEMBER MIKULSKI: I'm sorry, I have to 

leave right now.

CHAIR MARKOWITZ: Okay.

MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: Thank you very much. 

Thank you.

MEMBER REDLICH: But thank you for --

CHAIR MARKOWITZ: Thank you.

MEMBER REDLICH: Thank you. On the 

topic of sarcoids, a common theme that I saw in 

several case was, in querying whether that person 

was a diagnosis of sarcoid had any exposure that 

could cause sarcoid.

Sarcoid is put into the SEM and it comes 

out with no exposures that could cause sarcoid. 

But if you actually go to the SEM and put in chronic 

beryllium disease, it comes up.

In setting for this clear exposure to 

beryllium, the SEM gets queried for sarcoid and 

says that there are no exposures that cause sarcoid.
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So, a simple fix for that, first, would 

be that since they're indistinguishable diseases, 

the SEM should be queried for chronic beryllium 

disease.

And/or if it's apparent from the other 

sources of information that beryllium was exposure 

for widespread over the years the person was working 

there, then you might not even need the SEM step.

CHAIR MARKOWITZ: This is Steven.

MEMBER REDLICH: I don't know I'm being 

clear on that.

CHAIR MARKOWITZ: Yes, you are. I 

found the same thing, that there would be queries 

for sarcoidosis which would be the end of a dead 

end because there is nothing that causes 

sarcoidosis, that we know of, except for its 

relation to beryllium. So it makes no sense to 

make that query.

It should just be --

MEMBER REDLICH: That's right. And 

then that information would be said to someone as 

saying, this person had no exposures that caused 
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their disease.

CHAIR MARKOWITZ: You have a sarcoid 

case in which the claims examiner overcame that 

obstacle, did address the issue of beryllium but 

did so properly or improperly?

And this is a general question, I mean, 

for anybody who looked at a sarcoid case. It can 

be you, Mani, it could he John, Ron. We need to 

talk about cases here. Sarcoid --

MEMBER BERENJI: Yeah, this is Mani. 

So I had two sarcoid cases. One of them was for 

a survivor and the other was for an actual claimant, 

so I'll talk about the claimant.

So this is actually a relatively younger 

claimant. He was in his 50s. He actually was 

diagnosed with sarcoid in the early '90s.

He actually was working at the, let me 

check and see, he was working over at the Hanford 

plant. But he was primarily working as an IT 

specialist.

Wasn't necessarily what we considered 

to be working in the actual metals or anything like 
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that. Primarily doing IT work, instrument 

technologist and a supervisor.

So it was interesting to see that, you 

know, he had seen a couple of specialists over the 

years, but he didn't actually apply for benefits 

until like the late 2000s.

And he had multiple tests done for 

beryllium. And I'm actually looking at the results 

right now. He actually had a total of 12 tests, 

I'm sorry, ten tests done over the course of ten 

plus years.

And nine out of ten were normal, except 

for one that was considered, quote, uninterpretable 

in 2017.

So, I feel that with the sarcoid cases 

in general, I mean, this is just a generalization 

from my point of view, I feel that there might need 

to be some sort of addendum to the current procedure 

manual because I feel that there is a lot of nuance 

with these cases.

Just going based on the regular 

protocol, you know, checking the SEM, I feel that 
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it doesn't do these folks justice because there 

could be some other exposures that haven't been 

really looked at.

And it's still kind of an evolving 

disease. We still don't know, at least from a 

medical standpoint, if it's related to any other 

type of exposures that might not be identifiable 

in the SEM.

CHAIR MARKOWITZ: Was he on steroids 

for those ten years, do you know offhand?

MEMBER BERENJI: He was put on steroids 

when he was first diagnosed in the '90s. And then 

when he was claiming for, applying for benefits 

through Part E, essentially the claims examiner 

denied, at least the final decision came on, came 

in to early 2019.

And essentially he was denied because 

of sarcoid that was spread to the right paratracheal 

lymph node. I mean, that was the, that specific, 

those specific parameters. Not just sarcoid, but 

sarcoidosis of the right paratracheal lymph node.

So I thought that was interesting 
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because I felt that kind of missed the point. I 

mean, obviously this gentleman has had issues for 

a very long time. He was first diagnosed in the 

early '90s. The disease evolved over time.

And unfortunately, his clinician, and 

again, this is just another side note with respect 

to organization of the files that were sent.

It's hard to be able to kind of 

understand what a person has been through if some 

of the medical records are truncated. So this is 

just a side note for Rachel and the folks who compile 

these records because it's hard to make any type 

of assessments if we're not given full medical 

records or parts of the medical record are 

truncated.

CHAIR MARKOWITZ: This is Steven. 

Just one last question. Was this a pre-1993 case?

Was this considered a pre-1993 case or 

a post-1993, do you remember?

MEMBER BERENJI: Yes. So this man 

actually started working in the late '80s. Let 

me see if I can get an exact date.
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CHAIR MARKOWITZ: No, the issue is when 

he was diagnosed with sarcoidosis.

MEMBER BERENJI: Was diagnosed in 1990, 

can I give an exact year, is that okay?

CHAIR MARKOWITZ: Sure.

MEMBER BERENJI: Okay. He was 

diagnosed in 1994.

CHAIR MARKOWITZ: Okay. Any comments?

MS. LEITON: Dr. Markowitz, I just want 

to say, we provide, all the records that we provide 

are the records that are provided to us. So we 

can only provide you guys what we have.

CHAIR MARKOWITZ: Thanks.

MEMBER BERENJI: But it's hard to make 

determinations when parts of a medical record are 

truncated. I mean, this is just a general comment.

It would be helpful to actually have 

sorted records, so we don't have to kind of decipher 

things for hours and hours on end. But that's just 

a side comment.

MEMBER REDLICH: But this is someone 

who had a diagnosis of sarcoid based on the tissue 
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biopsy, correct, and had beryllium exposure?

MEMBER BERENJI: Yes, that is correct.

MEMBER REDLICH: But the issue was a 

negative BeLPT and was done when the person was 

on steroids?

MEMBER BERENJI: That I can't comment 

on. He had multiple tests done for beryllium over 

the course of ten-plus years. I can't tell you 

for a fact if he was on steroids at any one of those 

testing times.

MEMBER REDLICH: Okay. So, I guess, 

when we're done with that case.

CHAIR MARKOWITZ: Yes, I think we're 

done.

MEMBER REDLICH: It's on the other 

theme of sarcoid. There was one woman who worked 

at the Pantex plant from 1979 to 2005. And in 

various sort of control clerk, accounting clerk, 

the administrative clerks.

And had a diagnosis of sarcoid. There 

was only one thing that was performed after she 

had been on steroids that was negative.
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And so, the -- then basically queried 

again, her job title as not having exposure. But 

she clearly could have worked in multiple sites 

over those many years at this plant.

So it does seem that, another thing I've 

seen on several cases is that people with 

administrative titles, but that are physically in 

multiple sites at some of these settings, are 

labeled as that job category not having beryllium 

exposure.

She did have hearing testing done the 

whole time she was there. And she had past 

barometry done as part of workplace surveillance. 

So, that would suggest that she was around noise 

and someone felt there should be barometry done.

From reviewing a number of these cases, 

it does appear that some administrative type of 

jobs are still in areas where one can have beryllium 

exposure. And it's been well documented that 

administrative assistants and non-production 

workers that are in the vicinity can get beryllium 

disease.
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So, I think it's an example where the 

funds, again, is sort of assuming that it's like 

a office that is not anyway connected to the 

facility. And that doesn't appear to be the case.

CHAIR MARKOWITZ: Question. This is 

Steven. This is a post-'93 case, right? Did she 

ever have a positive BeLPT?

MEMBER REDLICH: No. She only had one 

done when she was on steroids.

CHAIR MARKOWITZ: Oh, only on steroids. 

Okay. But, did she need the other criteria? 

Post-'93 criteria.

MEMBER REDLICH: Yes. Yes, she had 

granulomatous lung disease. And her pulmonologist 

wrote that he thought it was consistent with 

beryllium disease.

CHAIR MARKOWITZ: And she was denied?

MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: That just sounds like 

an incorrect decision because, maybe I'm 

misremembering the evolution of the procedure 

manual, but it seems to me that it acknowledges 
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the steroid use detail.

MEMBER REDLICH: Yes. His wording 

might have been slightly different but I think it 

was more semantics. I don't have it right in front 

of me.

He suspects occupational related lung 

disease. The findings were the dissimilar pattern 

on biopsies if it was beryllium related.

So, anyway --

CHAIR MARKOWITZ: Yeah.

MEMBER REDLICH: So, I think if that 

pulmonologist had understood that there could be 

a false BeLPT, and again, also the SEM was sort 

of then came out that this person had no exposure 

to anything that could cause sarcoid.

CHAIR MARKOWITZ: Ms. Leiton, can you 

remind us post-'93 case, post-1993 cases of 

sarcoid. Is the instruction on the procedure 

manual that they be treated as beryllium cases until 

proven otherwise?

MS. LEITON: There are circumstance 

which that is the case. I don't want to, I mean, 
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I'd have to look at the exact language of the 

procedure manual, which I can pull up in a minute.

But yes, we will consider sarcoidosis 

beryllium disease when there is a positive 

beryllium test.

CHAIR MARKOWITZ: Sure.

MS. LEITON: And there are other 

evidence. So it basically, it really, it's easier 

to do that with pre-'93 because there are certain 

tests that are required and it's not necessarily 

a diagnosis at all.

For post-1993, if you just give me a 

second --

CHAIR MARKOWITZ: Sure. Sure.

MS. LEITON: -- I'm probably going to 

bring John in here for one second.

CHAIR MARKOWITZ: Carrie, was this, 

Steven, was this -- CMC look at this case or just 

the claims examiner?

MS. LEITON: Yes, CMC did. And see, 

the statement of accepted fact says occupational 

toxic exposure, there are no toxic chemicals linked 
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to job titles responsibilities.

CHAIR MARKOWITZ: Oh.

MEMBER BERENJI: I'm sorry, I pulled 

up the, I'm actually looking at the procedure manual 

right now. So if you look at Section 1810, 

presumption of CBD, diagnosis of sarcoid.

If you actually look at the third 

paragraph, let's see, hold on one second. It says 

here, for Part E claims, a CE can evaluate a 

pulmonary sarcoid claim as CBD.

So that's actually in the procedure 

manual.

MEMBER REDLICH: So I think that the 

CE was probably influenced by the statement of 

facts, which said there were no toxic chemicals 

linked to job titles and responsibilities for this 

claimant.

Despite many, many years of employment 

in a plant that I looked at the claimant. It just 

had beryllium in multiple different places in her 

questionnaire comments on beryllium exposure. The 

occupational questionnaire.
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So I think, again, it's where the SEM, 

it seems with the sarcoid, there are two issues 

with it. One is, as we already mentioned, that 

sarcoid shouldn't be put in as a diagnosis into 

a SEM because it will always come up with no 

exposure.

But also in a facility that there is 

felt to be widespread opportunity for beryllium 

for clerical workers, I think there needs to be 

a look at that. You know, if that person was truly 

in a physical location where there was no contact 

with any of the sites with beryllium.

And that just, and frequently the 

questionnaire comments on that, that I, my job took 

me to all the multiple different buildings. I 

walked through production areas. So the 

questionnaire, actually, did some idea that yes, 

even though it was a clerical job they were 

physically in production areas.

MS. LEITON: Dr. Markowitz, can I say 

something?

CHAIR MARKOWITZ: Sure.
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MS. LEITON: Can we just, we run into 

problems with sarcoids and beryllium disease 

because you can file for sarcoidosis all by itself 

under Part E and maybe in some cases, like in AWE 

facility, they're not entitled to Part E.

Or in other cases, they will 

specifically say sarcoidosis. We're looking at 

under Part E.

We couldn't determine that it was CBD 

under Part B. And therefore, we're looking at just 

sarcoidosis because we couldn't make that 

determination.

When we get back to the procedure 

manual, she is correct that it does say you have 

to have a positive BeLPT. But I'm going to let 

John, so we've had this discussion with other 

physicians about sarcoidosis versus beryllium 

disease.

So, I'm going to let John explain it 

a little further.

MR. VANCE: Yes. Okay, good 

afternoon, everyone, it's John Vance. You're 
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lucky I sit right down the cubicle hallway here.

Yes. So, what you need to understand 

for sarcoidosis is, and I think that this is where 

people need to understand, it's a wonderful, 

technical reality of our legislation is that what 

we have done is carved out an exception for 

sarcoidosis.

We are basically saying that 

sarcoidosis, in some instances, could have been 

a misdiagnosis. In other words, that the 

sarcoidosis actually represents chronic beryllium 

disease.

Okay, so when you think of, think of 

it as like an exception under our process whereby 

we generally would look at CBD as just what it is. 

But if we see sarcoidosis, the CE should be looking 

at it and saying, okay, this could possibly be a 

misdiagnosis of CBD.

And they begin going through the 

requirements under the law to determine whether 

or not they have evidence that meets the other set 

criteria under the law for establishing CBD. 
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Because then what they do is they basically say, 

depending on the pre or the post, under Part B, 

they're going to say, if I've got the necessary 

criteria met and a diagnosis of sarcoidosis, I can 

accept the case as CBD. Okay.

What you need to think about though, 

is that under Part E, you could actually have a 

misdiagnosed, a sarcoidosis misdiagnosis of CBD 

being accepted, or you could be looking at 

sarcoidosis in and of itself. Because, again, a 

person can file for any condition that they think 

is work related under Part E.

If we're not looking at sarcoidosis as 

a misdiagnosis of, if we're not treating it as a 

misdiagnosis of CBD, we're going to look at it 

purely as a claimed sarcoidosis. And that's why 

when you look at it in the site exposure matrices

as sarcoidosis, you're not going to see any health 

effects because we don't have any established 

humanistic epidemiology that says, oh, 

sarcoidosis, in and of itself, is known to be 

associated with exposure to X, Y or Z toxin.
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So then what we do is we would turn to 

a physician and say, okay, do you believe that this 

condition is related to some toxic substance by 

way of aggregation, contribution or cause. So then 

we leave it specifically to the physician.

So just think of it as, sarcoidosis can 

be a misdiagnosis of CBD or it can be a condition 

on its own right.

MEMBER REDLICH: Yes. So I think it's, 

I think in this case there was taking into account 

that many, many years of time periods a person 

worked, the location and I think clear beryllium 

exposure.

I had seen other similar cases, I 

reviewed quite a few where there was a statement 

from the physician that they felt that this was 

a false negative BeLPT because the person was on 

steroids. And the manual says you can state that.

MS. LEITON: Yes. If you have a lung 

biopsy to support it.

MR. VANCE: Right. And that, the 

reason that that exists, that standard of steroidal 
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medication, is because under the law we need to 

have an abnormal BeLPT. The one carve out that 

existed, the existence of this prescription for 

steroidal medication, because that's basically 

saying that the abnormality in the BeLPT is being 

masked by the medication usage.

MEMBER TEBAY: This is Calvin Tebay.

MEMBER REDLICH: It's just a lot of CMCs 

and physicians are not necessarily aware of that.

MEMBER TEBAY: Yes, this is --

MEMBER REDLICH: In fact --

MEMBER TEBAY: -- Calvin Tebay. Oh, 

go ahead. Go ahead.

MEMBER REDLICH: Okay.

MEMBER TEBAY: This is Calvin Tebay. 

And I agree with what Mr. Vance has said, and 

everybody else, regarding this topic. And this 

is my fourth year attending these meetings and now 

on the board.

And what I don't agree with though is 

the abnormal. What we just talked about as 

abnormal.
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Some of the sarcoidosis CBD issue would 

alleviate itself if we had, we need to start talking 

about borderline test results again.

MS. LEITON: Okay, we can't do that 

legally. We've been over that so many times with 

our lawyers and --

MEMBER TEBAY: But the problem is that 

this conversation is somewhat invalid because we're 

not talking about the standardized diagnosis 

process of CBD, which affects sarcoidosis.

So, we're kind of talking around 

everything instead of really talking about what 

is being used to diagnosis CBD and having that 

sarcoidosis factor.

So, I guess this conversation can happen 

over and over, but we're not going to solve anything 

until somebody starts talking about what we talked 

earlier. The procedure manual needs some 

adjustment on diagnosis criteria. And that's 

going to help alleviate some of the confusion 

between sarcoids and CBD.

MEMBER REDLICH: Well, and there have 
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been cases that I have reviewed that have been 

indeterminate and a letter was written explaining 

that they felt that this indeterminate was actually 

a reason for being indeterminate. They felt it 

was positive and then it was accepted.

So, I think that there are one or two 

knowledgeable physicians who write what it takes 

for a situation like this, where steroids or a 

testing factor, might be involved. But 

unfortunately, most, either CMCs or patient 

pulmonologists reviewing these cases don't know 

that that's possible.

So it then also creates inconsistency 

in how some of these are adjudicated. And I think 

this is a, you know, and I also weigh in terms of 

looking at the extensive exposure, the time period.

So I think people need to remember that 

sarcoid is not a common disease. It's much less 

common then the prevalence of beryllium disease 

in beryllium exposed workers.

CHAIR MARKOWITZ: So, this is Steven. 

We've got about --
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MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: -- eight, nine more 

minutes.

MEMBER REDLICH: Sorry.

CHAIR MARKOWITZ: No, no, no problem 

at all. We want to discuss claims. Clearly, we 

want to discuss claims more.

MEMBER REDLICH: But I guess also the, 

it seems to me the point that we've made, I'm not 

sure that everyone is in agreement that, to put 

sarcoid into the SEM is, you know, if it has 

granulomatous lung disease that's been 

misdiagnosed as sarcoid, then it would make sense 

if your querying exposures to put beryllium disease 

in and not sarcoid and at least see what comes out.

CHAIR MARKOWITZ: This is Steven. I 

think that would help. The Page 175 of the 

procedure manual, quote, for a Part E claim, the 

CE can evaluate a pulmonary sarcoidosis claim as 

CBD, end of quote. And then it goes on to say that 

they will require a BeLPT.

So, the fact that sarcoid is not linked 
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to any exposure in the SEM may, for some people, 

steer them along the wrong path.

So we need to close out the discussion 

on claims.

MEMBER MAHS: Can I ask one question, 

Steven?

CHAIR MARKOWITZ: Sure. Sure.

MEMBER MAHS: It has to do with sarcoid. 

And a number of the cases that I reviewed, it 

appears to have predominately cutaneous sarcoid.

But some suggestions based on CT 

pulmonary involvement, particularly the 

mediastinal lymph nodes, and some others. But this 

is a question for the medical doctors.

At what point would you say that's 

inconsistent with recent pulmonary involvement?

MEMBER REDLICH: So you're saying if 

there is skin involvement and, what's the extent 

of this pulmonary involvement too?

MEMBER MAHS: Some pulmonary 

involvement. It doesn't appear great in terms of 

the presentation of the granuloma per se, but there 
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is certainly some suggestions based on the 

interpretation of the CT. Possibly related to 

beryllium.

MEMBER REDLICH: Well, you can have 

people that, for some reason, have more of a 

predominant of a skin presentation then pulmonary. 

I think it makes sense to have evidence of 

pulmonary disease.

But in those settings, I mean, I'd also 

read some cases where there was clear pulmonary 

involvement. But for convenience purposes and 

safety purposes, the skin is biopsied.

But based on either CT imagining or lung 

function there was clear involvement. And I think 

that that is very consistent with chronic beryllium 

disease. Even if we, you know, the skin is the 

more dominant.

MEMBER MAHS: Yes. Some of the cases 

I reviewed I would say that they, and I would agree 

with CMCs interpretation, the pulmonary 

involvement was not like there. And so they made 

a negative determination of CBD sarcoid 
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relationship.

MEMBER REDLICH: Well, I think if there 

is no suggestion at all of any pulmonary 

involvement, that that would be the unit goal given, 

in this setting. If there was a BeLPT that was 

positive, then there also could be pulmonary 

involvement with normal PFTs in a normal CT scan.

But I'm assuming these are situations 

where the BeLPT was negative.

MEMBER MAHS: Yes. And that's the 

other, so the quandary that the BeLPT is negative 

is clear cutaneous sarcoid based on pathology. 

Some suggestions on CT that there is also pulmonary 

involvement but this lack of a positive BeLPT, the 

case is denied.

And so you're sort of in a quandary, 

what does the claimant do in the case? Because 

clearly they're on steroids already.

MEMBER REDLICH: Yes. I guess the ones 

I've seen that has basically had some evidence of 

pulmonary disease based on either PFTs or imaging.

CHAIR MARKOWITZ: Okay, so this is 
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Steven. We need to close this case out. But I'm 

sure we're coming back to beryllium again.

MEMBER REDLICH: I had one very quickie 

that is just on the subject of SEMs.

CHAIR MARKOWITZ: Very quick question. 

Quick question for Carrie and Doug. If we go 

literally beyond 4:00 p.m. cut off by a few minutes 

is that permissible?

MR. FITZGERALD: Yes, we're okay.

CHAIR MARKOWITZ: Okay. Okay, go 

ahead.

MEMBER REDLICH: Well, just very 

quickly. This was a case for asthma COPD and 

pulmonary fibrosis.

There was clear asbestos exposure. And 

this was at K-25 and Oak Ridge for many years. 

And then it said that asbestos, the SEM said that 

asbestos, there was no exposure that causes 

pulmonary fibrosis.

So I'm not sure how pulmonary fibrosis 

and asbestos would not be linked in this case.

MEMBER SILVER: Carrie, this is Ken, 
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I read the same case and that jumped out at me as 

well. The doctor followed up with a stiff letter 

to the claims examiner rebutting that contention.

I think Fitzgerald stated that we should 

transmit our observations about the cases related 

to the categories of the board's purview. And 

since the SEM is front and center, I think we could 

really fill up that category with claims examiner 

overreliance on the SEM by just typing in sarcoid 

and flying blind or believing that there is no link 

between pulmonary fibrosis and asbestos or 

underreliance on the SEM.

Probably in some of the other cases that 

we've seen. I think DOL would get a lot of good 

feedback from us if we put all of those observations 

in the right category.

I didn't mean to cut you off, were you 

going to elaborate more on this case?

MEMBER REDLICH: No, no. I think this 

is a easily fixable issue. Because then what 

happens, that information gets fed to a CMC that 

says that there was no exposure that could cause 
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pulmonary fibrosis.

CHAIR MARKOWITZ: What's the case 

number, by the way? Is it an ILD case?

MEMBER REDLICH: It was --

MEMBER SILVER: 91 --

MEMBER REDLICH: Yes, go ahead.

MEMBER SILVER: COPD 9190. Are we 

talking about the same one, 9190?

MEMBER REDLICH: This is a different 

one.

MEMBER SILVER: Oh.

MEMBER REDLICH: Oh no, I think, let's 

see. Yes, 9190.

CHAIR MARKOWITZ: So, when you write 

up your comments on the particular cases, if SEM 

is an issue then you should be specific in 

addressing it.

Anything else on that case, by the way? 

Okay, so I'm going, we're going to move on.

We've reviewed, by my method, at least 

80 percent of the cases given to us. At least one 

person has reviewed. We've probably discussed 
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eight of them here. So there is a lot more that 

we can look at.

The question is, how do we move forward 

on this? We've got a meeting in 11 weeks. I think 

we need a group that can continue this discussion, 

for one.

If that's a subcommittee then that means 

it would be an open meeting scheduled at least six 

weeks in advance with an open telephone line to 

the public, which is fine, as opposed to working 

group in which we don't need to publish that meeting 

in the literature, in the federal register. And 

it doesn't have to be open.

For me it's a practical question. Our 

preference always is we have open meetings. 

They're open to the public. The challenge here 

is determining, because we need to make some 

progress.

And so, people want to weigh in on this 

issue?

MEMBER DOMINA: Hey, this is Kirk 

Domina. I think we ought to just do a working group 
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so that way we can get stuff and then the public 

will be able to hear it when we meet in November 

because it is a pressing issue.

CHAIR MARKOWITZ: Other comments?

MS. LEITON: Dr. Markowitz, this is 

Rachel.

CHAIR MARKOWITZ: Yes, sure.

MS. LEITON: I just wanted to mention 

that we will be, I think we're scheduling some 

meetings with, with the Board to talk about cases 

with our hearing reps, like we've done in the past. 

So, I just want to put that out there.

I think that they're already being 

schedule or Carrie, can you --

PARTICIPANT: Next week.

MS. LEITON: The first one's next week. 

So, the purpose of that is just so that you can 

get from the hearing reps' perspective what they 

look at and what process they go through and to 

answer any questions about cases that you guys 

already have. So I just want to put that out there.

CHAIR MARKOWITZ: Okay, thank you. I 
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think I would agree with Kirk here that we should 

probably go with the working group because we have 

to, we may need to meet more than once by phone 

because we need to work out some categories of 

concerns on these claims so that we can make 

progress on kind of an overall framework. That 

we can plug the claim review into.

It's sort of a chicken and egg thing. 

We've have a review claims done to understand what 

the possible categories are, but now we have a 

better sense of that.

So --

MEMBER REDLICH: I mean, I think we 

could, not right now but I think based on what we've 

done we could all propose some general categories. 

And I bet there would be a lot of overlap.

CHAIR MARKOWITZ: Sure.

MEMBER REDLICH: One can compile that. 

And then I think that would just help organize 

it.

CHAIR MARKOWITZ: Good idea. Who 

wants to serve on this group?
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MEMBER DOMINA: This is Kirk, I'm in.

CHAIR MARKOWITZ: Okay.

MEMBER REDLICH: I'll be willing to 

since there is so many pulmonary cases. I think 

it just also should be noted that we're obviously 

focusing on the ones that we thought there were 

issues with. I think we've already have claimed 

that we thought were reasonably adjudicated and 

we agreed with.

CHAIR MARKOWITZ: That's --

MEMBER REDLICH: I don't want it to seem 

like we, at least I did not, you know, there were 

a number I agreed with. And I suspect that's true 

for others.

CHAIR MARKOWITZ: That was true --

Steven. Other volunteers?

MEMBER FRIEDMAN-JIMENEZ: This is 

George. I'd like to be in the group.

CHAIR MARKOWITZ: Okay. Okay.

MEMBER DEMENT: Steven, this is John.

CHAIR MARKOWITZ: Yes.

MEMBER DEMENT: I'm not sure I 
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understand what the subgroup is going to do not 

having the input from those that are not on the 

subgroup with regard to claims that they've 

reviewed and have concerns about.

I don't know how we capture the group, 

our Board's collective experience based on the 

subgroup.

CHAIR MARKOWITZ: Well, if we could 

agree on a sort of draft set of categorical 

concerns, then we can, and through soliciting input 

from everybody, and then send the initial set out 

to the broader group for input, that would allow 

some vocal attention at the same time it will get 

broader input. Does that make sense?

MEMBER DEMENT: Yes. Yes, to be honest 

with you, most of my concerns have related to things 

we've already made recommendations on.

MEMBER REDLICH: I agree.

MEMBER DEMENT: You know, we can beat 

it to death but we've already made recommendations 

on 90 percent of the groups who were put together.

CHAIR MARKOWITZ: You know, and I 
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understand that, but I think that there's 

additional concerns. I think, for instance, we 

haven't really focused on the medical input very 

much in our recommendations to date.

MEMBER FRIEDMAN-JIMENEZ: This is 

George. I think it's valuable to have concrete 

examples of what we have talked about in the 

abstract in the past. I think that makes it more 

clear and more real, and I think it's valuable.

MEMBER DEMENT: I agree with you 

George. I think that would be helpful.

CHAIR MARKOWITZ: So we've heard 

actually, this is Steven, we could come up with 

these initial set of categories and then tag them 

with individual claims that demonstrate what we're 

talking about.

Other comments? Okay, so we have a 

working group, unless I hear otherwise. I haven't 

heard anybody in favor of performing a 

subcommittee.

And there will be an opportunity to, 

for you to have second thoughts and join these two 
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working groups. But the next step then will be 

to schedule a call for this group to secondly 

solicit some categories of issues that people 

should send in to the Board Members.

And thirdly, on the individual claims 

that you reviewed, if you could provide a, for the 

ones that you agreed with and have some comments, 

that's fine.

For those that you had some concerns 

about, if you could write up those concerns and

send them to me. And I'll sort them through with 

the working group and figure out how to get them 

over to DOL from there.

Does that sound all right?

MEMBER REDLICH: Yes. And I would also 

just say that if there are ones that one agrees 

with but took a lot of effort to come up with the 

final adjudication, that might also be worth 

noting.

CHAIR MARKOWITZ: Yes, I would say that 

all the ones that we agreed with we should state 

whether it was complicated or not.
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Okay, any further --

MEMBER REDLICH: Okay.

CHAIR MARKOWITZ: -- discussion on the 

issues of claims, otherwise we just went a couple 

minutes on the next board meeting in November?

So, next board meeting is scheduled 

November 20th and 21st. And we had talked about, 

last time, about doing this in Nevada, the Nevada 

Test Site, but actually I looked through the numbers 

of claims by site and we've been going down them 

in descending, by descending numbers ranking.

And the next one actually is Paducah, 

Kentucky. Which has the additional advantage that 

it's not a renovated site so that the tour would 

allow us, actually, to see a fair amount of a history 

of a gaseous diffusion plant.

There were three. One at Portsmouth, 

one at Oak Ridge and one at Paducah.

So, Paducah is not the easiest place

to get to but it is next in line. So does anybody 

have any comments on that?

MEMBER DEMENT: So, George, would we 
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do a tour on the 19th and the meeting on the 20th 

and 21st?

CHAIR MARKOWITZ: Correct. And 

there's a chance, we'll look, when we get closer

to the schedule, we'll look at whether we can make 

a, Thursday the 21st, whether we can do our work 

in a half day with the idea of getting out of there 

later in the day. But it depends on the agenda. 

It depends on how much we have to accomplish.

I know people, that things arise. For 

one Board Member I know there is an issue with the 

21st, and so if someone has to leave early, someone 

has to participate by phone, then that's fine. 

That's the nature of what we're doing here.

Do save time for the Quilt Museum in 

Paducah, it's a spectacular museum.

So, any closing comments or questions?

MEMBER REDLICH: Just one. Well, I 

think it would be helpful if people do notice, let's 

say, an issue with the SEM if they, sometimes it's 

helpful to just print out the example. I mean, 

something like this.
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I've gone to the website, the SEM 

website. So if people haven't, I think it's 

actually helpful.

CHAIR MARKOWITZ: Okay. Doug, any 

closing comments?

MR. FITZGERALD: No. I mean, if we're 

concluded here I would just say we're concluded 

and thank you very much for all your efforts on 

behalf of the Department of Labor.

CHAIR MARKOWITZ: Okay, and I echo the 

thanks. Thank you to Ms. Leiton and Mr. 

Fitzgerald, Ms. Rhoads, Mr. Vance for participating 

and to the Board Members and to the public.

And we will elaborate an action list. 

I think probably some items. And get back to you 

about the working groups and the follow-up 

activities. Thank you very much.

(Whereupon, the above-entitled matter 

went off the record at 4:12 p.m.)
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