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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

MEETING

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WEDNESDAY

NOVEMBER 20, 2019

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The Board met in River Room A at the 

Holiday Inn Paducah Riverfront, 600 N 4th Street, 

Paducah, Kentucky, at 9:00 a.m., Steven 

Markowitz, Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY

JOHN M. DEMENT

GEORGE FRIEDMAN-JIMENEZ

MAREK MIKULSKI

KENNETH Z. SILVER

MEDICAL COMMUNITY

MANIJEH BERENJI

ROSE GOLDMAN

STEVEN MARKOWITZ

CARRIE A. REDLICH
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CLAIMANT COMMUNITY 

KIRK D. DOMINA

RON MAHS

DURONDA M. POPE

CALIN TEBAY*

DESIGNATED FEDERAL OFFICIAL

DOUG FITZGERALD

*Present via telephone
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C-O-N-T-E-N-T-S

Welcome/Introductions ......................... 4

Dr. Steven Markowitz, Board Chair

Review of Agenda ............................. 15

Dr. Steven Markowitz

Board Operation Update ....................... 19

Doug Fitzgerald

DEEOIC Updates ............................... 20

John Vance

Review Action Items and Responses ........... 110

Dr. Steven Markowitz 

Claims Status Data, 2016-2019 ............... 128

Claims Review: Asthma, ILD, CBD,

Sarcoidosis............................ 154

Public Comment Period ....................... 312

Adjourn ..................................... 400
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P-R-O-C-E-E-D-I-N-G-S

9:11 a.m.

MR. FITZGERALD: Good morning, 

everyone. My name is Douglas Fitzgerald and I'm 

the Designated Federal Officer for this Advisory 

Board, that's DFO. I'd like to welcome you to 

today's meeting at the Department of Labor's 

Advisory Board on Toxic Substances and Worker 

Health here in Paducah, Kentucky.

On behalf of the Department of Labor 

I'd like to express my appreciation for the hard 

work of our Board members in preparing for this

public meeting and their forthcoming 

deliberations.

I also would like to thank my 

alternate DFO, Carrie Rhoads, as well as Kevin 

Bird and the contract staff for doing a lot of 

work to get this meeting off the ground, getting 

materials out to the public.

Just a couple of housekeeping items. 

First of all, in the unlikely event of an 

emergency the exits are fairly well marked out 
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here so I don't think there will be any problem.

The restrooms are to the left and 

across the restaurant past the elevators for your 

convenience.

As the DFO I serve as a liaison 

between the Board and the Department of Labor. 

I'm responsible for approving meeting agendas and 

for opening and adjourning meetings while 

ensuring all provisions of the Federal Advisory 

Committee Act or the FACA are met regarding 

operations of the Board.

I'm also responsible for making sure 

that the Board's deliberations fall within the 

parameters outlined in its enabling statute and 

charter.

Within that context I work closely 

with the Board's chair, Dr. Markowitz, and the 

Office of Workers' Compensation Programs to 

ensure that the Board as an advisory body to the 

Secretary is fulfilling its mandate to advise and 

is addressing those issues of highest priority 

and of greatest benefit to the Secretary of Labor 
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who is ultimately responsible for the 

administration of the Energy Employees 

Occupational Illness Compensation Program.

And finally, I also work with the 

appropriate agency officials to ensure that all 

relevant ethics regulations are satisfied.

We have a full agenda to cover over 

the next day and a half. Copies of all meeting 

materials and submitted public comments are or 

will be available on the Board's website under 

the heading Meetings.

The Board's website can best be found 

by entering "Advisory Board on Toxic Substances 

and Worker Health" in any internet search engine.

During Board deliberations I'd like to 

remind the members that when discussing specific 

cases to be mindful not to use personal 

identifying information or PII in those cases.

The FACA requires that the minutes of 

this meeting be prepared to include a description 

of all matters discussed today and any 

conclusions reached by the Board.
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As the DFO I prepare the minutes and 

ensure they are 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, but if they're available sooner 

they'll be posted sooner.

Although formal minutes will be 

prepared according to FACA regulations we also 

prepare verbatim transcripts and they will be 

available on the Board's website as soon as 

possible.

The Board's website has a page 

dedicated to this meeting. The page contains all 

materials submitted to us in advance of the 

meeting, and we will publish any materials that 

are provided by our presenters throughout the 

next day and a half.

There you can also find today's agenda 

as well as instructions for participating 

remotely in both the meeting and the public 

comment period later today.

If you are participating remotely I 
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want to point out that the telephone numbers and 

links for the WebEx sessions are different for 

each day so please make sure you read the 

instructions carefully.

If you're joining by WebEx please note 

that the session is for viewing only and will not 

be interactive.

The phones will be muted during the 

public comment period which opens at 4:30 this 

afternoon.

During Board deliberations and prior 

to the public comment period I would request that 

the people in the room remain as quiet as 

possible since we are recording the meeting to 

produce transcripts.

The Chair will also note that the 

public comment period isn't a question and answer 

session, but rather an opportunity for the public 

to provide comments about the topics being 

discussed and considered by the Board.

If for any reason the Board members 

require clarification on an issue that requires 
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participation from the public the Board may 

request such information through the Chair or 

myself.

I'm looking forward to working with 

all of you today at this hearing, and hearing 

your discussions over the next two days.

With that, Mr. Chairman, I convene 

this meeting of the Advisory Board on Toxic 

Substances and Worker Health.

CHAIR MARKOWITZ: Thank you. This is 

Steven Markowitz. I want to welcome back members 

of the Board. Welcome our new member of the 

Board, Dr. Rose Goldman, and the other members. 

We are happy to be here in Paducah. It's a 

beautiful day outside. Maybe we'll actually get 

outside, who knows.

I want to thank some people, Mr. 

Fitzgerald, Ms. Rhoads who are the designated 

federal officials who work with us. 

I want to thank Mr. Vance actually for 

coming today and being both -- presenting but 

also being available for questions, comments and 
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interaction.

Of course we always thank SIDEM, Kevin 

Bird and his group for the support that they give 

this meeting.

Yesterday we had a great tour of the 

Paducah site, Gaseous Diffusion Plant. Arranged 

by Greg Lewis. Thank you, Greg. I know Greg's 

here. He's outside, but he's coming back. So 

thank you, Greg.

And thanks to the DOE officials, I 

didn't catch all their names yesterday, who 

arranged this tour and also led us through this 

tour. So it was very informative I thought.

And I want to thank members of the 

public, people from the USW Local here, from the 

Center to Protect Workers' Rights, from the 

Resource Center and others. You'll have the 

opportunity to introduce yourselves in a moment, 

but thank you for coming and listening to us and 

in the public comments sessions having an 

opportunity to speak about the program.

Let's do introductions and then I'll 
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go over the agenda and see if anybody has any 

corrections or suggestions.

I forgot to welcome Mr. Nelson, the 

Ombudsman, whom I couldn't see right off as well.

I'm Steven Markowitz. I'm an 

occupational medicine physician and 

epidemiologist from the City University of New 

York. 

And I run the Former Worker Program 

for DOE at 14 different sites, 7 different states 

across the country.

MEMBER REDLICH: Carrie Redlich. I'm 

getting over a cold. Professor of medicine at 

Yale and director of the Yale Occupational 

Environmental Medicine. And I'm also a 

pulmonologist.

MEMBER GOLDMAN: Hi, Rose Goldman. I 

just joined the committee. I'm associate 

professor of medicine and also environmental 

health from Harvard Medical School.

And I'm a clinical occupational health 

physician and I practice at Cambridge Health 
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Alliance.

MEMBER FRIEDMAN-JIMENEZ: Good 

morning. I'm George Friedman-Jimenez. I'm an 

occupational medicine physician and an 

epidemiologist at Bellevue NYU Occupational 

Environmental Medicine Clinic.

MEMBER POPE: Good morning. My name 

is Duronda Pope. I'm a retired Rocky Flats 

worker and I currently work with the United 

Steelworkers Emergency Response Team.

MEMBER MIKULSKI: Good morning, Marek 

Mikulski. I'm an occupational epidemiologist at 

the University of Iowa. 

I direct a Former Worker Program for 

the former DOE workers from two sites in the 

state of Iowa.

MEMBER MAHS: Morning, Ron Mahs. I'm 

a claimant representative. I spent my last 15 

years working at the Oak Ridge plant and since I 

retired I just do safety training around the 

country for our international and CPWR.

MEMBER BERENJI: Mani Berenji, 
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assistant professor at BU School of Medicine, 

practicing occupational medicine physician.

MEMBER DEMENT: John Dement. I'm 

professor emeritus in the Division of 

Occupational and Environmental Medicine at Duke 

University and participated with the Building 

Trades Former Worker Program for the last 20 plus 

years.

MEMBER SILVER: Ken Silver, associate 

professor of environmental health in the College 

of Public Health at East Tennessee State 

University.

Twenty years ago last week I turned 

out Los Alamos workers and families for a private 

meeting with Dr. David Michaels working with Bill 

Richardson to create this program at the Cities 

of Gold Casino in Pojoaque, halfway between Los 

Alamos and Santa Fe.

And one thing led to another and a lot 

of the people who were at that meeting have 

passed on, but now in Tennessee each year one or 

two of my students have family members affected 
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by the program.

MEMBER DOMINA: I'm Kirk Domina. I'm 

from the claimant community representing the 

Hanford Atomic Metal Trades Council in Richland, 

Washington. 

I'm a current Hanford worker, USW 

member. I've been there since 1983. I guess 

that's it.

CHAIR MARKOWITZ: If we could go 

around the side.

MS. RHOADS: Carrie Rhoads. I'm the 

alternate DFO with Department of Labor.

MR. BIRD: Kevin Bird with SIDEM.

STEFAN: Stefan with SIDEM.

MR. HARTMAN: Tim with SIDEM.

CHAIR MARKOWITZ: Yes, please.

MS. GILL: Good morning, I'm Alison 

Gill with the Paducah Resource Center.

MR. HARBISON: James Harbison with the 

Worker Health Protection Program.

MS. DISMORE: Hi, I'm Jill Dismore 

with Brightmore Home Care.
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MS. SLAUGHTER: Hi, Jenny Slaughter 

with United Energy Workers.

MS. BROCK: Good morning, I'm Denise 

Brock, the NIOSH Ombudsman.

MS. JARISON: Deb Jerison, Energy 

Employees Claims Assistance Project.

MS. QUINN: Trish Quinn with the 

Center for Construction Research and Training, 

and with the Building Trades National Medical 

Screening Program.

MS. CHEN: Anna Chen. I'm with the 

Building Trades Medical Screening Program.

MR. M. NELSON: Good morning, I'm 

Malcolm Nelson, the Ombudsman for the Energy 

Employees Program.

MR. BALLARD: Good morning. I'm Chris 

Ballard, vice president with Critical Nurse 

Staffing and a home healthcare provider under the 

program.

CHAIR MARKOWITZ: Okay, thank you. 

And actually we're going to find a few minutes in 

the agenda for Mr. Nelson to make some comments.
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So let's review the agenda. We're 

going to -- Mr. Fitzgerald is going to give us a 

brief update on the status of the pending 

recommendations within the Department of Labor.

Then Mr. Vance who's head of the 

Branch of Policy Regulation and Procedures is 

going to discuss various updates in the program 

including the Procedure Manual, the SEM, et 

cetera. 

Then we're going to discuss some of 

the items from the last meeting or two that 

either we raised as issues that we wanted 

feedback on or items for ourselves to continue 

discussion.

And we're going to talk about claim 

status data. So these are data -- these are the 

accepted versus denied claims for the most common 

conditions seen in the program over the last 

three years.

And actually the Board members have a 

copy of that, paper copy of that in your folder. 

It's available on our website for those of you 
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who are on the phone or visiting by web.

And for the members of the audience 

here, we're going to show that on the screen so 

you'll be able to see what we're talking about.

Then we're going to discuss a little 

bit the reopened claims data. Those are claims 

that DOL reopened after the change in some of the 

procedures and policies pursuant to some of the 

recommendations we had made regarding 

presumption.

We discussed that briefly before. 

We're just going to touch base on that again.

And then we're going to discuss 

claims. The Board has been provided with I think 

approximately 70 claims and 4 conditions since 

July. Sarcoidosis, chronic beryllium disease, 

interstitial lung disease, and the fourth one is 

asthma, occupational asthma.

So we're going to be spending a fair 

amount of time discussing individual claims. 

We're going to protect personal information. 

We're not going to mention anything in the 
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individual claims that we discuss that would 

betray identity of that person.

That's going to take up much of the 

afternoon. Then we have a public comment period 

4:30 to 6. 

Ms. Rhoads, how many people do we have 

so far?

MS. RHOADS: Four so far.

CHAIR MARKOWITZ: Okay. So we 

encourage people here, people on the phone if you 

want to make a public comment that would be 

great.

And you should email Ms. Rhoads, is 

that how -- if you're present here just talk to 

her, but if you're online or on the phone just 

email Ms. Rhoads and indicate that you'd like to 

speak.

Tomorrow we're going to discuss 

Parkinson's-related disorders. The subgroup we 

have has been working on that.

And then we're going to discuss the 

public comments, both those that have been sent 
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in as well as those that are obtained later 

today.

And then pick up any issues that are 

left over from today, or any new issues. 

And then finally, a review of the 

Board's working and whether any improvements are 

in order.

So are there any other issues that 

Board members would like to address? Okay. 

Well, if you come up with anything let me know 

during the day and we can find time for them.

So I turn it over to Mr. Fitzgerald 

now.

MR. FITZGERALD: Thank you, Steven. A 

brief update is a bit of an understatement.

There is not much to convey in terms 

of the recommendations that came out at the last 

Board meeting that are pending with the 

Secretary's office because they are pending with 

our new Secretary of Labor who has not had an 

opportunity to really review those 

recommendations and the other materials that the 
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program may have presented to the Secretary in 

terms of response to those recommendations.

If there was any question -- it's a 

matter of record what the recommendations were. 

However, we're just waiting for the Secretary's 

office to respond. And we will obviously publish 

those as soon as we have those cleared.

CHAIR MARKOWITZ: Thank you. Mr. 

Vance.

MR. VANCE: Good morning, everyone. 

My name is John Vance. As Dr. Markowitz 

mentioned I'm the policy branch chief for the 

Energy Compensation Program.

I was asked to provide some updates 

and some information about where the program is, 

where we're going. 

And I also want to start by just 

saying thank you. You make my life very 

interesting. Don't think that the work that you 

are doing is in vain. We spend a lot of time 

looking at and considering the input of the 

Advisory Board.
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I know that the director of our 

program Rachel Leiton is very interested in 

getting as much feedback and information as we 

can to improve the quality of our case outcomes, 

to find areas of our program that can be improved 

for not only claim processing but also for the 

outcomes for our claimants. 

So it is a very serious process. It's 

something that we're very interested in hearing 

from you on. And the work that you are doing 

does have an effect. It is something that we 

spend a lot of time within the Department of 

Labor evaluating and considering and implementing 

change as a consequence of your input.

And as I go through some of the things 

I'll mention today I'll sort of highlight some of 

the things that we're working on that are a 

direct consequence of the input that you have 

provided. So again, thank you.

Let me just go through some things 

that I thought you might be interested in hearing

about with regard to program updates.
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The program continues to receive a 

fairly large number of cases on a weekly basis. 

From our Resource Centers we get a weekly tally 

of new claims being received.

I just did a pull of the cases that 

had been submitted from September 28 to October 

25. We were looking at 626 new claims. So these 

would be claims being filed as new originating 

cases or add-ons to existing cases.

Our weekly tally runs from about 130 

to a high of 184 during that time frame.

So our claim intake process is still 

running at a fairly active clip. So this is 

pretty consistent with what we have seen over the 

past year as far as our claim numbers. 

So it's not a program where we're 

seeing a significant reduction in claims that are 

coming in. It's a pretty consistent number that 

we are seeing with our case intake process.

Some of our new initiatives that we're 

looking at for 2020 and actually are already 

engaged with expanding – we are centralizing our 
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medical benefit authorization process. So this 

would be for management of post adjudication case 

activities relating to claims with a living 

employee who is receiving medical benefits.

So we have a dedicated staff that is 

centralized out of Washington, DC but we have 

staff in all of our jurisdictional offices that 

are -- their singular focus is medical benefit 

adjudication. 

So this would relate to activities 

relating to home healthcare. We're going to be 

transitioning that group to take over durable 

medical equipment and other types of ancillary 

medical services such as therapeutic care and 

oxygen therapeutic care and medical supplies and 

different kinds of things that we see associated 

with medical benefit authorizations including 

home modifications, auto modifications and that 

sort of thing.

That group as of right now has 19 

staff. We are in the process of hiring 11 

additional staff that will be dedicated solely to 
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medical benefit authorization.

We have a program integrity group that 

is now dedicated specifically to evaluating 

claims that we receive for waste, fraud and 

abuse.

They are an analytical group that is 

looking at instances of issues with how providers 

interact with the program, how different 

individuals interact with the program.

And they're doing a lot of data 

digging and data analysis to identify areas of 

potential fraud or abuse of our program.

We are also going to be expanding our 

quality assurance program. Right now the program 

engages in systemic quality assurance through our 

existing managerial oversight of the process, 

supervisory reviews, performance evaluations.

We also do annual accountability 

reviews which I'm sure you're all familiar with 

for quality assurance.

We also have a supervisory review 

process that's a systemic sampling of cases 
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looking for quality assurance on outgoing cases.

This is a consequence of actually a 

GAO recommendation from several years ago. So 

that is a quality assurance process.

But we are going to be engaged with 

the creation of a dedicated group of staff that 

will be evaluating quality assurance and their 

singular focus will be decision quality within 

the area of recommended decisions, final 

decisions by our final adjudication branch, and 

medical benefit authorization decisions. And 

that will be their singular focus.

I am the lead supervisor of this 

process. I have one person that has been hired 

and retained already. She comes from one of the 

other OWCP worker compensation programs and 

already has a great depth of experience in 

quality assurance so she is already in the 

process of designing our quality assurance plan. 

And we will be expanding that unit by three 

additional staff shortly.

Some other updates. We will be seeing 
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two new additions to the Special Exposure Cohort 

class. 

The Y-12 class in Oak Ridge has been 

designated for the period of January 1, 1977 

through July 31, 1979.

Y-12 already has an existing series of 

SEC classes so this is just an additional one.

We have done our preliminary 

assessment based on input that we received from 

statistical data from the National -- or NIOSH. 

And we do our own internal evaluation 

to determine the number of cases that are 

potentially affected by this new class. For Y-12 

it's approximately 280 claims.

And that will require the Department 

of Labor to evaluate those cases to determine 

whether or not there's any potential for that 

individual or the survivor to be qualified under 

the Special Exposure Cohort.

So we try to throw as broad of a net 

as possible for any case that is not currently 

compensated under Part B for the SEC to determine 
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whether or not this has an effect.

So we'd be looking for employees that 

have employment during that time frame, have one 

of the potential specified cancers. And then we 

actually commit to a manual review of each one of 

these cases.

The other site that's been added which 

is significantly smaller is the West Valley 

Demonstration Project in New York. The period of 

the SEC designation is January 1, 1969 through 

December 31, 1973.

That site is a very small site and 

there are only 20 potential claims that are 

impacted by that SEC designation.

The designation is effective November 

24. We plan on publishing a circular notifying 

the public of that and then we will initiate case 

reviews.

We've already begun the preliminary 

assessment of cases, but we can't process any of 

those claims until the effective date of the SEC 

which is November 24.
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Prepare yourselves. Dr. Markowitz 

asked for an update on the Site Exposure 

Matrices. So I have quite a list. So, settle 

in. Are you ready? All right.

And this is -- what I asked for was 

just some interesting information that you might 

find interesting about our Site Exposure 

Matrices.

So I've got several bullet points and 

I'll try to summarize and provide additional 

information as we go.

The public is making significant use 

of the Site Exposure Matrices. In a typical 

month we have approximately 1,300 different users 

based on unique IP addresses access the website 

and view over 20,000 pages of the Site Exposure 

Matrices.

We continue to receive public 

submissions with regard to facility information 

that is then evaluated by our SEM contractor for 

additions and updates to the Site Exposure 

Matrices.
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A total of 129 DOE sites have SEM 

profiles including all of the major DOE sites. 

The current focus is updating and improving those 

profiles.

The Hanford site has the largest 

amount of information, Kirk, at 1 million cells 

of data.

At Paducah the spreadsheet is smaller 

with about 80,000 cells of data. Its size 

reflects the one mission focus of the GDPs.

Other sites like Idaho National Lab 

and Los Alamos National Lab have 220,000 to 

275,000 cells of data. So we're starting the day 

early talking about cells of data, but I thought 

it would be interesting to just give you a size 

and scope of how much information is maintained 

in SEM.

The Site Exposure Matrices currently 

contains information for over 16,400 unique toxic 

materials used in DOE and RECA facilities covered 

under Part E.

We have added four new site profiles 
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in the past year including Weldon Spring Quarry 

and the Weldon Spring Raffinate Pits.

profiles have been developed for over 

3,500 uranium mines and all covered uranium mill 

or transporters or buying stations.

These profiles identify the historical 

contractors and owners to the extent such 

information is available.

All of the DOE sites that were 

remediated by the DOE FUSRAP program which is the 

Formerly Utilized Site Remediation Action Program 

in the nineteen eighties and nineties have now 

been profiled in the Site Exposure Matrices 

except those few which don't have any 

documentation relating to their activities.

We have also done work in conjunction 

with DOE site closure profiles. These are 

profiles for facilities that have been shut down 

or were in a period of remediation. 

Those are generally very unique 

profiles because the work activities are so 

distinct from the operational period. So those 
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are being profiled distinctly in the Site 

Exposure Matrices.

The ones that are undergoing that 

update is Rocky Flats, Mount, Feed Materials 

Production Center, and Area IV of the Santa 

Susana Field Laboratory.

And those actually will have their own 

profile within the Site Exposure Matrices that 

you would have to search for under closure 

profile.

The Site Exposure Matrices version 18 

has been captured. For those of you that are not 

familiar we go through a process of evaluating --

the Department of Labor has its own internal 

variant of the Site Exposure Matrices that is 

updated on a realtime basis.

There is a periodic capture of that 

information and then it is sent through a process 

of security review by the Department of Energy. 

That review then allows us to then publish a 

version of the same Site Exposure Matrices that 

existed at that time of capture to the public.
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So you're generally looking at a 

public version that's six months behind the 

version that's being updated realtime for 

Department of Labor employees.

So we are on version 18. And we are 

expecting that public release of that version by 

the end of the year or shortly thereafter.

Specific to Paducah the SEM team just 

completed the profile for the Paducah DUF6 

facility. SEM profiles of the Paducah and 

Portsmouth depleted UF6 facilities have been 

posted in the internal Site Exposure Matrices 

within the last month.

These facilities convert the large 

inventories of depleted uranium hexafluoride at 

the sites which was a product of the enrichment 

process to a more stable uranium oxide for safer 

long-term storage.

As a result of this effort nearly 100 

toxic substances were added to the Paducah 

profile along with approximately 120 labor 

categories and aliases.
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The Paducah site's spreadsheet is now 

up to version 52.

So that's my SEM spiel right there. I 

hope that was not too much. But I thought that 

was all information that I thought you would find 

useful.

We are also working hard to make 

updates to our Procedure Manual. Now, the 

Procedure Manual is an internal guidance document 

for our staff, but it is public facing for folks 

to understand and see how our processes work for 

evaluation of claims.

We are currently in the process of 

publishing version 4.0. I was really keeping my 

fingers crossed that we would have had this done 

a week or so ago, but we had a last minute 

administrative issue that came up that required a 

little bit more vetting at a higher level of our 

Procedure Manual.

But we are good to go with version 4.0 

which I'm hoping will be published today or 

tomorrow.
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And let me give you some updates with 

regard to what's going to be happening.

Our versions of the Procedure Manual 

are generally going to be reflective of changes 

we've identified through interactions with our 

staff identifying process issues that they have 

questions about or need clarification on how to 

do certain activities.

We also make changes due to input that 

we receive from stakeholders such as the Advisory 

Board and also the public.

Many of these changes go through a 

very deliberate evaluation process. Any edit to 

our Procedure Manual must go through multiple 

tiers of clearance. It must also go through a 

legal vetting process. And then we actually have 

a process by which it has to go through a union 

process where it's basically federal employee 

unions get an opportunity to review that. And so 

it's a very laborious process, but it does go 

through a very rigorous process of review.

Some of the things that are going to 
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be happening in version 4.0. And these are just 

sort of the highlights.

There are always going to be a series 

of technical fixes and updates to the content. 

And there is the usual series of those edits and 

changes.

As a consequence of a regulatory 

change that occurred we have to require claimant 

signatures on claim forms now. So our process is 

changing to require that. We will no longer 

allow authorized representatives who are nonclaimants to sign the claim forms so that we make 

sure that they're aware of their responsibilities 

for providing accurate information. So that 

process will be instituted with the publication 

of 4.0 of our Procedure Manual.

As a direct consequence of input from 

the Board we have actually added an instruction 

in our guidance that would allow our industrial 

hygienist staff to interact with claimants.

It's not going to mandate that 

contact, but it is going to allow a process to be 
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present that would allow IH and claimant 

interactions where it's deemed necessary.

We actually are right now looking at 

our first instance of this and we're sort of 

working through the logistics of it. And 

hopefully that will occur this week.

As a consequence of input from the 

Board we have modified our labor categories with 

regard to asbestos exposure. 

So we have a presumption in the 

Procedure Manual that relates to asbestos 

exposure for particular labor categories.

We had messed around with this in the 

past and had changed it to rather than a 

presumption for an entire period of time we had 

separated it out and basically asked the 

industrial hygienist to evaluate each case on a 

case-by-case basis.

The Board had asked why and when we 

went back and looked at it we were of the opinion 

that we should be having our industrial hygienist 

look at more and more cases and give more 
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customized responses.

But there was a point by the Board 

that that may be having a detrimental effect with 

regard to how those presumptions for the exposure 

would be affecting causation presumptions. 

So what we have done, we have expanded 

the standard for significant exposure to asbestos 

from the period of 1942 through 1995 rather than 

1986.

The labor categories remain the same. 

We did add uranium millers and miners to the 

list of qualifying labor categories. So that 

addressed one piece of input from the Board.

And I don't believe that was a formal 

recommendation. I think that was just something 

that had come up in conversations and discussions 

with the Board.

We have always struggled with the 

issue of diagnosis versus symptoms. We receive a 

lot of claims for illnesses that are hard to 

define as either a true diagnosis or a symptom. 

So basically we provided some clarification as to 
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how the CE is to approach those type of 

situations.

And basically it boils down to asking 

the physician to provide a qualified opinion 

about whether or not the condition that's being 

addressed is a diagnosis or a symptom.

We've clarified guidance regarding SEM 

searches for pneumoconiosis, for pulmonary 

fibrosis and interstitial lung disease. 

Basically that those can be interchangeable.

All are searchable now under 

pneumoconiosis - other in the Site Exposure 

Matrices.

As a side note we also made a 

modification to the Site Exposure Matrices based 

on information that I heard during a conversation 

during some calls that we had with our staff 

where staff was providing the Advisory Board some 

recommendations with how to go about evaluating 

claims for pneumoconiosis - other and why 

asbestos, coal dust and silica was not listed in 

the toxins for pneumoconiosis, other.
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They were being treated solely under 

health effects for asbestosis and chronic 

silicosis and black lung essentially.

We move those toxins under the 

pneumoconiosis - other. So that now reflects 

some input that I heard that I was like, I had 

asked that question why doesn't asbestosis, 

silica and coal dust appear under that 

pneumoconiosis - other category in the Site 

Exposure Matrices.

After evaluating it we now have those 

toxins under there. So that is a direct 

consequence of Dr. Redlich, I think you had 

identified that in a conversation and then that 

drew in a question that I had about how we would 

want to do that.

We've also provided updates with the 

role of our medical benefit examiners in 

evaluating claims for medical benefits.

So that group that I was talking 

about, the centralization of our medical 

authorization process, those case adjudication 
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activities are being conducted by medical benefit 

examiners.

Our Procedure Manual is being updated 

to reflect that new reality.

We have also clarified the 

requirements for obtaining medical benefits with 

regard to the submission of letters of medical 

necessity.

This is basically where a physician 

has provided some sort of written rationale or 

justification for a medical service such as home 

healthcare, oxygen equipment or supplies, home 

modifications or what have you. Any of the 

ancillary medical services that are covered in 

our Procedure Manual.

And it also updates some guidance that 

we have with regard to allowing home healthcare 

providers to provide transportation to and from 

medical appointments.

So, I moved along pretty quickly but 

those are the updates that I have for you.

Just some other quick things that I 
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thought you might be interested in. I and my IH 

team did commit to a series of trainings at all 

of our district offices in the first half of this 

calendar year.

We were talking about proper claim 

adjudication, assessment, making sure that folks 

were evaluating cases appropriately with regard 

to exposure analysis and applying that based on 

information in the case file, making sure that 

claim staff are carefully evaluating all of the 

information in a case file with regard to the DAR 

occupational history questionnaire and also the 

veracity of their Site Exposure Matrices 

searches.

We also had a very lengthy discussion 

in those sessions with regard to medical opinions 

supporting claims with specific focus on medical 

opinions that relate to aggravation and 

contribution which is an aspect of our standard 

for evaluating cases under Part E and the 

importance of claim staff to construct their 

exposure analysis around medical opinions that 
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are received from physicians that are relating to 

aggravation and contribution.

And the main theme there is that when 

a physician provides a medical opinion of 

aggravation and contribution the role of the 

claims examiner is to validate that the physician 

has an accurate understanding of the exposure 

history relating to the toxin that the doctor has 

identified.

So long as the doctor has identified 

an accurate understanding of those exposures and 

has some sort of medical health science basis to 

establish an aggravating or contributing 

circumstance to the disease in question that 

would be sufficient for acceptance under the 

program given our standard that exists is not 

merely causal, it's also aggravation and 

contribution.

All of our staff received that 

including our Final Adjudication Branch folks. 

It was a lot of travel. And our staff was very 

receptive to it. And we're hoping to continue 
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our efforts to engage the staff in improving the 

quality of their exposure analysis.

And that's all I've got on program 

updates.

CHAIR MARKOWITZ: Thank you. 

Questions from the Board? Dr. Dement.

MEMBER DEMENT: Thank you for that, 

John. I had a question. It goes back 

specifically to the other pneumoconiosis. 

So where would -- just if a claimant 

has interstitial lung disease where would you put 

that person?

MR. VANCE: So what we've done is 

we've basically added that. There's three that 

we've basically said it's interstitial lung 

disease, pneumoconiosis and pulmonary fibrosis.

They would all be searched now under 

pneumoconiosis - other in identifying the toxins 

that the employee could have been potentially 

exposed to that are linked to those diseases.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: Just to re-ask that 
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because I'm one of those people who's logged in 

multiple times to the SEM and spent many, many 

hours putting in different terms and seeing what 

comes out.

So a clinician gives a diagnosis. And 

it's not going to be a pneumoconiosis. It's most 

likely going to be interstitial lung disease or 

pulmonary fibrosis.

Currently you're not able to enter 

that. Now, maybe this is a change that's coming. 

But you're not able to enter that as a 

condition.

So the clinician isn't going to enter 

in pneumoconiosis. Because that's not the 

diagnosis. Not necessarily the clinician, but 

the claims examiner, whoever, they're looking at 

the diagnoses that a physician has given this 

patient.

MR. VANCE: Correct. Depending on how 

it's presented if the doctor identifies one of 

these three the instruction will be that the 

pneumoconiosis - other search category is what is 
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applied for identifying the potential toxins that 

that employee had contact through either their 

labor, work process, incident, area, location and 

that sort of thing.

MEMBER REDLICH: Because just 

following up there are like 100 different 

diagnoses that as an occupational physician for 

30 years I have never, ever diagnosed.

And yet the common -- most common

diagnoses that are not in there. So I don't 

quite understand when we have all these rare 

conditions listed individually why we wouldn't 

list the term pulmonary fibrosis. Or 

interstitial lung disease.

MR. VANCE: The guidance that's going 

to exist is that in the Procedure Manual when 

this comes out, when it's published it's 

basically if a CE sees pulmonary fibrosis as a 

diagnosis, or interstitial lung disease, or 

asbestosis, or anything like that they are going 

to be able to search under that pneumoconiosis -

other looking for the toxins that are associated 
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with that employee's work process, labor, or 

whatever linkage they can do to identify --

MEMBER REDLICH: Okay. And then 

asbestos is going to be in that category.

MR. VANCE: Correct.

CHAIR MARKOWITZ: Steve Markowitz. I 

have a question. Wouldn't it be less prone to 

error if you simply added the term pulmonary 

fibrosis, interstitial fibrosis of the lung, et 

cetera, into the SEM and when the claims examiner 

looks at that diagnosis directly from the medical 

records gets to the pneumoconiosis - other.

So that the claims examiner -- there's 

no room for the claims examiner to forget to 

translate pulmonary fibrosis to pneumoconiosis.

MR. VANCE: I'd have to look to see. 

Without looking at the Site Exposure Matrices 

right now I'm not certain if those don't already 

appear as aliases or not. And I'm not sure. I'd 

have to look and see.

Because when we have these conditions 

they actually identify aliases of those 
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particular conditions. And you're right, there 

is a history of lots of -- if it's happened in 

the history of medicine it's probably going to be 

something that we're going to have to deal with 

in this program.

But I would say I'd have to look and 

see how the Site Exposure Matrices currently 

presents whether or not if you're searching 

interstitial lung disease does that come up as an 

alias of pulmonary fibrosis. I'm just not 

familiar with that specificity without looking at 

it right now.

MEMBER REDLICH: You'll probably hear 

this come up again just because of the fixable 

items.

There are a number of examples of 

where what the SEM spits out is sort of beyond 

any common sense.

And I understand how someone who 

doesn't have the expertise to know what the most 

common cause -- occupational cause of pulmonary

fibrosis is why when asbestos isn't there that 
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they would recognize that that's a problem.

So anything that then takes all the 

different claims examiners to get trained in 

doing properly if the system could be fixed.

And so at least currently in the most 

recent group of cases that we reviewed that was 

one of the most common easily fixable problems.

CHAIR MARKOWITZ: Dr. Dement.

MEMBER DEMENT: Yes, just as a followup because it's going to come up in a specific 

case that I reviewed and it has to do with a 

sheet metal worker at Rocky Flats who was there 

for many years, 30 years plus.

When the claims examiner looked at the 

SEM, came back with aluminum, carbon steel and 

synthetic vitreous fibers, but no asbestos.

I wondered how could that possibly be. 

So I went to the SEM and traced back through it. 

And if you just put in Rocky Flats, you put in 

sheet metal worker, sure enough asbestos is 

there.

When you put in other pneumoconiosis 
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it disappears. It made no sense. And so the 

claim actually went through the whole process of 

CMC and IH review without asbestos having been 

popped out from the SEM.

Somehow that filter is just not 

working right. And I'm looking at it right now 

and I think maybe it was updated since I last 

looked at it. It's not.

MR. VANCE: No, the change that I was 

talking about with regard to adding the asbestos 

silica and the coal dust to the pneumoconiosis -

other will actually be reflected in the public 

update that occurs at the end of the year.

So I think in that particular 

situation that problem would be solved with this 

update because now what you're going to see is if 

you're searching for pneumoconiosis - other those 

toxins will now show up.

MEMBER DEMENT: So asbestos will show 

up under other.

MR. VANCE: Yes.

MEMBER DEMENT: It doesn't do it here.
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MR. VANCE: It doesn't do it on the 

public version now. This is an update that's 

going to occur at the end of the year.

But it's occurred within the internal 

one that the claim staff is using to adjudicate 

cases now.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: A number of 

claims that I've looked at have reflected what I 

think is an inadequacy of the treating physician 

understanding of the exposure.

And I think that the SEM could be a 

very valuable resource for treating physicians 

out in the community, but it's not entirely 

intuitive as our discussion is illustrating.

So I'm wondering if you could put 

together sort of a guide. I followed how the 

National Library of Medicine has developed their 

mesh subheadings over the last 30 years. This is 

not simple. Hierarchical classification can be 

very complicated.
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But I think if we put together, say, 

the most common 50 or 100 diagnoses and how you 

find them in the SEM it could be fairly brief and 

make sure that it works.

That would go a long way toward 

straightening out the primary or the treating 

physician's access to this exposure information 

which is one of the weak links in the diagnostic 

process.

So I'm asking could there be a guide 

created either in the SEM or in the Procedure 

Manual that would be sort of a SEM for dummies, 

for people like me that don't do this every day, 

how you find the exposure information in the SEM 

reliably and don't run into the kind of paradoxes 

like Dr. Dement was describing.

CHAIR MARKOWITZ: This is Steve 

Markowitz. I have some questions, but if anybody 

wants to continue this line.

MEMBER REDLICH: Just one other quick 

thing while we're on the topic of SEMs and things 

that are hopefully quickly fixable.
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And maybe this has been done already. 

But if someone has a sarcoidosis they put into 

the SEM sarcoid and then there are never any 

exposures that could cause sarcoid.

So it would seem that when that is the 

diagnosis one could put sarcoid in under the 

conditions, or one could make sure that one 

entered chronic beryllium disease into the SEM.

Because you're not creating the 

opportunity for that exposure to exist. So you'd 

get some -- just things again that don't -- sort 

of defy common sense where someone might have 

worked for 30 years around beryllium, but then 

they've been given the sarcoid diagnosis. And 

then they look to see if there was exposure at X 

site that caused sarcoid.

So that would be another one where the 

issue of the diagnostic conditions that you can 

enter into the SEM.

Because if you simply added sarcoid in 

there then it would create the opportunity to 

consider that as a possibility.
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MR. VANCE: Let me just comment on 

that because sarcoid, as soon as you have the 

word sarcoid you have to start going down sort of 

a dark path with regard to how the program 

adjudicates cases for sarcoidosis.

Because sarcoidosis and under our 

program is first evaluated potentially as a 

missed diagnosis of chronic beryllium disease.

So when we receive one of these claims 

for sarcoidosis the claims examiner is trained to 

say, okay, could this potentially be a missed 

diagnosis for chronic beryllium disease.

We would then go through the Part B 

test of evaluating that against the required 

legislative stipulations for acceptance of a 

chronic beryllium disease case.

So in other words, if you're 

presenting with a claim for sarcoidosis we would 

look at it and say, okay, could that potentially 

be a missed diagnosis of chronic beryllium 

disease because we then look at whether or not 

the establishment of the CBD criteria under the 
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law are met.

If the answer is yes to that then your 

case is going to be accepted for chronic 

beryllium disease.

If you don't go through that, if you 

do not meet that standard then what we would do 

is look at sarcoidosis as being under Part E as

something that is affiliated with some other type 

of toxic substance other than beryllium.

MEMBER REDLICH: No, I do understand 

how that whole process works. But I can say that 

somewhere it appears that it gets cut off because 

sarcoid gets put into the SEM and there's no 

potential causative exposures.

Because -- and I've looked through a 

lot of sarcoid claims. So I do think that 

process needs to be looked at again.

It wouldn't stop that process, but one 

simple solution of prematurely having it come to 

a halt would be putting sarcoid into the SEM.

And even if you go through the entire 

process what the SEM spits out is frequently very 
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tightly related to the question that the claims 

examiner may ask the CMC.

So instead the claims examiner doesn't 

ask the CMC were there work exposures at X site 

that caused this person's disease. They will 

say, you know, and they'll list what the SEM 

spits out.

So it plays a huge role, maybe even 

too big a role in some of the decision-making. I 

just think it's an area you should look at 

because I do understand the process and it makes 

sense. It's just that for some reason it's 

getting cut short before that is being 

considered.

MR. VANCE: Okay.

CHAIR MARKOWITZ: This is Steven 

Markowitz. I have a few questions. 

So, you mentioned that there's going 

to be some improvements in the quality assurance, 

expansion of personnel and the like.

Given our task 4 which is to look at 

the quality of the industrial hygiene medical 
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input into the process, right now are you 

envisioning or planning any changes in the 

quality assurance as it impacts the industrial 

hygiene and medical evaluations?

MR. VANCE: The focus of the quality 

assurance program that's being put in place, the 

planning that we're doing is going to be 

decision-specific. So in other words we would be 

looking at a sampling of decisions that are being 

issued across the board.

So in other words we would not be 

selecting a particular type of decision. Just 

these are the decisions that are being issued, 

and then an evaluation of that particular 

recommendation and the development and evidence 

that fed into that decision.

So that would encompass industrial 

hygiene reviews as part of Part E cases, but it 

would not be limited to that.

So it's basically all of the 

adjudication activities that could occur in a 

case could potentially be presented for review in 
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this quality assurance program.

And that would be at the district 

office level with the recommended decisions, the 

Final Adjudication Branch and their final 

decisions, and then our medical benefit 

adjudication activities.

CHAIR MARKOWITZ: So likewise, we're 

charged to provide advice on the use of medical 

evidence by the claims examiner. So that will be 

part of this newer enhanced review process.

MR. VANCE: That's correct. It will 

be any information that a CE or a FAB adjudicator 

or medical benefit adjudicator used or relied on 

to arrive at a determination of compensability.

So that would have to encompass both 

the employment and the medical evidence that's 

been presented in the case.

CHAIR MARKOWITZ: Yes. Dr. Berenji.

MEMBER BERENJI: Mani Berenji from 

Boston University School of Medicine.

So you did mention the update that 

you're planning to incorporate the industrial 
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hygienist who actually contact the claimant.

MR. VANCE: Yes.

MEMBER BERENJI: So I'm actually going 

through the Procedure Manual right now. So I 

believe, and correct me if I'm wrong, this is in 

section 15-11.

MR. VANCE: All right. So Procedure 

Manual version 3.1 is currently up on our 

website. Version 4.0 I'm hoping to have up -- I 

just had a zinger email today saying it really 

needs to be up as quickly as possible. I was 

hoping to have it up today.

So version 4.0, let me just walk you 

through what's going to be out there. This is 

going to be basically as of right now an optional 

process where there is an identified need to 

engage with the claimant to ask questions about 

some sort of difference of opinion or information 

that we think would be useful in talking with the 

claimant.

The first instance that we got, and 

I'm just going to talk in generalities. So we 
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have a physician who has offered an opinion of 

aggravation and contribution for an employee with 

prostate cancer.

The doctor is basically of the opinion 

that this employee's consistent exposure to TCE 

was a significant factor in contributing to the 

onset of prostate cancer.

Like I said before the role of the 

claims examiner is to determine that the 

physician has an accurate understanding of the 

exposure.

They did their role in evaluating the 

case based on the construct of exposure from the 

treating physician and sent it to an industrial 

hygienist.

The industrial hygienist looking at it 

is saying the person in this occupation, and I 

don't remember what the occupation was, they just 

could not understand where that employee would 

have had any reason to ever work with degreaser 

agents or whatever it is that would have had them 

in contact with TCE. And they wrote an opinion 
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to that effect, that there would likely have been 

based on their professional judgment

insignificant exposure.

That contradicted what we were hearing 

from the treating physician.

In looking at the occupational history 

questionnaire and the nature of the information 

from the treating physician it was pretty clear 

that the claimant was saying that for whatever 

reason he did do a lot of work with this stuff.

So I flagged it as a case and said why 

don't we use this as our pilot to determine 

whether or not if we talk to the claimant they 

can shed any light on how exactly did you use 

this material, what was the nature of the work 

that you did with it, the frequency and that sort 

of thing.

So what is going to happen is that the 

claims examiner is responsible for the logistics 

of setting up a call.

The claims examiner will be on the 

call. We will arrange a call with the claimant. 
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The industrial hygienist will moderate the call. 

They'll basically go through and ask a series of 

questions.

Those are going to be probing 

questions. They're going to be asking describe 

what you did, what's the nature of the type of 

work that you did with this material.

All of these kinds of questions to try 

to elicit a better understanding of what the 

employee did with this material.

The CE and the industrial hygienist 

are going to basically construct a memo from that 

that describes the nature of the exchange.

That information thus far will be 

relayed to the claimant and said is this an 

accurate portrayal of the conversation that we 

had.

That information will then be fed back 

to the industrial hygienist for consideration as 

to whether or not the information is sufficient 

to convince them that their original 

characterization of exposure is accurate or must 
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be modified based on that input.

MEMBER BERENJI: Do you mind me asking 

a follow-up question to that? 

MR. VANCE: All right.

MEMBER BERENJI: So when they actually 

have that deliberation between the industrial 

hygienist and the claims examiner if there's a 

need to do additional research like, say, in 

PubMed, for instance, or in some sort of current 

updated database to be able to look up a 

particular exposure depending on what the worker 

explains is there any process by which that would 

be further explored?

Because at least based on my previous 

reviews of these other IH reports it seems like 

they kind of go through the same verbiage in 

terms of these are the resources we reviewed.

But you actually can see that there's 

a repeated pattern by which they look at the same 

references time and time again.

Is there any -- at least in this 

current update will there be any anticipation of 
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looking into current literature on specific 

exposures based on what the worker describes to 

the industrial hygienist?

MR. VANCE: No. We're not envisioning 

that. The function of this interview will merely 

be to focus on the issue or toxin that is at 

question in the case.

So in this particular case it's TCE. 

The claimant could always provide additional 

information from whatever expert that they want, 

but as far as additional research along the lines 

that you're talking about the answer is no.

CHAIR MARKOWITZ: Dr. Dement.

MEMBER DEMENT: Excuse me. Just to 

continue the follow-up on the industrial hygiene 

updates.

And I think the language is somewhat 

consistent across them. But I'd like some 

definitions at least for my part to understand 

them.

And perhaps it even goes back to the 

legislation that established the program. They 
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often use the word "significant."

And by significant it could mean lots 

of things to lots of people. I assume that it 

passes sort of the first test. This is an 

exposure that's beyond de minimis and should be 

considered with regard to the outcome of the 

claimant. Is my interpretation correct? 

MR. VANCE: I would say so. I mean, 

the Procedure Manual talks about this low, 

moderate, high, and significant range, and then 

insignificant.

I think the direction that we've been 

moving in is a bifurcation, either insignificant 

or significant, and then providing additional 

information that the doctor can evaluate and 

consider in his or her evaluation of causation.

I think that's open to debate as to 

the proper characterization of the level of 

exposure, especially in the absence of any 

specific monitoring information.

MEMBER DEMENT: Same question and it 

has to do with the changes in the manual perhaps.
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I see a comment, the reference, very 

low, low, moderate, and high. Is there any tag 

to a reference level for any of that?

For example, low is only low if you 

have a reference level.

MR. VANCE: I think the best answer I 

can give you is it would depend on the subject 

matter expert who's looking at it and rendering 

an opinion in the absence of any definitive 

evidence.

So in other words looking at these 

cases you're often going to find that there is no 

industrial hygienist information, or industrial 

hygiene information at all in the case.

So we have to rely on the 

characterization of exposure based on the best 

judgment of the expert looking at it.

And this is the terminology that our 

industrial hygienist utilized. And so if you 

would be making a suggestion of defining or 

applying a specific definition, or changing the 

methodology that they employ now that's what we 
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would be looking for as far as input from the 

Board.

MEMBER DEMENT: Often when we have 

done exposure reconstructions for studies that 

I've done we use the same terms. I mean, it's 

not quantitative. It's clearly qualitative.

But to at least tag it to something, 

low relative to occupational exposure 

recommendation standards at the time.

So I do think it would be helpful if 

the hygienist says it's low or very low to at 

least say relative to what. What are you 

comparing it to? Is it 5 parts per million that 

was in effect in 1965, or is it 0.5 parts per 

million that's in effect now?

So I think some relative qualification 

of that would be very helpful. It would make the 

exposure assessments better.

The other thing, I don't know if the 

manual is going to change it. I consistently see 

this comment in the reports that I've reviewed 

that exposures beyond mid-nineteen nineties would 
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be within occupational exposure standards in the 

absence of data. There's no data so why make 

that statement?

Is that just a carryover from the memo 

that was rescinded? Is this something that's 

required that they put in there every time?

MR. VANCE: It's something that we 

utilize to basically say by 1995 our industrial 

hygienists feel pretty confident that they should 

be able to see something that would allow them to 

more reliably opine on the characterization of 

exposure.

And if they don't see that then they 

can't make a judgment that there would have been 

significant exposure.

Now, I think you and the Board has 

identified this as an issue and I know that it's 

been something that has been heavily debated as 

to how we could amplify or clarify that language, 

or provide more context to that language.

So the answer to your question is I 

would be really looking forward to something from 
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you guys that would help us with that.

It's a very, it's a challenge.

MEMBER DEMENT: Yes, it is. But I 

think we all recognize that things improved at 

the DOE sites as more industrial hygienists were 

employed in programs beyond radiation protection 

emphasis.

But I don't think it's fair to say in 

the absence of personal or area exposure 

monitoring then you assume.

I think it's just stated as it is. 

Stated appropriately.

MR. VANCE: Yes, and I think that's 

the nature of the conversations that I've been 

having with the industrial hygienists as to how 

we can improve that language, or improve the way 

that we communicate that.

But again, our view, and don't get me 

wrong. When we do have data after 1995 that 

would suggest that there was an exposure beyond 

some nominal level and a dangerous interaction in 

some way that would be something the IHs would 
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recognize and report on.

But I think that there is an 

acknowledgment that by the mid-nineteen nineties 

that the same type of dangers that existed would 

have been identified much more readily and would 

be in the case file.

And we tend to see a lot more 

occupational safety and data information in cases 

after 1995 that allows the IHs to basically say 

yes, absolutely. Look at it, it's right there.

But again, you're right. I think 

there are other instances where you're just never 

going to have that level of detail in every 

single case.

CHAIR MARKOWITZ: Steve Markowitz. 

The current language assumes that post '95 that 

DOE facilities somehow managed to assess across 

the board what the significance of potential 

exposures were for the portfolio of toxins within 

the complex which they couldn't possibly have 

done.

I'm sure they did it for certain 
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signal agents like beryllium, maybe asbestos, but 

certainly couldn't do it across the board.

So it's that assumption which is 

erroneous. But we accept the invitation to 

assist you in developing more appropriate 

language. 

MR. VANCE: I do want to make it very 

clear that the Department of Labor is in no way 

suggesting that after 1995 everything was picture 

perfect and that there were absolutely no dangers 

that existed, or no incidents that existed at the 

site. That is not the case.

We readily recognize that there were 

instances of exposure that occurred after 1995. 

And I know that we have accepted claims based on 

solely post 1995 exposures that occurred.

It's just that our industrial 

hygienists feel that after that date that they 

would anticipate to see some reporting, some 

assessment, or something that they can rely upon 

in order to characterize that exposure.

And it may not be something 
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necessarily identifying a particular monitoring 

level or something like that, but at least 

something that would be indicative or convincing 

to them that an exposure occurred beyond a 

nominal level.

CHAIR MARKOWITZ: So, we're going to 

come back to this when we do claims review and 

we'll think through new language that might 

assist DOL. Dr. Berenji.

MEMBER BERENJI: So again, just kind 

of focusing on this industrial hygienist-claimant 

interaction.

To me this is phenomenal and I really 

appreciate the fact that you all have actually 

considered that because there's a lot of 

information that can be gathered by just talking 

to the claimant, by talking to the worker and 

getting an understanding. So to me that's great.

I'm a big fan of quality assurance and 

I'm really also happy to see that you guys are 

continuing to improve upon that.

I'm actually really trying to be of 
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use at least for you all to be able to provide 

language in terms of how this quality assurance 

can be done in a more optimized manner, 

especially when you have a complicated case with 

multiple exposures, multiple diagnoses, multiple 

symptoms.

In the medical world we always have 

what's called case conference. It depends on our 

specialty. But we actually do have a process by 

which we can convene.

So at least from a quality assurance 

enhancement perspective when it comes to 

deliberating a particular case where there's a 

lot of exposures, a lot of diagnoses would there 

be a consideration to incorporate some sort of 

case discussion, not only including the claims 

examiner, but also the industrial hygienist, the 

physician or medical director? 

Has there been any thought as to how 

to incorporate the updated information from the 

worker and actually having a discussion about how 

to proceed?
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MR. VANCE: Yes, we've had -- well, 

okay. So you covered a lot of ground.

I would say for our quality assurance 

program it would probably be absolutely the case 

that we're going to have findings from a much 

more in-depth evaluation of these cases around 

the construct of the decision under review which 

may be limited to a particular condition, issue, 

or what have you.

As far as our claimant interactions 

the challenge that we are facing, and I'll try to 

say this as delicately as possible.

And this has been something that we 

recognize that the Board is very interested in 

with regard to obtaining better quality 

decisional outcomes.

And let me choose my words because 

it's a debate that we have had and we've 

struggled with it.

In a worker compensation environment 

where there's a lot of money involved in the 

outcome people are going to provide information 
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in the presentation of the claim.

So a worker will provide lots of 

details. And now we are going to be in a 

position where we're going to be questioning the 

claimant about those.

We could be very well into a scenario 

where we're asking a claimant about something and 

it doesn't make sense.

The question would be how do you 

determine the accuracy of the information and how 

do you apply an adjudicatory process to that. 

That will be the challenge.

Because in looking at this particular 

case there have been questions about whether or 

not it's accurate that there would have been any 

reason for the type of employee that this 

employee was working with this material. But 

that's the question that we're going to be 

asking.

So the questions when we ask that are 

going to be probing. We're going to be saying

describe it. What were you specifically doing. 
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How were you using it. 

That information has to complement 

other information that we know about this 

employee. 

So the question that the Board should 

be wrestling with because we are wrestling with 

it is how do you make these kinds of judgments 

because there are going to be instances where 

people are going to enhance information about the 

type of work that they did because this is a 

worker compensation program.

We generally will trust the 

information from the claimant if it is 

consistent, if it is detailed in describing work 

activities that are corroborated by other types 

of information.

But what do you do in the instance 

where that information doesn't align with any 

other information we have about that employee or 

other resources? How reliable is that 

information?

So claimant interviews are very 
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helpful in obtaining that type of information, 

but then how do you use it if it doesn't align 

with other information in the case file.

And that's the struggle in any kind of 

worker compensation program.

I personally think it's going to be 

great. We will be getting much more detailed 

information about it.

And I would say in the vast majority 

of cases that I've seen the information we get is 

actually very illuminating and very trustworthy.

But we have to be mindful in this type 

of an environment where there is large amounts of 

money on the line of misinformation. 

And we just have to figure out how do 

we make sure that the claim outcome is an 

appropriate one based on the best possible 

information.

CHAIR MARKOWITZ: Steve Markowitz. I 

would just say that that's normal. In the 

occupational medicine encounter we probe. We try 

to get detail to verify the experience.
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We compare that experience with what 

we know in general about that particular 

occupation or that work setting.

We look at how repeatable the 

information is within the interview. Say, 

compare the interview to the OHQ. 

So that's normal. And that's all I 

can say. Dr. Goldman.

MEMBER GOLDMAN: Another point on it 

is somebody has -- just to follow up on what you 

said.

Somebody has a certain job title. And 

so the IH person does everything for that.

But frequently they're asked to 

substitute. Somebody is out of work and so that 

job, they get stretched to go fill in, or go 

clean up something. And that isn't their usual 

job title, but they're asked to do that.

So I'm wondering if there are ways --

so if you talk to the worker and they tell you 

that's what they did if there's a way to then 

follow back with other people, other workers 
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about that.

Because it wouldn't appear in the 

usual job record.

MR. VANCE: Absolutely. That is 

actually a very frequent occurrence in most DOE 

sites where you had workers doing a variety of 

things.

That's why I think these claimant 

interviews are so critically important because I 

think someone who was doing it, who was there and 

can explain it and provide a reasonable, 

compelling and convincing story about the nature 

of why it was they were engaged in this 

particular activity that would have been outside 

the routine for their labor category is very 

helpful.

And we know that. We know that in 

looking at some of these cases there were 

instances that people that were doing very 

administrative tasks could have potentially have 

gone in and done other types of work activities 

of a very production related type of activity.
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It's the question of how do you judge 

and assess that accurately, and how do you make a 

judgment that that's a factual presentation of 

information that we can rely on in order to apply 

it in the adjudication process.

So we would use lots of different 

resources to try to corroborate that information 

and compare it to other information we know about 

that process.

CHAIR MARKOWITZ: Steve Markowitz. 

We're very happy to hear that DOL views these 

interviews that we recommended as being 

critically important.

Will the industrial hygienist get a 

chance to ask questions, or is it only -- you 

made it seem as if the claims examiner was taking 

the lead. Will the IH be able to speak?

MR. VANCE: Let me explain how it is 

that we're envisioning this working because we're 

actually in the middle of trying to figure out 

the logistics again.

So the IH or the claims examiner will 
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identify an issue that needs to be addressed. 

So the claims examiner says it would be very 

helpful, or a question arises from an industrial 

hygienist.

So it can be the claimant or the 

industrial hygienist that are raising a question 

that they think talking to the claimant may help 

resolve some issue.

That information then falls to the 

claims examiner to schedule basically a 

conference call with the claimant.

The industrial hygienist and the CE 

will be participating on that call.

The questions will be formulated --

the one that we are working on right now, the 

questions are being formulated by the industrial 

hygienist. 

So our industrial hygienist is 

constructing a series of questions. And the CE 

will coordinate the call, be present, and sort of 

explain the nature of the call, but then it's 

going to be turned over to the industrial 
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hygienist to lead the claimant through a series 

of questions and then also seeking out other 

information as the claimant provides that data.

The CE and the industrial hygienist 

will maintain notes of the conversation. They 

will then prepare a memo that basically details 

the scope of the call, the nature of the 

communication.

They'll agree on a final version which 

will then be submitted to the claimant. The 

claimant will be asked to verify that it's an 

accurate portrayal of the conversation.

Once that has been done that 

information will be rerouted back to the 

industrial hygienist. And it could be a 

different industrial hygienist than the one 

actually reviewing the case, and asked for them 

to reevaluate the case based on whatever the 

nature of the issue is that sort of necessitated 

the phone call.

CHAIR MARKOWITZ: Quick question. Why 

wouldn't it be the same industrial hygienist? 
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They actually spoke to the claimant.

MR. VANCE: Contractor. We have 

contract industrial hygienists and they wouldn't 

be -- it's not part of their contracted 

responsibilities --

CHAIR MARKOWITZ: The federal IH is on 

the phone, but it's the contractor.

MR. VANCE: Correct.

CHAIR MARKOWITZ: The contractor IH 

report, will that come back to the federal IH who 

actually was on the phone call?

MR. VANCE: As of right now, no. What 

would happen would be -- and we are in the midst 

of working out the logistics.

The phone call is meant to collect 

information that is to address an issue. That 

information is assembled into this memo and then 

submitted back to more than likely an industrial 

hygienist that did not participate in the call.

That information in the phone call 

would have to be considered and weighed by 

another industrial hygienist that's probably 
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reviewed the case in the past to determine 

whether or not the original assessment of 

exposure needs to be altered based on this new 

information.

And that then would produce another 

industrial hygienist supplemental report that 

would go through our normal clearance process. 

And that process involves generally 

having a federal industrial hygienist review that 

report and then release it for incorporation into 

the case file.

CHAIR MARKOWITZ: So my question is 

how many federal industrial hygienists are there?

MR. VANCE: We have two.

CHAIR MARKOWITZ: So of those two 

couldn't that supplemental report in the process 

go back to the one who was on the call?

MR. VANCE: Yes.

CHAIR MARKOWITZ: Okay, thank you. 

Dr. Redlich.

MEMBER REDLICH: Do these two federal 

industrial hygienists, do they review all of the 
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work that's been done by the contract?

MR. VANCE: Yes. A vast majority of 

the IH reports are individually screened by our 

team industrial hygienist lead.

Some of them go through -- some of the 

basic ones are not any longer. We have those go 

through the process and they are released with 

not -- I mean, each one is looked at, but not to 

the same degree -- there are certain types that 

aren't reviewed in-depth. But they're all 

screened basically by our team.

MEMBER REDLICH: So this sort of --

without the perspective of knowing what exposures 

actually caused the diseases that we see as 

occupational physician or occupational pulmonary 

physician, there becomes this, you know, 

thousands and thousands of exposures where when 

we actually talk with the patient knowing let's 

say the much narrower list of relevant exposures 

we can then hone in on those questions.

So as one suggestion it might be very 

helpful if the -- because the industrial 
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hygienist report and opinion carries a huge

amount of weight.

Especially because most of your CMC 

physicians do not have our expertise, and they 

depend very heavily on the assessment from the IH 

person and the SEM.

Again, that also focuses as does the 

claims examiner. Because that really then 

focuses the questions that are asked.

And it might be helpful, I think many 

of us would be happy to sort of occupational 

medicine perspective that I think would just help 

facilitate the process. 

It might also be very time- and costeffective because one wouldn't be chasing 

exposures that really, you know, most of the 

exposures and most of the disease listed in 30 

years I have never seen a case of.

MR. VANCE: Yes. As a policy branch 

chief that's worked for this program since 2001 

I've seen it all. So everything that you have 

said I agree with.
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I am always looking for ways to make 

this process more efficient, more of a resource.

MEMBER REDLICH: Because almost the 

SEM seems to sometimes make it less efficient 

because it now has just generated numerous 

irrelevant exposures that sometimes hide the 

basic. Like it was a dirty, dusty environment.

MR. VANCE: Yes. It's an ongoing 

process and the scope of the SEM has a huge 

amount of information. And any methods or 

logistical solutions that we can offer to 

evaluate 626 cases a month -- if you're talking 

about that's our intake you have to also 

understand the administrative reality of with 

that number of claims. Not all of these of 

course are going to be Part E cases.

But you're talking about a fairly 

robust volume of claims going through this 

process. And so anything that you -- I think 

this is to the entire Board.

Any efficiencies that you can find are 

going to be very helpful.
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MEMBER REDLICH: We've seen one of the 

most common cases. You know, COPD, the pulmonary 

cases.

There's a very limited number of 

exposures that actually cause those diseases. 

So, if the IH people understood that they would 

then know what to focus on.

It's not that list of 7,000 chemicals 

and the like. It's a very, very small list. And 

that's really what's lacking here.

CHAIR MARKOWITZ: I have a few 

questions. So, can I go, Dr. Berenji? Short 

answer questions. 

MR. VANCE: I love short answer.

CHAIR MARKOWITZ: The contractors. 

You've got Banda for industrial hygiene. You 

have QTC for the medicine. Any significant 

changes in the contracts or the contractor 

functions that we should be aware of?

MR. VANCE: The contracts are going to 

go through a re-bidding process in the next year. 

We have to have a new contract in place for the 
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industrial hygienists by April 30 of 2020.

And I don't know the exact dates for 

the QTC re-bid. But we have to exercise option 

years which add onto the contract and both of 

those are coming up for renewal.

CHAIR MARKOWITZ: Has there been any -

- in terms of the federal industrial hygiene 

occupational medicine or toxicology expertise has 

there been any change in the people or resources 

that you have or use in that in the last 6 or 12 

months that we should be aware of?

MR. VANCE: No.

CHAIR MARKOWITZ: Okay. How many 

public submissions to the SEM are there per 

month, per year, whatever? In recent times.

MR. VANCE: I'll have to get you that 

specific information. I'll probably get that 

today. I'll just go back the last six months and 

see what we have.

CHAIR MARKOWITZ: Is it possible to 

know how many of those are accepted by the 

contractor and DOL in terms of revising the SEM?
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MR. VANCE: Absolutely. I can get a 

full summary of the last few months of public 

submissions and the work that has been done in 

conjunction with that.

I do know that some of the public 

submissions have resulted in pretty sizable 

alterations to some of the information in the 

Site Exposure Matrices. So I'll work to get that 

information to you.

CHAIR MARKOWITZ: Okay. So to the 

public, keep up the work. Good work.

The SEM, you talked about additions to 

particular agents, but what about the exposure 

disease links? That depended originally upon 

National Library of Medicine Haz-Map program.

In the past six months or year since 

we've last talked about this has that evolved at 

all? How is that updated? How do you make sure 

that whatever is new and established in 

occupational medicine is incorporated in the SEM? 

Not the agents, but the link in particular.

MR. VANCE: Well, I mean we continue 
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to work with the information that we receive from 

Haz-Map. We have our toxicologist onboard who's 

also evaluating updates to IARC.

And in fact, she's made two 

recommendations that we are going to likely move 

on with regard to new presumptions. 

And I should have written it down, but 

it's one that involves lindane and another that 

involves -- I'll have to get you the update, but 

there are two presumptions and these are based on 

IARC data.

And we've already constructed out the 

presumption. And more than likely what we will 

be doing is issuing an interim update to our 

Procedure Manual to incorporate those into our 

procedure.

So these are going to be two new 

additional presumptions. I'm trying to remember. 

 It's non-Hodgkin's lymphoma.

CHAIR MARKOWITZ: With lindane.

MR. VANCE: Lindane and penta --

CHAIR MARKOWITZ: Pentachlorophenol?
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MR. VANCE: Pentachlorophenol, yes.

CHAIR MARKOWITZ: You mentioned that 

100 new agents were added to the Paducah SEM. 

Just curious because you're 15 years into 

constructing the SEM. Paducah we learned started 

1952.

How is it that 15 years into the SEM 

we discover that there are 100 additional agents 

that existed at the site?

I don't doubt it, I just want to know 

how it works.

MR. VANCE: Our -- Paragon is the team 

that does the research. They are constantly 

scouring the Earth for records.

And they have new treasure troves of 

data. And sometimes I, you know, just as an 

example, like I go through cases quite frequently 

and I'll find information that I think is kind of 

interesting that they've never seen before that I 

forward on. I'm like you guys should look at 

this. And that has the effect.

I mean, so records are found all over 
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the place.

The real story was a lot of our 

uranium mills and mine information came from one

individual that had stored all of these records 

in his basement. And so somehow they got their 

hands on that.

So sources of information are out 

there. They are constantly being found and 

scoured. And one path leads to another and 

sometimes they will just uncover records.

And if they're looking at a particular 

process it could be that those records are stored 

in a different location.

So a lot of the closure site material 

that's introducing them to new information, 

sometimes in the closure information they may 

have processing data that goes back to some 

period in history that they didn't have access 

to. And that information then feeds into updates 

to the Site Exposure Matrices.

CHAIR MARKOWITZ: Does the industrial 

hygienist usually redo the SEM when they get the 
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referral from a CE? Or do they usually --

MR. VANCE: Yes. It's our process to 

go through and test the exposures and make sure 

that that information is accurate and correct at 

the time that they're reviewing the case.

CHAIR MARKOWITZ: My final question. 

You mentioned some revised asbestos language in 

the Procedure Manual which will be available 

perhaps tomorrow at noon after we end this 

meeting.

Is it possible that we could look at 

that language during this meeting just so we can 

actually have some conversation about that?

MR. VANCE: Yes, I can do that. The 

language isn't specific to asbestos. That was 

merely a change to the Site Exposure Matrices.

The language that changed is the 

addition of a statement with regard to 

interstitial lung disease, pulmonary fibrosis and 

pneumoconiosis.

CHAIR MARKOWITZ: No, I was referring 

to the language about significant exposure, '45 
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to '86, or '95.

MR. VANCE: Yes, I can get that for 

you.

CHAIR MARKOWITZ: Okay, great. Thank 

you. We're going to take a break soon but let's 

see if we can finish these questions. Ms. Pope.

MEMBER POPE: I was wondering if 

there's a process in place that asks -- that can 

assess the quality control of the resource 

centers, their effectiveness in helping the 

claimants.

MR. VANCE: Yes. I know that the 

resource centers are a contractor for the 

Department of Labor. 

I know that they have their own 

internal quality control mechanisms. We have 

reporting with regard to their activities. So we 

can actually monitor the functionality of the 

resource centers.

And I do think that in the past 

they've gone through a quality assurance review 

by federal staff. So, I do know that there is 
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quality assurance oversight of our resource 

center activities.

And as far as my understanding, you 

know, the resource centers are amazingly well 

adept at responding to issues that the Department 

of Labor needs to engage with.

The resource centers have taken on a 

large onus in responding to phone calls and that 

sort of thing, and that's something that our 

Branch of Outreach and Technical Assistance has 

been monitoring and assisting with.

Our resource centers are also overseen 

by a federal manager. And I know her, she used 

to work with me, so I know what kind of person 

she is. She's a very detail-oriented and very 

motivated person.

So yes, I think the answer is yes, we 

do have a quality control evaluation process 

evaluating the work of the resource centers.

But I also know that the resource 

center contractor themselves are very, very keen 

on making sure that they are satisfying the 
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requirements of the contract.

And that means that they are being 

responsive to claimant interactions, they are 

being responsive to assisting with medical 

benefit and claim submissions, and providing good 

customer service with regard to any interactions.

As far as I'm concerned the resource 

centers have done a tremendous job in that 

regard. They're there, they're available, 

they're on the ground helping folks.

Issues that come up with regard to any 

kind of problems are quickly addressed. So if 

there are concerns we need to know about it and 

we take action with the resource centers to 

resolve those issues.

CHAIR MARKOWITZ: Other questions, 

comments?

MEMBER REDLICH: This is a very quick 

one.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: This is another very 

quick one. In terms of the total number of 
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claims let's say that go to a CMC in a given 

month about how many would that be?

MR. VANCE: I wouldn't even be able to 

--

MEMBER REDLICH: Just to get a sense 

of the volume.

MR. VANCE: I'd have to go back and 

get the statistical information on that or 

otherwise it would just be a complete guess. And 

it fluctuates month to month. It just depends on 

the sequencing of the cases, the population, or -

-

MEMBER REDLICH: Sure. Just like a 

range.

MR. VANCE: That would be another 

request by Steve for statistical data. 

(Simultaneous speaking.)

CHAIR MARKOWITZ: Complete with 

rationale, yes. Other questions? Dr. Mikulski.

MEMBER MIKULSKI: This is Marek. 

There's a whole wealth of information data 

available through former worker programs.
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It has been obtained following a 

rigorous methodology and research protocols.

I wonder to what extent it would be 

possible to tap into those resources and inform 

your industrial hygiene process.

I know in the past we had done some 

educational seminars for CEs and I thought that 

these were really helpful in terms of providing 

our input to help with the understanding, the 

environment of these sites.

Is there any way that we could maybe 

be of help to your adjudication process with this 

information?

MR. VANCE: Well, my response to that 

is I think that any information that the resource 

center or the Former Worker Screening Program can 

provide in case adjudication activities is always 

welcome.

We do get screening data. We do get 

information from the Former Worker Screening 

Programs that actually are incorporated into the 

official case file.
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That information is oftentimes very 

critical because it usually involves an in-depth 

interview and screening process, an initial 

medical screening that provides diagnostic and 

other types of information, clinical data, that 

then feeds into the overall adjudication process.

And I think that the Former Worker 

Screening Program is also very helpful in 

communicating information to potential claimants 

and to the public. 

So that's the big thing that I always 

encourage is that any outlets for information 

about our program and sources of evidence that 

can be used to assist the claims process is 

critical and that's where I think the Former 

Worker Screening Program is essential in giving 

us information that helps inform our claim 

process, and inform the public about the benefits 

that are available when you are screening 

individuals that are identified with potentially 

compensable diseases.

CHAIR MARKOWITZ: Steve Markowitz. A 
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follow-up question to the Haz-Map.

So, I don't follow Haz-Map and its 

evolution. Is that routinely updated? Is there 

an existing contract between NLM and the creator 

of Haz-Map?

I think the DOL's contract with the 

Haz-Map organizer was suspended or finished at 

some point.

The real question is is Haz-Map 

updated and are those updates incorporated into 

the SEM?

MR. VANCE: It is updated. Not all of 

the updates that occur are uploaded and reflected 

in the Site Exposure Matrices. 

So it's Dr. Jay Brown who still is 

managing that process. He's in a status of 

trying to find someone else to host that platform 

and struggling with that.

That's something that the Department 

of Labor is aware of, but we don't really have 

responsibility for any kind of management of HazMap.
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So Haz-Map still represents a 

significant source of data for the Site Exposure 

Matrices, but that doesn't necessarily mean that 

we are in complete -- that they are in complete 

agreement.

CHAIR MARKOWITZ: So as Haz-Map 

changes, adds or subtracts, who from DOL makes 

that decision whether that change in Haz-Map 

should be incorporated into the SEM?

MR. VANCE: That's a determination 

that's made under my branch with the medical 

health science unit. 

It's usually a collaborative effort to 

evaluate the request or the change, whatever it 

is, and decide whether or not that is reflective 

of something that we believe is appropriate for 

the program. 

CHAIR MARKOWITZ: Any other? Mr. 

Mahs.

MEMBER MAHS: Just to follow up on Dr. 

Goldman. 

Something that the IH could check when 
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they have the -- some of the claims I've gone 

through, they disallow several of the toxins or 

chemicals because the SEM said it wouldn't be 

applied to this occupation.

Well, it depends on the occupation. 

Just like myself, if you're on construction I 

might be exposed to welding fumes, to cutting 

torch metal dust, epoxies, different cleaning 

chemicals every day because you mix crafts.

But if you look at the SEM in my 

occupation I wouldn't have exposure to those.

MR. VANCE: Right. Yes, and I agree -

- the function of our claim process is to try and 

get as complete a picture of the exposures as 

possible. And the SEM is one resource that we 

use.

The Site Exposure Matrices is 

populated from information and primary source 

evidence. In other words there's something on a 

document that says we know that this material was 

there and that this laborer or person, whoever 

the labor category was that would have been there 
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would have engaged in that activity.

If it isn't on a piece of paper 

somewhere it's not going to be in the Site 

Exposure Matrices. 

We would then turn to other sources of 

information such as the occupational history 

questionnaire, former worker screening material, 

clinical information from a physician, industrial 

hygiene records in the document acquisition 

request, or any other source of information in 

the file to try to build out a better 

understanding of the exposures.

So SEM is merely one resource that we 

use. And it is very true that you could have 

situations where employees are exposed to things 

that have nothing to do with their particular 

labor category and when you search in SEM you 

don't find anything like that under that labor 

category.

But hopefully in applying different 

kinds of filtering to your SEM search you can 

maybe identify and corroborate those exposures 
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through, say, a work process, or incident, or 

area, or location, or some combination of those 

things.

CHAIR MARKOWITZ: Okay. So, I guess 

the last question.

MEMBER DOMINA: When you have somebody 

whose work is highly classified and your claims 

examiners are privy to that walk me through how 

you would do that.

MR. VANCE: Generally if we have any 

understanding that there could potentially be a 

classified circumstance and engagement that would 

be something that we could address through a 

process.

I think that what we do is have --

Paragon has folks that are cleared to do that and 

engage with a discussion with the claimant I 

believe.

It has never been an issue where we 

have had to have a classified interview that I'm 

aware of that has caused us to sort of shut down 

the whole process.
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I do know that there are things in the 

Site Exposure Matrices that are sensitive that 

require some level of effort to make sure that 

we're not publicly disseminating this type of 

information.

It's basically we handle those 

circumstances when they arise and they don't 

arise very often. And when we do we generally 

find it's not really a classification issue. 

It's not a security problem.

And if it does we have resources to be 

able to address it. But as of right now I'm not 

aware of an instance where that's become an 

issue.

CHAIR MARKOWITZ: Go ahead, Dr. 

Redlich.

MEMBER REDLICH: Sorry to talk so 

much. One last SEM item that you might look at 

that has come up I think repeatedly is where an 

exposure such as asbestos might be widespread in 

multiple buildings at a site where someone has 

worked there for many years during a period of 
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time when we knew that was a widespread exposure.

But their very specific job category, 

you know, secretary, then results in it showing 

no exposure.

So, it seems that one should take into 

account how open the space is and the duration of 

employment and the likelihood that that person 

was only in that one job category that seems to -

- that exclude what would seem to be a sort of 

obvious exposure.

I just mention that as one of the 

themes that's come up on a number of cases, 

particularly more with women than with men, not 

necessarily, but as a sort of more administrative 

job that is in a facility with a lot of exposure 

that may be open.

MR. VANCE: Yes, and I think that 

speaks to his concern which is that -- and this 

is a challenge that I think we're always welcome 

to receive input about how to handle these 

situations where you have folks that performed 

administrative functions, whether they were men 
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or women.

Under what context would they have 

been brought into contact. And contact means 

proximity, work activity, all these kinds of 

things that factor into an industrial hygiene 

assessment that brought them into contact with 

some of these very hazardous materials.

And that has been a challenge for a 

long time is what's your rationale, what's your 

justification for saying someone that worked in 

that type of capacity would have had reason to be 

exposed, or what would have been the extent or 

the interconnectivity of their work and their 

exposure to these materials. How did that occur. 

And that's been a challenge.

MEMBER REDLICH: I do think there's 

just some basic common sense that sometimes seems 

to be lacking.

Twenty years from 1950 to '70 is 

different than six months in 2001. And that sort 

of just overall magnitude.

You know, obviously if it's 20 years, 
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30 years, a number of years ago there is much 

greater likelihood. 

CHAIR MARKOWITZ: This is the last 

comment. Dr. Goldman.

MEMBER GOLDMAN: This is just a very 

quick add-on to what Carrie said which is a job 

that's very typical for this kind of thing is a 

janitor.

So the janitor or the custodians where 

it wouldn't link to this, but they're all over 

the plant.

So I think that that would be a job 

title that could be highlighted as inviting a 

larger amount of potential exposures based upon 

the facility name.

CHAIR MARKOWITZ: You forgot to 

mention fire fighter.

Okay, we're going to take a break. 

We'll come back at 5 after 11:00. Thank you.

(Whereupon, the above-entitled matter 

went off the record at 10:51 a.m. and resumed at 

11:11 a.m.)
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MR. FITZGERALD: Okay, we're going to 

reconvene here. 

Before we actually get back to 

business just wanted to let people know that are 

participating via WebEx that if they would like 

to take advantage of the public comment period 

please call the operator at *0.

And if you're in the room and would 

like to speak there's a sign-up sheet over here 

where the water is to my left. 

Okay, call the operator after 4:30 

when we change lines, *0. Thank you.

CHAIR MARKOWITZ: So, I would remind 

the Board members if you could speak directly 

into the microphone when you speak. Announce 

your name.

And also if you have a comment or a 

question if you could just put your name card 

upright that would help.

I think Mr. Calin Tebay is on the 

phone. And I think he's able to talk to us. If 

so I would welcome you. He's a Board member.
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If you wouldn't mind just saying hi 

and introducing yourself briefly.

MEMBER TEBAY: Good morning. Calin 

Tebay. I'm a representative of the Hanford 

Workforce Engagement Center and also Hanford 

Site-wide Beryllium Health Advocate. Thanks for 

having me.

CHAIR MARKOWITZ: So, if you have 

comments or questions you're just going to have 

to interrupt us. It's fine, just jump in.

MEMBER TEBAY: Sounds good.

CHAIR MARKOWITZ: Okay, good. That 

was a nice test case. Good.

Okay, we're coming back to the agenda. 

I just want to briefly review a couple of action 

items that we haven't talked about so far. These 

are items from the last couple of meetings.

This actually, Mr. Vance, I don't 

think you need to come back to the table. But 

there was a couple of public comments last time, 

one from Ms. Vina Colley and one from Mr. Robert 

Roth about additions that should or needed to be 
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made to the SEM, one regarding neptunium and I 

can't remember what the other one was.

And we had simply asked to make sure 

that whatever information be provided, or at 

least they be informed about the procedure for 

adding, suggesting that information go into the 

SEM. So we're hoping that was done.

If you could later just get back to us 

about that.

And the second item was a certain 

number of claims were reopened as a result of the 

evolution in the Procedure Manual, in particular 

in relation to some of the presumptions that were 

partly accepted by the Department of Labor.

And the Department of Labor promised 

that they would provide us with updates on the 

number of claims that have been reopened and the 

outcome of those, the reopening of the claims.

So I don't think the Department of 

Labor necessarily has that today, but we would 

request that the Department of Labor provide that 

update in the foreseeable future so the Board can 
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take a look at that.

We're going to put up now the 

recommendations. So, this will be particularly 

helpful for Dr. Goldman, but I think helpful for 

the rest of us.

We're going to look at the cumulative 

recommendations made by the Board since 2016, 

since it was created.

And for the Board members I think 

there may be a paper copy of this in the folder. 

So if it's easier for you to follow along.

And I don't want to spend a lot of 

time on this. I don't want to re-discuss, relitigate these recommendations. I just want to 

make sure that the current status of the 

recommendations, that we are agreed upon them.

Because I reviewed them. I wasn't 

sure with a few exactly where we were at.

So I will march through these, raise 

the questions and people can chime in.

So, first recommendation had to do 

with rescinding the Circular 15-16 which the DOL 
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agreed to do and did.

The second was adding Institute of 

Medicine to the SEM. Briefly, this had to do 

with a report that the IOM put out probably six 

years ago on the SEM to the Department of Labor.

And there's back and forth between us 

and the Department of Labor as to the sources 

that should be routinely looked at and 

incorporated into the SEM.

We had recommended that a subset of a 

table from the IOM report, that the Department of 

Labor make sure that they include those sources.

And the department agreed in a limited 

fashion to do that.

And so the question was, and I see 

here Dr. Cassano who's no longer on the Board and 

Dr. Berenji, the question was was there any 

follow-up that the Board wanted to do to look 

again at that list.

The particular issue, for instance, we 

recommended that EPA IRIS information, that the 

national -- the California program for evaluating 
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chemicals, those data be used, that the NIOSH 

reports be used, National Toxicology Program, in 

addition to the IARC, the International Agency 

for Research on Cancer.

And I think Department of Labor wanted 

some assistance from us in wading through some of 

those sources to figure out the extent to which 

they would be truly useful.

I think that's where we left off. And 

I take it from the comments this morning that I 

think IARC is probably the main source that's 

being used to update the Haz-Map which on the 

face of it would appear to be rather limited in 

terms of the sources.

The question is, and I don't want a 

long discussion on this, but should we further 

pursue this issue. Dr. Berenji.

MEMBER BERENJI: Yes, I'm happy to be 

a point person for the Department of Labor if 

they need additional resources.

I mean, I do feel that Haz-Map would 

be a good resource. The National Library, other 
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resources as indicated. So I'm happy to continue 

this effort.

CHAIR MARKOWITZ: The Haz-Map is the 

base program they use to create their exposure 

disease links within. But these other sources 

should take a second look, require a second look. 

Dr. Goldman.

MEMBER GOLDMAN: I think the National 

Toxicology Program monographs that have come out 

are important.

The other thing to consider, there are 

certain committees and review committees from the 

National Research Council and IOM. I would 

support using their reports that have come out 

because they're really very well researched and 

pull together a lot of information.

CHAIR MARKOWITZ: Does anybody want to 

work with Dr. Berenji on sort of re-looking at 

this issue in a limited way for additional 

sources that DOL might use to update the SEM in 

terms of the exposure-disease link?

Okay, so the volunteers include -- Ms. 
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Rhoads, the volunteers include Ms. Pope, Dr. 

Friedman-Jimenez, Dr. Goldman. That's in 

addition to Dr. Berenji. Okay, thank you.

The next item was that we recommended 

that former workers be involved at the resource 

centers in actually conducting the occupational 

health interviews. And the department agreed 

with that, to the extent that they were able to 

do that. They said that hiring DOL workers was 

of some priority. At the resource centers, 

though, it's a contractor that does that and the 

department has limited say in dictating who 

should be hired in that process.

We've discussed the next 

recommendation which was we had recommended that 

the industrial hygienist be able to interview the 

claimant. We've already -- we've received that 

update, so that's good.

We recommended the policy notes --

well, there were some policy calls that DOL makes 

periodically, national calls. 

And the Board I guess voted in favor 
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of making the notes from those phone calls 

public. And the Department of Labor didn't agree 

with that.

The next recommendation that's F is 

case files should be made available to claimants 

through a public portal. And the Department of 

Labor agreed with that and says that it's 

working, both OWCP -- well, EEOICPA but more 

broadly within the Office of Workers Compensation 

Program in making available to claimants' 

electronic records.

Page 2, G, we recommended that the 

Department of Labor enhance its scientific and 

technical capabilities. The Department of Labor 

didn't agree with that.

H was we recommended that the entire 

case file go to the consulting medical physician, 

contract medical consultant, excuse me, or the 

industrial hygienist. And the department thought 

that was excessive and didn't agree with that.

Next is asbestos presumption. We had 

recommended several aspects of altering the 
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Procedure Manual to make sure that the 

presumptions around asbestos embedded what we 

know about -- medical science knows about 

asbestos. And I think those -- that 

recommendation was mostly accepted.

I do see here though that there was an 

issue of whether the job titles in the list that

are a matter of the asbestos presumption, whether 

the job categories listed was complete.

And I see here that it says that Dr. 

Markowitz, Mr. Domina, Mr. Mahs, Dr. Mikulski and 

Dr. Dement will work on a response.

Does anybody recollect what our 

thinking was? Dr. Dement?

MEMBER DEMENT: I think we did work on 

updating the list a bit. But I honestly can't --

don't recall exactly where that stands. I don't 

think it was a formal Board recommendation.

CHAIR MARKOWITZ: Right, right. I'd 

be willing to take a new look at that list if 

anybody else wants to join me. Any volunteers? 

Dr. Dement and Mr. Domina and Mr. Mahs. Okay. 
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You got that? Okay. 

Next is the asthma presumption. And 

Dr. Redlich, it says here -- you may have done 

this already I think. But we made 

recommendations around the language on modifying 

the Procedure Manual language around occupational 

asthma.

Much of that was accepted. And I know 

that all the language we had recommended was not 

accepted, but the question I guess, Dr. Redlich, 

is whether this is closed essentially.

We had recommended some language much 

of which was accepted, some wasn't, and end of 

story.

MEMBER REDLICH: Since there's a new 

manual coming out I'll review it when the new one 

is out.

CHAIR MARKOWITZ: Okay. So, Ms. 

Rhoads, occupational asthma. And Dr. Redlich 

will call upon others if she wants some 

assistance.

The COPD presumption. The Board had 
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revised -- submitted a recommendation, revised 

the recommendation a number of times. Ultimately 

the Department of Labor and the Board don't agree 

on a presumption for COPD. 

Next page, L, the occupational health 

questionnaire revisions. So, Mr. Vance, if you 

could just bring us up to date.

So, we had made -- there had been 

discussion about the occupational health 

questionnaire. I know that the department had a 

draft of a new questionnaire. Where are we and 

how can we help?

MR. VANCE: Okay. So I do know that 

we have a completely re-drafted occupational 

history questionnaire that is going through 

scrutiny.

We actually had Paragon draft it up. 

And it was structured around much of the input 

that we got from one of your recommendations.

So, right now the document itself, we 

have got basically a spreadsheet and it's much 

more open-ended, and I think it incorporates a 
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lot of the recommendations about how you'd want 

to categorize information by work activity and 

various other types of things.

So it's right now going through an 

internal clearance review, and then I think we're 

going to probably be wanting to pilot it.

So it's still in a draft status. I'm 

not sure where it is with regard to the eventual 

piloting, but I do know that we do have a redrafted occupational history questionnaire that's 

in development.

CHAIR MARKOWITZ: So the question I 

guess is if it's permitted that we take another 

look at this, when would be the most useful time 

for us to provide some input? Further input.

MR. VANCE: I don't have an answer for 

that. I recognize that it would be very 

important to have the Board look at our version 

once we get to a point where we think we're going 

to begin implementation and then getting any 

thoughts about that.

But I just can't give you an answer to 
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that question at this point.

CHAIR MARKOWITZ: So let me say that 

it's a Board request that perhaps after clearance 

so that you have a product that you believe 

you're going to use that we be provided with that 

and with some limited period in which we can 

provide input into that if that's all right.

MR. VANCE: All right.

CHAIR MARKOWITZ: Dr. Berenji?

MEMBER BERENJI: Yes, I just want to 

state that I'm happy to review any updated 

questionnaires. So if you need a point person to 

moderate that I'm happy to take the initiative on 

that.

CHAIR MARKOWITZ: Okay. Next is the -

- thank you, Mr. Vance.

So next is our recommendation that two 

borderline beryllium lymphocyte proliferation 

tests be considered the same as one abnormal, and 

that was not accepted by the department.

And then finally, we had requested the 

sample of CMC reports, or really claims which we 
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could look at and -- which we've been provided 

with. So the department agreed with that.

We've also -- one of our 

recommendations which I think sits with the 

Secretary is that the Board be provided with 

resources to actually conduct a review of a 

larger set of claims. But I think that's still 

pending.

So if there are no questions about 

this we'll move on. Yes, Mr. Domina.

MEMBER DOMINA: I have a question for 

Mr. Vance. Under the asbestos presumption, on 

that mesothelioma, on why we dose those first 

before we accept them under E, why we're dosing 

them under B.

MR. VANCE: Well, under --

MEMBER DOMINA: Radiation dose under 

Part B. It's getting dosed before they'll accept 

it under E.

MR. VANCE: Well, if it -- so you've 

got to remember Part B has its own distinct 

adjudication process, and then under E.
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If it meets the -- there is no 

presumption for mesothelioma that exists under 

Part B. So it's got to go through the dose 

reconstruction methodology.

If it is under Part E, mesothelioma we 

already have a presumption for under our 

causation standards for acceptance. So, you 

could have a case where we have a dose 

reconstruction ongoing on Part B, but we're able 

to accept it under Part E because of the 

presumption.

And I believe it's like -- it's a 

fairly straightforward presumption under Part E. 

I don't know the exact standard that exists.

MEMBER DOMINA: Yeah, but why does it 

have to go through B first when it takes six to 

eight months when you know it's going to get 

accepted under E?

MR. VANCE: They should be able to 

process the B, and as -- they don't have to wait 

for the Part B dose reconstruction. They should 

be able to issue a separate and distinct decision 
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under Part E accepting the claim if it meets the 

qualifications for approval.

They shouldn't have to wait 

necessarily for the dose reconstruction to allow 

that to occur, unless the presumption doesn't 

apply.

MEMBER DOMINA: Well, we can talk 

offline. That did not happen.

CHAIR MARKOWITZ: Steve Markowitz. 

The potential issue with mesothelioma, two 

aspects.

One is the life expectancy is a year 

or less so a prolonged evaluation under Part B is 

problematic because the person could easily pass 

away in the meantime.

And secondly, it's virtually unique in 

how it's caused by asbestos exposure. So the 

likelihood of being accepted under Part E is very 

high. So, it's --

MR. VANCE: Without knowing the 

specifics it's very hard to ever comment on a 

case. So we've got to sit down and talk about 
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it.

MEMBER DOMINA: I have the information 

with me.

MR. VANCE: And I'm also, just 

following up on your earlier comment, I am going 

to find out the process we go through for 

interacting with folks on classified information. 

So I'm following up on that right now.

MEMBER DOMINA: Thank you very much.

CHAIR MARKOWITZ: I'm sure there are 

relatively few mesotheliomas in the system and if 

they can be flagged when they come in so the E 

and B are simultaneous and so. Dr. Dement.

MEMBER DEMENT: I have a resource 

issue. Given our request for resources and 

obviously their limited ability to provide them, 

I have another request.

As we review these claims and as 

future Board members review these claims that we 

revisit how they're delivered to us.

A non-indexed with thousands of pages 

of material to review requires us to spend 
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probably 80 to maybe even 90 percent of the time 

we have to put on review trying to find 

information.

So even a crude index. And we saw 

such an index when we had the conference call 

with the claims examiner does exist. And request 

that future claims for review have such an index 

that we can actually get to the relevant 

information more quickly.

CHAIR MARKOWITZ: When we discuss 

claims, reviewing claims this afternoon or as 

soon as we get to it if we decide we want to look 

at additional claims then we should definitely 

make that part of the request. 

Or if we decide that there are a 

certain number of the claims we've already 

received that we want to re-look at, or look 

further at we can make that request. So let's 

not formulate a recommendation at the moment, but 

just postpone it till a little bit later if we 

could.

Other comments? Okay. So, next we're 
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going to look at the claim status data the 

Department of Labor has given us which we may 

have briefly looked at in our September phone 

call.

And you, for the Board members, you 

have a paper copy, but for the public it will 

appear on the Board. 

And if for some reason you can't see 

it up here because it's not big enough it's also 

on the back board. So if you turn around you'll 

be able to see it more clearly.

Actually, this -- okay, well. Yeah, 

let's skip this. We'll come back to this one. 

The report 1182 or something, or 1158. Let's do 

report 1158 -- it starts RPT1158. Second from 

the bottom. Okay.

So, speaking to the public here, can 

you all see this? Because if you can't see it 

behind me you can certainly make it out if you 

turn around. It should be the same thing, Board 

members, you have a paper copy of.

And for anybody on the phone, Mr. 
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Tebay, you have access? You're looking at this 

online?

MEMBER TEBAY: Yes, sir.

CHAIR MARKOWITZ: Okay, great. Okay, 

so let me just summarize what we're looking at. 

The Board requested for common health 

conditions -- and by the way, I think we've made 

this available on our website. Is that right?

And so I think if you go to our

website, today's meeting, you will see this. If 

not, then we will make this available.

In any case, so we requested for the 

most common conditions how many were accepted and 

how many were denied and the reasons for denial 

over the past three years.

This is not a longitudinal look. 

We're not looking at how, you know, 2010 to 2013 

compares to the most recent period. This is a 

snapshot of what claims looked like over the past 

three years.

And this first thing we're looking at 

here is the most -- the top 20 health conditions. 
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And they're organized by ICD, International 

Classification of Diseases, ten codes.

And we're looking at the numbers of 

claims in that time period, three years. And the 

number that were approved, number denied, and the 

number of claims that are still pending.

And then the percent approved I 

calculated, I removed the claims pending and I 

just looked at of those that have been resolved 

what the percentage approved was.

And I highlighted in yellow the 

columns that were of most interest to make it 

easier to read.

And finally on the right you'll see 

the reasons for denial. Now, you'll notice there 

are only two reasons cited.

There are additional reasons and they 

are in this spreadsheet. They are hidden in this 

spreadsheet, which we can show them, but then the 

table would be so small we wouldn't be able to 

read it.

So they are the less common reasons 
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for denial and less relevant to our discussion. 

But if anybody wants to look at it they are 

there. And for that matter if you want to know 

the ICD codes they're there as well.

So you can see -- this is the top 20 

health conditions. But we also have it broken 

down to the top ten -- we're not going to move to 

this, but we will in a moment, cancer, 

respiratory, neurologic and renal. Okay?

But right now it's the most common 20 

conditions. You can see the total number of 

claims, that there are a handful of conditions 

which claims exceed 1,000 during the three-year 

period.

And by the time you get to the bottom 

of the list you're in the range of two to three 

hundred claims during the three-year period as 

opposed to 1,000 or more.

If you look at the percentage 

approved. So skin cancer, now this cannot be 

melanoma. This must be the more common skin 

cancers, basal cell, or squamous cell carcinoma 
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of the skin which are not metastatic and are 

resolved fairly quickly usually. Say 27 percent 

of those are approved.

The next is chronic obstructive 

pulmonary disease of which 52 percent are 

approved. A large number of claims, over 2,100 

and somewhat over 50 percent are approved.

Now, I just want to point out that if 

you look at row number 16 you see emphysema.

Actually, yeah; thanks, Kevin.

You see emphysema, 310 claims. If we 

were to group these we would group emphysema with 

row number 2 of COPD.

Actually, emphysema you see 52 percent 

are approved. So it's the same whether it's 

called emphysema or called COPD.

Prostate cancer, 3 percent are 

approved. Hearing loss, almost 50 percent are 

approved. Over 1,000 claims.

We see skin again, skin cancer again 

appear, a similar percentage approved pretty 

much, 35 percent.
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Asthma, a large number of claims, 832, 

62 percent or almost two-thirds are approved.

Pneumoconiosis due to asbestos. This 

is asbestosis, 83 percent are approved.

Chronic kidney disease, one-third. 

Other interstitial pulmonary diseases. We had a 

discussion about that earlier, 53 percent which 

is not quite as high as asbestosis which is 83 

percent.

Sleep disorders, 38 percent. Now let 

me say that some of these conditions are 

consequential conditions, right. So they're not 

primary conditions caused by toxins, but they 

were associated with a successfully claimed 

condition that leads to sleep disorder. My 

hunch.

Lung cancer, 41 percent approved, 

whereas GI cancer -- I'm sorry, this is 

metastatic disease, 12 percent.

So just so you know, people 

understand, these are cases in which the disease, 

the cancer has spread to another location. And I 
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think these are claims for where the metastatic 

cancer has appeared rather than what the primary 

cancer is.

Pleural plaques which are caused by 

asbestos, 83 percent. So that's very similar to 

asbestosis, was also 83 percent.

Fourteen is secondary malignant 

neoplasm. That's very similar to what I just 

mentioned under 12 which is metastatic cancer.

Parkinson's disease, 47 percent have 

been approved. Silicosis, 59 percent. Breast 

cancer, like prostate cancer almost none of them 

have been approved, two percent. And melanoma, 

12 percent. 

And then finally, polyneuropathy. 

You'll see when we get to the neuro conditions, 

neurologic conditions, there are all kinds of 

ways of discussing neuropathy. They're more or 

less grouped.

So you can see about 57 percent of 

those called polyneuropathy were approved. But 

we'll look a little bit more at that when we look 
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at them next.

So then finally, if you look on the 

right, why -- if you scroll back up, Kevin -- why 

were these denied, those that were denied.

And you can see that by and large it's 

negative causation, that the claims review 

process just didn't accept that this disease was 

caused by a toxin at Department of Energy.

And then the second most common reason 

was the medical information was insufficient. 

And you see that most commonly for the asbestosis 

and silicosis which is that the review process 

didn't have the medical information that they 

needed or deemed supportive to say that this 

person had asbestosis or silicosis. And that's 

less so, that's less true for other conditions.

So if there are no comments I would 

just march down. Go ahead, Dr. Friedman-Jimenez.

MEMBER FRIEDMAN-JIMENEZ: Question. 

The breast cancer finding is striking given that 

IARC classified rotating shift work as a 2A 

probable cause of breast cancer in humans.
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The question is, under which part 

would this be approved? I know it's not ours,

but is this included under section B? Is there 

any section under which rotating shift work could 

be identified as a cause of breast cancer?

CHAIR MARKOWITZ: Well, Steve 

Markowitz. Part E is about diseases caused by 

toxic substances. Part B is partly about that 

for silicosis and chronic beryllium disease, but 

it's mostly about radiation.

So rotating shift work, noise, all 

those other occupational exposures, very real, 

very important are not covered by the act. 

You can correct me, Mr. Vance, if I'm 

wrong, but that's what I think. What we've heard 

before. So, somebody would have to go to 

Congress.

Yeah, Dr. Silver.

MEMBER SILVER: Question for the 

Board. We've been reviewing a lot of lung 

claims.

I notice that the top five conditions 
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denied on the basis of insufficient medical 

information are all respiratory; 46.8 percent for 

asbestosis down to 18 and a half percent for 

COPD.

But what's going on? Insufficient 

medical information in arguably occupational lung 

disease.

CHAIR MARKOWITZ: Well -- Steve 

Markowitz. We haven't looked at any asbestosis 

claims I don't think. 

MEMBER SILVER: Well, they've kind of 

penetrated in our ILD and pneumoconiosis 

categories.

CHAIR MARKOWITZ: Okay. So to the 

extent that that's relevant when we discuss those 

claims that will be interesting. Dr. Redlich.

MEMBER REDLICH: Go ahead.

CHAIR MARKOWITZ: Dr. Goldman.

MEMBER GOLDMAN: Okay. We were just 

talking because it seems like bilateral pleural 

plaques would be pretty, you know, diagnostic for 

asbestos.
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So it's sort of funny that it's 

negative causation. Unless it's something left 

from the pneumonia, but bilateral pleural 

plaques, that's about it.

And then the medical information being 

insufficient. I mean, you have an X-ray. So 

that seems like hard to understand.

CHAIR MARKOWITZ: Dr. Berenji, did you 

want to say something?

MEMBER BERENJI: Yes, thank you. So I 

just had a question or a clarification I guess 

regarding the claims pending column.

So, I've been doing some calculations. 

At least for the first two, approximately 25 

percent of the cases are still in pending status.

Do we have an understanding as to how 

long they have been in pending status? Is this 

in order of months, years?

CHAIR MARKOWITZ: We weren't provided 

-- we didn't request that information, so. 

MEMBER BERENJI: Can I make a request?

CHAIR MARKOWITZ: For these particular 
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claims? You think we should get that information 

for the same set of claims?

MEMBER BERENJI: Absolutely. I mean, 

a lot of these folks might be in limbo for years 

with no updates. So, I'm curious.

CHAIR MARKOWITZ: Okay. So Ms. 

Rhoads, if you could just add that. Thank you.

Any other comments? Dr. Redlich.

MEMBER REDLICH: Just to be fair, I 

would say that there are some claims that there 

just really is no medical information that's 

appropriate.

But I had a question, just a simple 

one as far as counting. Because I realize that -

- and maybe someone could just explain how this 

works.

So let's say someone has a claim 

accepted for a condition like COPD. Then there 

may be a second claim filed for benefits or 

compensation once a diagnosis has been accepted.

Is that correct? So the claim is for 

-- not for the original condition, but for 
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benefits related to that condition. Does anyone 

understand what I'm asking, or?

No, no, no, let's say a case for COPD 

-- because the claims are not -- any given person 

can have multiple claims. So the number of 

people and the number of claims are not the same. 

There are more claims than there are people, at 

least that's my understanding.

So for something like one of the, you 

know, COPD or asbestosis, that may be accepted. 

And then there would be at a later point in time 

a new claim related to the benefits would seem 

reasonable and those seem usually to be accepted.

So I'm only asking that because the 

percent accepted, does that include these followup claims related to the benefits for the given 

condition?

CHAIR MARKOWITZ: That's a good 

question. Do you happen to know, Mr. Vance, 

offhand?

MR. VANCE: All right. I was 

struggling to understand totally. But I -- this 
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would represent each unique claim that's filed 

for a condition, whether that's COPD or 

asbestosis.

If you're talking about those medical 

benefits that are associated with the care of an 

accepted illness by a living employee, that's not 

reflected in this.

If you're talking about additional 

claims for like say, a consequential illness. So 

let's say if you have chronic beryllium disease 

and you have sleep apnea that's being aggravated 

by that, I don't know whether that would be 

reflected in this. I'm not sure if that answers.

MEMBER REDLICH: Well, it seems like 

some were maybe the claim was accepted, but then 

in terms of the extent of the impairment related 

to that claim, that that would be a second. Am I 

incorrect about this?

MR. VANCE: If you're asking about 

what would the benefit outlay from the 

acceptances of these cases, so in other words, 

how much money was paid as a consequence of these 
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accepted conditions for impairment, wage loss, or 

survivor benefit due to the acceptance of these 

conditions, we can get that information but 

that's not what we have here.

MEMBER REDLICH: So are these -- these 

are unique, because it -- it seems, someone could 

get, let's say, worse COPD, or --

MR. VANCE: Once we've accepted COPD, 

we've accepted COPD and any effects from that for 

the duration of the claim.

MEMBER REDLICH: Okay. I got it.

MR. VANCE: So in other words, if you 

have -- the best example is asthma. You have an 

asthma attack at work due to dust exposure you --

or exposure to cement dust or what have you.

And we accept that that exposure 

aggravated asthma, we're accepting that asthma 

forever. It's not a temporal approval, it is 

approval for work-related asthma for the duration 

of that person's life.

MEMBER REDLICH: Okay.

CHAIR MARKOWITZ: Okay, so let's, if 
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we could look at cancers. So this is a similar 

list because the most common -- many of these 

cancers make the top 20 list, although at the 

bottom you see bladder cancer which was not on 

the top 20, and you can see that 15 percent were 

accepted.

But overall, lung cancer is the most 

commonly accepted, 41 percent. Later I'm going 

to raise the idea of us looking at some lung 

cancer claims so we have better insight into the 

ones that are denied. But we'll get to that.

But the other ones we've seen on the 

previous page. I'm not sure we learn a whole lot 

new by looking at cancers separately.

Any cancers not here that in the 

occupational medicine world we might expect to be 

here? Mesothelioma wouldn't make this list 

because there aren't that many even though it's 

usually occupational in origin.

Okay, so let's go onto the next which 

is lung conditions. I mean, liver cancer 

wouldn't be here because it would be fewer in 
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number. It would be below the top ten.

Pulmonary conditions. Some of these 

you'd be tempted to combine. For instance, 

number ten, unspecified pneumoconiosis and number 

four, other interstitial pulmonary disease.

Turns out they have identical 

acceptance rates, so combining them would just 

increase the overall number of claims.

MEMBER GOLDMAN: So is other 

interstitial pulmonary disease, is that like 

beryllium disease? Like, it's not clear from the 

list what's chronic beryllium disease.

CHAIR MARKOWITZ: So, we have a, I 

think we have a separate -- Kevin, if you go to 

the CBD tab. So these are CBD, chronic beryllium 

disease listed under pneumoconiosis due to other 

inorganic dusts, 274 cases.

So these are not -- so this is the ICD 

code or codes that they carved out for us as 

representing CBD.

Now, if we go back to the respiratory 

conditions and now we're looking at number 4, 
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right? Other interstitial pulmonary disease.

We have the -- the ICD codes are 

provided in this table. I just hid them so we 

could read this. We can look at that, but you 

can see right off that there were 516 claims for 

other interstitial pulmonary disease and we just 

learned there are 274 for CBD. So I suspect 

these other interstitial pulmonary disease is not 

CBD.

It could represent a whole -- it could 

be asbestosis, silicosis. Could be mixed dust 

pneumoconiosis. Could be CBD. But that's the 

working diagnosis they're using.

And it is true if you look at this --

well, 83 percent of the asbestosis cases are 

accepted. Silicosis, it's roughly 60 percent. 

And then when you get to the less specific 

diagnoses, the interstitial pulmonary disease, 

pneumoconiosis, it goes down to 53 percent.

Okay. Any comments, questions? 

Otherwise let's move on to the next which is 

neurologic.
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Sleep disorders, top ranked. I'm 

assuming most of this is secondary, consequential 

disease to some other primary usually pulmonary 

disorder.

But number two is Parkinson's. And we 

see 47 percent are accepted. And the main reason 

those that aren't accepted is negative causation. 

Eighty-four percent is negative causation.

We're going to talk about Parkinson's 

disease a little later today or tomorrow. DOL 

asked for help in identifying the toxins and the 

exposure conditions and so we are working on 

that.

And we also looked at some Parkinson's 

disease claims previously, if you recall. Even 

if you don't recall, we did.

And then you see neuropathies. And so 

neuropathies are listed in several different 

rows, right. It's row three, other and 

unspecified polyneuropathy. Row five, 

hereditary, motor, idiopathic neuropathy. I 

suspect six, autonomic nervous system, I suspect 
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there's some neuropathies in there.

Number eight, peripheral nervous 

system. Nine, inflammatory polyneuropathy. My 

guess is that these are all probably variations 

of the same thing. Maybe not entirely, but there 

are different ways of describing neuropathy.

And if you look at the percentage that 

are accepted it's around 45 or 50 percent for all 

of these categories unless I'm mistaken here, 

right.

Polyneuropathy, 57 percent. 

Hereditary motor, I don't know how you would call 

something hereditary and then say it's due to a 

toxic exposure, but regardless, 42 percent. Row 

eight is 46 percent and 52 percent. So about, 

close to 50 percent of neuropathies are approved.

We haven't looked at any neuropathy 

claims so we don't really have any insight into 

that.

And then lastly, there's some 

Alzheimer's, but relatively little Alzheimer's 

disease is approved, 11 percent.
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If you look at number ten, toxic 

encephalopathy, very few cases, 33. Most are 

approved. And the few that have not been 

approved it was due to negative causation.

And I thought this was of some 

interest because solvents are common in the 

industrial world including the DOE complex.

Cognitive impairment is probably 

reasonably common. And the general -- I'm not 

speaking about the Department of Labor, but in 

general, occupational medicine doesn't do a good 

job of recognizing and attributing cognitive 

impairment to occupational exposures. And I 

think we see this here in the dearth of claims, 

frankly.

Dr. Goldman.

MEMBER GOLDMAN: There has actually 

been -- I reviewed this recently and there's 

actually a very good paper on this. It was from 

an international organization, I'm not sure if it 

was WHO, about how to grade chronic 

encephalopathy related to past solvent exposures 
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and giving a whole checklist of things that are 

very good predictors.

CHAIR MARKOWITZ: If you could send 

that around, yeah.

MEMBER GOLDMAN: I'd be happy to 

forward. It came up on a case that I saw, a 

veteran who had past exposures. But it was a 

very, very helpful way to be able to put forth 

some criteria for that. Do you want me to send 

you that paper?

CHAIR MARKOWITZ: Sure. Please do. 

I'm not saying the Department of Labor program is 

not recognizing important central nervous system 

disorders due to toxic exposures because you can 

see there are almost no claims for central 

nervous system disorders, encephalopathy. So the 

claims aren't even being submitted. So this is 

not -- I'm not commenting on the functioning of 

the DOL program. 

I'm making more of a comment about 

occupational medicine in general that it's an 

under-recognized issue and that -- and this is in 
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a way confirmation that it's under-recognized 

because we have this comprehensive workers' 

compensation system which is getting claims for 

many different conditions and it's not getting 

claims submitted for cognitive issues.

Yes, Dr. Goldman.

MEMBER GOLDMAN: So one of the 

diagnoses -- I mean, you have Alzheimer's which 

is very specific, but there's another more 

general diagnostic ICD-10 which is cognitive 

impairment. And I'm surprised that that wouldn't 

be on the top ten because that's a very common 

disorder. And I'm wondering if you looked at 

that more general diagnostic code, cognitive 

impairment, so stated.

CHAIR MARKOWITZ: I can follow up with 

DOL and ask -- Steve Markowitz -- ask about that. 

But my sense is it would have appeared on this 

list if there were a significant number of 

claims. But we'll ask. We'll identify the 

relevant ICD codes. Ms. Rhoads, if you could 

just make a note of that. The relevant ICD codes 
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and we'll ask how many claims were submitted.

Okay, let's move on. Chronic kidney -

- oh, Dr. Berenji.

MEMBER BERENJI: Thank you for 

recognizing me. I just had a question about the 

fact that there's a dearth of these claims for 

cognitive impairments.

It's probably most likely due to lack 

of education among the workers. So I'm not sure 

if there's been any efforts by DOL or the 

resource centers to at least have some sort of 

FAQ sheet just to kind of give folks an idea of 

what to be on the lookout for.

CHAIR MARKOWITZ: You know, Steve 

Markowitz. Let me say the former worker programs 

which have conducted 100,000 exams for the last 

20 years of the complex, we don't address this 

issue, for a number of reasons.

One is it's not easy to address in a 

screening examination. It's easy enough to do a 

simple mental screening test, but then the 

follow-up becomes expensive and complicated and 
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prolonged.

So it's an issue that is, as I said 

before, I think general occupational medicine is 

just not -- hasn't received the attention it 

should receive.

And I'm not, again, I'm not saying the 

DOL program is in any way insufficient or 

inadequate in addressing the issue. I think it's 

a more general problem.

If we could go to the next is kidney 

disease. And most of these are variants of the 

same conditions, as far as I can tell.

Actually, almost all the claims are 

for chronic kidney disease. And several of the 

other categories should simply be added to that 

probably.

A third of those claims are 

compensated or approved. And those that aren't 

it's because of negative causation. We see that.

We don't know whether those are 

secondary or consequential conditions, right. If 

they're secondary to some other condition that a 
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person had or whether they are due to toxic 

exposure to the kidneys. But these are the 

results.

Next is chronic beryllium disease, 274 

claims under Part E. Seventy-eight percent are 

accepted. And when it's not accepted it's not 

because of negative causation, but because of the 

medical information is insufficient. The 

documentation isn't there. That's the reason the 

DOL cites.

And finally, beryllium sensitivity, or 

almost finally, beryllium sensitivity is 327 

claims, 93 percent were approved, and when it 

wasn't approved it was for lack of medical 

information.

And then finally, on chronic 

silicosis, 91 percent were approved. This is --

I'm sorry -- this, I should point out, is Part B 

claims. If it's accepted under Part B it's 

automatically accepted under Part E. Yeah.

MEMBER DEMENT: Most of these would 

actually be RECA claims. Right?
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CHAIR MARKOWITZ: RECA? I don't know. 

You think so?

MEMBER DEMENT: I suspect a lot of 

them came from the uranium. 

CHAIR MARKOWITZ: Unless they're Part 

B. Okay, so any comments on these tables?

I think it was helpful to the Board to 

see these data because it helped orient us both 

to the magnitude of claims, the salient 

conditions, the degrees of approval and the main 

reasons why some claims are not approved.

It's a few minutes after 12. I think 

we're going to break for lunch. And start up --

is 1 o'clock okay? Enough time? I think so. 

Oh, I'm sorry, Dr. Silver, did you 

have a comment?

MEMBER SILVER: Another question to 

put out there to the occupational physicians who 

have dealt with solvent encephalopathy.

A Los Alamos worker Ben Ortiz made me 

his wingman specifically because he had chronic 

solvent encephalopathy. And it was extremely 
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difficult for him to keep track of paperwork, 

remember what happened at meetings, et cetera. 

And his daughter became his authorized 

representative. That's just my experience.

But I think it takes a lot of mental 

stamina to deal with the Department of Labor 

program. And these people essentially may be 

lost to follow-through. Just a thought.

CHAIR MARKOWITZ: Yes. If there are 

no other comments or questions we'll take a break 

for lunch. We'll start up again at 1 o'clock. 

Thank you.

(Whereupon, the above-entitled matter 

went off the record at 12:04 p.m. and resumed at 

1:07 p.m.)

CHAIR MARKOWITZ: Okay, we're going to 

get started. Welcome back.

Mr. Tebay, are you on the phone? He 

is? Okay, good.

So we're going to spend most of this 

afternoon discussing individual claims which the 

department has provided for us.
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I want to just first though review the 

department's own medical audit of its claims. 

And so the department has a process whereby the 

medical director reviews approximately 50 claims, 

completed claims, per quarter.

And we've looked at this before. I 

can't recall, probably a couple of meetings ago. 

I think it was this term of the Board. You may 

recall this.

But in any case, so I looked at the 

last five quarters. So all of 2018 and the first 

quarter of 2019.

So what happens is the medical 

director reviews the claims, divides them into 

various categories and then they're sent over to 

the policy branch, looks at -- looks and 

evaluates the medical director's audit and agrees 

or disagrees, and then recommends or prescribes 

an action that should be taken to correct any 

problem that the medical director found.

So, bear with me. I'm going to give 

you a few numbers. The director screens about 50 
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-- this is not available on a table, I'm just 

going to give you the numbers -- about 50 claims 

per quarter. So in five quarters about 250 

claims total.

Two hundred fifty claims total, 2018-

2019. About 40 percent of those were for -- I'm 

sorry. One hundred of those were for impairment. 

So he looked at the issue of impairment. How 

did the claim handle impairment, and found that 

28 percent, roughly a fourth of the ones that 

addressed impairment needed improvement. That's 

the term used.

There were weaknesses and needed to be 

redressed, meaning the department had to go back 

and re-look at the claim, make some decision, 

determination about that. So one quarter of the 

impairment claims.

He looked at 83 claims for causation, 

how good was the causation analysis in the claim 

and found that one out of 83, or one percent 

needed improvement.

And then there were about 60 claims 
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looked at for other issues. I lumped them all 

together because they're less common and probably 

less pertinent to what the Board looks at. And 

of those others, again one quarter of them needed 

improvement.

So we have three categories. We have 

the causation evaluation, one percent needed 

improvement, we have the impairment, 28 percent 

needed improvement, and the other category, 23 

percent needed improvement.

So what you see right away, two 

things. One is 28 percent of claims evaluated 

for impairment needing improvement is a lot. 

That's a lot of correction, a lot of -- that's a 

common, there seems to be a pattern of some. 

It's a minority, but it's 25 percent of claims.

But on the causation front, frankly, 

only one problematic claims evaluation was found.

So I'm just going to leave it at that 

because we're going to now discuss claims. We're 

going to mostly focus on causation and medical 

evidence, not on impairment.
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But the question I think really is 

looking at the number of claims we're looking at, 

a limited number, but is our experience 

reflective of what the department's own internal 

audit is finding over the last five quarters. 

Make sense? Okay, good.

Okay. So we talk about individual 

claims. We do not mention anybody's name, we 

don't mention the number of their file.

We will cite in some cases the last 

four digits of their claim number or their file 

number for the purposes of keeping track who 

we're talking about.

And so it can be a little awkward 

because we're discussing the particulars of a 

case. We're not going to look at those 

particulars on the screen because that's private 

information.

And yet we're going to be making 

observations and trying to make sense. Hopefully 

it will be a coherent discussion.

So, people have volunteered to discuss 
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certain claims and the floor is open. 

MEMBER DEMENT: It's a continuation of 

some of the discussion that we had this morning 

and it has to do with a claim that was filed for 

interstitial lung disease.

It's an older person born in 1939, 

worked at Rocky Flats from basically '67 to 1998. 

So he had a long-term employment there as a 

sheet metal worker.

Started out as a journeyman, then 

foreman, general foreman, then superintendent, 

worked himself up.

He filed a claim for interstitial lung 

disease, really was the classification based on a

CT scan.

The initial review by the CE and the 

SEM didn't identify asbestos as one of the 

exposures. And we've discussed that this 

morning, sort of why that would occur based on 

what are perceived to be some changes that will 

be made in the SEM at the next release.

But be it as it will, the individual 
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didn't have an identified exposure to asbestos. 

He had some other materials that were sent to the 

IH for review.

So that was, to me, that was a flaw 

that tainted the rest of the review. And so that 

was fatal flaw number one.

Then it was sent to the IH who was 

also sent the -- with a statement of facts which 

just basically listed a lot of information, some 

aluminum synthetic vitreous fibers and I think 

diesel. Can't remember. I have it listed here. 

Anyway, the IH just reviewed those.

They were sent the OHQ and the OHQ 

does say that individual had a minimum of two 

years of asbestos exposure directly. But that 

wasn't considered in the IH review.

So the IH review basically came back 

with minimal exposures to these other materials. 

That was then sent to the CMC who also didn't 

identify asbestos exposure in sheet metal worker. 

So fatal flaw number one, fatal flaw number two, 

and fatal flaw number three.
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And fortunately for the worker about 

the time the final decision to deny he had a 

former worker exam and the individual finally 

said -- the physician who issued that report --

this is asbestosis. Go file a claim.

So he filed. The claim was then 

awarded based on the asbestos presumption which 

easily was satisfied.

So I guess for me there was a number 

of issues here that I think could be made better. 

And I think the SEM, the update sounds like that 

might address it. Because I went through the 

SEM, I've tried to replicate why this would 

happen.

As I went through the SEM if you put 

Rocky Flats and you put sheet metal worker you 

have asbestos and a lot of other exposures.

If you then restricted it to 

pneumoconiosis other, then asbestos disappears. 

So that was the issue, I think the problem with 

this statement of facts based on the CE's review.

But it also didn't consider the 
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occupational history questionnaire, not just the 

listing of the asbestos specifically having 

worked with it, but if you go into the SEM and 

some of the buildings that the worker actually 

says that he was involved in it's specifically in 

those buildings as a sheet metal worker.

So I think you could have gotten the 

asbestos exposure through various routes.

I guess in terms of comments for 

improvement. Hopefully this interstitial lung 

disease, you know, a horse is a horse, of course, 

of course. You know, interstitial lung disease, 

if you have asbestos exposure, is that not still 

asbestosis. So the physicians can address those 

issues, but I think that needs to be addressed.

And I think it's a fairly consistent 

pattern. Unless the CMC sees the words 

asbestosis specifically, and I'm not sure that 

interstitial lung disease or being looked at from 

a perspective there. In fact, just a 

pneumoconiosis caused by asbestos and silica and 

other things.
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The IH report contained the standard 

language about exposures post 1995. And I think 

that needs to be addressed.

I guess that's my basic comment about 

it.

CHAIR MARKOWITZ: Steve Markowitz. So 

how could an industrial hygienist in an 

occupational medicine position, how could it not 

occur to them that a sheet metal worker in that 

era had asbestos exposure?

MEMBER DEMENT: That to me sort of 

boggles my mind. It's a given exposure. If you 

don't want to use SEM, use Google.

CHAIR MARKOWITZ: Let me just make a 

comment. The Sheet Metal Workers Union is the 

only union, only trade that has had a continuous 

asbestos medical screening program since 1985. 

And with many, many publications that derive from 

that. So it is kind of a signal of the 

construction trades and what you will find if you 

look hard.

And people have looked for a long, 
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long time. So that's why I raise the question 

how could an industrial hygienist and physicians 

not understand that.

MEMBER DEMENT: The question was asked 

I think several times today. As a physician, 

industrial hygienist, you're given of course the 

statement of facts based on the CE's report, 

right?

But you know, in some ways don't you 

need to use your other professional judgment to 

say, you know, this is a worker who has an 

established known exposure certainly back in the 

time frame when this individual was there, 

certainly pre 1995.

CHAIR MARKOWITZ: Dr. Goldman.

MEMBER GOLDMAN: I have a question. 

Sheet metal workers usually have a pretty high 

exposure. And one of the questions I have, if 

you just did it by buildings.

So for asbestosis you need a 

significant amount of exposure. It's not a 

slight exposure. Somebody with mesothelioma, a 
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slight exposure, you could make that case.

So a question I have is if you were 

going to go to a broader, you know, okay, you're 

in the building, getting back to what Carrie 

said, you're a person who's not a sheet metal 

worker, but somebody who's just working there, 

could you get asbestosis?

You know, not like lung cancer, but 

asbestosis from sort of just slight but chronic 

long-term exposure which is different than the 

sheet metal worker, where, I mean, that is like a 

classic major exposure.

But if we were going to try to broaden 

it. I mean, how would we put in something that 

would deal with length and intensity of exposure 

for that?

MEMBER DEMENT: Yeah, I think as a 

hygienist just thinking about how I would 

approach those situations, I don't generally -- I 

take materials in buildings as being a potential 

for exposure. But unless you can go a little bit 

deeper and say how would that occur then I have a 
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hard time making that direct link.

Especially, I could probably do it for 

mesothelioma, but especially for asbestos. 

Probably not.

So I would go back. And this is one 

of those cases if that would occur and I had an 

individual who did -- I would go back and ask 

how, how were you exposed.

It wasn't uncommon for some of these 

buildings as we saw out in Paducah to be 

constructed of transite. And that could become 

damaged, repaired.

In fact, during the time period in the 

sixties, early seventies up into the eighties a 

lot of that work was done without a lot of 

control. 

So the direct worker exposure plus the 

indirect worker exposure could occur. So that's 

the type of information I like to dig more into.

And you would, if you're taking this 

worker's history you would be doing exactly the 

same thing.
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CHAIR MARKOWITZ: I mean, I think 

we'll get to this but there are a certain subset 

-- the minority, a certain subset of the CMC 

reports which are clearly inadequate. This 

sounds like one of them.

By the way, was that -- the last two 

digits of that case was 15? Anybody else have an 

ILD case they want to discuss while we're on 

interstitial lung disease? 

I'll discuss a case while you guys are 

looking. This is a pulmonary fibrosis case that 

was denied.

I agreed with the decision. It was a 

person who worked as a decontamination worker for 

two years and then a draftsman designer for 26 

years. And I thought the claims examiner's 

statement of accepted facts was well written.

The industrial hygienist -- so one of 

the problems with the industrial hygiene 

evaluation I see, and Dr. Berenji referred to 

this before, is that it's a standard set of 

references that are used almost independent of 
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the case.

My review is I never see reference to 

an occupational health questionnaire. The only 

thing particular to the case is a reference to 

the SEM. Otherwise it's a set of six other 

standard references, some of which are probably 

relevant.

But, and I can't tell whether the 

industrial hygienist actually looks at the 

occupational health questionnaire or not. The 

SOAF of the CE does seem to itemize which 

documents are sent to the industrial hygienist. 

To my knowledge, it seems that the claims 

examiner is sending the occupational health 

questionnaire to the industrial hygienist. But, 

you know, let's -- when we look at individual 

claims let's look at that. Let's try to address 

that.

Maybe the industrial hygienist looks 

at the OHQ and uses it, but I don't see it in 

their report. I see reference to the SEM and the 

standard references.
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And so I don't know what to make of 

that. That's true for the EE-3 form as well. 

There's some occupational information there.

And then this was a decontamination 

worker for two years and the industrial hygienist 

says he may have been exposed to some of the 

relevant agents, but at low to very low level.

And I'm clueless as to how the 

industrial hygienist decided that, the low to 

very low. Or whatever synonym we might come up 

with because decontamination worker to me is a 

very generic kind of title.

The physician, very nice report. The 

CMC -- actually, the physician did refer to the 

occupational health questionnaire. So the 

physician looked at it. So that was good. It 

went beyond the IH report.

But ultimately relies on the 

industrial hygienist estimate of the dose of this 

low to very low. And can't come to the 

conclusion that there's any occupational 

relationship.
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So given what I looked at in general 

yes, I would agree of this as a denial, but it's 

an instance in which I'd like to know in that 

two-year period of decontamination what did the 

person do and what were their exposures. 

And that information is obtainable if 

you dig, if you do one of these interviews. That 

was my assessment of the case.

MEMBER DEMENT: What was the case 

number?

CHAIR MARKOWITZ: 1504.

Dr. Berenji, I think you may have 

reviewed -- I don't know whether you have the 

case -- a couple of the ILD cases. I can give 

you case numbers if that helps. And also Dr. 

Silver, if you have a -- okay, great, go ahead. 

And what's the last two digits if you could?

MEMBER SILVER: I'm going to do two at 

once, 1346 and 0411.

I admit I chose these because of my 

colorful interest in the history of the fuel 

cycle. They're both uranium mill with a little 
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bit of mine worker exposure.

And as we learned at our first meeting 

when the Part E amendments passed in 2004, miners 

and millers originally covered by RECA were 

written into Part E for an additional $50,000. 

RECA provides $100,000 and Part E provides an 

extra $50,000 so as to provide parity between 

EEOICPA claimants and uranium miners and millers.

So what happens is they initially file 

a claim with the Department of Justice. And that 

occurred in both cases. One is -- and they're 

both around 80 years old. One worked for eight 

years as an ore hauler when he was in his 

twenties. And the other worked as a personnel 

manager periodically going underground in his 

thirties and forties.

So the decades go by and one way or 

another they both wind up at National Jewish 

Hospital where based on X-ray evidence, pulmonary 

function tests and job histories they're 

diagnosed with pulmonary fibrosis.

The Department of Justice approved 
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their claims each for $100,000. And to DOL's 

credit, it didn't take more than six months for 

DOL to look over the claim record and issue the 

$50,000 supplement in each case.

So neither got sent to an industrial 

hygienist or CMC. So it may be helpful for the 

new Board member to know that this little side 

track exists on their party for people with 

interstitial lung disease from the mines and the 

mills.

And then one of them went on to get 

home healthcare benefits under Part E. 

CHAIR MARKOWITZ: What was the 

diagnosis?

MEMBER SILVER: Pulmonary fibrosis.

CHAIR MARKOWITZ: Are there any other 

ILD claims that people looked at? We can come 

back to it if you find any.

Can we do sarcoidosis? Okay. How 

about asthma? The last two digits. What's the 

last two digits?

MEMBER MAHS: 67.
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CHAIR MARKOWITZ: Okay, thanks.

MEMBER MAHS: Mine's COPD and 

occupational asthma. And denied claim was 2016 

and then it was approved in 2019.

Had a statement of the case. And I 

couldn't read my own writing last time so I 

printed pages off this time.

August 25th, 2015 they filed a claim 

with worker's comp. Cited COPD. Submitted the 

form EE-3, occupational history and a 

representative of DOE verified he worked at 

Hanford site for various DOE contractors and 

subcontractors between '76 and 2005.

He did not submit any medical evidence 

with the claim. Seattle District Office obtained 

-- and this sort of leads to what John said this 

morning -- they obtained employment documentation 

from the DOE through a document acquisition 

request.

The DAR records were thoroughly 

examined for potential radiological dose records, 

incident accident reports, industrial hygiene 
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safety records, job descriptions, medical 

records.

They do not indicate a diagnosis of 

COPD or any other chronic respiratory condition.

The office on two different occasions, 

August 2015 and October requested medical 

information and had 30 days to find it. If he 

didn't send it in they recommended they deny the 

claim.

They denied from lack of medical 

information.

Then he got an authorized 

representative in 2018. They recommended on 

6/28/2019 recommended acceptance of the claim, 

impairment under Part E of COPD and occupational 

asthma in the amount of $105,000.

He filed a claim -- it repeats in 2015 

and 2018 seeking his benefits. They requested to 

have the medical doctor perform an impairment 

rating. The district office referred the case to 

a doctor and asked her to provide an impairment 

evaluation according with the American Medical 
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Association.

The district office received the 

impairment evaluation performed by the doctor. 

Had 42 percent impairment.

Stated in the employee's occupational 

illness compensation regulations the employee 

must be covered, a Department of Energy 

contractor or subcontractor to be eligible. And 

they were.

Table 5 on pages 104 to 107 are AMA's 

guide for evaluation on your COPD and 

occupational asthma concluded that the 

respiratory condition belonged to class 3 based 

upon results of pulmonary function tests and 

shortness of breath which limits your activities 

and daily living.

Again, this will repeat a lot of it. 

Their data supports that he worked as a material 

moving equipment operator at Hanford Plant as 

having been significantly exposed to ammonia.

Such exposures would have been 

associated with the gas storage activities as 
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well as the tank farm operations that support the 

activities at 200 east and west tank farms.

His exposures through the mid-nineties 

would have been occasional and would have been at 

very low levels.

However, there is no available 

evidence, personal and/or area industrial hygiene 

monitoring to support that after the mid-nineties 

as exposure would have exceeded existing 

regulatory standards.

And again that question comes up how 

did they estimate what he had at that time and 

where he worked because there was nothing there 

to substantiate it.

It bothers me on a lot of these. No 

matter how intelligent these guys are, the IH is 

and how much education he's got he can't tell 

from 1,000 miles away what the guy did 30 years 

ago.

If they've got the information they're 

confined -- to me if they were to ask for

affidavits or if they've got witnesses that 
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worked in these areas that should be proof enough 

of one person's word. It would seem like.

This is a lot of repeat from the first 

part. 

And highly likely that in his capacity 

as material moving equipment operator at Hanford 

was significantly exposed to multiple toxins. 

Please refer to the following table. And it 

names quite a few of them and they're all at 

occasional, low to moderate, or very low rates. 

Again.

My question, I had two questions on 

that. They waited almost four years after the 

first filing to be able to collect his money or 

get something done.

It seemed like if they had a standard 

questionnaire or answer sheet from the claims 

examiner to let him know up front we need this 

type of medical information, not a one-page 

letter from a doctor. That's what he sent the 

first time. I skipped that somehow.

Of what he actually needs, what kind 
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of proof they need, or what kind of medical 

history they have to submit.

And to round it out, I mentioned this 

morning it seemed like a lot of these cases after 

they get an authorized representative they win 

their suit or win their case because they have 

experienced people helping them.

Where do you find an authorized 

representative? Anybody? I'm just curious. And 

how would they go about finding somebody?

MR. VANDER BOEGH: Word of mouth. I 

was an employee out there and I just represent 

primarily a lot of PGDP people. I'm sorry, I 

didn't mean to --

MEMBER MAHS: No, no, that's fine.

MR. VANDER BOEGH: Really, that's what 

we're finding. We cannot get --

CHAIR MARKOWITZ: Very briefly. If 

could just-- Normally we don't engage back and 

forth, but very briefly.

MR. VANDER BOEGH: They know me as a 

whistleblower. They know that I stand up for all 
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the nuclear workers at the Paducah plant.

But they come to me and they won't go 

-- so really they prefer coming to somebody 

that's actually a sick nuclear worker and I am.

I've got the same experience that 

they've got. And I'm not real happy about it, by 

the way. I used to play basketball. So it's 

respiratory illnesses mainly that the plant sees 

from chronic beryllium disease.

We're just here to bring the facts. 

And we have a hard time -- we're not real big, 

but we're very effective because we work with 

John.

John and I met back in 2010. So it's 

hard for workers to get the word out. I'll 

advertise occasionally just to help people 

understand there's somebody there.

MR. FITZGERALD: You're signed up for 

the public comment period, correct?

MR. VANDER BOEGH: Yes.

MR. FITZGERALD: Okay. Take it up 

then. Appreciate that, thank you.
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CHAIR MARKOWITZ: Thank you. You 

know, just the former worker programs which are 

at most DOE sites have -- most of them have staff 

in the community.

For our program we have mostly 

retired, some current workers who help former 

workers and will help them find an authorized 

representative. And that's true for the 

construction worker program and many of the 

programs.

I imagine some of the resource centers 

would also steer people in the right direction.

MEMBER MAHS: Well, that was just a 

thought I had up front if they were told where 

they could find one if they wanted one. It would 

help just like what needs they have for their 

medical history.

CHAIR MARKOWITZ: So what did the 

authorized representative do in this case that 

helped win the case? What was missing?

MEMBER MAHS: He found what medical 

records he needed and had a couple of affidavits 
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from people that he worked in different areas. 

If that was the same one I'm thinking, that's one 

or the other.

CHAIR MARKOWITZ: Any other -- anybody 

else have a case they want to discuss? Dr. 

Dement.

MEMBER DEMENT: We're on asthma, 

right?

CHAIR MARKOWITZ: Asthma, yes.

MEMBER DEMENT: This is 413. Number 

413. This is a case of an individual who 

actually worked here in Paducah '91 to 2014, and 

then again for a year or so in '17-'18.

Lots of jobs. There's a very complex 

history. Janitor which we talked about. A 

window washer, a painter, a lubricator, and then 

a material handler. So they had lots of 

different jobs here at Paducah.

The claim is for asthma, acute 

bronchitis and COPD as the present claim.

The claim was denied for all three in 

March of this year.
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For the most part I think the record 

of denial, is probably, I would probably agree 

with most of it.

Did not build the medical side of it 

at least in my opinion very strongly.

The individual had a chest X-ray in 

2010 and the interpretation was some 

hyperinflation consistent with COPD.

PFTs have been normal pretty much 

throughout the years. 

Some exposures -- and I think the CE 

actually worked pretty hard through the SEM with 

all these different job classifications to come 

up with some exposures for the IH to review.

The IH did review them, sort of --

this is a hard one for anybody to review, but 

came up with pretty low exposures for most of 

them.

And he reviewed -- the reviewed 

exposures were ammonia, diesel exhaust, oxides or 

nitrogen, actually silica.

CHAIR MARKOWITZ: So they were 
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treating this as a COPD case.

MEMBER DEMENT: Yes.

CHAIR MARKOWITZ: Asthma case --

MEMBER DEMENT: Asthma was sort of 

blended in with a review of the COPD. And so 

both of them actually went to the IH and the CMC 

as a group.

I pretty much agree with most of the 

review and assessment. Except I took strong 

exception to the comments in the CMC report.

I also note that in the DAR request 

there was a record that came back from the site. 

It was a request for use of respirators for this 

individual.

And the stated reason was acid gases 

UF6, oil mist, and gases undefined. So and 

clearly there were some exposure to this 

individual.

One comment and I think this is the 

one that I had. The CMC's review of the case, 

Pretty factual for the most part, but then I 

don't think ever considers the combination of all 
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these different exposures as opposed to each 

individual exposure as contributing overall to 

COPD.

The -- let me find the comment. This 

is the one where I think the individual made the 

comment that occupational exposure standards are 

specifically designed to keep risk below 1 in a 

million.

And that seems like a pretty 

uninformed comment by a CMC. 

CHAIR MARKOWITZ: What was the 

relevance of that comment?

MEMBER DEMENT: Just trying to justify 

non-attribution to low exposure.

CHAIR MARKOWITZ: Dr. Goldman.

MEMBER GOLDMAN: I think I might have 

just looked over that case a little bit just to 

get oriented.

What I wondered about, it seemed to me 

that the person had a lot of, could have had 

exposure to solvents or irritants I should say, 

irritants as an exacerbating factor.
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And when I just again briefly looked 

it over it looked like that was not addressed, 

that there was a lot of emphasis on latency, 

allergic type of asthma and not really wondering 

if there could have been maybe not the cause of 

the COPD, but exacerbations related to exposure 

to irritants.

So I don't know if I was missing 

something there, but I wondered about that.

MEMBER DEMENT: Yes, I did note in the 

comments about the latency issue which I thought 

was not appropriate. 

And I agree, I think there were some 

exposures that were on the OHQ. Actually, the 

OHQ listed some of these that were on the list 

for respiratory use. I don't think they were 

considered.

The Board's gone around and around on 

this with COPD. With COPD is it not the 

combination of all of these vapors of gas, dust 

and fumes together that's the best predictor of 

risk?
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And how we as a board can formulate a 

recommendation that's going to be acceptable is I 

think a challenge for us.

CHAIR MARKOWITZ: Okay, so asthma. 

Dr. Friedman-Jimenez, comments?

MEMBER FRIEDMAN-JIMENEZ: Are we done 

discussing those cases?

CHAIR MARKOWITZ: We're still on 

asthma. Do you have an asthma?

MEMBER FRIEDMAN-JIMENEZ: I looked at 

three asthma cases that no one else had picked 

and I discovered why.

I agreed with all three of them. I 

didn't have a problem with the final decision.

But in trying to get to know the SEM 

it turns out that when you put in asthma nothing 

comes up. 

It doesn't list any of the causes of 

asthma in the SEM. And I tried occupational 

asthma, work-related asthma, work exacerbated 

asthma, work aggravated asthma. Nothing except 

coal miner's pneumoconiosis, miner's asthma, 
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which probably isn't even asthma at all.

So, my comment is not on these cases 

particular which are 5938, 0125, and 1066, but 

the general observation that the SEM does not 

seem to reflect, unless I'm missing something 

big, the causes of asthma.

I mean there are several hundred 

sensitizing agents that have been clearly 

identified as causing asthma and then even more 

irritants that aggravate asthma. The list is 

really, really long and I think that's a 

shortcoming of the SEM that maybe we've raised 

before, but I didn't remember that.

CHAIR MARKOWITZ: Steve Markowitz. So 

the Procedure Manual says that any exposure can 

aggravate a cause or contribute to asthma in the 

workplace.

But correct me if I'm wrong, Mr. 

Vance, or you can straighten us out on this. And 

therefore they don't send it to industrial 

hygiene review. It's supposed to go directly to 

the CMC.
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But I think that's the reason why it's 

not--they don't link it to any of the 250 known 

causes because they acknowledge that the universe 

of agents that people were exposed to at DOE 

could do this. But if you could be more 

specific.

MR. VANCE: All right. So this is 

John Vance again.

So Dr. Markowitz is correct. So we 

used to try to inventory all of the things that 

were known to be associated with occupational 

asthma and we found the exact same thing. 

There's just anything can trigger an asthmatic 

attack or an asthmatic reaction.

So the standard has been vastly 

expanded. And I think that's reflected in the 

numbers. 

When you look at the asthma claim 

approval rate it's because the standard that 

exists for asthma is so open.

And basically the threshold for an 

asthma claim to be approved is merely that there 
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has been a diagnosis of occupational asthma, and 

I think that we have taken some language that the 

Board has provided with regard to how to go about 

establishing that.

And then a physician reviewing the 

case needs to evaluate the history of the 

worker's exposure to toxins and hopefully 

identify some toxic material that was a 

triggering mechanism for an asthmatic 

exacerbation, or could be sort of looked at as 

the source cause for an occupational asthma.

So it's a very liberal interpretation 

and it's not predicated on necessarily a lot of 

effort on our part to evaluate the exposures that 

the employee encountered, but merely that the 

medical information from a physician would be 

indicative of a work-asthma relationship.

Whether that is through cause, 

aggravate, or contribute. It's a very simple and 

much more broad standard than exists in other 

types of scenarios for other kinds of conditions.

But really it relies on a physician 
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taking an interview with a claimant or survivor 

and just asking some questions about well, what 

was the nature of the work. What were the nature 

of the substances that they encountered and 

basically saying well, if this person was 

reacting to their work environment it was 

probably due to X, Y, or Z.

So long as the doctor is identifying 

that toxic substance triggering mechanism that 

case is more than likely going to be approved.

And I do know that we did make some 

revisions to the diagnostic and clinical evidence 

that we would need for work-related or 

occupational asthma that the Board had 

recommended. So it's a much more broader thing.

We generally will not evaluate the 

case for occupational asthma using an industrial 

hygienist.

Does that answer? Does that provide 

more background?

MEMBER FRIEDMAN-JIMENEZ: Yes. I do 

remember the discussion with Dr. Redlich and the 
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changes that were made in the Procedure Manual.

Two of these cases, the asthma 

diagnosis was denied, but it was called COPD and 

that was accepted which I think -- I mean the 

person did seem to have COPD.

But the question of why the asthma 

cases were denied based on lack of medical 

evidence, it seemed that maybe they hadn't really 

read the Procedure Manual in detail.

Although the CMC was quite good, Dr. 

Soo. So I don't think that's the issue. 

CHAIR MARKOWITZ: I have a related 

question to this. The claims examiner sent out 

the statement of accepted facts and sends it to 

the CMC in an asthma case. And the CMC is 

supposed to accept these accepted facts.

MR. VANCE: Correct.

CHAIR MARKOWITZ: Correct. So the 

claims examiner says this person has asthma and I 

just need to know whether it's occupational 

asthma or not.

And the CMC looks at the available 
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records and says I don't see evidence this person 

has asthma.

Now, I can't blame the CMC. Okay, he 

or she wasn't asked that question, but they 

looked at the records and they don't see asthma 

so how can they answer the question of 

occupational asthma if they don't see asthma.

But clearly the CMC was answering a 

question that wasn't asked of him or her. So, 

what does the department do in that situation?

MR. VANCE: Well, my first comment is 

welcome to the world of worker compensation claim 

examining. 

There's so many different issues that 

can come up. And I would say when we interact 

with our CMCs, when we interact with our claims 

examiners we're constantly stressing the fact 

that you have to make sure that you're asking the 

right question.

If you get an answer to a question 

that you shouldn't have asked in the first place 

it can create these kinds of diabolical problems 
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that are hard to escape from.

So if the question is when a person 

files a claim that starts us down the path of 

what it is that we need to look at. 

If somebody files for occupational 

asthma that's what we're going to look at the 

case for.

If there's confusion as to whether or 

not it should be occupational asthma or a COPD 

claim that's something that we may ask the 

claimant to clarify. That might be something 

that bears out through the development of the 

case through the medical evidence.

Generally what I would say is when we 

are evaluating a case where a physician has been 

asked a question and either doesn't understand, 

or needs further clarification as to what it is 

that the CMC needs to be doing the doctor should 

not respond when they're unclear as to what's 

going on and should ask the CE to clarify.

Now, does that always happen? No. So 

then you end up in the scenario where the doctor 
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is asked a question and they're responding to 

that question but it's not producing a resolution 

to the issue that should actually be evaluated.

So the first step in any one of these 

cases is trying to make sure that the claims 

examiner has established the factual basis for 

accepting a diagnosis.

So if a doctor is saying this person 

has, say, an asthmatic condition, asthma is kind 

of interesting because you might have asthma, but 

the question that we need to then say or have 

someone answer is that okay, we know this person 

has asthma, or a reactive airway disease, or 

something.

But in order for us to sort of 

characterize it as occupational asthma we need a 

physician to look at it and say oh, there was 

some work-related exposure that can explain that 

condition.

Asthma is very challenging for that 

reason. Because you can have asthma, you can 

just have asthma and then it be classified as 
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asthma, but then when you're in a working 

environment you're exposed to something that 

makes it worse, or you've had a reaction or an 

exacerbation.

Does that--How do you characterize 

that, as occupational asthma or worsening of 

regular asthma? 

What we'd be looking for is that 

physician's opinion that asthma has been either 

caused, aggravated, or worsened by something in 

the workplace. That's what the CMC should be 

focused on unless it's a question of whether or 

not -- do we even have the evidence to show that 

this person has asthma. And that's -- it's 

dependent on good claims examination.

CHAIR MARKOWITZ: Okay. Steve 

Markowitz. The problem there is that in this 

interaction the person with the greater expertise 

about disease is the doctor. Right?

So a claims examiner is doing the best 

he or she can. They looked at all the records. 

They looked at everything. They assembled 
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everything. And is assembling the best SOAF that 

they can.

But some of these -- not just asthma. 

COPD, some of these diagnoses are tricky. And 

so they pass along accepted facts that don't 

really correspond to reality.

A physician sees that and says I can't 

answer that question because there's a different 

kind of problem here.

And I understand the sense of making 

the claims examiner the traffic cop, in a sense 

the arbiter.

But here, but in this situation you've 

got this conflict in which the CMC, now part of 

the problem with the CMC is the CMC may not get 

every last medical record. Right? So they may not 

have all that information.

And so I understand that it's tricky, 

but it seems like a tension that somehow needs to 

be resolved in a more satisfactory -- because I 

looked at another -- it was the same. If I can 

just introduce another case.
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It was an asthma case. It was an 

engineer at Savannah River for a couple of 

decades.

And the statement of accepted facts 

said the person had asthma. And the physician 

looked at it and said no -- looked at the records 

and said I don't see real evidence of asthma here 

so I can't make the judgment about occupational 

asthma because the person doesn't have asthma.

And I looked at the medical records. 

The personal physician had called it asthma 

several years before.

And it may have been in this kind of 

continuum between asthma and chronic obstructive 

pulmonary disease that older people get that can 

sometimes be a little confusing.

But regardless, the personal physician 

called it asthma. And what the physician, the 

CMC said. I don't see bronchodilator response. 

I don't see a methacholine challenge test. These 

are specialized tests that can prove to a high 

level of certainty that a person has asthma.
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And so they questioned the SOAF, 

didn't confirm the asthma and said no, there's no 

evidence of occupational asthma. In fact, no 

evidence of asthma.

So I disagree with that CMC, both 

their reading of the underlying medical 

literature and their veto of what the CE had 

decided.

That seems to be an awkward kind of 

situation.

MEMBER POPE: I agree with you, Dr. 

Markowitz. I had somewhat the same situation in 

3767 where they approved it for COPD but denied 

it with the asthma.

And there was supporting information 

from the attending physician to support that the 

asthma was definitely there. He had the work 

history to prove that he was exposed to the dust 

and the other asbestos, cadmium oxide, cement, 

crystalline silica.

But they had other supporting 

documents there to indicate that there was some 
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asthma -- the asthma was present with this 

individual.

But they denied it on the asthma and

approved it on --

CHAIR MARKOWITZ: On COPD. Other 

asthma cases. Yes.

MEMBER MIKULSKI: I had a case that 

plays into what we've talked about here right 

now. The last three digits is 536.

And this was a Hanford worker who 

worked mostly in the office administrative 

positions in the seventies and the early 

eighties.

And has been diagnosed with asthma. 

Placed on the positive response to bronchodilator 

test in mid-2017.

The primary care physician which I 

think in this case was actually a pulmonologist 

opined that based on the review of their work 

history and specifically work in one particular 

building which according to SEM had exposures to 

diesel fumes it's more likely than not was the 
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case of occupational asthma and CMC agreed with 

that initially, but sort of overrode that opinion 

saying that in their review of medical records 

which were very, very scarce for this person they 

believed that these were seasonal attacks of 

asthma not related to any exposures.

To which the claimant presented 

another opinion from another primary care who 

consented with the first opinion.

And it kind of kept going in between 

the doctors and the case ultimately got denied.

CHAIR MARKOWITZ: What was the job 

title?

MEMBER MIKULSKI: So, this person 

worked as a senior secretary and stenographer, 

but they did have several months of exposure as a 

temporary expeditor in one of the buildings that 

according to SEM did have exposures to diesel 

exhaust. So I believe this was a plutonium 

recycled test facility building.

And I second what Dr. Friedman has 

said. I've looked for any links to asthma either 
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by building or aliases.

And the only thing I could actually 

find was that miners, asthma as the coal workers, 

pneumoconiosis. 

So in other words there was really no 

specific links to asthma for any of the exposures 

from Hanford site.

CHAIR MARKOWITZ: Other cases of 

occupational asthma? Yes.

MEMBER SILVER: I have two from Oak 

Ridge. One spent 25 years between Y-12 and K-25 

as an electrician. And the other was a janitor 

for four years around the time that the K-25 

demolition was getting underway.

They have two elements in common. One 

is that they both wound up in the hands of a 

pulmonologist who sees a lot of Oak Ridge workers 

and knows the site pretty well.

And in both cases the claims examiner 

cited what Mr. Vance said which is that they 

don't try to find a specific agent. They rely 

heavily on the physician's opinion and the 
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medical evidence provided.

So the electrician had a history of 

pulmonary problems. I don't know how many times

they requested the medical record, but when it 

was finally all in hand that pretty much made it 

a slam dunk.

In 1978 the documented bronchial 

trouble and 1993 acute bronchitis. In 1998, 

quote, "industrial related bronchospasm" while he 

was currently employed.

He didn't file until he was retired 

around age 70, but with that evidence in hand the 

pulmonologist seeing him had no trouble writing a 

succinct but very convincing letter of opinion 

that it was asthma.

Initially the claim for impairment was 

denied, but the claims examiner sent it back to 

the certified independent medical examiner, 

specialty plastic surgery, to take another look 

at the AMA tables.

Apparently, I'm not an expert, but 

according to the final decision the independent 
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medical examiner used the wrong tables in the 

fifth edition of AMA for evaluating asthma and in 

the end 10 percent impairment was awarded.

And then in the case of the janitor, 

it's interesting that there was no 

contemporaneous medical evidence when the person 

was employed.

The pulmonologist seems to have taken 

at face value that this never smoker denied 

symptoms prior to ever having been exposed at K25. And some of the job tasks were packing up 

waste containing boxes and I'm not clear about 

the process, but grinding the boxes if they were 

over the weight limit. Leave it to your 

imagination.

Sweeping, dusting and cleaning excess 

oil from motors and bystander exposure to 

asbestos removal as K-25 was getting mothballed.

And the janitor had a strong response 

to a broncho challenge test and that pretty much 

won the case.

CHAIR MARKOWITZ: So did they get CMC 
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reports?

MEMBER SILVER: No. The claims 

examiners went pretty much by the book in relying 

heavily on the treating physician's medical 

opinion.

And in the first case sent the 

impairment evaluation back when they found an 

error. So, good job claims examiners.

CHAIR MARKOWITZ: Other cases of 

asthma?

MEMBER SILVER: Those numbers were 

1633 and 0073.

CHAIR MARKOWITZ: How about chronic 

beryllium disease? Actually, I'll do a COPD case 

while you're sending it. This is a COPD case.

Machinist for 20 years. A carpenter 

for seven years. It was denied.

And I agree with the claims examiner's 

statement of accepted facts and agreed with --

for the most part with the industrial hygiene 

report.

Again, as I said before this 
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industrial hygiene report didn't actually cite 

the occupational health questionnaire so who 

knows whether it was actually reviewed or not.

But here the problem was the CMC 

report. The CMC denied it. And this was -- the 

logic of the CMC was there was no asbestosis and 

therefore I couldn't link asbestos to COPD which 

is contrary to Asbestos 101.

You wouldn't link the presence of 

interstitial lung disease or asbestosis to the 

presence of COPD in an asbestos exposed worker.

You wouldn't make one conditioned on 

the other. And the person had multiple other 

exposures that you could attribute to as a 

machinist and carpenter at a minimum on 

exacerbation or aggravation.

So, this was one of those really lousy 

CMC reports that unfortunately we've seen a few 

of.

But otherwise at the claims examiner 

level, at the industrial hygiene I didn't have 

any dispute with what they said. It was denied.
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MEMBER DEMENT: Isn't that consistent 

with the earlier, maybe still existing 

presumption on COPD? I mean it ties it to 

asbestos exposure long-term.

The other report that you and I think 

Dr. Wilmer reviewed also said that 15 years post 

exposure when the COPD was diagnosed and the 

person didn't have pneumoconiosis, therefore it's 

not attributable.

CHAIR MARKOWITZ: Yes. Well, 

unfortunately asbestos is one of the few agents 

listed -- linked to COPD in the SEM.

But the finding of obstructive lung 

disease in the asbestos exposed shouldn't be 

dependent or conditioned upon the finding of 

interstitial fibrosis since they are somewhat 

different disease processes. 

Okay. Kevin, do you have that slide 

that she wanted to show?

MEMBER REDLICH: Are the slides coming 

up? I just wanted to bring to everybody's 

attention the American Thoracic Society 
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periodically publishes sort of official documents 

that go through extensive review and are approved 

by the American Thoracic Society. 

In this case it also went through 

extensive review and approval by the European 

Respiratory Society.

And this was looking at the burden --

sort of the idiopathic lung diseases, the ones 

that are not asbestosis, silicosis culprits, of 

course, pneumoconiosis, but the not garden 

variety, but the COPD, sarcoid, and asthma, and 

looking at what burden of those diseases are due 

to occupational exposures.

And what was novel -- this has been 

looked at before in terms of asthma and COPD and 

that's why we've I think recognized that a 

substantial contribution of asthma and COPD that 

may not be initially recognized as clearly 

occupational is.

And this document looked at most 

importantly interstitial lung disease and also 

sarcoid which had not previously been evaluated 
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and the occupational burden estimated in a 

systematic evidence-based fashion.

So, the next slide just gives the 

overall bottom line result of this extensive 

review of the literature and analysis that took a 

number of years.

I am the senior author on this. 

Maybe-- but it did go through extensive review.

So asthma, COPD, that prevalence is 

very consistent with prior -- multiple prior 

reviews and studies in terms about anywhere from 

14 to 16 percent of those cases being 

attributable to occupational exposures.

Importantly we looked at IPF which is 

idiopathic pulmonary fibrosis, also termed 

pulmonary fibrosis or interstitial lung disease 

without a clear cause such as rheumatologic 

disease or something like silicosis.

And impressively over 25 percent of 

that was attributable to work exposures.

And this is in all people, not workers 

working only in industrial settings. So it 
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really shows a substantial burden of occupational 

fibrotic lung disease in some of the cases we've 

discussed.

And then also the sarcoid was a very 

high burden. Thirty percent. And this was 

attributable to work exposures.

And the other -- we haven't really 

dealt with hypersensitivity pneumonitis, but when 

that becomes chronic it looks like idiopathic 

pulmonary fibrosis.

So, I think the bottom line is that --

one thing is pulmonary fibrosis is a much less 

common condition than COPD or asthma, but I think 

the message is that when it does occur, 

especially in workers who have worked with 

asbestos and dust and fumes that those are 

substantial contributing source.

In terms of what exposures contribute 

to that similar to COPD the nature of the 

literature is that many of these workers have 

mixed exposures to asbestos dust, fumes.

And so the most common exposures that 
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contributed to that in addition to sort of a 

generic dust, fumes, particulates including 

asbestos were metal workers, metal working 

machinists.

And also there was a component of 

farmers too that's probably overlapping.

But the metal working and the asbestos 

and general dust and fumes. And so I think 

that's very relevant to this workforce. 

I'd be happy to send the article 

around. But I think that --

CHAIR MARKOWITZ: Steve Markowitz. I 

have a question. So you must have done a big 

literature review because a lot of diagnoses, a 

lot of toxins.

Is the underlying scientific review 

that you did in support of these, did you broadly 

identify specific toxins such that that work 

might be usable within the SEM to improve the 

exposure-disease link?

MEMBER REDLICH: Yes, I think that --

it's similar to COPD in some regard in that those 
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studies have shown sort of the type of working 

exposures, dust and fumes.

And individual studies give some idea 

of starting to tease out what that exposure is.

But when you also consider it no one's 

exposed to just a single exposure. They may be 

working in a building that had a lot of asbestos, 

but there's also -- working as a machinist, or 

around other dusty, dirty environments.

And if you're thinking also typically 

many years of exposure. And in those workplaces.

So it's very hard to identify one 

causative agent.

But this involved extensive review of 

evidence-based literature search and review of 

available literature. There are numerous 

evidence tables in the document and an appendix 

with more information.

And it actually did -- I didn't 

include this table, but it did look at metal, 

wood, and silica individually and what those 

individual exposures contributed as also a 
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contributing.

So those were sort of the biggest 

contributing factors.

And it was felt that given the time 

period that many of these studies were done that 

asbestos invariably was another important 

contributing factor.

CHAIR MARKOWITZ: Another question I 

have is sarcoidosis. Was a lot of that 

misdiagnosed chronic beryllium disease?

MEMBER REDLICH: It included some.

CHAIR MARKOWITZ: Dr. Goldman.

MEMBER GOLDMAN: Carrie, how much did 

sort of what happened at 9/11 where all those 

workers had such a combination of dust, oils, 

whatever that mixture was.

And then now studies have gone 

farther, seen more people being diagnosed with 

real sarcoidosis, not necessarily chronic 

beryllium disease.

Does that help inform that there 

actually could be mixed dust oil exposures that 
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could lead to what we call sarcoidosis?

MEMBER REDLICH: It actually -- I 

don't believe any of the World Trade literature 

studies were included just because there were 

pretty strict criteria for inclusion in terms of 

the diagnosis.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: Just a quick 

comment regarding the World Trade Center study.

It was not that thorough how well the 

chronic beryllium disease was excluded from those 

sarcoid cases. Not all of them were worked up.

And there is some U.S. Geologic Survey 

data that there was some beryllium in the World 

Trade Center dust. 

So it's not 100 percent certain that 

they were not beryllium related. Some had 

negative lymphocyte proliferation tests, but some 

did not.

MEMBER REDLICH: And I didn't include 

the table that broke down individual exposures, 
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but beyond the sort of more general category 

that's also been used for the extensive COPD 

literature of vapors, gases, dust and fumes, 

metal dust was accounted really for 8 percent of 

all, which is a high percentage when you consider 

that many patients have actually worked in an 

office their entire life.

CHAIR MARKOWITZ: Steve Markowitz. 

When you call this occupational burden is this 

aggravate, contribute, or cause as a standard 

roughly you think?

MEMBER REDLICH: Who are you asking?

CHAIR MARKOWITZ: Oh, I'm sorry, I'm 

asking you actually. So in the underlying 

studies. I know there are many. There are 

probably hundreds of studies here that vary 

greatly.

But when you look at the percentages 

do you think they're looking sort of strictly at 

cause, or do you think they're including cases 

where COPD was aggravated or exacerbated by the 

occupational exposures?
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MEMBER REDLICH: They-- for COPD 

there's actually a pretty good literature both in 

smokers and non-smokers.

In fact, the fraction that is 

contributed by these exposures in non-smokers is 

actually higher than that fraction.

So I think this is considering 

smoking. And actually in the non-smokers we 

didn't include it in that but it's an even higher 

fraction.

And smoking is less of a contributor 

to interstitial lung disease. It really is not a 

major risk factor the way it is for COPD.

CHAIR MARKOWITZ: Okay, thank you. 

Shall we move on-- shall we discuss sarcoidosis?

MEMBER REDLICH: I would just add one 

last thing about this. I think that it's 

important to recognize that most pulmonary 

physicians unfortunately, especially with a 

condition like interstitial lung disease, they do 

not think about the etiology of the cause because 

they're really concerned about the treatment.
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And so I think lack of any recognition 

of it being work-related. These were all cases 

and many of these were from settings where there 

had been a thorough workup for other known causes 

of ILD. 

So the asbestosis and the silicosis 

had been eliminated. So it's important to 

recognize that the lack of a treating physician 

recognizing any work-relatedness does not in any 

way rule out the possibility.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: I'm just 

looking through the article now and I'm not clear 

on how much you took into account the prevalence 

of exposure.

In other words, if you have an 

attributable risk in an exposed group it can be a 

certain percent.

But then if only part of the 

population is exposed then that percent is lower 

in the entire population.
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So my question is what attributable 

risk did you use?

MEMBER REDLICH: If anything this is 

probably an underestimate because of issues of 

duration of exposure.

I don't want to get into the 

technicalities of calculating the population --

most of these studies it was looking at the most 

common occupation that person had for a period of 

time.

And I think that is something that we 

take into account in terms of duration of 

exposure. 

And so these were generally not the 

one month that someone's worked, but their most 

common occupation.

CHAIR MARKOWITZ: Dr. Berenji.

MEMBER BERENJI: I have a CBD case if 

we're still on CBD.

CHAIR MARKOWITZ: We're just starting 

CBD. That would be great.

MEMBER BERENJI: I'm right on time, I 
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love it. So, let's see. So the last three 

digits are 334.

So, I thought this was an interesting 

case first of all because out of all the cases I 

reviewed it was the shortest number of pages. 

But that kind of made me wonder that there might 

be some documentation missing.

And this is an additional comment that 

Dr. Dement made earlier about indexing these 

files. 

At least in this case it was 

relatively easy to scroll through, but I did 

notice that there were a lot of items missing.

For instance, there was no statement 

of accepted facts. There was no--I didn't see an 

IH report. I did not see any CMC report.

So at least if there's some sort of 

face page stating what's actually in the file 

would actually make our job a lot easier. So 

just an FYI.

So at least in this case I thought the 

occupational health questionnaire was very 
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telling. I'm actually going through it right now 

again.

The second pass through actually 

reveals more information than I realized on the 

first review.

So this gentleman actually worked at 

the Savannah location, Savannah River I should 

say. And we actually had the pleasure of 

visiting that site back in the springtime. So it 

was actually interesting to actually read the 

case and actually use my previous experience 

visiting the site to kind of gain some more 

perspective. So this is the true benefit of 

being on this Advisory Board.

Nevertheless this gentleman worked as 

a laborer. If you actually look at what he 

describes in his work activity this is very 

telling because he actually worked underground in 

Building 400 and he also worked in the F and H 

units.

He describes working around a lot of 

dirt and he remembers actually packing up 
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contaminated dirt into bags.

So just based on my experience on this 

Advisory Board, kind of understanding the nuances 

of the decontamination process this individual 

was most likely exposed to a lot of different 

agents that unfortunately was not properly 

documented in the statement of accepted facts 

which unfortunately was not in my file.

But also in terms of doing a formal 

analysis it's hard to be able to do that if we're 

not actually picking up this qualitative 

information that's within the occupational health 

questionnaire.

So I'm actually really looking forward 

to reviewing your new draft from the Department 

of Labor so we can actually gain a better 

understanding of what we're missing especially 

when it requires us to really look into these 

text fields into what people actually say, and 

then being able to further investigate when the 

IH does their phone call with the worker.

So to me this is very important. I 
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think this is probably the most important part of 

this case.

But this gentleman was actually 

applying for CBD as well as hearing loss. And 

unfortunately there was limited medical 

documentation available in this case review.

But when I actually reviewed what 

medical history he had he actually did document 

that he had a history of sarcoidosis.

So this is where the plot thickens 

because unfortunately there's just not enough 

information to be able to decipher how he came 

about developing sarcoidosis, when was he 

diagnosed, who diagnosed this gentleman.

And unfortunately he did have some 

additional testing which was provided in this 

file. 

He did have a lymphocyte proliferator, 

a proliferator testing done which was negative, 

but that was only one test date.

So, I feel like in this case the most 

important things to realize is that not having 
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the appropriate information and making a denial 

based on that to me would require at least in my 

humble opinion a reassessment of this case.

CHAIR MARKOWITZ: Do you remember was 

this a post 1993 case?

MEMBER BERENJI: This gentleman was 

working at Savannah River in the eighties. I can 

get you an exact date. Hold on. 

So he was working at Savannah River in 

1984 and he was kind of in and out of the 

location through the mid-eighties. And then he 

finished his position there in '91.

CHAIR MARKOWITZ: So this is a claim 

within the past three years, one of the recent 

claims.

MEMBER BERENJI: Yes. I believe this 

was denied in 2018.

CHAIR MARKOWITZ: Other CBD cases? 

Dr. Dement.

MEMBER DEMENT: Fairly brief case I 

think. 

This is a case of an individual whose 
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employment history -- the employment history is 

one that -- the claim was for COPD, sarcoid and 

sleep apnea. He worked at Hanford for a period 

of time, 2009 to 2013, and INL for a couple of 

years.

The OHQ listed beryllium. There were 

four records from the DAR request testing for 

beryllium sensitivity that were all normal, and 

seven additional ones that were I guess after 

employment and they were all normal.

The PFT was mild fibrosis. Lots of 

different jobs. Production systems, utilities 

operator, nuclear facility operator and a staff 

specialist.

Any beryllium exposure is pretty well 

acknowledged. The issue for this individual is 

that there's no indication of beryllium 

sensitivity and so based on the criteria that is 

in place and operable it was denied based on lack 

of sensitivity.

And one issue I think is one of the 

physicians noted that this individual was on 
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steroids and it's possible it could be masked by 

the -- mask the sensitivity test.

So it's probably something that at 

least in my opinion might still be an open case.

There was a CT that actually the 

reviewing physician noted that suggested 

sarcoidosis of the lung. He had cutaneous 

sarcoid diagnosed in 2016.

So this individual has been on some 

steroids prior to at least some of the latter 

sensitivity tests.

It's sort of complicated by a whole 

series of early ones prior to the diagnosis that 

are all negative.

So I didn't disagree with the 

determination based on the criteria that we have 

at hand.

CHAIR MARKOWITZ: He had multiple 

negative beryllium LPTs at the time when he was 

ill with chronic lung disease. 

MEMBER DEMENT: This preceded -- the 

negative beryllium sensitivity tests. This is 
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the question that I have. They seemed to have 

preceded the CT showing suggestive evidence of 

sarcoid.

But the individual had cutaneous 

sarcoid diagnosed much earlier. So, sort of a 

complicated --

CHAIR MARKOWITZ: Yes.

MEMBER DEMENT: -- of steroid use and 

non-steroid use I think.

CHAIR MARKOWITZ: But had some LPTs 

off steroids.

MEMBER DEMENT: I think so.

CHAIR MARKOWITZ: That is complicated.

MEMBER DEMENT: So there's no evidence 

of sensitivity. So all in all I think the 

criteria were applied appropriately.

CHAIR MARKOWITZ: Other CBD cases?

MEMBER REDLICH: I have -- it's in the 

sarcoid COPD category.

So this is a man who worked from 1970 

to the present. So that's like 49 years at 

Savannah River Site, initially as a janitor, a 
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laborer, and moved up, operator and a procurement 

specialist.

And so the claims examiner notes that 

the diagnosis of CBD was made in 1981, pre-1993 

after. And it was actually a pre-employment --

documentation pre-employment that the person did 

not have CBD because they have records going back 

to pre-employment evaluation.

And then in the statement of facts 

documents that throughout the course of its 

operations the potential for beryllium existed at 

Savannah River site.

And then he sort of cites the language 

as far as the diagnosis of sarcoidosis, as far as 

under which criteria to use.

And then the question that the CMC is 

asked is -- so I think one could say that one has 

potentially enough information at that point.

And this was a confirmed diagnosis. 

No one was questioning the diagnosis of pulmonary 

sarcoid.

The question was is it at least as 
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likely as not that the employee's exposure to 

beryllium at the DOE facility, I think everyone's 

familiar with the wording, was a significant 

factor in aggravating, contributing, or causing 

the diagnosis of sarcoidosis.

So the first CMC replies that thank 

you for referring this case. And this is an 

occupational medicine board-certified physician.

Thank you for referring and cites the 

language as far as the diagnosis of sarcoid and 

COPD from the Procedure Manual and states that 

this person he believes has chronic beryllium 

disease and not sarcoid.

So from the statutory viewpoint the 

answer to the question posted is that it's not at 

least as likely that the employee's exposure to 

beryllium was a significant factor in the 

diagnosis of sarcoid.

Instead, as per the June 16, 2017 

guidance it's much more likely that this person 

has CBD.

And then he gives a rationale. He 
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says despite the presence of some differences 

between sarcoid and CBD there is still sufficient 

overlap.

And as -- explained his rationale for 

saying that this is CBD.

And so then after that though the CE 

sends an email that they don't think this 

physician understands sarcoidosis. And 

sarcoidosis is only accepted -- and then 

basically sends the case to another CMC.

And that CMC basically answers the 

question yes. So, the patient was eventually 

accepted as sarcoid, but I think if one followed 

the various guidance that this would have been 

appropriate to diagnose as chronic beryllium 

disease. 

So there wasn't an IH assessment. It 

wasn't needed. We don't have the SEM involved 

here. We have documentation of pulmonary sarcoid 

that was new since employment.

CHAIR MARKOWITZ: So, I got a little 

lost. It's an accepted CBD case?
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MEMBER REDLICH: No, it's accepted for 

sarcoid.

MEMBER GOLDMAN: Did he have a 

positive beryllium sensitivity test, or he didn't 

have it done?

MEMBER REDLICH: No. Because he was 

diagnosed years ago in 1981 with sarcoid. And 

there's documentation of that in the records. In 

fact, it was a little earlier than that, but it 

was after his employment.

There was actually a pre-employment 

chest X-ray which showed no sarcoid.

CHAIR MARKOWITZ: I'm sorry, this was 

an accepted case claim as an occupational 

sarcoidosis.

MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: That is not 

considered CBD.

MEMBER REDLICH: Yes. I found it 

actually -- I was looking some of the accepted --

I know we tended to look at the denied claims. 

I found looking at some of the 
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accepted claims helpful to -- and some of them 

were very correct.

It's just that I think this was 

accepted for the wrong condition.

And it's good it got accepted, it's 

just that I think someone else could have easily 

just answered -- I've seen other cases where 

answering the question would have just been no 

because beryllium doesn't cause sarcoid.

CHAIR MARKOWITZ: Questions? 

Comments? Mr. Mahs.

MEMBER MAHS: CBD case.

CHAIR MARKOWITZ: Ok.

MEMBER MAHS: CBD case.

MEMBER REDLICH: Can I just say one 

other thing about this? I think -- I think to me 

this illustrates that maybe there needs to be 

further training of the -- the question is 

everyone -- it is confusing and it took me a long 

time to figure this out.

But I think it shows that even when 

things are clearly delineated the implementation 
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of that down the sort of -- the train of steps 

can go wrong.

And I'm not sure that the current 

review process might have picked up that this was 

what I consider a misadjudicated case.

MEMBER GOLDMAN: You're saying it 

should have been beryllium.

MEMBER REDLICH: Yes. And I think 

that actually in terms of just optimizing uses of 

resources, time and the like that the claims 

examiner could have made that decision without it 

needing to go out for further review.

CHAIR MARKOWITZ: But the error was 

with the CMC?

MEMBER REDLICH: Well, the question, 

the CE noted the diagnosis of sarcoid. So that 

was not in the question. Or the year it was 

diagnosed which was pre 1993 and confirmed after 

49 years of employment at Savannah River starting 

as a janitor and a laborer that this person had 

beryllium exposure.

Then wrote a somewhat complicated, you 
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know, you need to meet these criteria. It should 

have been clear that this person met the pre 1993 

criteria. There's evidence of --

CHAIR MARKOWITZ: Chronic respiratory 

--

MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: Other comments or 

questions about this case? Yes, Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: I agree that 

training the CEs in this specific confusion would 

be useful.

And I don't remember exactly the 

language in the Procedure Manual, but maybe a 

note in the Procedure Manual that there is a high 

possibility of misdiagnosis of chronic beryllium 

disease as sarcoidosis, and that that should be 

addressed by the CMC.

Some way to get the CE to feel more 

comfortable with -- it sounded like the CMC had a 

very well reasoned and well stated opinion which 

was then questioned by the CE.
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MEMBER REDLICH: This person actually 

cited some of our documents that we have 

submitted. So this was a more recent case.

And they cited from our quoting in 

summary in which situations in which a covered 

beryllium employee has been diagnosed that it 

would more likely be CBD than sarcoid.

So this person was really quite 

familiar with and appeared to be knowledgeable. 

So he wrote.

And the other concerning thing was 

that this wasn't someone who didn't give any 

thought to the letter that they wrote in response 

to the CE's question. They gave a detailed 

explanation for why this should be CBD and not 

sarcoid.

CHAIR MARKOWITZ: Well, yes, sure. To 

answer George's question there is language around 

sarcoidosis in the Procedure Manual, 

differentiate pre and post 1993.

But they do recognize the potential 

for confusion and a way how to deal with it. I'm 
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not sure it's adequate, but it's there. Dr. 

Goldman?

MEMBER GOLDMAN: So, having discovered 

that I'm a little concerned now that the person 

who really made a thoughtful response and then 

was sort of put down saying you don't understand 

sarcoid, what is that person going to do the next 

time they get a case?

So having discovered this is there a 

way to get back to this person who seems to have 

really done a good job and read this to say this 

has been re-looked at and your reasoning was 

logical and valid.

CHAIR MARKOWITZ: You're asking 

whether CMCs get feedback?

MEMBER GOLDMAN: Well, the first CMC, 

yes. Because that person who wrote this, what 

the committee now thinks is a more accurate note 

is told you don't understand sarcoid.

So what does that person feel now 

after they've gone to the trouble to do this. 

And if that person is going to be used again and 
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gets another case how are they going to respond.

It just seems like the person did get 

feedback from the CE, and that the person now is 

going to know they shouldn't give that answer and 

they were correct the first time.

They are getting feedback that's sort 

of an incorrect feedback. So it seems like if we 

feel that way there ought to be now a response 

back to that person that your thinking was 

reasonable.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: I found the 

language in the Procedure Manual. It's very 

clear and explicit.

It says as such a diagnosis of 

pulmonary sarcoidosis is not medically 

appropriate under Part B if there is a documented 

history of beryllium exposure. That's very 

clear.

MEMBER REDLICH: And what's clear in 

this case, if it was a post 1993 it would be less 
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clear because of the issue of those criteria and 

meeting the BeLPT. And that would need to be 

addressed to meet the statute requirement.

So one would have to either see if 

there had been one, if it was a reason it was 

negative, or the like, or couldn't be done and 

address that.

But this was pre 1993. And 

acknowledged as pre 1993 by the CE.

MEMBER GOLDMAN: So it's feedback to 

the CE then.

MEMBER REDLICH: Yes, I would think. 

And whoever is performing oversight of the whole 

process. 

CHAIR MARKOWITZ: Comments, questions 

on this case? Otherwise we'll move on. Ms. 

Pope.

MEMBER POPE: I just had a quick 

question for Mr. Vance. What is the frequency of 

I guess oversight over the CEs, that their 

training, re-training, re-certification?

MR. VANCE: Okay. So if you're asking 
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just like, are you talking about like performance 

assessment?

MEMBER POPE: Right.

MR. VANCE: Well, you know, every year 

employees have to go through a performance 

assessment just for the qualifications of the 

position.

That involves just like any other type 

of job a supervisory oversight of the work, the 

performance, the accuracy, quality, the 

timeliness and all those kinds of things.

These cases also, depending on the CE 

you could have their work being reviewed more 

frequently by a supervisor or senior.

Other CEs are given a little bit more 

leeway simply because they either have the 

experience or the knowledge to be able to apply 

their adjudicatory skills independently.

And like I mentioned before we do have 

internal quality control mechanisms evaluating 

the work that's being done by our staff through 

accountable review, by systemic review, by our 
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supervisory staff in addition to the regular 

performance assessments that are done by 

supervisory staff.

And I would just say the sarcoidosis 

cases are probably some of the more challenging 

ones.

The thing in the conversation that you 

have to keep in mind is that sarcoidosis as Dr. -

-

CHAIR MARKOWITZ: Friedman-Jimenez?

MR. VANCE: -- Jimenez mentioned, you 

know, if you're looking at it, yes. If you see a 

diagnosis of sarcoidosis you can treat it as a 

misdiagnosis of CBD.

However, the statute lays out the 

requirements that have to be satisfied in order 

for us to establish a viable CBD case.

So even though the word sarcoidosis is 

there, you still need to meet those statutory 

provisions that are in the law.

And that is pretty much solely reliant 

on a medical opinion saying oh, this is a chronic 
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respiratory disorder that's consistent with 

chronic or is consistent with a CBD condition. 

So we would still need that.

If that was absent from a case file 

you could very well end up with the CE saying 

okay, I don't have enough here to allow me to say 

that this sarcoidosis is a misdiagnosis of 

chronic beryllium disease.

They could then maybe look at it as 

this is just sarcoidosis. I'm looking at it as a 

condition in and of itself that could have been 

aggravated, or contributed to, or caused by 

another type of toxic substance exposure.

So this is a uniquely challenging 

problem that exists with regard to how we treat 

sarcoidosis. It can lead to a lot of confusion

and a lot of interesting outcomes in the cases.

December 6, 2019

CHAIR MARKOWITZ: Dr. Goldman.

MEMBER GOLDMAN: So in this case 

though the first CMC person did do what you just 

said, made the linkage and that was rejected by 
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the CE.

Was that not sufficient when the CMC 

put it together that way, or did they need a 

treating physician or something else?

MR. VANCE: It's really hard for me to 

comment on something without looking at the 

actual specifics of it.

There can be any number of issues with 

regard to what the CE was evaluating, the weight 

of evidence that was being assigned to the 

quality of the input from the CMC.

It's just really hard to know without 

looking at it specifically and finding out what 

was the justification for the CE to say that 

there was a problem with this CMC versus someone 

else. It's very hard to comment on that.

CHAIR MARKOWITZ: Other questions, 

comments on this case? Mr. Mahs, you wanted to 

do a case?

MEMBER MAHS: Yes, Ron Mahs, case 

3044.

The final decision was made on July 
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16, 2018. The reasons set forth below. Your 

claim for chronic beryllium disease is approved 

for payment of $150,000 under Part B of the act.

You're entitled to medical benefits 

for CBD and beryllium sensitivity retroactive to 

your filing date of October 17, 2016.

And some of these are six, seven 

hundred page claims so I may have missed it, but 

usually if it's that much time between the filing 

and the claim it's either been denied or reopened 

or something and the only item I found were they 

needed to identify buildings worked in.

In support of your claim you provided 

a report dated November 23, 2005 and signed by 

the doctor documenting positive blood beryllium 

lymphocyte proliferation test dated September 3, 

2004 and October 6, 2004.

Test results established the diagnosis 

of beryllium sensitivity. Reviewed these test 

results as well as chest X-ray, CT scan, exercise 

test, pulmonary function test including your 

beryllium sensitivity have progressed to CBD. 
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This diagnosed November 23, 2005.

In addition, you completed employment 

history claiming employment at Coors Porcelain 

from June 27, 1981 to 2009 at the district 

office. Request to corporate verifier for Coors 

confirmed you were employed at Coors Porcelain in 

this time frame.

The corporate verifier noted that you 

participated in a beryllium screening program 

while employed at 600 Ninth Street location.

However, they had no information 

regarding the specific buildings you worked in. 

And this was the only thing I saw 

where there could have been a delay.

You provided affidavits from work 

associates attesting that you worked in Building 

16.

District office reviewed the evidence 

of record and issued the recommendation June 7, 

2018 to accept your CBD under Part B of the act 

as you were a covered beryllium employee. 

It was on a finding of facts and claim 
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for benefits based on beryllium sensitivity in 

2016 you worked for Coors Porcelain as a 

beryllium vendor covered employee, January 1, '85 

to December 31, '85. One year.

You were monitored for beryllium 

exposure presented -- during this employment. 

You were diagnosed with beryllium sensitivity in 

2004 based on an abnormal LPT.

You were diagnosed with CBD in 

November 2005.

And the conclusion of law. A covered 

beryllium employee shall in absence of 

substantial evidence to the contrary be 

determined to have been exposed to beryllium in 

the performance of the duty for the purpose of 

compensation program if and only if covered 

beryllium employee was, one, employed at a DOE 

facility, present at a DOE facility, or a 

facility owned and operated by a beryllium vendor 

because employment by the United States a 

beryllium vendor or contractor of DOE during the 

period beryllium dust particles or vapors may 
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have been present at such facility.

It seems like they don't have to prove 

a longer time frame if they're working for the 

vendor.

A covered beryllium employee means the 

following. If and only if the employee is 

determined to have been exposed to beryllium in 

performance of duty in accordance with section 

7384 of this title a current or former employee 

as that term is defined in section 8101 of Title 

5.

You may have been exposed to beryllium 

at a DOE facility or facility owned, operated, or 

occupied by beryllium vendor.

A current or former employee, or any 

entity that contracted with DOE to provide 

management and operation management integration 

or environment remediation of a DOE facility or 

any contractor or subcontractor that provided 

services including construction, maintenance of 

such a facility.

Current or former employee of a 
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beryllium vendor or a contractor, subcontractor 

during a period when the vendor was engaged in 

activities related to the production.

Term covered beryllium illness means 

the following. Beryllium sensitivity as 

established by an abnormal beryllium lymphocyte 

proliferation test performed on either blood or 

lung cells, established chronic beryllium 

disease, any injury, illness, impairment or 

disability sustained as consequence of covered 

illness.

You're a former employee of a 

beryllium vendor and worked at Coors Porcelain 

during a period when the vendor was engaged in 

activities related to the production or 

processing of beryllium.

You were diagnosed with CBD. And be 

entitled to the compensation.

And what I understood from that she 

only was a covered employee for one year while 

she was exposed, so it wasn't a long time frame 

of being exposed if you're working for a 
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beryllium vendor.

CHAIR MARKOWITZ: Accepted CBD case.

MEMBER MAHS: She had the one-year 

time as being under the program. 

CHAIR MARKOWITZ: Mr. Domina.

MEMBER DOMINA: Under 10 CFR 850 for 

the beryllium standard for DOE sites you only 

have to have one day to be accepted.

CHAIR MARKOWITZ: Dr. Dement?

MEMBER MIKULSKI: Is this another 

case?

CHAIR MARKOWITZ: Hold on. Any other 

comments on this case? Sure, Ms. Pope.

MEMBER POPE: I think what aided in 

her -- this claimant case getting approved was 

the fact that she had those two affidavits, those 

two coal workers that verified her presence in 

that one building that they were questioning that

there was beryllium existed in that building 

before.

So I think that was supportive 

information that aided in her getting her claim 
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through.

CHAIR MARKOWITZ: Okay. Any other 

comments? Otherwise let's move on to another 

case. You had one, Dr. Mikulski?

MEMBER MIKULSKI: Yes. This is a 

sarcoidosis pre 1993 CBD case.

CHAIR MARKOWITZ: Was it accepted or 

denied?

MEMBER MIKULSKI: This is a denied 

case.

CHAIR MARKOWITZ: Okay.

MEMBER MIKULSKI: And I talked about 

this case before. The last three digits are 580.

And I have to say what prompted me to 

look in more depth at this case was an unusually 

fast turnover between the questions to the CMC 

and the eventual response. I believe it took the 

CMC one day altogether to issue an opinion, 

whereas the sheer volume of this case which is 

over 2,000 pages would have required a much more 

in-depth look and investigation of the records.

In any case, this is a former Y-12 K-
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25 worker who worked in the various positions, 

various jobs for over 40 years, between 1970 and 

2014.

Their job titles included chemical 

operator, janitor, utility special projects 

coordinator, and so on and so on.

This claimant was diagnosed with 

pulmonary sarcoidosis in 1978. And following a 

subsequent diagnosis of prostate cancer in 2016 

filed both claims under Subtitle B and Subtitle E 

for cancer and for lung disease.

Both claims were eventually denied in 

2018. 

However, the CE did an excellent job 

in moving the claim from sarcoidosis to a pre 

1993 and asked the CMC specifically for an 

opinion whether the medical evidence on record 

meets the guidelines to establish a pre 1993 

diagnosis.

So CMC issued an opinion that kind of 

was based on a mix of the pre 1993 and post 1993 

criteria where they took -- selected spirometry 
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results from 2016, married them with sarcoidosis 

diagnosis from pre 1993 and said that the 

claimant meets two out of the pre 1993 criteria 

without offering any further explanation.

So this was a huge file. There were 

hundreds of pages of historical medical 

documents. 

I know the OCR wouldn't do much 

justice in trying to find specific medical 

records.

However, after looking at the 

individual medical test results it did appear 

that the claimant had evidence of clinical course 

consistent with pulmonary disorder.

As a matter of fact they were 

hospitalized for over 16 days by a pulmonary 

group where they did a series of tests which 

resulted in putting him on two years of steroid 

therapy.

The claimant did have radiographic 

evidence of diffuse reticulonodular patterns 

which were initially thought to be of the 
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infectious pathology.

However, the skin test PPD for 

tuberculosis which would have been most 

consistent with that pattern were negative.

And had a series of abnormal pulmonary 

function tests between 1976 and 1981 that did 

show a marked obstruction with FEV1 to FVC ratio 

as low as 67 percent without this being 

specifically evidenced in the record. So I 

actually had to make those calculations myself.

So this claimant was eventually denied 

in 2018. And this is basically the information I 

wanted to share about this claim.

CHAIR MARKOWITZ: Steve Markowitz. So 

they met the pre '93 abnormal radiology, abnormal 

pulmonary function. So which criteria didn't 

they meet?

MEMBER MIKULSKI: They met all the 

criteria.

CHAIR MARKOWITZ: Oh. And they got 

denied.

MEMBER MIKULSKI: Yes. So they had a 
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positive PFT, they had a positive chest X-ray, 

they had a positive clinical course consistent 

with the diagnosis of pre 1993.

On top of that they also had a 

positive -- I'm sorry, not a positive. A 

borderline LPT from 2016 which given the time 

from the last exposure might have explained that 

the response would have weaned off.

CHAIR MARKOWITZ: And the CMC did not 

believe it was CBD.

MEMBER MIKULSKI: No.

CHAIR MARKOWITZ: And what did the CMC 

miss?

MEMBER MIKULSKI: The CMC missed 

pretty much most of the pre 1993 criteria. So 

the only one that they have acknowledged was the 

pre 1993 diagnosis of sarcoidosis based on the 

clinical X-ray.

And they said, a bit confusing. In a 

statement where they mixed all those criteria a 

diagnosis of pre 1993 CBD needs to include three 

of the five criteria.
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The claimant has only two positive 

criteria which include post 1993 CT scan criteria 

and the diagnosis of sarcoidosis.

CHAIR MARKOWITZ: We're not sure what 

medical records the CMC got. They're very 

voluminous.

MEMBER MIKULSKI: As I said this would 

have been a very laborious process of going over 

individual records. OCR does not really offer 

much help, optical character recognition.

Most of the pre 1993 records are of 

course handwritten. It wouldn't have been 

possible to pick up those records based on any 

sort of a search. And doing it manually may 

involve hours.

We really don't know from this how 

much access to the medical records the CMC had 

for this case.

CHAIR MARKOWITZ: Any comments or 

questions on this case? Because otherwise we're 

going to take a break and then come back and 

discuss more cases. Yes, Dr. Dement.
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MEMBER DEMENT: Sounds like a case 

that needs to be re-reviewed.

CHAIR MARKOWITZ: Yes. Dr. Silver and 

Mr. Domina.

MEMBER SILVER: Can someone refresh my 

memory as to the payment schedule for CMC 

reviews? Are they paid by the case or by the 

hour?

CHAIR MARKOWITZ: By the hour, isn't 

it? By the case? A page per case ratio.

MEMBER SILVER: I know what our pay 

rate is, but that might have explanatory power.

CHAIR MARKOWITZ: Mr. Domina.

MEMBER DOMINA: What did the SOAF say 

in that one? Unless I missed it when you were 

talking.

MEMBER MIKULSKI: No, I don't have 

that information. 

CHAIR MARKOWITZ: At break maybe you 

can look at the index. Okay, so we're going to 

take a 10-minute break or so. So let's come back 

here at a little bit after 3:15.
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(Whereupon, the above-entitled matter 

went off the record at 3:06 p.m. and resumed at 

3:23 p.m.)

CHAIR MARKOWITZ: Okay. So we're 

going to spend probably the next 20 minutes or so 

reviewing cases and then we're going to discuss 

what we've learned from the cases, the more 

generic issues. 

And then we're going to stop at 25 

after 4 but we'll probably start at 4:30 with the 

public comment session. We're just going to take 

a couple of minutes before 4:30 for a very short 

break.

And I think we're going to -- Mr. 

Nelson, if you could make some comments tomorrow 

morning that would be very helpful. Just to 

continue the flow for today.

If anybody in the audience here wants 

to make a public comment and you have not signed 

up there's a signup sheet right over here along 

the wall here.

And if anybody's on the phone or 
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online and wants to do the same they can tell the 

moderator. Oh, they have to email? Okay. 

So later when you get on the other 

line if you press *0 then you'll be able to tell 

the moderator you want to make a public comment.

Okay, so let's do another claim. Dr. 

Berenji.

MEMBER BERENJI: Yes. I have a claim, 

last three digits are 048.

So this was a survivor claim. The 

interesting thing about this particular case was 

that her significant other had formerly filed a 

claim a few years back in 2014 for beryllium 

sensitivity.

And that claim was actually accepted 

in 2015 I believe it was. 

And then unfortunately the initial 

worker, he actually had been working as a nuclear 

engineer over at the Idaho National Laboratory 

from the late seventies till about 2003 or so.

So he ended up passing away from a 

stroke in 2016. And then his significant other 
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applied for a survivor benefit in 2017.

So this is where terminology I think 

comes into play depending on what you're actually 

claiming.

So the worker himself had initially 

filed for beryllium sensitivity. And he actually 

got the claim approved because that's what he 

filed under.

And if you actually look at the 

Procedure Manual to be qualified for beryllium 

sensitivity you actually have to have one 

positive LPT test which he showed documentation 

for.

The survivor, the spouse actually 

filed for benefits claiming CBD. And 

unfortunately again terminology is key here.

The fact that the significant other 

had filed under CBD the claims examiner 

essentially stated that there wasn't enough 

medical documentation to satisfy the requirements 

for CBD.

So the claim unfortunately was denied 
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for the survivor based on the semantics of the 

case.

I thought that was interesting. I 

mean really in terms of should this have been 

accepted I'm not really sure.

The worker himself had been working at 

the Idaho National Laboratory since the late 

seventies. 

And this is where the occupational 

health questionnaire really comes into play 

again. 

You actually look at where he was 

working during those years. He actually had 

exposures to multiple different types of 

chemicals.

He also had exposure to uranium ore as 

well as different uranium byproducts during his 

work in the late seventies and early eighties.

So, he -- I'm not sure if he actually 

applied for additional benefits prior to his 

initial claim, but again in terms of the survivor 

when she was applying for survivor benefits she 
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was unfortunately denied because she had applied 

for CBD and her significant other had applied for 

beryllium sensitivity.

CHAIR MARKOWITZ: Just to clarify, the

sensitivity claim was accepted.

MEMBER BERENJI: That is correct.

CHAIR MARKOWITZ: The survival CBD 

claim was not accepted.

MEMBER BERENJI: That is correct.

CHAIR MARKOWITZ: And was there 

medical evidence to support -- beyond the 

sensitivity to support CBD?

MEMBER BERENJI: There was not 

unfortunately, at least not with what the 

survivor had submitted.

So, that begs the question. I mean, 

could this case be reopened and if she could 

submit that documentation with pre and/or post 

'93 criteria I believe she'd actually have a 

case.

But since her significant other is now 

deceased due to what appears to be a stroke it 
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doesn't appear that he actually died of beryllium 

sensitivity and it was never clearly documented.

It would be interesting to go back to 

the initial worker's claim and actually review 

his claim to see if he actually had submitted any 

additional X-rays, CT scans, or any additional 

testing that could document he actually did have 

CBD.

It's just it's not clear based on what 

I have here because this is from what the 

survivor was filing for.

CHAIR MARKOWITZ: The survivor claim 

did not include the medical records?

MEMBER BERENJI: At least from what I 

have here. There's only 252 pages of records 

submitted.

I did see the occupational health 

questionnaire from her significant other, the 

worker, and there was one laboratory report 

showing the positive LPT.

I'm trying to see if there was any 

additional records in terms of medical 
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documentation, but I don't see it in what I have 

available here.

MEMBER GOLDMAN: What site was this?

CHAIR MARKOWITZ: Idaho.

MEMBER BERENJI: Idaho.

CHAIR MARKOWITZ: Comments or 

questions? Dr. Goldman.

MEMBER GOLDMAN: So if you apply for 

the sensitivity are you still -- I mean somebody 

who got the beryllium sensitivity test, I would 

assume they got the PFT and the chest X-ray as 

part of that, and that the only thing that was 

positive was the sensitivity.

CHAIR MARKOWITZ: I wouldn't assume 

that.

MEMBER GOLDMAN: No? Oh, okay. 

Because then if one did assume that then you 

would know that he didn't have CBD at least then.

But if he made the mistake on the --

if he did have it and he just made the mistake on 

sensitivity and she could get those old records 

then you would have CBD.
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CHAIR MARKOWITZ: The former worker, 

if they get beryllium tests you get an X-ray and 

PFTs.

But current workers, certain 

subpopulations of current workers will get a 

BeLPT, but I don't know whether they are offered 

or whether they necessarily accept also having an 

X-ray and pulmonary function and spirometry.

MEMBER GOLDMAN: This is Rose Goldman 

again. They would be told they have a positive 

beryllium sensitivity test and then not get a 

chest X-ray and PFT?

CHAIR MARKOWITZ: I can't confirm what 

the site occupational medicine practices do 

onsite, but workers may select to get a BeLPT and 

may not get the other tests and then may be 

referred to their outside physician for further 

workup. So it's possible.

MEMBER REDLICH: I previously reviewed 

a number of the BeLPT claims and they seemed 

reasonable that the people who were sensitized 

had been evaluated and did not have any evidence 
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of lung disease at that time.

I can't say that for all of them. And 

the ones that were denied had a negative BeLPT 

and no evidence of any lung disease. So they 

seemed appropriate.

CHAIR MARKOWITZ: Other comments, 

questions? Otherwise another claim? Do we have 

another claim?

MEMBER REDLICH: I have one.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: I'll try to do this 

quickly because I know we're running short on 

time.

So this is an example of again the CBD 

sarcoid and the question of when a BeLPT is 

negative.

So this is a woman who had worked for 

three or several years as an electrician in the 

nineteen eighties at Savannah River Site and was 

diagnosed in the nineteen nineties with clear 

sarcoidosis at the time with pulmonary 

involvement and also conjunctival eye 
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involvement.

So the biopsy was done of her eye. 

But it was clear by chest CT scan and pulmonary 

function test that she had interstitial lung 

disease also and not simply the eye involvement.

Her disease was severe enough that she 

basically was started on 80 of prednisone and has 

been on pretty high dose prednisones since then.

So, now this did not go to a CMC. 

This was the CE's report.

So basically the statement of facts in 

this case -- in addition to that there is a 

letter stating from a physician.

She then more recently had a BeLPT 

that was negative. And there is a letter stating 

that after many years of steroids it could be 

falsely negative.

And then there was also -- she had 

been asked to request to submit evidence that she 

had CBD.

So this person did reach out to her 

treating pulmonologist who reviewed her records 
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back to 1997 and explained in an email that it 

wasn't appropriate to do a lung biopsy in the 

setting of having documented the disease.

And she did have a bronchoscopy later 

on because she actually had hemoptysis and at 

that time the bronch was done because of the 

hemoptysis and the infection that she had which 

was a consequence of high dose steroids for many 

years and it would definitely not be appropriate 

at that point in time to biopsy for -- to confirm 

the diagnosis.

So this information the claims 

examiner had.

And then their summary of the 

statement of the facts acknowledged the 

diagnosis.

It sort of referred to her one note 

that she didn't have evidence of active disease 

which I'm not sure what that was referring to 

given the years of high dose steroids.

And basically -- so it didn't go to a 

CMC or the like, but then the decision -- I think 
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there was -- the SEM was queried for sarcoidosis 

and there was found to be no exposure just by 

working at Savannah River in the nineteen 

eighties as an electrician. So her claim was 

denied.

And I would say that this is an 

example of a false negative BeLPT that was 

explained in a letter.

And yes, there was also a lack of a 

tissue diagnosis, but that was also explained by 

the pulmonologist that it would not be 

appropriate to get tissue.

And there was clear CT scan and 

pulmonary function testing and then the needing 

treatment. 

So anyway, I guess this is also -- in 

terms of what would do to fix this problem.

So I think to fix this problem the CE 

number one would appreciate that there was 

beryllium exposure.

And actually the person in their notes 

that there was a reason for the BeLPT to be 
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falsely negative actually requested getting a 

second -- wanted the patient to get another BeLPT 

done.

In the setting of being on high dose 

steroids for years and actually having a fungal 

complication, infection, her immune system 

clearly is not functioning well.

So there would be absolutely no point 

in getting another BeLPT or to get tissue 

diagnosis.

So those requests being made of the 

claimant when there's documentation for a reason 

specifically addressing those concerns and part

of the criteria.

So I think that again this is a CE who 

didn't really understand these issues.

CHAIR MARKOWITZ: Steve Markowitz. I 

have a question.

So this person met the post '93 

criteria except for the positive BeLPT. That's 

part of the question.

And the other part of the question is 
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we learned previously that DOL acknowledges that 

someone on steroids might have a false negative 

and might invalidate the utility of the BeLPT and 

would accept a case even without that under those 

circumstances. I thought that's what we learned 

previously.

Does this case satisfy those criteria?

MEMBER REDLICH: Yes, except the other 

piece that is missing is that the tissue 

diagnosis was not from the lung. But there's 

clear pulmonary involvement and a pulmonologist 

documenting that based on the CT scan findings 

and the lung function.

I was just saying that in the past 

there's been some discussion of where the biopsy 

was taken.

And we have discussed before that 

there are medical reasons why you biopsy what is 

most accessible and least risky.

And there's even a letter from the 

pulmonologist indicating it would not be 

indicated to do an invasive procedure in the lung 
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when you could make the diagnosis.

So those issues that could be issues 

were addressed in the documentation that the CE 

had.

And the CE even put it in her letter 

mentioning that a BeLPT could be falsely 

negative, but still requesting a second BeLPT and 

-- request you submit a lung biopsy showing a 

process consistent with CBD.

And no evidence was submitted. 

CHAIR MARKOWITZ: Comments? 

Questions? Any other cases? Yes, Dr. Silver.

MEMBER SILVER: Sorry to follow one 

downer with another. 

This is a CBD claim at Los Alamos. 

When this program was adopted Richard Miller, the 

advocate from the union pointed out that it was 

the first entitlement program for workers in a 

quarter century. 

And during that quarter century the 

rest of the social safety net was undergoing a 

big shredding.
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I think this gentleman's experience 

with the EEOICPA program sort of illustrates a 

lot of human suffering that the program doesn't 

reach.

He had a 25-year career at Los Alamos 

starting at around age 40. Much earlier as a 

late teen and in his twenties worked a year at a 

uranium mill and spent two years on the 

construction services company Zia at Los Alamos.

His last 10 years were as a supervisor 

at a process at Los Alamos that is frankly 

notorious for chemically intensive work with 

plutonium.

So there would have been a lot of 

chemical exposures, neutron exposures, alpha 

radiation and job stress because of the national 

security imperative that surrounds that unit.

He'd been a construction supervisor 

earlier in his career and was detailed after the 

Tiger Team reports pretty much when he first 

started to enter a large number of buildings at 

Los Alamos that had some kind of violation of 
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regulatory standards to follow up on the Tiger 

Team recommendations.

So roll the clock forward. He's in 

his early sixties. He's experiencing shortness 

of breath.

He'd been enrolled in the beryllium 

worker surveillance program under the site 

occupational medicine program and all told 

between 2002 and 2011 he had four negative LPT 

tests, but one X-ray showed a nodule in the upper 

right lobe of his lung.

And then a subsequent X-ray showed 

nothing going on. Back when he had shortness of 

breath his pulmonary function decrements were on 

the order of 77 percent of normal.

And then his later pulmonary function 

tests were fully normal. So I've spent a little 

time in this community and it seemed to harken 

back to how medical test results would sometimes 

change in a company town atmosphere. I had hoped 

those days were over, but something in my gut 

bothered me.
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While on the human side after having 

his CBD claim denied he developed prostate cancer 

and got a very small probability of causation 

from NIOSH.

The chemotherapy led to liver damage 

and he was diagnosed as well with cataracts and 

narrow angle glaucoma.

His dose to the eye was an order of 

magnitude less than what NIOSH says might be 

because of glaucoma and cataracts.

And his misery continued with a 

diagnosis of colon polyps, not yet cancer, 

hearing loss.

By that time he'd gotten an authorized 

representative. The audiogram never passed 

through the hands of a physician so he did not 

get compensation for hearing loss, plus he didn't 

have more than 10 years of chemical exposure 

before 1990.

So, just seems that -- I live in a 

part of the country now where people live in fear 

of being thrown out of the workforce in their 
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late fifties, early sixties.

And here's a man who has this cascade 

of health problems and a long history of going 

into multiple sites at Los Alamos.

So I was a little disappointed that 

the CE did not send it to an industrial hygienist 

to rake over some of those earlier work areas.

One of them were the high explosive 

sites, the firing sites and there was some hint 

in the literature that nitro organic compounds 

have some ocular toxicity.

I just felt that someone in this 

situation might have gotten a little more of a 

claimant friendly look from a claims examiner.

So there are a lot of people out there 

with complex chemical exposures. We haven't been 

to Rocky Flats yet, but when we do I'm sure we'll 

meet some plutonium workers who are in the thick 

of neutrons, alpha chemicals.

And Los Alamos is about to start 

producing even more plutonium pits. Hopefully 

the precautions of medical surveillance programs 
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will be more rigorous this time around.

Is that enough of a downer?

CHAIR MARKOWITZ: On that note any 

comments or questions?

MEMBER GOLDMAN: What about the lung 

nodule?

MEMBER SILVER: Well, the subsequent 

chest X-ray didn't see anything. 

MEMBER GOLDMAN: Did he get a CT scan?

MEMBER SILVER: That never happened.

MEMBER GOLDMAN: You know what I'm 

thinking. That probably should happen for a 

nodule with that kind of exposure.

MEMBER SILVER: I agree. His 

authorized representative came in kind of at the 

last minute for an appeal hearing and wasn't 

really holding his hand through the whole 

process.

Nobody was. It's a non-union site. 

He wasn't yet a former worker so he was kind of 

on his own out there.

CHAIR MARKOWITZ: The former worker 
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program offers low dose CT scan for early 

detection of lung cancer to a subset of workers 

at risk.

But it's only offered by a couple of 

the larger former worker programs and not by the 

others. But it is on the national medical 

protocol.

MEMBER SILVER: You have to be a 

former worker.

CHAIR MARKOWITZ: Yes, former worker. 

If you're a current worker at Paducah, 

Portsmouth or K-25 then you also are eligible. 

Otherwise no other current worker is eligible.

Okay, so let's move on. What I 

thought we should do for the next 40 minutes is 

talk about more in general about the limitations, 

what we've seen today and previously in the 

industrial hygiene evaluation, the CMC 

evaluations.

This is under task 4 of the Board, 

evaluate the objectivity, consistency and quality 

of the industrial hygiene and medical input into 
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the claims evaluation process.

And then later we can get to --

perhaps today, perhaps tomorrow the claims 

examiner part of that under task 2 for the Board.

First, let's just discuss about the 

industrial hygiene. I don't think we need to 

come to conclusions.

I think that if we get the issues out 

and begin to develop some recommendation that in 

a telephone meeting with the Board in a couple of 

months we can formulate some recommendations 

which we could vote on.

So I don't think we should feel the 

pressure to do that today and tomorrow morning, 

but I think we should move in that direction if 

we see fit.

So let's discuss what we've seen so 

far about the objectivity, consistency and 

quality of the industrial hygiene evaluations.

Dr. Dement.

MEMBER DEMENT: I think we've 

discussed some of the issues before. I think 
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John Vance gave a report with regard to some of 

the upcoming changes which I think are positive 

with regard to the IH assessments and their 

ability to have some discussions with workers to 

fill in holes in the information particularly.

I think first of all it's important to 

realize that these assessments by the industrial

hygienist are -- they're qualitative in nature.

They're largely at least as they're 

structured now predicated on their own experience 

with either the type of work being done or the 

site itself. And we know that's sometimes quite 

variable.

I think the assessments could be made 

better if a couple of things would happen.

One is that scope of knowledge with 

regard to the particular job and exposure be 

identified.

For example, if you're going to be 

assessing an exposure to asbestos or silica I 

think the hygienist, given the job category, the 

site and the exposure needs to state what he or 
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she is assessing.

What's the basis of that exposure. 

Was it simply having been in the facility, or is 

it something that he or she has knowledge of that 

the individual has, that's done a task, for 

example. A task -- the task and materials gives 

the particular of exposure. So I think they 

could be better.

And there are some reports that I've 

seen that happen and I found them very helpful 

where the hygienist said this person in this job 

category would have done these things. Therefore 

these are my opinions with regard to the 

exposure.

I think the other area where it could 

be at least made less objective at least is to 

require the hygienist to not just give low, 

medium, high, whatever their category is, but to 

tag that to what's the basis of that.

It's low, but it's low relative to 

what. Is it low relative to the exposure 

standards at the time, or is it low relative to 
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now.

Anyway, tag where that reference point 

is with regard to exposures.

I think the third area, maybe it's the 

fourth, I lost count, is to reword the assessment 

post 1995.

We all recognize that things got 

better. A more appropriate statement of what 

that state of knowledge is needs to be in the 

industrial hygiene report.

CHAIR MARKOWITZ: Steven Markowitz. I 

have a question about this low, medium, high 

because all these reports have the IH judgment 

about this job title in relation to this 

particular exposure taken from the SEM.

And it's very low to low, or 

occasionally it's moderate.

I agree with you that I don't know 

what those words mean, but the problem with 

pegging it to like a legal standard or regulatory 

standard at the time is those aren't necessarily 

protective.
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And is it true that the IH could know 

how that exposure relates to the prevailing 

standard at the time. You know what I mean?

MEMBER DEMENT: Well, I think for a 

lot of tasks, and again it depends on hygienists.

If you tell me that you're using 

asbestos or silica and you're doing this task 

based on my own personal experience or even the 

literature, published literature, I can say that 

likely would have been excessive based on current 

standards certainly and probably even the 

standards in the past.

So you can make a qualitative 

assessment of that.

My comment is that just to state 

what's the basis of it. A lot of times in 

assessments that we've done using multiple 

hygienists to assess exposure into these broader 

categories of low, medium, high, you would tag it 

to some known exposure standard or guideline.

Say okay, this is where we are, this 

is the guideline. And then you would ask the 
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individual to assess where they would place this 

task or exposure in this paradigm.

Then the next question you would ask, 

what is your basis of it. Is it one, direct 

experience having measured it. Is it two, is it 

from the published literature, or is it specific 

to the site. So there's several categories.

And what you can do with that is if 

it's -- there's no basis except just published 

literature that's fine, but at least you know 

where it came from.

So anyway, I just think the hygienist 

exposure assessments could be -- there's always 

going to be guesswork, but at least state the 

basis for the guesswork.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: My other thing that I 

found that sort of is just a theme was -- because 

there's the concentration of exposure and then 

there's also the years of employment.

And you need to take that into 

consideration. So there's a difference between 1 
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year, 2 years, and 20 or 30 years.

And also then further back in time as 

a general guideline.

So I feel like that word of high, low, 

is then taken by -- and usually low by the CMC 

who doesn't have much training or experience and 

isn't thinking, okay, that's exposure for someone 

who spent 30 years in this environment where 

there was likely variable exposures over a number 

of years.

I think that's the type of guideline 

that could be given to the CEs that you really 

need to consider not just what they're estimating 

as an amount, but the duration.

CHAIR MARKOWITZ: Guideline to the CMC 

you mean.

MEMBER REDLICH: And also to the CEs 

in terms of the way they -- because the CEs take 

this information and then frame the questions.

And I think sometimes the question --

things can go wrong at several stages.

CHAIR MARKOWITZ: But the IH reports 
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I've seen, they do include duration. They have a 

table with the job title and the years that that 

person worked at that job title. And so that 

information is there.

Now, like you I don't know if it's 

used by anybody else but at least it's in the 

report.

MEMBER REDLICH: A lot of the ones I 

was thinking was the SEM, but didn't actually go 

into each person.

CHAIR MARKOWITZ: Dr. Berenji.

MEMBER BERENJI: Great insight by Dr. 

Dement and also by Dr. Redlich.

Just as additional comments at least 

as my experience doing independent medical 

evaluations I do get requests from insurance 

companies to opine on questions that they issue 

to me as an independent medical examiner.

But a lot of the times if I see 

something that's not quite adding up and I feel 

that there's additional insight that could be 

helpful in the case in terms of determining next 
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steps I do feel that the CMC or in my case as an 

independent medical examiner I have the 

obligation to provide those additional medical 

facts.

I mean, in my work as an independent 

medical examiner I've seen cases where someone 

comes to me for condition X and they have 

condition Y which is actually causing more of an 

issue.

Whether or not it's related to the 

initial exposure or question at hand to me that 

needs to be understood that there are other 

medical circumstances that are affecting this 

individual.

So I feel that the claims examiners, I 

understand they have a lot on their plate. They 

obviously have a lot they have to deal with.

But just issuing one or two questions 

to the CMC and just expecting the CMC to address 

those few questions without allowing the CMC to 

provide additional insight based on their medical 

opinion based on the medical review, I feel it's 
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a bit shortsighted.

So hopefully there can be some 

discussion about nuance. Every case is 

different. You can't necessarily put people into 

certain buckets and expect them to have the same 

outcome for every single case.

CHAIR MARKOWITZ: We have to accept at 

some level that the professional experience and 

expertise of the industrial hygiene will 

necessarily play a role. That's why we go to 

them.

But what is missing, and the Board's 

talked about this since 2016. What really needs 

to be a significant part of the process is the 

claimant, is the claimant's experience at the 

workplace, is what the claimant did, what the 

claimant was exposed to from their perception, 

what levels. Not quantitatively, obviously, but 

the way we normally talk to workers about their 

exposures.

And it's through a better improved 

occupational health questionnaire. It's through 
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a direct interview that that can take place.

I don't see any evidence in those IH 

reports frankly that anything the claimant says 

makes much of a difference.

Maybe it does, the IH doesn't cite it, 

but I don't see it in the reports. I don't see 

the IH cite the claimant, the claimant's 

experience and the OHQ or anything else as to --

they cite their expertise. They cite standard 

textbooks and the like.

And personally I think the IH would 

probably welcome frankly some real personal 

information from that worker about their 

experience because they can make a better 

judgment about the exposure.

MEMBER DEMENT: I agree with you 

totally. I know personally I have in the past 

had cases sent to me for review at the outset 

based on what the job category was. I would say 

they're not exposed.

But when you actually get to the point 

of discussing it with the individual you find 
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that this is not true.

And so put yourself in the place of 

the claimant. You've got this broad occupational 

history asking about zillions of exposures, but 

probably there may only be four or five that 

really are relevant to your case. But they're 

not developed well in the OHQ at least currently.

And that may be always the case even 

with one that's more task-based and asked more 

specific questions.

So I think you are left with at least 

in my opinion as it comes to the hygienist a not 

well developed description even from the worker 

themselves about what they've done.

Hopefully the new occupational history 

questionnaire can direct you better. I'm 

interested in if you tell me you were exposed to 

benzene, tell me how.

You can do it in two sentences and it 

will give me great insight. So that to me, the 

new occupational history questionnaire to at 

least pull these things out as it goes to the 
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hygienist.

And then the hygienist saying well, I 

know about these exposures. I have some 

experience with that either myself, published 

literature, or from the site.

I don't -- and I need to ask a few 

additional questions. And it may be only 10 

minutes' worth of additional discussion with the 

claimant to get that better.

And as a hygienist I don't necessarily 

have to have experience with every material to 

give some qualitative level of exposure.

If you're telling me you were working 

with solvents and I know something about 

solvents, the vapor pressure and sort of what you 

were doing with it I can have an idea of where 

the magnitude of exposure would be just based on 

telling me what you did.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: I do feel like 

sometimes the piece that's missing is it's almost 

a shotgun approach at every potential exposure 
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without -- I would say if it's pulmonary fibrosis 

I don't really care about the solvents because I 

know that that doesn't cause it.

What I do care about is asbestos and 

dust and metals and that. And so then you target 

it to that exposure. 

I've found looking at a lot of these 

that whatever sort of qualitative other 

information is on questionnaires where the person 

just describes, well, I was cleaning in all these 

different buildings around whatever that type of 

-- or it was frequently very dusty, that that 

qualitative information at least for the 

respiratory component is extremely helpful.

Because I think the SEM in attempting 

to be more precise is spinning a lot of wheels 

that aren't really relevant, or if anything can 

detract from what the relevant exposures might 

be.

At least for the more common 

respiratory conditions.

MEMBER DEMENT: I agree. I think a 
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lot of industrial hygiene time is being used to 

do assessments on exposures that are remotely 

relevant to the outcome.

You know, a long time ago the NCI 

developed for its own studies some case control 

an occupational history questionnaire that 

started and started with asking sort of the 

outcome first. Then it asked the job.

Then it goes down, it sort of branches 

and it goes and asks specific questions after you 

get into that one place.

What we don't have here -- we have 

this whole piece of occupational history. Most 

of it's not very relevant. It probably didn't go 

to the relevant part.

I don't know how to fix that except 

ask a lot of broad questions and have the ability 

to go back to it.

CHAIR MARKOWITZ: But that's why 

experts are included in the process. They're 

supposed to sift through that and do triage till 

they get to the point.
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Other questions or comments? Dr. 

Berenji.

MEMBER BERENJI: So, I know Dr. Dement 

has mentioned this at previous Board meetings, 

but I'm just going to reiterate that for the 

record.

I mean, when it comes to the IH and 

really understanding the worker's occupational 

history I know gases, vapors, fumes, dusts, 

mists, this all comes into play.

And I know the Department of Labor has 

had some issues over the years with these 

particular terms.

But as we all know just getting a 

sense as to where a worker has been over their 

life course in their work depending on where they 

were working at what particular time we have to 

be able to utilize these terms.

And I know that at least for right now 

it seems like it's a closed case, but really if 

there's a way to at least get the industrial 

hygienist to understand that these terms really 
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do help us create a story of where the worker has 

been and what they've been exposed to I think 

it's worth reconsidering.

CHAIR MARKOWITZ: So, if there are no 

further comments on the industrial hygiene can we 

talk about the CMC, the medical evaluations?

MEMBER REDLICH: How about the claims 

examiner?

CHAIR MARKOWITZ: We'll get to them 

next.

MEMBER REDLICH: Okay.

CHAIR MARKOWITZ: Dr. Berenji.

MEMBER BERENJI: Again, I know that 

the Department of Labor had made a determination 

about providing the entire case file to the CMC.

And please correct me if I'm wrong, 

but at least according to this grid that we were 

provided today it does not want to proceed with 

providing the entire case file.

I guess from our end this is 

considered to be a closed case, but I highly 

encourage the DOL to at least reconsider because 
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to really make a full determination the CMC 

should have the entire case file. I mean that 

should be a given.

And it's just unfortunate that we have 

a disagreement in terms of how that should be. 

But I do disagree with that and I really think 

there should be reconsideration.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: The main 

reason given is that it's too much for the CMC to 

go through.

And I think that can be addressed 

fairly simply by a good index to what's in the 

record.

We've all gone through these 2,000, 

3,000 page records and it's incredibly timeconsuming.

If there were a good index it would 

save -- as John said 80 or 90 percent of our time 

in doing review, and more importantly would save 

80 or 90 percent of the CMC's time in doing the 
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review.

So, I think that issue can be 

addressed by indexing. It's some work. I mean 

someone's going to have to do that and so whether 

a CE does it, or you hire someone else to do it, 

to go through and pick out where's the SOAF, 

where's the final decision, where are the PFTs, 

what pages are these on.

Half a page index giving you a guide 

to where the important information is.

Then if you need more you can go 

searching through. And I've actually gone 

through several 3,000 page records and the only 

thing I've found was that the pulmonologist said 

he can't interpret this PFT because there's no 

height in the chart.

And so the guy had to wait six months 

for them to find out what his height was. But 

his height was in another PFT report that wasn't 

cited that I -- after 45 minutes I found.

I mean, it's really incredible how 

much time you can burn on this.
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But I think the main objection that 

I've heard, and John, correct me if I'm wrong, 

the main objection has been that it's just too 

much information for the CMCs to go through. 

That can be addressed.

Are there any other objections to 

providing the full medical record?

MR. VANCE: You have seen these cases. 

You know what's involved. And it's just a 

question of keeping in mind when you're talking 

about a process, you're talking about the 

adjudication, the administration of over whatever 

number of cases are going through this process.

You've got to think of that logistical 

side of things. If you have the entire case file 

-- and I've seen case files. When you're talking 

about a case file you have to remember about the 

entire population of files.

We have cases that have tens of 

thousands of pages of documents. So you have to 

be mindful of a recommendation saying well, send 

the whole case file.
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Some of these case files are huge. 

And so you also have to be aware of that kind of 

a scenario.

MEMBER REDLICH: To play devil's 

advocate. I mean I have been carefully through 

at least 50 or more of these cases.

And I can't actually think of a single 

one where that CMC having more information would 

have ended up with a more accurate decision.

I think the bigger issues in terms of 

different ones are what questions the CMC is 

asked, whether a CMC was even needed, where the 

treating physician had the correct answer.

So I think that -- I think the quality 

of the CMCs is such that most of them do not have 

training in occupational medicine in terms of 

thinking about causation. 

They may be boarded in occupational 

medicine, or they may be a pulmonary physician 

who really doesn't think in terms of causation.

So I think that that's the least of 

the issues and probably the hardest to fix given 
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the more limited pool of high-quality physicians 

who could actually have the expertise to decide 

that.

So I think as often as possible the 

correct decision could have been made earlier in 

the stage before it went to a CMC.

Or if the CMC was asked the correct 

question. So I would just -- not to -- the 

process of how the CMCs are selected and what 

company.

I think the physicians unfortunately 

that work for a lot of these sort of disability 

type evaluation contractors really have extremely 

limited experience in cases like this.

CHAIR MARKOWITZ: Steve Markowitz. 

Mr. Vance, I have a question. I'll make a 

comment first.

So, some of the CMC evaluations are 

excellent. I'm a little surprised actually how 

good they are because this is not the most --

frankly reviewing claims as a medical doctor, 

it's not the most desirable type of work. I mean 
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let's be real about that.

So you have some really excellent CMCs 

and some excellent reports.

There's another group and I think it's 

the minority, the reports are not acceptable. 

My question is what process is in 

place to identify the poor reports. I know that 

the medical director evaluates a certain number 

of claims every quarter.

Within the contractor, the QTC, is 

there a quality assessment process in place? If 

there is it's not working, but what is it at 

least?

MR. VANCE: There is a quality 

assurance process internal to QTC and their 

evaluation of CMC opinions. That's informed by 

our auditing process. That's informed by 

quarterly engagement we have with the contractor.

And we have had situations where we 

have identified physicians that have been 

problematic and we've gone through remedial 

training and more closer oversight of their work 
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by our medical director. So I mean that's the 

process.

And I think that we would be looking 

for any further engagement or input that the 

Board would have on how to better screen or 

identify reports that are problematic, or what 

the actions of the program should be.

But we basically contract out to QTC 

to have physicians evaluate these cases and 

provide medical opinions from qualified 

physicians.

Each one of our CMCs is a qualified 

physician. Now, whether or not the quality rises 

to the level that the Board would like to see, 

that's how do you best address that.

And the program does do that, but I 

think that additional information about the 

things that you see as defects in some of the 

opinions would be very helpful.

CHAIR MARKOWITZ: So, just if I could 

respond. So, my guess is most of the CMCs do 

have paper qualifications because it's an easy 
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enough thing for the contractor to look at and 

that there's some relevance between their 

qualifications and what they're asked to do 

although that is an aspect.

What I'm concerned about is that the 

medical director in the last five quarters has 

looked at 83 claims for the purposes of looking 

at causation in particular and only found one 

that needed improvement. And that's not in our 

experience.

Whereas on the impairment front when 

he looks at claims, it's 100 plus claims, 28 

percent need improvement.

It's suggestive there's a systematic 

problem with impairment evaluation because 28 

percent is too high.

But just sticking on causation for the 

moment, I think the review of causation 

competence in the CMC report is incomplete.

I think it's probably not the emphasis 

of the medical director. 

We all have our strengths. You 
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wouldn't ask me to do impairment evaluations, 

believe me, but I'm okay on causation. So I 

think that's what's going on and we need to 

address that. Ms. Pope.

MEMBER POPE: I think a similar 

problem, a similar concern is also with the CE 

because the CEs are building the case.

And so they are framing the questions 

and they are earmarking so to speak the different 

documents that the CMC and the IH are looking at.

So, who evaluates those cases that the 

CEs -- because I'm sure there's bad players in 

that group of people that are building the cases, 

the CEs.

So who's evaluating those cases that 

they're developing? You can have similar 

problems in that category as well.

CHAIR MARKOWITZ: Mr. Domina.

MEMBER DOMINA: I'll agree with 

Duronda on that because some of the ones that I 

looked at, the sooner in the process there's a 

mistake, it gets bigger as the case goes.
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Like one of mine I was going to wait 

till tomorrow where I did where it rolls in the 

SEM, the job title, the SOAF. The job title was 

presented wrong. Okay. And it happened to have 

been a Hanford worker who was a health physics 

technician at Hanford and both Idaho Falls.

Well, this one was mostly adjudicated 

in '18. And I know some of you may remember I've 

had heartburn with a health physics technician in 

the SEM because up until recently they weren't 

listed.

So when they did this last year, that 

showed what happened was -- this guy was a 

technician the whole 30 years.

But when it went to the CE, from the 

CE to the IH on the SOAF it listed him as a 

health physicist.

So now all of a sudden the job title -

- when they pulled the SEM last year it showed 

like, I don't know, 16 or 18 substances for Idaho 

Falls and 160 for Hanford.

You go to Hanford today there's 2,099. 
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It was pulmonary fibrosis. It got weeded out 

because, you know, it's aluminum and some other 

benign things. Asbestos is never in there.

And I do know this came up on our 

September 4 conference call because Dr. Dement, 

Dr. Markowitz, I think somebody else was on it. 

John Vance was on it too.

And then the other part is the filters 

that the CEs have that we don't have access to

denied this claim.

And then so when I'm looking at this, 

it was on a disk I believe we got this summer I 

had no idea if the guy is still alive or dead.

Well, unfortunately he passed away. I 

found the obituary in Idaho newspaper in like 

February and there's no survivor, you know?

But when you go from 100 and some 

chemicals or substances to 2,099 there needs to 

be a process that you go back and look at those 

claims.

Just like what John talked about 

earlier about reopening some of these claims. 
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It's a travesty to these people 

because it fell apart in the beginning and then 

it just -- and how an IH and a CMC who both 

reviewed it didn't notice that this person was 

listed as a technician all along and then it got 

to a health physicist somewhere along the line

for a few years, you know, towards the end of the 

guy's career which he never was.

CHAIR MARKOWITZ: Dr. Redlich.

MEMBER REDLICH: I agree with all of 

the comments that were just made. And I didn't 

mean to damn all of these CMCs because a number 

of them are excellent.

I think that as a solution to one of 

these issues is that if these physicians do have 

expertise in determining causality which is the 

main question they are asked, typically they're 

asking did A exposure cause this -- did X 

specific exposure cause this disease.

And I think the real question is did 

employment at whatever, you know, sites over this 

period of time cause this patient's condition.
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And then let them see what 

information, exposure information has been 

collected.

But they should have the expertise to 

look at that, and more expertise in a certain way 

because the question has been narrowed down by a 

CE and an IH that don't have the perspective of 

what can cause this condition.

And I think -- because a number of the 

ones that I had questions with the final 

conclusion, the issue was this physician wasn't 

asked the right question.

And if they had been asked a broader 

question instead of, you know, did aluminum cause 

your COPD, or did your work exposures as a welder 

or whatever cause it, or instead of asking -- and 

the similar thing with the sarcoid being asked, 

does beryllium cause sarcoid.

So I think it's sometimes the 

question.

CHAIR MARKOWITZ: Just to play devil's 

advocate. You're not going to get physicians to 
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work as CEs.

The CE has a limited set of knowledge 

and formulates the questions, and sometimes 

they're not going to be right.

And then there ought to be a 

corrective process when they refer it to the IH 

or the CMC which allows that SOAF to be corrected 

over time, right? With additional input from the 

IH and the CMC.

I don't see how else you could do it. 

I don't see -- I mean, there may be some CEs 

that are just not doing the right thing, but 

necessarily their knowledge is limited and 

they're necessarily going to miss the mark 

sometimes.

I mean, it needs to be corrected, I'm 

not saying it doesn't, but it's kind of the 

nature of the beast I think. But Dr. Goldman.

MEMBER GOLDMAN: So, I'll just say I'm 

coming to this committee new. This is my first 

time.

But as an observer --
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CHAIR MARKOWITZ: Welcome, welcome.

MEMBER GOLDMAN: I'm going to throw 

something out that's maybe totally naive, but 

whatever. But what I'm hearing is it's an 

imperfect process just by all of these factors.

So what I'm wondering as a sort of 

systematic way to deal with this because we're 

sort of randomly looking at things.

What if there was a system where for 

all the cases that were rejected, that were 

declined, and I know there's tons of them, that 

there was a random sample of the declined that 

had some systematic way that it went to either 

another CE or another level of review sort of 

like what we're doing but in a systematic way and 

would cut it down to only those that are declined 

so that there might be yet another way to be 

looking at these things and picking up some of 

these things.

Because it just seems -- and that 

there might also be for the more complicated 

things that you know ahead of time, the beryllium 
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and the sarcoid seems really complicated, that 

for all of those that get declined there is this

second level of sort of an automatic review that 

doesn't have to have the person applying for it.

Now, maybe that's not possible, but 

just a thought.

CHAIR MARKOWITZ: Dr. Dement. And we 

have a couple of more minutes and then we're 

going to take a short break before public 

comment.

MEMBER DEMENT: I would agree with Dr. 

Markowitz. The CE plays a key role and without 

them, without their work, this thing would just 

grind to a halt because there has to be some 

sifting through this information and ferreting 

out what's important and what's not.

And for the most part I don't think 

they do that bad a job based on what I've seen. 

Sometimes they miss it, sometimes they don't.

But I do agree that it's the 

responsibility I think and it should be of the 

hygienist and CMC to look at what they've given 
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in terms of these accepted facts, to also look at 

the OHQ and some other information just to make 

sure -- that what's there is correct.

The other thing is I like the idea of 

a stratified random sample based on even 

causation as a reason for rejection.

CHAIR MARKOWITZ: You want a variant 

of accepted facts to be corrected facts.

MEMBER DEMENT: Yes.

CHAIR MARKOWITZ: Okay.

MEMBER REDLICH: It's true. I mean, a 

lot of the statement of facts are very accurately 

put together. For --- How many total CEs are 

there? Are we talking 100, 200?

MR. VANCE: Claims examiners, I think 

we're in the neighborhood of 240 to 250. I can 

get the exact numbers.

MEMBER REDLICH: And do they all do 

all types of cases? Is it geographically based, 

or do you have a group that let's say have more 

expertise in a certain area?

MR. VANCE: They're trained to 
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evaluate and apply the criteria that are under 

the statute for adjudicated cases. So they 

handle whatever cases come across.

The only distinction that we have 

right now is the medical benefit group that's 

handling the -- post adjudication medical benefit 

authorization process.

MEMBER REDLICH: I mean, personally 

for something like the beryllium sarcoid I really 

think those are very challenging for a nonmedical person to appreciate some of the issues 

that have come up repeatedly such as it can be 

pulmonary sarcoid even though the biopsy was 

taken here.

Or when it's legit that there is a 

negative BeLPT, understanding immunosuppression.

I mean, as just a potential solution, 

and we do this more and more in medicine. We 

have nurse practitioners and PAs that are doing 

very specialized areas that are only in 

interstitial lung disease clinic, or only in the 

asthma clinic. And they're very good. They don't 
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know all of pulmonary, but they know ILD really 

well.

And you could consider a group that 

have more experience. Because any one of these 

things if you see it intermittently it's very 

challenging.

And being able to sift through 1,000 

pages and pick out -- I mean, two cases that we 

didn't get to are two that were basically it was 

not recognized that it was pulmonary sarcoid 

because I mean -- I'm just finding a tiny one 

page in the middle of 1,000 that is relevant.

But they did have evidence of like a 

biopsy on the bronch that was pulmonary sarcoid 

that hadn't been recognized because the major 

diagnosis was let's say neurosarcoid.

But I think things like that are 

something that would be hard to train all of the 

CEs, but you might consider it.

CHAIR MARKOWITZ: And on that note we 

will take a five-minute break and resume at 4:30 

for the public comment session. Thank you.
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(Whereupon, the above-entitled matter 

went off the record at 10:00 a.m. and resumed at 

10:10 a.m.)

CHAIR MARKOWITZ: Okay -- this is 

Steven Markowitz. We're going to begin the 

public comment session. Mr. Fitzgerald, are 

there any comments you need to make for this 

session or are we good?

MR. FITZGERALD: I think we're good to 

go.

CHAIR MARKOWITZ: Okay, if there's 

anyone on the phone and you want to make a public 

comment you're welcome to. Just press star zero 

and wait for the operator and tell the operator 

that you'd like to speak and then you'll be added 

to the list. So thank you.

I'm going to ask people to limit their 

remarks to about seven minutes or so, roughly 

seven minutes.

And I will give you some indication 

when your seven minutes is up so we request 

cooperation.
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Our first is going to be a phone 

caller, Terrie Barrie. Ms. Barrie?

MS. BARRIE: Hello.

CHAIR MARKOWITZ: Terrie, you there?

MS. BARRIE: Yes I am, Doctor.

CHAIR MARKOWITZ: Okay. We welcome 

your remarks.

MS. BARRIE: Okay, well thank you. 

Good afternoon, Dr. Markowitz and members of the 

Board. This is Terrie Barrie, founding member of 

the Alliance of Nuclear Worker Advocacy Groups.

I appreciate you allowing me the 

opportunity to provide comments.

The U.S. Ombudsman released his 2018 

report to Congress a couple of weeks ago. The 

report includes recommendations to DEEOIC which 

will improve the program.

I'd like to call to your attention a 

concern detailed on page 31 of the report about 

the first responders.

And I quote, Over the years 

individuals who worked or had worked as first 
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responders approached us to complain that the SEM 

database did not list all of the buildings, all 

of the incidents, and/or all of the toxic 

substances they encountered in the course of 

performing their job, end quote.

I searched the SEM for 25 of the major 

sites and I provided the spreadsheet which is 

listed on your website to see how many toxic 

substances are reported for fire fighters.

I found it astounding that with the 

exception of the Hanford site the average number 

of toxic substances listed which a fire fighter 

could have been exposed to is 22, only 22, where 

the average number of total toxic substances at 

the sites other than Hanford is 1,770.

According to the Ombudsman's report 

the first responders suggested that, quote, It is 

time for the program to re-think its approach to 

compiling information in the SEM database about 

their exposure, end quote.

ANWAG supports the first responders' 

request and encourages the Board to look into 
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this issue.

I was happy to hear that Department of 

Labor is instituting a quality assurance program 

to review claims, although I do have some 

concerns whether this will interfere with the 

Board's statutory responsibilities.

I'm hoping that this is the result of 

a federal court decision handed down last 

December, Adams v. DOL.

The court remanded the case back to 

DEEOIC. The case involved a claim adjudication 

which the Board also has identified as problem 

areas.

For instance, the claimant was 

previously approved for beryllium sensitivity, 

but despite the fact that the claimant's 

assertion that the beryllium exposure caused, 

contributed to, or aggravated her COPD claim the 

claims examiner failed to list beryllium in the 

statement of accepted facts to the industrial 

hygienist.

The court also found that DEEOIC 
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relied too heavily on information in the SEM.

But what I found most interesting and 

intriguing is the court's statement on risk 

factor.

From page 339 I believe of the 

decision, and I quote, DOL's final decision fails 

to have a rational connection between the facts 

and the ultimate choice made when it cherrypicked evidence supporting its decision and 

neglects to substantially confront the 

relationship between the elevation of risk and 

aggravation of the disease.

I remember the Board discussing how 

the DEEOIC determines whether an exposure 

aggravated disease or condition.

In light of the court's decision 

perhaps the Board may be able to provide guidance 

to DEEOIC on whether increased risk factor is 

related to the aggravation standard in the 

statute.

I'm not asking this for this 

individual claimant, but as an overall program 
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policy.

I will provide the link to the court 

decision in my written comments.

I am disappointed that the latest 

version of the Procedure Manual was not provided 

to the Board before the meeting despite Ms. 

Leiton's statement during the Board's 

teleconference in September that it would be 

released the end of that month.

I have two concerns I'd like to bring 

to the Board's attention about -- the new 

Procedure Manual.

How long has the claims examiner been 

using this new version? And according to John 

Vance today the personal physicians will now need 

to validate their understanding of the exposure.

The reason these two questions, these 

two concerns is that an AR came to me a couple of 

weeks ago that she was told by the claims 

examiner would feel better accepting the 

rationalized report from the treating physician 

after the claims examiner had a toxicologist 
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review that letter.

It's important to note that the 

personal physician provided peer reviewed 

scientific studies supporting his decision.

I ask the Board to carefully review 

the changes to the Procedure Manual when it is 

finally released and weigh in on whether it is a 

reasonable request by DOL.

And I would also like to point out for 

future references if you ever discuss lung cancer 

claims that the SEM links beryllium exposure to 

lung cancer. So I just found that out and I 

thought that would be interesting for you.

Thank you again for the opportunity 

and for your work to improve the program. Thank 

you.

CHAIR MARKOWITZ: Thank you very much. 

Next is Ms. Vina Colley who is on the phone I 

think.

MS. COLLEY: Yes. I'm Vina Colley 

with National Nuclear Workers for Justice and we 

want to thank you for allowing us to speak and 
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thank you for holding these important meetings.

The National Nuclear Workers for 

Justice has long asked for a meeting in Paducah 

and for Portsmouth and we're very honored that 

you are at Paducah, and hopefully at your next 

meeting that you will be at Portsmouth.

We are also hoping that they re-look 

at the SEM database to find out what happened to 

-- our union put together a very specific data on 

the buildings, what was in the buildings, what 

the workers could be exposed to and so far I 

don't know what happened to that data, but it 

needs to be put back into the SEM and the Board 

needs to look at that procedure that the union 

put in.

And we also would like for the Board 

to get the Moody report with the radiological 

chemical report by Kenton J. Moody dated January 

5, 1995, and it was done by Lawrence Livermore 

National Laboratory to be added to the list of 

the exposures for the Portsmouth Gaseous 

Diffusion Plant, the Paducah, Kentucky plant, and 
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the Metropolis plant.

These three sites handled reactor fuel 

from Russia and many other sites like Hanford, 

Savannah River and the reactor fuel was being 

reprocessed without the workers' knowledge and we 

were being exposed to transuranics like 

plutonium, americium, neptunium, technetium-99, 

cesium-137, et cetera.

Not to mention the fluorides and the 

other chemicals that we were exposed to such as 

tricoethylene and stuff.

And now that americium has been found 

in the air monitors offsite and has shut down one 

school in Piketon we are now looking at testing 

many more schools.

The ASA report has found americium 

offsite 14 miles from the Piketon plant now. And 

we can see we have a critical situation going on 

here with the workers and the community, which 

the Board I know doesn't address the community.

I met with some workers last week and 

a contractor with a cancer told me he has two 
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affidavits of proof that he worked at the plant, 

that -- it isn't good enough now for his cancer 

even though it is an SEC cancer.

So he went to the local union hall and 

he requested the records. And he was only told 

that the DOL has picked up these records.

My question is how do these workers 

and families get proof of employment if the DOL 

is going around and picking up these workers' 

records and what are they doing with them? Are 

they keeping them? Are they destroying more 

records? If so we need to know.

I also was told that Social Security 

now is charging for records, for workers to get 

their records. It seems everyone is bloodsucking 

money from the workers.

The SEC at the Piketon and Paducah and 

Oak Ridge was the first SEC site mandated by 

Congress.

Now at Portsmouth they are making 

workers and families petition for an SEC to prove 

that their families either worked there, or had 
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the cancer.

So if we're an SEC site why are they 

making these families do this? It's just mindboggling why this is happening.

The resource centers is misleading to 

workers and families that these centers are 

helping them file claims.

The center doesn't help them put 

together what is needed in their files. The 

resource center employees are not certified 

advocates. They need help putting claims 

together.

When the workers come in there with

their claims and the families, they need to have 

this 800-page manual sitting there beside the 

worker's claim and look at the records to see 

what they need before they send these records 

off, because once they send these records off to 

DOL they're going to be guaranteed to be turned 

down and once you get a denial it's hard to 

overturn these records.

So these resource centers need help 
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putting these records and claims together.

Again, I want to thank you for 

allowing me to speak and I'm really concerned 

about the program. 

Some of the CMCs, just like myself and 

my records were sent to someone, a CMC which I 

have their name. 

And they were told that I worked at 

Paducah, I smoked a pack of cigarettes every day 

my whole life. And I don't understand -- and I 

never worked at Paducah. I'm a Portsmouth gas 

diffusion worker.

So I'm just wondering how many of our 

claims are getting so confused and mixed up and 

our diagnoses are being confused and mixed up to 

where these denials need to be overturned because 

they don't have our records.

So, there's a lot of things I'm 

concerned in the program, but I am thankful that 

the Board is listening. I heard some very good 

comments from some of the people there on the 

Board today.
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And I'd also like to know if you have 

public comments today for the workers there at 

Paducah or is that tomorrow?

CHAIR MARKOWITZ: Public comment 

session is today.

MS. COLLEY: Okay. I never heard 

anyone there. Did anyone give public comments 

today?

CHAIR MARKOWITZ: We received a couple 

of written comments in the last couple of days if 

that's what you mean.

MS. COLLEY: Okay. Because some 

workers told me today, they understood that they 

were supposed to give comments tomorrow so 

there's some type of confusion there for them I 

think.

CHAIR MARKOWITZ: Yes, so we welcome 

written comments today, tomorrow, you know, 

whenever actually. But the public comment period 

is for today. 

Yes sure. And Ms. Colley, there are 

some people here who are going to make some 
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comments so maybe they are included.

MS. COLLEY: Okay, thank you. And 

again I'd like to offer you to come to 

Portsmouth. And I'll be glad to get us a tour 

for the group.

And we have asked many, many times for 

Portsmouth and Paducah so you know, now it's 

Portsmouth's time. Thank you.

CHAIR MARKOWITZ: The next is Mr. 

Stephen McFadden. Sure, right up there where the 

microphone is.

MR. MCFADDEN: I basically wrote and 

printed my comments. 

So I'm a child of the Manhattan 

Project. Dad worked at Hanford. High school 

science student, two scientific degrees and 

worked by the summer internships and student 

employeeships at the DOE and ERDA labs.

So I wanted to raise occupational 

health issues relating to students, interns and 

summer workers.

So these folks are working with 
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potential exposure to exotic toxics often in 

classified areas, in legacy facilities with 

little information about what's being done, with 

no access to photos of the workplace, little 

documentation of the work that's being done or 

what work they did.

And if they get uncommon disease not 

often diagnosed with long latencies, difficult to 

attribute, little epidemiological statistical 

power.

If you don't know the agent and 

there's not a signature biomarker you're probably 

not going to be able to prove causation. And 

research involves unknowns by definition, and 

therefore unknown risks. And occupational health 

is a lagging science.

On statutory issues SEC exposure 

cohorts require 250 days of work. Students may 

work less.

EEOICPA has monetary limits which 

coordinate with other benefits. So with a long 

disability you may end with zero benefit by the 
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end.

Students have little baseline for 

income. The definition of child is basically 

dependent as opposed to based on SSA -- based on 

right to inherit.

And the EEOICPA was passed in 2000 

which is six decades into the nuclear weapons 

program. And there may be Social Security and 

other workman's comp decisions that were made 

prior without information.

So my view is that EEOICPA was done on 

the cheap presuming that other benefits were 

accessible.

So I want to whip through three 

examples.

At Lawrence Livermore this was an SEC 

cohort, U Cal Davis Department of Applied Science 

a.k.a. Teller Tech had students that were student 

employees out at Lawrence Livermore.

It's an SEC cohort. For instance, in

the biomed computer center there were 20 solvents 

used in that building. So if you got hit with 
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the solvent the question is which 1 of the 20.

But more importantly DAS students were 

given a letter which said that their stipend was 

not taxable.

Now, if they filed for no withholding 

on a W-2 no Social Security benefits were taken 

out. That means they're not covered by Social 

Security disability whereas if they had 

withholding taken out and filed for a refund at 

the end of the year then they were covered for 

Social Security disability for those years.

So DOE at Livermore had grad students 

with Top Secret security clearances working in an 

SEC cohort who was not covered for Social 

Security disability, child, old age, or survivor 

benefits and therefore bear risks.

Example two, high performance fuels 

laboratory. You're probably familiar with FFTF 

at Hanford. It's a liquid metal, i.e., sodium 

fast breeder reactor.

It was fueled by NUMEC if you've read 

the Seymour Hersh, the Samson Option, and Kerr-
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McGee Cimarron which is the Silkwood case.

So page 19, I watched them for a few 

days stuffing fuel pins. It's basically the 

Silkwood process by hand. So they want to 

automate that.

So the high performance fuels lab was 

developing a device to walk the pellets up, have

them tip over and laser scan them in a device 

that would be in a plutonium clean room which 

could be remotely serviced. So this is an 

engineering feat.

They had the device fabricated 

offsite. They took delivery at Pasco Airport so 

they could have their engineers work on it 

outside of union rules.

Then they had it moved to the basement 

of the 309 building which is the plutonium 

recycled test facility. 

So they had me spray paint four cans 

of spray paint in the basement of the plutonium 

recycled test complex. This is not a bright 

idea. 
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So a third example is -- the key point 

about the third -- and Hanford's SEC cohort.

The key point about the third example 

is I was in an administrative building but 30 

yards away down the hall was the 3706 building 

which had been the first radiochemistry lab in 

the Hanford 300 site.

And so there are reports which say 

there were multiple grams of plutonium in the 

vacuum system. And we're talking about 1945 

filter technology.

So, just stepping foot on the site 

there are unknown hazards.

Let me cover SSA's definition of 

disability. First they require disability to be 

severe. And there's a tendency for noncombination if you have multiple disabilities.

They require a medically determinable 

impairment. And that means you have to have the 

diagnosis, and if you don't have a diagnosis you 

lose.

Then you have to show objective 
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medical evidence. That means, well, they sort of 

define what that is.

You need a medically determinable 

impairment. But they always talk about objective

evidence and it's whatever they say it is more or 

less.

So, you have problems with severe and 

getting a formal medical diagnosis, and then 

supporting with objective evidence.

Social Security is run by -- the 

claims are made by disability examiners who have 

maybe 6 to 10 weeks of experience.

They go to a state agency medical 

consultant in Texas for instance. Some of the 

SAMC's are running 20,000 cases a year. That 

means maybe the average case gets six minutes of 

review which is about enough to say insufficient 

evidence through DLI, date last insured.

You must prove that you got disabled 

before the date last insured. 

Now, if somebody is working in stocks 

they need 20 out of the last 40 quarters. That 
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means no more than five years later can they file 

a claim.

The claimant is denied after the five 

years. That will be res judicata against them. 

They can never apply again.

So within five to nine years your 

cases are all dead.

The effect of a denial is a lot of 

people who are denied never work again. The 

lifetime average income is severely impacted 

because it's a 35-year inflation adjusted income 

average.

You may have little old age benefits. 

You need 40 quarters to be able to be eligible 

for old age benefits.

Res judicata applies against reopening 

cases on grounds of new evidence or new issues.

And unless in the first application 

you beat res judicata the case will go through 

and four years later it will come out a denial 

with no black letter right to appeal because the 

first thing you have to do in reopening an old 
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case is beat res judicata.

Now, in the HALLEX and POMS there are 

lists for -- SSA listing has like 14 categories 

and there are lists of exceptions to res judicata 

and dates.

Like for instance, they did not have 

immune disorder category before 1993. So if you 

were denied before '93 and then they added immune 

disorder you may be able to get another bite at 

the apple. SSI --

CHAIR MARKOWITZ: I'm sorry, you're 

sort of wrapping up?

MR. MCFADDEN: SSI has major issues 

economically. So you have nuclear fuels and 

weapons workers have unknown number --

undisclosed hazards working at targets for both 

nuclear annihilation and Cold War espionage. 

EEOICPA was done on cheap.

You really shouldn't have -- former 

nuclear workers destitute. DOE had students with 

Top Secret security clearances working at SEC 

cohorts who did not even have SSDI coverage.
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And SSA's a severe and objective 

medical evidence and formal diagnosis 

requirements are problematic.

And statutory changes may be needed 

and maybe your designated federal official could 

talk to the congressional committees to see if 

there's anything they could do to change statute 

if you feel that is necessary. Thank you a lot.

CHAIR MARKOWITZ: Thank you. There 

may be members of the audience ought to talk to 

those congressional committees.

But in any event, before we go on to 

the next is there anybody, have we got anybody 

from the phone who wants to speak? -- Okay, so 

one? Okay.

I also would encourage anybody who has 

come in since the beginning of the public comment 

period, or anybody who's changed their mind and 

would like to make a public comment, we would 

welcome your comments.

Okay, let's move on to Evelyn 

Jeffords.
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MS. JEFFORDS: Well, I've had a claim 

in for many years. My husband worked at the 

plant. Gary Vander Boegh is my representative. 

He's my spokesman also if it's all right.

Can you speak for me?

MR. VANDER BOEGH: Oh, now?

MS. JEFFORDS: Now.

MR. VANDER BOEGH: I can if you want 

to just let me summarize it real quick.

CHAIR MARKOWITZ: Well -- what's the 

claim for and what's happening with the claim. 

Can you just tell us in your own words?

MS. JEFFORDS: My husband worked at 

the plant.

MR. VANDER BOEGH: And your husband's 

name was --

MS. JEFFORDS: Robert Jeffords, yes.

CHAIR MARKOWITZ: What's happening 

with the claim?

MR. VANDER BOEGH: Her claim was 

denied for three of the five statutory 

requirements for beryllium disease. The claim's 
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examiners in this area do not approve claims for 

the statutory requirements. They denied the 

claim based on procedures. 

Now, she's one of about -- well, 

several. There will be several people that can 

share this. But, to keep this moving, and I 

don't want to take more than seven minutes for 

the whole thing I would say, but Ms. Jeffords has 

fought this claim. She heard about me. 

Somebody asked this morning how did 

they find out about authorized representatives. 

I'm the only authorized representative that came 

forward and requested Rachel Leiton to set a 

number or a program of tracking where they could 

help people at Hanford. 

We've got people calling us all over 

the nation. I'm C-001 as an authorized 

representative for Ms. Jeffords. She's one of at 

least a dozen that had their claims, that were 

forced to go to federal court even though the 

statutory requirement would have approved her 

claim where everybody else in the nation was 
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getting their approval. She's now close to 90. 

She just turned 89, or getting close.

MS. JEFFORDS: I'll be 90 in November.

MR. VANDER BOEGH: Okay, now with that 

said, her claim is absolutely in front of the 

judge and we will be looking at reopening those 

claims because of the landmark decision that 

we're so proud of for federal judge, and some of 

you heard me talk about it, a precedent-setting 

decision that overturned the CBD claim for 

Charles Stone. 

Once you overturn a claim that was 

illegally denied, Judge Russell issued the only 

arbitrary and capricious decision against DOL. 

Then we are able to go back and we're going to 

ask for -- Mr. John Vance, or whoever he is, to 

reopen all the claims that were statutory 

compliant. 

Everybody else got paid across the 

nation but since we had four whistleblowers from 

Paducah that triggered this sick worker program; 

Ron Fawlor, Chuck Deuschle, Bud Jenkins -- I 
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represented Bud and he passed away before he 

could get compensated -- And John Tillson. 

We're the group in Paducah, Paducah 

Gas. We've got several of my co-workers back 

here and have got several people that never 

worked in the plant except Jean Gross who we 

worked together. She was a subcontractor and I 

was Lockheed Martin.

Evelyn is just here because she wanted 

you all to hear her story. I can give it to you 

and it will be a claim that will be reopened in 

federal court before Judge Thomas B. Russell 

hopefully.

CHAIR MARKOWITZ: If you want to 

briefly tell her story, that would be great.

MR. VANDER BOEGH: Excuse me?

CHAIR MARKOWITZ: I said if you want 

to briefly tell her story.

MR. VANDER BOEGH: Oh, yes, yes. Her 

husband was actually a guard under my dad, Don 

Vander Boegh. My mother and dad both worked at 

the plant. They also worked at -- my mother 
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worked at Oakridge. She built the bombs. My 

grandfather was in the Manhattan Project. So I'm 

one of the products of the plant.

 I'm not the first born because her 

first born in our family died after my mother --

Jean helped me with the claim, my mother's claim 

-- and she was exposed to radiation and vapors 

coming out of the K-25 plant. 

When Evelyn came to me, she pulled out 

the documents that she had and, lo and behold, it 

said there was a guy by the name of Don Vander 

Boegh that he worked with. We as an authorized 

representative developed her claim and we 

enhanced it, go after all the records, and now 

we're finding that the records are disappearing. 

They fired the lady in Oak Ridge that 

was giving us the records, Amy Rothrock. These 

are all things that Jean Gross is aware of. Then 

they became -- they put somebody else in and now 

we're suspecting that they are destroying the 

records when we file claims. Her records --

we've got partial records. Her husband was a 
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guard with three of the five criteria and nobody 

would believe us when we originally -- nothing 

changed -- I've got another claimant right back 

in the back, Minnie Donald. She'll verify every 

time we submitted the records to DOL, and I met 

John -- almost 10 years ago. We just needed to 

get the right people to understand the evidence. 

Fair enough? 

When we have to do this, we now go in 

federal court and we're going to try to reopen 

her claim and reverse the denial. She's been 

waiting how many years? Nine years for me to 

overturn this denial.

CHAIR MARKOWITZ: So what was the 

reason for the denial?

MR. VANDER BOEGH: She didn't meet the 

305 criteria because they decided that COPD 

wasn't indicative of chronic beryllium disease. 

You and I have talked about some of this. Judge 

Russell just -- we just had an approval. 

They went out and got a CMC. With 

Evelyn's permission -- the CMC is not for you but 
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it's for Charles Stone, but that CMC report 

clearly indicates that for five years Charles 

Stone was being abused and she's got the same --

her husband had the same thing as eight more that 

we filed and got denied in federal court until 

Judge Thomas B. Russell got a hold of this claim.

Now we can go back and they've got to 

follow this consistent pattern and that's what 

we'll do. There is nothing else. Evelyn just 

wanted to come down. She was nervous. She has a 

little bit of a problem speaking for people but 

she did a great job in front of the mayor of 

Paducah, Bill Paxton. 

He told her he wasn't going to talk to 

her that night. We got that on video. Go look 

at the city meeting on August 28, 2012, and there 

she is trying to tell the mayor and he wasn't 

going to listen to her. We document a lot. I'm 

Lockheed Martin and that's where I get my 

expertise. There's not a CD that's 10,000 pages 

I can't go through in probably a day -- and we 

catch it all.
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CHAIR MARKOWITZ: On the list is David 

Jeffords. Does David Jeffords also want to 

speak? Okay --

MR. VANDER BOEGH: No, that's her son 

and that's who I'm really working to help also.

CHAIR MARKOWITZ: Okay. 

MR. VANDER BOEGH: Is that it?

MS. JEFFORDS: Yes.

MR. VANDER BOEGH: All right. Let's 

go back to the back.

CHAIR MARKOWITZ: Okay. So thank you 

very much.

Our next speaker is Gary Vander Boegh.

MR. VANDER BOEGH: Well, you told me a 

while ago --

CHAIR MARKOWITZ: Reset the clock for 

seven minutes.

MR. VANDER BOEGH: You teased me. He 

said I was going to have to wait to last.

CHAIR MARKOWITZ: No, you're not the 

last actually. We have more. Go ahead.

MR. VANDER BOEGH: Really everything I 
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want to do here today is I want to thank John 

because first time I ever met John the first 

thing he did was say, Why don't you come up. We 

took David Nowlin, Ronald Reagan's ethics 

attorney. 

I done this because I'm a decorated 

Lockheed Martin employee. Jean Gross knows all 

about it so everybody can snicker in the back row 

but we don't care about snickers. You brought up 

something about the CMCs. When I was assisting 

Department of Energy under Don Seaborg, I was a 

whistleblower. He asked me to be one because 

something was wrong at Paducah.

 We found out what it is. You're going 

to hear from some people. We found the 

plutonium, and I brought this up to Rachel Leiton 

at our June meeting and I asked her, Why are you 

not considering the exposure evidence of the 

plutonium? We've got a thousand cylinders of 

plutonium out there. 

And by the way, you know plutonium 

can't be a big bunch of heavy -- you can have 
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plutonium as big as that in a cylinder, right? 

We could see it from here. It's inside the 

cylinders and we've already captured that. What 

we do is I'm not only an environmental engineer 

and an authorized representative, but I'm a 

witness for the Department of Energy, Department 

of Justice, and the FBI. 

Now, I filed my whistleblower 

complaint at the request of Don Seaborg -- Jean 

knows him well -- and they ran Don out of the 

plant, and then came after me. We're going to 

get there because this is honesty and integrity 

and you're going to find out that Paducah 

claimants because of Ron Fowler, Chuck Deuschle, 

Bud Jenkins, and he was my claimant. And his wife 

died and they wouldn't pay him. 

We're getting so many claims and I did 

make some notes but I'm not going to get through 

them. I'll get you all your own personal 

documents. We found plutonium and there's not a 

worker in here -- Mike Driver is sitting right 

back there. 
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We all found the plutonium when we 

were there so you don't have plutonium in your 

technical basis document or your authorization 

basis for Paducah. So the SEM is a bogus SEM. So 

if you can't evaluate worker's claims, and I 

think you all would agree, if you conceal the 

chemicals we were being exposed to.

I'm a sick nuclear worker. I don't 

like it. I worked in the 720 building and what 

you brought up today, what we found is a pattern 

of the workers being diagnosed wrongly because in 

the 720 building Jean and by the way, right there 

is Harbison -- you know him -- and Fred Buckley. 

They all knew, and we interviewed and worked 

together, that plutonium is all over the plant. 

You won't find it in the technical basis 

documents. 

We're also going to hear from somebody 

that also pointed out that it's not just here. 

It's at Portsmouth. We sent it to Portsmouth. 

And Kirk can back me up because it's his own USW 

membership that also got exposed. We had Hanford 
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early on. 

Then we brought in the Russian 

uranium, Uranium One, go to Tucker Carlson on 

November 2, 2017 and buckle your seatbelt. 

That's my information that Sean Hannity and 

Tucker Carlson are talking about, Uranium One in 

Paducah, Kentucky. 

We were processing uranium nuclear 

reactor returns. Depleted uranium -- I'm a civil 

engineer so I just learned all this from Dr. 

Chris Busby and everybody else, at Portsmouth by 

the way. They've been here. I brought them in. 

We're telling the truth and we just 

want everybody in the back that works for Cold 

War Patriots and Denise Brock and all of them 

that don't work for us, we want all of them to 

keep snickering and making a joke out of it but, 

by God, I'm watching my worker die.

Vina Colley that just got off the 

phone, there will be another speaker, we're the 

Nuclear Whistleblowers Alliance and, 

unfortunately, I've got to be the chairman
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because everybody else is too busy. 

I'll get it done because I'm a 

Lockheed Martin decorated two-time president 

award winner and I don't care if anybody likes 

that or not. We're just getting at the truth and 

Kirk knows me well, I'm going to get the workers 

the money that they deserve without any political 

leader saying they don't deserve it. 

I reported all of this to Donald 

Trump, uploaded to Make American Great Again, 

January 2017. So I've built my background. I've 

given it to DOJ Christopher Wray. If you want me 

to call -- well, I ran out of battery. There's 

Bill Campbell right there who will tell you what 

I was doing for you. 

So I'm the nuclear whistleblower and I 

will be in the headlines. I put myself there. 

Oh, yeah, I know what they did to Karen Silkwood. 

In fact, I've been warned and so have my 

cohorts; Vina Colley, Jeff Walburn, Chick Lawson 

out of Portsmouth. 

We're going to bring it all together 
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for you. It's all about honesty, truth, and all 

of this subjective -- we just had a decision by 

Judge Russell that was then cited in the Adams 

versus DOL decision. You can't cheat nuclear 

workers by hiding their facts and John knows 

this. John can't change anything but we're going 

to help him. We're going to help him change this 

whole thing. Concealing factual evidence and 

some of it is crossing the line into the criminal 

area. We want Jean Gross to be able to honestly 

say there's plutonium out there. 

We're going to let her read Mitch 

McConnell's own document. How's that? Fair 

enough? Really that's all I've got. You all did 

a great job. I want to thank you all. You 

brought up the very things, and at least I got 

here. 

But every time, and John knows, I had 

a 10:00 hearing and when I had the 10:00 hearing 

-- yeah, 10:00 -- I had Anthony Zona on the 

phone. That never goes well because he never 

understands what happens at Paducah, he's in 
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Cleveland. 

John and I are going to work through 

these things. I can honestly say John Vance and 

Jim Bibeault are some of the best people I've 

ever had to work for -- work with and I'll try 

not to work for. No, I don't think John would 

want me working for him. 

By the way, I built the landfill at 

the plant. I designed the landfill. I save $60 

million in the first 60,000 ton. I got a t-shirt 

and then I got terminated because I wouldn't put 

radioactive plutonium from the C30 -- 1 building 

into the landfill. 

I want to tell you, I'm sure I wasn't 

with you today and I wasn't going to tell you 

what building not to go into, but I'll tell you 

after I get done. You all will get your own 

email. If you went into the plant and you 

breathed, remember what you said earlier? Look, 

everything around that plant is loaded with 

beryllium. 

I was exposed in the 720 building. I 
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complained right after I started working. It was 

raining down from the ventilators. Jim Key 

stepped up and told Congress the ventilating 

systems are all the same in the machine shop. 

They didn't separate them so what did 

we do? We went in there and we started working. 

I started in '92. Next thing I find out I'm 

breathing plutonium, neptunium, everything. So 

we're going to give you the documentation.

Thank you Dr. Markowitz.

CHAIR MARKOWITZ: Thank you very much. 

Good luck, John.

Our next is Donna Hand on the 

telephone. Ms. Hand.

MS. HAND: Yes, thank you.

CHAIR MARKOWITZ: I want to thank you 

for your long detailed written public comment --

written comment that you sent in.

MS. HAND: Correct and then I won't 

dwell on -- when I use it because I think one of 

you should have it. The first thing is the site 

exposure matrices. I would like to look at the 
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definition of the site exposure -- this is 

actually in the statute and this came directly 

from the public law that was passed.

And it says in there, The term site 

profile means an exposure assessment of a 

facility that identifies toxic substances or 

processes that were commonly used in each 

building or process of the facility and the time 

frame during which potential for exposure to 

toxic substances existed.

You know, why did Congress use the 

word potential? Then in the definition of toxic 

substances, toxic substances again has had the 

potential because of its radiological nature, 

chemical nature, and biological nature. So it 

doesn't have to definitively cause it, but does 

it have the potential to do that.

This is a legal definition. I know 

there's a difference between the medical 

causation and the legal causation. And just like 

with black lung, if you meet the legal causation 

or criteria, then it's accepted underneath these 
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programs.

The other issue is that back in 2005 

OWCP determined at that time that these are the 

references that the District medical consultants, 

which are now contract medical consultants, will 

use, as well as what will be in each district 

office. 

One was the National Library of 

Medicine, specifically PubMed. A lot of the FAB 

decisions was based on PubMed but, yet, now they 

are ignoring this. The Agency for Toxic 

Substance Disease Registry, the toxicological 

profile is supposed to be used. Again, they are 

not. They are saying anything from the internet 

you can accept.

Back in 2010 when the advocates met in 

Washington, D.C. with John Vance and Jeff Kotsch, 

they said that we would start using the hazardous 

substance database. You know, that you can use 

that. But -- again, we used that as references 

for our physicians, our treating physicians, and 

they are ignored because they said it's not well 
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rationalized.

There's a list of questions there that 

I've got; A, B, C, D, E, F, and G, that I would 

like for the Board to look at and respond. 

Specifically, Number F. When the NIOSH chemical 

guide in OSHA both informed the public about 

target organs affected by a toxic substance, can 

a claimant use that target organ of the toxic 

substance to provide a scientifically-known leak 

of exposure and claimed illness.

For example, I have a client that had 

optic neuropathy. When we went to NIOSH chemical 

guide, plutonium and nitric acid will cause optic 

neuropathy; target organs, eyes. He was exposed 

to plutonium nitric acid. In his testimony before 

the final adjudication grant he informed them 

that he was at a higher level than what the IH 

has stated. We requested to have a communication 

or conference with the IH. That was denied. 

In the final decision, the FAB hearing

officers then said level has nothing to do with 

it. He still denied it even though we informed 
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him of the level that was higher by testimony. 

Your other job is the work of an industrial 

hygienist. 

In OWCP, back in the very beginning, 

has interpreted at least as likely as not to be 

more than a suspicion and less in the 

preponderance of the evidence. OWCP has defined 

significant factors to mean any factor. OWCP has 

determined that aggregating and contributing to 

is defined to be the same as in a workman 

compensation principles. 

There is nowhere in the act or the 

regulations that says significant level of 

exposure is required. Nowhere. Just that, you 

know, did the person come in contact with it and 

did that toxic substance have the potential 

because of its nature to aggregate, contribute, 

or cause that illness.

The regulations do state that OWCP 

will consider the nature, frequency, and duration 

of the exposure to the toxic substance. So the 

industrial hygienists can only address the 
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nature, which is the route of exposure, 

inhalation, ingestion, and skin absorption. 

That's left out all the time. They don't even 

address skin absorption.

Is it soluble or insoluble, and the 

frequency, direct or indirect, chronic or acute, 

et cetera. Duration; daily, weekly, monthly, for 

how many years. Again, why does the IH determine 

significant levels when the act doesn't require 

it?

In fact, if you look at question 

number C, the FECA has now developed in their 

occupational disease checklist, the list that 

addresses nature of exposure, they've got 

primary, secondary, intermittent, and 

environmental. The degree of exposure; heavy, 

medium, light, and ambient. Frequency; hours per 

day, and how many years.

Can something like this be made? Back 

whenever Rachel Leiton just became the director, 

she was head of policy. So was John Vance, but 

in 2008 when the unified procedure manual was 
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created, she stated that in the Statement of 

Effects must be based on actual facts. Once 

interpretation might include levels of exposure, 

and that is might so it doesn't have to.

However, terms such as light, heavy, 

undue, severe, and abnormal should be avoided 

since they are subject to great differences of 

interpretation. That was determined by her back 

in 2008 when she did the unified procedure 

manual.

The other issues that you can read is 

like I told you the definition of covered illness 

means the illness or death resulting from 

exposure, and is it work related. Several court 

cases have already determined work related. U.S. 

Supreme Court cases have said is it work related 

which can be, you know, is it their job duty? Is 

it in their building area? Building area is 

never discussed, just labor category.

As you know, labor category does not 

define what actually the job or the task of the 

worker. There was a secretary. She was a 
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secretary of the polymer lab. She wrote in that 

she was a secretary. 

But as a secretary in the polymer lab, 

the only thing that separated her from the lab 

tech was a file cabinet and they were only about 

three feet high. Whenever they opened up things, 

she was exposed to it, too.

In the Pinellas Plant in the 

environmental report, in the outside air was 

tritium. In the outside air was krypton. In the 

outside air was cobalt. If you don't address all 

the issues and all the exposures in their work 

duties, you've missed some of the point. 

Whenever we tried to explain this and inform the 

IHs of the unusual exposures, it's completely 

ignored.

I will not go on because I know that 

it's time consuming but the main thing we'd like 

for you to do is determine what is wellrationalized report. Well-rationalized report, 

according to the regulations, are only needed for 

consequential illnesses. However, this program 
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now requires every doctor, treating physician to 

do a well-rationalized report.

I've had several doctors get a copy of 

the work history of my claimant and then show 

them where the site exposure matrix says that 

they were exposed to this toxic chemical and it 

has this health effect and they are still denied 

because it wasn't well rationalized.

The regulations only require medical 

evidence. What is entitled to a wellrationalized report? Is there a form? You know, 

you've got to have this, A, B, C, D. That would 

be guidance then that would be consistent not 

only for the CMCs but then for the treating 

physician.

Shouldn't the treating physicians be 

given the statement of accepted facts as well as 

the criteria for Part E that, at least as likely 

as not, was a significant factor and what that 

means. And does it just have to be causal that 

it includes aggravating and contributing to?

 Because whenever the case examiners 
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asked for the causal information from the 

treating physician, they're saying, I can't say 

that it caused it. This is a big problem that's 

been here since 2008. I've been working in this 

program since 2002 and then in 2008 I started 

representing claimants.

Chronic beryllium disease. Chronic 

beryllium disease symptoms are just similar to 

asthma symptoms. Chronic beryllium disease also 

has an upper respiratory infection. A lot of the 

workers will have upper respiratory infections 

before 1993 in their work history.

We also have workers that show up, 

chronic cough for three months straight. Yet, 

this isn't a chronic respiratory disorder that 

the Department of Labor will use for the pre-1993 

criteria. Pre-1993 criteria since 2008 has been 

treated for, tested for, or diagnosed with. That 

has not changed.

Then all the evidence; the chest xray, the pulmonary function test, or diffusion 

capacity test in the clinical course can be after 
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1993. So if you have COPD in 1982, you can still 

have a chest x-ray in 2004 or later on. These 

are final adjudication branch decisions that have 

been put into their significant decision list.

The only issues that -- I have a 

client that has been diagnosed with chronic 

beryllium disease but now her treating pulmonary 

physician doesn't know anything about chronic 

beryllium disease so he says she has asthma. 

Well, again, asthma like symptoms is 

what chronic beryllium disease is. That's why 

it's so hard to distinguish. Even several 

experts do not realize about chronic beryllium 

disease so there's an education that has to be 

going on. 

A medical narrative should address 

who, what, when, where, why, and how. If the 

treating physician doesn't have all that 

information, how can they do a well-rationalized 

report? If the CMC doesn't have all the 

information, how can they do a well-rationalized 

report?
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CHAIR MARKOWITZ: Ms. Hand --

MS. HAND: -- So again, I thank you 

very much. I would appreciate that, if you would 

finish reading all seven pages. And I was 

informed that this will be put onto the website 

in addressing issues that I have brought forth in 

these. Because it is very disgusting whenever 

you go and do what the Department of Labor, the 

EEOC says. You get the references. You have a 

talk with the treating physician. 

You give them the work history and 

they say, Okay, yes, I can write that it has 

potential, yes. I can do that. And then to say 

that's not sufficient enough but they don't tell 

you what is insufficient. And then you get 

denied whenever you've addressed everything they 

told you to address.

I really appreciate all of your time 

and your enthusiasm and work on this because I 

know it has taken hours and hours of your own 

personal time and your work time to discuss 

these, so I really appreciate the Board very 
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much. Thank you so much.

CHAIR MARKOWITZ: Thank you. Thank 

you for your written comments which amplify the 

comments you just gave us.

That ends our public comment period. 

I'm sorry, Deb Jarison. Of course. I'm so 

sorry.

MS. JARISON: Thank you, Dr. 

Markowitz, and members of the Board for allowing 

me to speak. My name is Deb Jarison. I'm the 

Director of the Energy Employees Claims 

Assistance Project.

I've heard from a couple people on a 

couple issues I thought might be something you'd 

be interested in and perhaps you can help DOL 

with them. One thing I've heard is that DOL has 

changed the way they are approving terminal 

claims. 

It used to be that a doctor's letter 

stating that a worker's/claimant's illness was 

terminal was enough to move the claim quickly. 

DOL is now requesting that the letter must state 
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that death is imminent. 

I don't know whether this is a change 

in policy or a lack of claims examiner training 

but several reasons occurred to me why this could 

be a bad idea. I'm not sure imminent death is a 

way that most doctors are used to writing 

letters. 

People in hospice can have different 

outcomes depending on the individual. Terminally 

ill patients and their families may face extreme 

emotional responses to hearing that they or their 

loved ones face imminent death. They've got 

enough stress to deal with.

Under the old guidelines it was 

possible to get a payment to a terminal claimant 

quickly. I've seen it happen in one case with 

Mr. Vance's intervention. Payment reached the 

claimant within the last day of her life. She 

wanted the money to provide for her disabled 

daughter and I was really grateful to DOL for 

making this happen.

I've also been hearing complaints 
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about medical billing issues. It's a really 

thorny problem and it's tough. The National 

Office of Medical Benefits Examiners have helped 

with this for people who are savvy enough to find 

them, but most claimants can't do that and I 

don't think there's a phone number published 

anywhere for the department. I found these 

claimants to be very compassionate and helpful

Claimants and doctors need more help 

and resources to handle the problems with medical 

bills. Claimants often can't find the resources 

to deal with problems with medical bills. The 

CE's can tell them to go to the resource centers 

but not how to address the problem specifically. 

They don't understand what to say to 

the resource center to get the problem fixed. 

Sometimes claimants can't even tell which bill is 

the problem. Sometimes claimants don't know 

there's a problem until they receive a collection 

notice which adds a lot of stress.

Claimants often don't get the 

information on why a bill was denied. Many don't 
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understand what the resource centers can and 

cannot do. It seems like some education with 

both claimants and doctors on this might be 

beneficial.

Claimants often don't have the 

language to explain the problem to their doctor 

or the resource center, especially when it comes 

to coding issues. It would be really helpful, I 

think, to claimants and physicians if DOL could 

develop clear, concise, step-by-step directions 

written for a lay person to explain how to deal 

with medical billing issues. 

These instructions could be provided 

in paper to claimants when they receive their 

white card to make sure that people without 

access to the internet have that information.

It would be helpful if claimants would 

also be given information on what each of the 

different players in the medical billing 

department do like the roles of the claims 

examiner, the resource center, the medical 

benefit examiners, and the billing contractor.
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Thank you very much. I really 

appreciate this Board and enjoy listening to your 

discussion.

CHAIR MARKOWITZ: Thank you. Mr. 

Vance, I got just a question after this comment, 

is it true that the claimant has to produce a 

letter that says, from a physician saying that 

death is imminent?

MR. VANCE: Okay.

CHAIR MARKOWITZ: Because that's tough.

MR. VANCE: All right. So, there's 

this -- nothing actually changed. What we have 

is a process for identifying claims for terminal 

status.

And the problem that we were running 

into was the fact that this created an incentive 

for lots of folks to come forward asking for 

their case to be categorized as terminal, with 

the expectation that that would create some 

expedited processing of their case.

So, basically, what we did was, we met 

with our staff and we just simply reiterated the 
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fact that when you're evaluating a case for a 

terminal status claimant, we need to have the 

appropriate documentation to support that that's 

factually accurate.

So, nothing's changed in our 

procedure, what we basically stipulated to our 

staff is that you need to have pretty good 

confident material or information that would 

substantiate that.

The reason why this is important is 

because in order to expedite cases, in order to 

create this system for moving cases through the 

process quickly, takes a lot of effort and a lot 

of resources.

So, we want to make sure that we're 

dedicating staff to that process in cases where 

we have a pretty good confidence level that that 

person is actually in an end stage, imminently 

terminal, however you want to characterize it.

Which is eminently difficult to do, 

because of the reasons that were discussed 

tonight, which is that it's very hard for a 
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physician to document that this person has days, 

weeks, or what have you, to live.

So, the Department of Labor does have 

a mechanism for moving cases along quickly. We 

will dedicate staff, we will dedicate resources 

and efforts to move claims through the process, 

and I think we have a very good track record of 

doing that.

But the reality is, there are a lot of 

folks that are using that process in a way that I 

think is disingenuous. And it's also a reality 

that we are faced with very challenging 

situations, trying to figure out, okay, you're 

terminal, what does that mean?

We don't really have a definition of 

that, we are just basically looking at it and 

saying, is there reasonable evidence to suggest 

that this person, given their medical or physical 

or psychiatric status, that they are at death's 

doorstep? And it is a challenge.

CHAIR MARKOWITZ: Well, this is a 

question for the physicians in the room. So, the 
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criteria for getting into hospice is --

MEMBER GOLDMAN: It's six months.

CHAIR MARKOWITZ: -- six months? Six 

months, so --

MEMBER GOLDMAN: So, yes. So, six --

hospice usually categorize terminal as about six 

months. If you're saying imminent, and many of 

us have been, tell families it's imminent and 

then, somebody's living on and on and it's -- you 

can't play God, actually.

But usually, imminent implies within 

days. You're at the bedside, you've called the 

family to be there. But terminal would be about 

roughly six months. And even that is not 

precise.

CHAIR MARKOWITZ: Well, my question is, 

terminal could be construed as being a year. I 

mean, you've got an illness, you know --

MEMBER GOLDMAN: Yes.

CHAIR MARKOWITZ: -- mesothelioma is 

terminal. But doctors are comfortable with the 

six-month hospice time frame. Would that help, 
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to use that time frame, because doctors are used 

to that?

MR. VANCE: This -- we treat it as a 

matter of days and weeks, because we're talking 

about a situation where we want to try to get the 

money into the hands of the individual that 

qualifies for it while they are alive.

So, we struggled with trying to define 

what terminal means and, yes, a lot of people 

commonly look at six months, but there are lots 

of different things that you have to consider 

when doing that.

So, my basic thought in this is that, 

whenever we can get convincing information that 

we're dealing with someone that does not have an 

extended period of time of life left, that the 

program will designate that case properly as 

terminal and try to move through this process, 

from start to finish, in as quickly a time as 

possible.

Especially when we're talking about 

imminently terminal people, where you are talking 
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about days of life, hours in some instances, 

where we're trying to move from a situation where 

we've got to issue a recommended decision, get a 

final decision in place, get payment 

documentation back and forth, oftentimes in very 

emotional fraught situations, where a employee or 

a survival is unable to actually sign 

documentation, where we are trying to then get a 

power of attorney involved, so that they can sign 

off on these documentation, and then, doing an 

expedited federal payment through the Department 

of Treasury.

That takes, it's like launching 

nuclear weapons, you've got to have --

CHAIR MARKOWITZ: Wait, wait, wait --

MR. VANCE: -- a certified, all this 

kind of stuff --

CHAIR MARKOWITZ: -- we don't use that 

analogy that here.

MR. VANCE: Well, it's like launching 

missiles, you have to have all these different 

people involved in the process. And so, it's a 
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very resource intensive process.

And I always point out, when you're 

talking all of these resources off our normal 

process, that means other cases are not being 

adjudicated. So, I mean, it's a challenge. And 

I know it involves some very difficult scenarios.

CHAIR MARKOWITZ: Okay. Thank you. 

Thank you very much. This ends our public 

comment period. We will resume tomorrow at 8:00. 

I'm sorry, what time? 8:30, 8:30, I'm sorry, 

8:30. I'm sorry, there's another person?

MR. NELSON: Oh, yes, there's two, 

these two right here.

CHAIR MARKOWITZ: Who want to speak?

MR. NELSON: Yes.

CHAIR MARKOWITZ: Oh, yes, come on up 

and give us your name.

MR. NELSON: I won't take much of your 

time, I know you're tired. My name is David 

Nelson and I worked out there in the '80s, and 

I've had two claims --

CHAIR MARKOWITZ: I'm sorry, speak a 
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little bit into the microphone.

MR. NELSON: I've had two claims, one 

was cancer and one was asthma, I guess it's 

asthma, after hearing about the beryllium today, 

I don't know it's not beryllium. But they were 

both denied.

And I worked for two years out there 

on the roofs. And the thing about it is, they 

let us go up there without any kind of 

protection. We didn't have any kind of PPE or 

anything. And they knew that that roof was hot. 

We found out later that the roof was actually 

100 times hotter than the legal limits.

So, I feel like that they need to 

reopen my claim and that people need to know the 

truth about how hot the roof is. A lot of people 

don't even realize that, they think, well, they 

were just working on the roof, they weren't 

around any of the contamination, but we were.

And they actually allowed me to bring 

it home. We wore our clothes up, just like I 

have on right now, we wore it home. My wife got 
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sick, she came down with thyroid cancer. My son 

actually got sick and died of Hodgkin's lymphoma.

And so, I feel like they need to 

reopen that and look at it again. And again, 

thank you for your time, I know you're tired and 

--

CHAIR MARKOWITZ: No, that's -- but Mr. 

Vance or maybe the Resource Center here can 

apprise you on how to proceed.

MR. NELSON: Okay.

CHAIR MARKOWITZ: Okay? Thank you.

MR. NELSON: All right. Thank you.

CHAIR MARKOWITZ: Next?

MR. NELSON: My name is Howard Cook. I 

worked for Allied Signal, Allied Chemical, 

Honeywell, and Metropolis. I retired in 2007.

I have a claim, it was denied. But 

that's not the reason why I'm speaking today. 

The reason why I want to speak to you today is 

that Honeywell seems to be the ugly stepchild of 

the sick worker program.

Any time we go for any kind of 
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treatment, I know over in Paducah that they have 

the scan, where they do a scan, to be sure that 

you don't have cancer.

Well, the ones in Metropolis are not 

eligible for that. And that's a big problem, 

because that's how you stay alive, is if you get 

treated early. But because we're the stepchild 

of the program, we're not entitled to it. All 

we're entitled to is Part B, under the cohort 

status.

Now people that worked before 1976, 

Allied done work for DOE, so they're entitled to 

Part B without any dose reconstruction. So, but 

after '76, you have to have the dose 

reconstruction.

Well, like I told you, I had a claim, 

I worked out there almost 26 years, and my 

percent was three and a half. Now, I didn't work 

in a bubble, which you'd almost think that you 

would have to work in a bubble, being around that 

type of radiation for almost 26 years and they 

say, oh, only three and a half percent.
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And you have to have 50 percent to 

qualify for the settlement. And I'm not aware of 

anybody, and we've had a bunch of people that 

have come down with cancers and died that hired 

in after '76, but I'm not aware of anybody that 

has got their settlement.

And I think it all falls back to the 

dose reconstruction. Now, I know we're not 

supposed to argue that, but the dose 

reconstruction, when you see something that's not 

right, you have to say something.

Now, with our plant, the only thing 

they use for dose reconstruction is a urinalysis. 

They don't use any samples, air samples, any 

other data that they collected out in the plant. 

Only thing they use is the urine samples.

Well, the urine samples, if you work 

Monday through Friday, you have to sample twice a 

month. And so, you'll be off Saturday and 

Sunday, you come back in Monday morning and 

that's when you leave your sample.

Well, we all know that the radiation 
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goes through your kidneys pretty quick. So, 

anybody that showed up positive or hot on Monday 

had to really be glowing on Friday. And that's 

not to say Monday, Tuesday, and Wednesday what 

they was exposed to, by Monday, it was all gone.

That would be like if a cop pulled me 

over and said, you been drinking? And I said, 

well, maybe a little bit. And he said, well, you 

go in next Monday and we'll check you and see if 

you're over the limit. Well, it don't happen 

that way.

CHAIR MARKOWITZ: You'd be a lucky guy.

MR. NELSON: Yes. Well, unless I was 

an alcoholic, then I probably wouldn't pass it.

And then, if you worked the shift 

work, you would have what we call long break. 

You'd get off Friday morning and then, you 

wouldn't leave a sample again until Wednesday 

afternoon.

Now, does that tell you why the 

urinalysis is not showing up any samples that's 

high enough to warrant a settlement?
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And then, we found out later that, 

from in the mid-'90s, we got some material from 

Fernald, the weapons plant in Ohio. And it was 

contaminated with plutonium and other daughter 

products.

And we was processing that and we was 

never sampled for plutonium exposure. So, we 

don't know what effect that's had on the workers 

out there, because we was never sampled, you 

don't know if you was exposed to it or not, but 

probably were. If you worked out there, you was 

exposed to it.

And then, I think also in late '90s, 

we started getting the uranium from Russia, to 

convert over to UF6. Well, we was just told that 

it was natural uranium. But come to find out, 

it's uranium-1 and it's weapon grades material 

and it's contaminated with all these daughter 

products that we're not licensed to handle in 

Metropolis.

And I know to get Part B, you have to 

say that you're doing work for DOE, but when 
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you're part of that treaty that they signed, I 

think in '89, where they was taking missiles to 

convert it over to electric use, they told Russia 

-- because Russia could not make the UF6 pure 

enough to sell on the open market.

That was a flaw that they had. And to 

get around that, our government told them, we 

have a plant in Metropolis that will process your 

uranium and make your UF6 pure enough that you 

can sell on the open market.

Now, if that's not working for DOE, I 

don't know what is. We were part of that treaty 

with the Russians, in order to get them to tear 

down their weapons and convert it over into UF6.

So, I just wish somebody would take 

another look at Honeywell and see why we're the, 

and I apologize, but we're the bastard child of 

the program. And we need to be treated better.

And I had a friend call me the other 

day, and he has cancer, and he said, I'm tired of 

it, I'm not -- they wanted to take his lymph 

nodes out and he said, no, I'm not going to do 
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it. I hear that all the time.

And it's frustrating when they call 

you and say, what can I do? And I say, all you 

can do is file a claim. And he says, I've 

already done that, I've been denied. And I said, 

well, you have to file another claim. And most 

of them have already filed two or three. So, 

it's already dead in the water.

But if we could take another look at 

the Honeywell plant and conditions that the 

people were working over there, and especially 

that dose reconstruction, that's --

CHAIR MARKOWITZ: Okay.

MR. NELSON: -- I think --

MR. VANDER BOEGH: DOE contract --

MR. NELSON: -- we got --

MR. VANDER BOEGH: DOE contract 

deposition.

CHAIR MARKOWITZ: Okay, thank you.

MR. NELSON: Okay. Thank you for your 

time.

CHAIR MARKOWITZ: Thank you. I'm 
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sorry, there's another speaker? Sure, come on 

up. There are two more? Okay. Five minutes 

each, because --

MS. DONALD: My name is Minnie Donald. 

And well, I have a lot of questions, but I'm not 

going to have time to bring them all, but I will 

-- somebody told me that I broke the record.

I have 14 illnesses approved and they 

have -- ever since Congress put this program 

together in 2001, I applied for all my illnesses 

and I got denied. But done through the years, 

they approved one here and one there.

And I put in for chronic beryllium 

disease. I had Gary to represent me and they 

denied me. They said I had nothing proving that 

I had that. So, we dropped it.

So, I got Donna Hand, the one you just 

got through talking to, she took over 

representing me. And I got approved for chronic 

beryllium disease in July of this year.

The same thing that I had when Gary 

represented me, but they denied me. That was, he 
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represented me in 2012 and they denied me. And 

the same identical x-ray that went by them, they 

approved it in July. So, what do you say about 

that?

MR. VANDER BOEGH: Oh, he's not -- who, 

me?

MS. DONALD: No, I'm talking to you.

(Laughter.)

MR. VANDER BOEGH: Oh, well, actually -

-

CHAIR MARKOWITZ: Don't yield too much 

of your time to him, that's my advice.

MR. VANDER BOEGH: I can't, I'm not 

going to -- I'm going to answer her question. I 

think it sucks, because we carried her claim with 

every -- by the way, this is -- oh, I'm sorry. 

I'm probably talking loud enough to probably get 

it over there.

We actually -- Minnie came to me and 

that's probably one of the first time, and it's 

not just her, we had claimants with three out of 

the five criteria, that they were then told by --
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well, John just left, because he already 

confirmed you're relentless, by the way. So, I 

think I'll use her as an AR next.

But what we just found was, the three 

out of the five criteria were being overridden 

because somebody said you could have a -- they 

just kept saying, before '93, when we had all of 

her x-rays, they didn't show any kind of chronic 

beryllium disease connection.

But it was COPD and we just won that 

with Charles Stone, and he's 90 years old, and 

Minnie got her claim turned around, and we never 

changed a thing, she never changed a thing.

So, she waited, since 2004, I came in, 

and I said, what is this? She meets three of the 

five criteria, automatically they were after me, 

I think, because I was helping workers. And 

Denise Brock just got up and left, and there's 

Jean going.

So, we all know they were not playing 

our claimants at Commonwealth Environmental 

Services. Minnie is an example. We then got 
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Donna Hand to go back, right, Minnie?

MS. DONALD: Right.

MR. VANDER BOEGH: And when Donna came 

in, all of a sudden, our claims are not being 

approved. Minnie gets a reopening by Rachel 

Leiton. And Rachel then says, well, all she 

needs is an x-ray. Well, guess what? It's the 

same x-ray that I had in 2012 when she got 

denied. Right, Minnie?

MS. DONALD: Right.

MR. VANDER BOEGH: So, what we're 

looking at is disparate treatment. Because in 

Paducah, we found the plutonium secret and in 

Paducah, we've linked it to an email and some --

well, it's actually a document from USEC, where 

Mitch McConnell is on it, in 1999.

And so, we just can't say -- we just 

don't need Mitch McConnell's help anymore, okay? 

He's given us enough help. Eighteen thousand 

claimants are just like her, I'm seeing them 

every day. Thank you, Dr. Markowitz.

CHAIR MARKOWITZ: Okay, thank you. All 
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right. Ms. Donald, anything else you'd like to 

say?

MS. DONALD: I have one more, if I have 

time. Do I --

CHAIR MARKOWITZ: Sure, go ahead, 

briefly, because there's one more person that 

wants to speak. But go ahead.

MS. DONALD: Okay. All right.

CHAIR MARKOWITZ: Oh, I'm sorry, did 

you -- are you finished?

MS. DONALD: Well, I mean, one more 

person --

CHAIR MARKOWITZ: Oh, yes, yes, there's 

one more person.

MS. DONALD: Oh, one more after me?

CHAIR MARKOWITZ: No, no, yes, sure --

MS. DONALD: Oh, I'm sorry.

CHAIR MARKOWITZ: -- if you have some 

final comments.

MS. DONALD: Okay. There is a limit on 

the impairment rating and there's a limit on the 

wage loss. But they got those two combined. 
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Okay. They owed me 18 years of wage loss and

they paid me for 12 and it topped me out. Now, I 

can't get any more impairment ratings and they 

still owe me six years' worth of wage loss, 

because those two are combined and they should 

not be combined.

And I had talked to Malcolm about it 

before and it came out in his book, the first of 

the year, saying that. But nobody never done 

anything about it.

Those two should not be combined, it's 

not fair and it's not right, because both of them 

have their own limit, but they got those two 

combined. You cannot get paid for both. So, who 

can straighten that out? They say, you need to 

go to Congress, but who? How? Who's going to 

Congress?

CHAIR MARKOWITZ: Well, no, no, I mean, 

that's actually --

MS. DONALD: I mean, well, anyway, I 

can't --

CHAIR MARKOWITZ: That's not what this 
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Board was asked to address to by DOL, so we can't 

address that. We cannot address that.

MS. DONALD: Well, okay, that is a 

problem --

CHAIR MARKOWITZ: But we hear you.

MS. DONALD: -- that need to be 

straightened out --

CHAIR MARKOWITZ: Yes, we hear you.

MS. DONALD: -- because they owe me six 

years --

CHAIR MARKOWITZ: Okay, thank you.

MS. DONALD: -- that I got promised and 

can't get back.

CHAIR MARKOWITZ: Thank you. Gentleman 

in the back?

MR. DRIVER: Dr. Markowitz, I actually 

called you a few years ago and had a very good 

discussion with you and I really appreciate, sir, 

all that you've done to try to help us. I'm very 

much aware of that. The rest of you, I don't 

know you.

My name is Mike Driver, I go by, or my 
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given name is Charles Michael Driver. I worked 

at the Paducah Gaseous Diffusion Plant for 14 

years. If I tried to give the information, all 

the information that I have to you, we'd need 

about a month, not five minutes. It is 

absolutely incredible.

I share just bits and pieces of 

information sometimes with people and they say, 

you're kidding? Can't believe this, this reads 

like some horror novel or something that's been 

written by somebody, it's just all been dreamed 

up.

So, I'm going to try to give you the 

high spots. Number one, everything, especially 

this guy right here, he's nuts, he's absolutely 

nuts, but he's right. He's right. I've never 

been able to find anything wrong --

MR. VANDER BOEGH: You are kidding, 

right?

MR. DRIVER: -- with what he has 

claimed. No, you know it, I've told you before. 

I've never found anything wrong, he's got it 
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right. Listen to him. Please.

And the rest of them, all of them back 

here, I've been sitting here, what, for an hour 

or so, listening to each one of them, they're 

telling you the truth.

I went to the plant because that was 

the best job and the best benefits that I could 

get. Nobody ever told me how dangerous it would 

be.

They said, yeah, you're working with 

uranium, but unless there was a full-blown 

release somewhere, you're not going to get hurt. 

There's nothing out here that will hurt you, 

boy, just go on out there and do your job. I 

heard that a thousand times if I heard it once. 

So, I did.

Now, after I served for three and a 

half years in security, in which case, we went 

all over the rooftops of every building there, 

laying on our bellies, shooting blanks at each 

other and practicing war games and things that 

you do when you're on a SWAT team.
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And then, I crawled around in the 

ditches, that we done found out later, they were 

all roped off with the yellow ribbons and 

everything, and all nice exposure for that right 

there. Goes on and on.

After working, I went over to working 

in one of the process buildings as a plant 

operator, Class A operator. Went through my 

training, passed with flying colors, excelled in 

every area.

My health was perfect, absolutely 

perfect, you couldn't ask to be any more healthy 

than what I was at that time. But that swing 

shift was about to kill me, I'm just not a 

nocturnal person. I like to get eight to ten 

hours of sleep at night, especially since I'm 

retired now.

But that swing shift, man, it hurt, it 

just hurt me. So, somebody walked in one day and 

said they're cranking up the powder crew again, 

they need people that wants to work on the powder 

crew. Everybody just sit there.
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I didn't know what the powder crew 

was, and I said, well, tell me about that. They 

said, we'll be doing straight days, for as long 

as they continue to overpack these barrels. 

Straight days? I'll take it.

So, I worked for the next five years 

as a crew leader, actually. Bud Jenkins trained 

me, which he's been mentioned two or three times 

here already. He trained me to be the crew 

chief, because he only wanted to be on there for 

a while and he got a chance to go to another day 

job.

So, I actually was the lead beagle, 

that's a Kentucky term. I was the lead beagle 

for the powder crew for five years, until we 

packed up all of the drums of UF4 uranium, which 

we found out later were contaminated with 

plutonium. Also contaminated with arsenic, lead, 

silver, nickel, and mercury.

Now, if you got time and you want to 

talk to me again, I'll be glad to come in and sit 

down and tell you where every one of those things 
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are found in the plant, because it was denied by 

Industrial Hygiene. It was denied that any of 

those elements were in the plant at all, and they 

were, in abundance.

And that's where I got exposed. That, 

plus then, when we finished that job, Curley 

Ware, who's dead now, he and I volunteered to 

work another year on a cleanup crew. That was 

the RARP group.

And basically, what we did is we went 

into all the buildings and where stuff was dusty 

and laying there for years and years and years, 

we went and we cleaned it all up. Operated 

forklift, I helped, Curley was ground man,

sometimes he'd operate the forklift.

We'd pick all this nasty stuff up, it 

was all contaminated from 30, 40, 50 years been 

sitting there, nobody ever touched it. And we 

put it in these big cargo boxes, about as big as 

this opening right here, huge boxes.

Packed all that stuff up, sealed it 

up. Industrial Hygiene, let's see, no, Health 
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Physics. Health Physics would come by, they'd 

take their swipes, check it out, look. 

Everything's below background.

That's another misnomer. What is 

background? Right here, background should be 

pretty, pretty low. But background, when you 

take a reading in one of those process buildings, 

that's all that's already there, that we get 

exposed to, plus whatever we stir up. That's 

going to make it sound simple, okay? That's as 

easy as I can do it.

So, I was poisoned with arsenic, lead, 

silver, nickel, and mercury, which was aggravated 

by my exposures to uranium, radioactive 

materials.

Well, the Department of Labor just 

threw that out the door, they said, no. And like 

I said, for years, well, from 2001 until 2007, 

they said there's no arsenic in the plant.

Arsenic is in the plant, it was 

injected into the system to kill any biological 

items that were in that plant, because when they 
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did the PIM program, back in the, what was it?, 

'80s or 90's, I can't remember exactly when that 

was, they discovered that there was actually 

stuff growing inside those old pieces of 

equipment. And so, they started then injecting 

arsenic into the system.

They lied about it for six years. 

This is the United States Department of Labor, 

whom you are challenging, whom you are supposed 

to be investigating right now. Same people --

CHAIR MARKOWITZ: Energy.

MR. DRIVER: Excuse me, my choice of 

words is my choice of words. You think for six 

years, they would lie repeatedly? While I fought 

and fought and fought to try to get my disability 

and try to get my healthcare, any kind of 

coverage, anything?

I may have been the first 

whistleblower, no offense to anybody else around 

here, because when I got sick -- well, out in the 

buildings, there's cells panels about as big as 

that screen right there, there's two or three 
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hundred gauges on there, and then, there's dozens 

and dozens and dozens of other areas of equipment 

and things sitting around. I know I'm getting 

past my five minutes, but you might find this 

interesting.

The night before I turned my badge in 

the next morning and left the plant, just walked 

out cold turkey, quit, the night before, I had an 

alarm come in one of my panels.

Now, you've got to remember, I aced 

every test I ever took, I knew that plant inside 

and out. I even went down in the tunnels between 

the buildings and checked them out when I was in 

the guard department, and nobody else did that.

But that night, I went out and I 

looked at that panel, and I could not remember 

what those gauges represented. I couldn't 

remember which one represented pressure or flow 

or temperatures. I couldn't. I couldn't 

identify any of them.

So, the next morning, when I walked 

out past the guard shack, I handed my badge to 
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the guard and I said, you turn that in this 

morning, right now. Tell them I'll give them a 

call, but I've got to find out what's going on. 

Because my memory was so bad.

Guess what? That was 21 years ago. 

My memory is still that bad. I have a really 

hard time remembering things. That's called 

toxic encephalopathy.

Also, walking from the parking lot in 

here, by the time I got in here and sat down, my 

legs were just doing this. That's called toxic 

neuropathy.

And just as the young lady back here 

said a little while ago, she was talking about 

not getting her lost wages. Guess what 

percentage of my lost wages have been offered to 

me? Applied for three times, by Donna Hand, and 

every time, they turn it down and say, no, you 

don't qualify.

Guys, we need your help really bad. 

People are being taken advantage to no end 

whatsoever. And it's not new. I know -- I used 
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to go to church with about half to three-fourths 

of the people who worked out at the Resource 

Center when it first started. That's another 

little story, and I will quit after I tell you 

that one.

Because people kept telling me, go to 

the Resource Center and tell them what buildings 

you worked in, they can tell what chemicals you 

were exposed to. So, I did that.

Very sweet young lady took me into her 

office. My wife was with me, she helped me to 

recall all the different buildings. Of course, 

it was every building out there, because I was in 

the guard department and I was a Class A 

operator. So, we took care of all of that. She 

was very polite.

We walked out to the counter, and I'm 

standing there at the counter, and she's getting 

one last paper, I think, I had to sign or 

something like that, and my wife's standing right 

there.

And there's another woman sitting at 
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the counter right there. Right there. And I 

heard her saying, yes sir, Mr. So-and-so, yes 

sir, yes sir, if you need anything at all, you 

call us, that's what we're here for, is to help 

you, we want to help you in any way possible. 

We'll fill out all your paperwork, we'll research 

this, we'll do that, do all this other stuff.

And as soon as she stopped talking, 

this other lady finally finished what she was 

doing, she turned to us, she goes, Mr. Driver, 

there's one thing I have to tell you. I said, 

okay, what's that?

She said, don't ask this office for 

anything else or any more help, because you're 

not going to get it. And she turned around and 

she walked off. Because I was a whistleblower.

Now, I've fought these people for 21 

years. They're long overdue. Long overdue. 

Now, I don't know if you can jerk a knot in their 

tail, I understand, I understand you all stand 

for what you stand for.

But people need to know this, from the 
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President's office all the way down. You got 

people that have whined and cried and fussed and 

carried on, I mean, we done everything we can. 

And they just turn a deaf ear to us, they don't 

care. So, thank you --

CHAIR MARKOWITZ: Thank you.

MR. DRIVER: -- for your time. I 

appreciate everything you've done and are trying 

to do. Just, good luck with it. And you want to 

hear more --

CHAIR MARKOWITZ: Okay.

MR. DRIVER: -- I'm easy to find.

CHAIR MARKOWITZ: Thank you very much.

MR. DRIVER: Thank you.

CHAIR MARKOWITZ: All right. Dr. 

Redlich wants to just, is not going to be here 

tomorrow, so she just wants to make one comment 

before we break. Then, we'll resume at 8:30.

MEMBER REDLICH: I appreciate 

everyone's input and I do want to say that I 

think we tend to focus on the claims that are 

problematic and we do appreciate the magnitude of 
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this effort and that there -- we obviously 

haven't brought up the claims that were 

appropriately adjudicated, which many were. So, 

I don't want to totally misrepresent. And we 

appreciate everyone's efforts.

CHAIR MARKOWITZ: Okay, thank you. So, 

thank you to people who spoke today, people on 

the phone, and we look forward to tomorrow at 

8:30. Thank you.

(Whereupon, the above-entitled matter 

went off the record at 6:08 p.m.)