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 UNITED STATES DEPARTMENT OF LABOR

 + + + + +

 ADVISORY BOARD ON TOXIC SUBSTANCES

 AND WORKER HEALTH

 + + + + +

 SUBCOMMITTEE ON EVIDENTIARY REQUIREMENTS FOR

 PART B LUNG CONDITIONS (AREA #3)

 + + + + +

 MEETING

 + + + + +

 WEDNESDAY,

 DECEMBER 21, 2016

 + + + + +

 The Subcommittee met telephonically at

2:30 p.m. Eastern Time, Dr. Carrie Redlich,

Chair, presiding.
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MEMBERS

SCIENTIFIC COMMUNITY:

JOHN M. DEMENT

MEDICAL COMMUNITY:

CARRIE A. REDLICH, Chair

LAURA WELCH

CLAIMANT COMMUNITY:

KIRK D. DOMINA

OTHER ADVISORY BOARD MEMBERS PRESENT

STEVEN MARKOWITZ

FAYE VLIEGER

DESIGNATED FEDERAL OFFICIAL:

CARRIE RHOADS
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 TABLE OF CONTENTS

Call to Order and Opening Remarks. . . . . . . .4, 5

 Carrie Rhoads

 Designated Federal Official

Roll Call and Introductions. . . . . . . . . . . . 4

Opening Remarks. . . . . . . . . . . . . . . . . . 9

 Carrie Redlich, Chair

Part B Cases . . . . . . . . . . . . . . . . . . .12

Silicosis/Pneumoconiosis ILD Cases . . . . . . . .22

Part B Recommendation

 Sarcoid Presumption. . . . . . . . . . . . .47

Other Recommendations. . . . . . . . . . . . . . .98

Other New Items. . . . . . . . . . . . . . . . . 108

Adjourn. . . . . . . . . . . . . . . . . . . . . 110
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1 P-R-O-C-E-E-D-I-N-G-S

2 2:35 p.m.

3 MS. RHOADS: Hello, everybody. My

4 name is Carrie Rhoads, and I would like to

5 welcome you to today's teleconference meeting of

6 the Department of Labor's Advisory Board on Toxic

7 Substances and Worker Health, the Subcommittee on

8 Part B Lung Conditions. I'm the Board's

9 Designated Federal Officer, or DFO, for today's

10 meeting.

11 First, we do appreciate the time our

12 Board members have put in for preparing for the

13 meeting and for the work they will do as a

14 result.

15 I will introduce the Board members on

16 this Subcommittee and I will do a quick roll

17 call. I will ask each Board member to do a short

18 introduction of themselves.

19 Dr. Carrie Redlich is the Chair of

20 this Subcommittee.

21 Dr. Redlich, are you on the line?

22 CHAIR REDLICH: Yes, I am.
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1 MS. RHOADS: Okay. And the members

2 are Dr. John Dement.

3 MEMBER DEMENT: I'm here. Duke

4 University Medical Center.

5 MS. RHOADS: Mr. Kirk Domina?

6 MEMBER DOMINA: Kirk Domina, Hanford

7 Atomic Metal Trades Council in Richland,

8 Washington.

9 MS. RHOADS: Dr. Laura Welch?

10 MEMBER WELCH: Yes, I'm here. Laurie

11 Welch, and I'm an occupational physician,

12 Buildings Trades Medical Training Program.

13 MS. RHOADS: Thank you.

14 Mr. James Turner is a member of the

15 Subcommittee, but he cannot be on the call today.

16 And Dr. Steven Markowitz, who is also

17 the Chair of the Board, is on the line.

18 MEMBER MARKOWITZ: Yes. Hi. Steve

19 Markowitz, Occupational Medicine and Epidemiology

20 from City University of New York.

21 MS. RHOADS: Great. Thanks.

22 We will meet today from 2:30 to 5:00
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1 Eastern time, and we will have a short break

2 sometime around 3:30, as the discussion allows.

3 In the room with me today is Melissa

4 Schroeder from Sidem, our contractor, and Norman

5 Spicer, an OWCP employee doing detail with our

6 group.

7 Regarding the meeting today, copies of

8 all meeting materials and any written public

9 comments are or will be available on the Board

10 website under the heading "Meetings" and the

11 listing there for this Subcommittee meeting. The

12 documents will also be up on the WebEx screen, so

13 everyone can follow along with the discussion.

14 The Board website is

15 dol.gov/owcp/energy/regs/compliance/advisoryboar

16 d.htm. If you haven't already visited the

17 Board's website, I encourage you to do so. After

18 clicking on today's meeting date, you can see a

19 page dedicated entirely to today's meeting. The

20 webpage contains publically-available material

21 that were given to us in advance of the meeting. 

22 We will publish any materials that are provided
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1 to the Subcommittee there. You should also find

2 today's agenda as well as instructions for

3 participating remotely. If you are participating

4 remotely and you are having a problem, please

5 email us at energyadvisoryboard@dol.gov.

6 If you are joining by WebEx, please

7 note that the session is reviewing-only and will

8 not be interactive. The phones will also be

9 muted for non-Advisory Board members.

10 Please note that we do not have a

11 scheduled public comment session today. The

12 call-in information has been posted on the

13 website, so the public may listen-in but not

14 participate in the Subcommittee's discussion.

15 About meetings and transcripts, the

16 Advisory Board voted at its April 2016 meeting

17 that Subcommittee meetings should be open to the

18 public. A transcript and minutes will be

19 prepared from today's meeting.

20 During Board discussions today, since

21 we are on a teleconference line, please speak

22 clearly enough for the transcriber to understand. 
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1 When you begin speaking, especially at the start

2 of the meeting, please state your name, so we can

3 get an accurate record of the discussions.

4 Also, I would like to ask our

5 transcriber to please let us know if you are

6 having an issue with hearing or with the

7 recording.

8 As DFO, I see that the minutes are

9 prepared and, then, certified by the Chair. The

10 minutes of today's meeting will be available on

11 the Board website no later than 90 calendar days

12 from today, per FACA regulations. But if they

13 are ready soon, they will be published before the

14 90th day.

15 Also, although formal minutes will be

16 prepared, we will also be publishing verbatim

17 transcripts which are, obviously, more detailed

18 in nature. The transcript should be available on

19 the Board's website within 30 days.

20 I would also like to remind the

21 Advisory Board members that there are some

22 materials that have been provided to you in your
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1 capacity as special government employees and

2 members of the Board which are not for public

3 disclosure and cannot be shared or discussed

4 publicly, including in this meeting. Please be

5 aware of this as we continue with the meeting

6 today. These materials can be discussed in a

7 general way, which does not include using any

8 personally-identifiable information, such as

9 names, addresses, specific facilities, if a case

10 is being discussed or documents named.

11 With that, I convene this meeting of

12 the Advisory Board on Toxic Substances and Worker

13 Health, the Subcommittee on Part B Lung

14 Conditions, and I am turning it over to Dr.

15 Redlich, who is the Chair.

16 CHAIR REDLICH: Thank you all for

17 joining.

18 Everyone else I asked to say one word. 

19 So, I'm an occupational medicine and pulmonary

20 physician and Director of the Yale Occupational

21 Environmental Medical Program.

22 Thank you for joining.
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1 I thought, as far as the agenda, that

2 it would be best for us to start with reviewing

3 it rather than the sarcoid presumption, just

4 because I think we realize that there really

5 already exists a presumption, but it is actually

6 the implementation of that presumption that has

7 created a lot of confusion, and I think a number

8 of the cases reflect that.

9 I sat in on one of the other

10 committees, and we have done a huge amount of

11 work in terms of the number of cases that we have

12 reviewed, which I think has been very helpful,

13 because, organizationally, I tried to organize

14 them to sort of pick out the ones that would be

15 most useful to review. And I think some of them

16 have some points that really address one of the

17 key issues, which is the presumption with sarcoid

18 and beryllium.

19 So, I know this is a little bit

20 confusing because what I did was I went through

21 all the cases and selected out the ones that

22 people had indicated were worthwhile to review. 
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1 There may be some others, and there was some

2 overlap because some cases ended up in more than

3 one bucket.

4 But I think maybe it is easier for me

5 to go in chronologic order. We did send another

6 list that was numbered. We just didn't keep it

7 in chronological order, but if you want to check

8 with the actual number, you would have to look at

9 the original list, if that is agreeable with

10 everyone.

11 And I thought it wasn't so much to go

12 into every detail of the case, but the point that

13 we thought -- and I think there were a number or

14 several that we had sort of concerns about the

15 final decision or the process or some other

16 aspect.

17 So, is everyone agreeable as far as

18 the plan?

19 MEMBER WELCH: This is Laurie Welch.

20 I am. It is just that I haven't --

21 you know, you are going to have to, I think,

22 guide the discussion because your notes on the
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1 trial are a little bit cryptic. So, I will see

2 what I can do as you go along.

3 CHAIR REDLICH: Well, I didn't want to

4 send out everyone -- that is fine. I had based

5 it on everyone's form that they had filled out. 

6 I was concerned about sending that around, if it

7 had too much information.

8 MEMBER WELCH: Okay.

9 CHAIR REDLICH: So, that is why I

10 didn't do that.

11 Okay. So, the first case that we have

12 listed was actually, I think, Laurie, you had

13 raised the question. The beryllium-sensitive

14 patient diagnosis was, I think, straightforward. 

15 You had raised the question, I think an aside

16 just as far as hearing loss, that the claim had

17 not been accepted for. But I think we will pass

18 on that.

19 I also just included this as a sort of

20 marker, for I think that the beryllium

21 sensitization cases were the ones that were most

22 straightforward, in that it was generally in
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1 terms of whether the test was positive or

2 negative.

3 I know there has been an issue in

4 terms of indeterminate, but I thought we should

5 maybe leave that question for later. But the

6 cases that we were given, we didn't have any

7 other issues related to them.

8 MEMBER WELCH: Okay.

9 CHAIR REDLICH: That's in hindsight,

10 when somebody dies.

11 Okay, and then, the next case on our

12 list, Laurie and I both reviewed. This was a

13 case that I think was an example. It was listed

14 in the group of CBD cases, but it was an example

15 where the sarcoid presumption was somewhat used. 

16 And I think it just illustrates some of the

17 problem with that, where I think a more clear-cut

18 presumption would be helpful.

19 And this is a little bit of a common

20 scenario, where the sarcoid diagnosis is made

21 several years in the past. In this case, it was

22 made in 2010. This is someone where I think the
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1 history of exposure to beryllium was not

2 questioned. It just doesn't sound right. It was

3 Los Alamos and that was assumed.

4 So, sarcoid was diagnosed in 2010, and

5 the patient was treated with immunosuppressive

6 therapy. It was also a pulmonary tissue that the

7 granulomas was found.

8 And then, they applied for CBD, and it

9 was initially denied because the BeLPT was

10 negative. So, it was a situation where there are

11 granulomas on one tissue and the BeLPT is

12 negative for somebody who is on steroids.

13 So, eventually, three years later, in

14 2014, there was a Director's letter. So, it was

15 finally accepted, but I think it was an example

16 of the hoops that you have to go through and the

17 time and effort. We are, hopefully, moving

18 forward.

19 In this case, this person -- there are

20 a number of others that are somewhat similar to

21 this that ended up in the denied case, I think

22 because there wasn't either knowledgeable
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1 pulmonologist or someone to move it forward. So,

2 this was, I guess, we could call it a successful

3 example of the sarcoid presumption or you could

4 also interpret it as a somewhat unsuccessful

5 example because it took such effort, that if the

6 presumption was more clear-cut back in 2012, the

7 diagnosis could have -- the case could have just

8 been resolved, and the time and effort spent over

9 the following two years.

10 MEMBER WELCH: Though, Carrie -- this

11 is Laurie again -- I think that the one thing

12 about this case is that Director's letter because

13 it lays out how --

14 CHAIR REDLICH: Yes, and by the

15 Director's letter, you meant?

16 MEMBER WELCH: From Rachel Leiton, the 

17 timing has stuck to the case. You know, so this

18 case was accepted as CBD for this reason. If I

19 remember correctly, it kind of laid out how

20 someone missed a diagnosis of sarcoidosis but a

21 normal BeLPT, the case can be accepted under a

22 presumption.
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1 CHAIR REDLICH: Yes.

2 MEMBER WELCH: It is something to

3 remember, I mean in some ways we could look at it

4 again and say, is this -- because it is laid out

5 very clearly this is a condition B policy. This

6 is the best way to explain it. Because I think

7 one of the things we found when we put together

8 all the different language where in the Procedure

9 Manual it refers to this presumption for sarcoid,

10 it is confusing. So, I think this Director's

11 letter may be a good layout in their own

12 language.

13 CHAIR REDLICH: Okay.

14 MEMBER WELCH: Do you see what I mean? 

15 Just as a placeholder.

16 CHAIR REDLICH: Okay. Yes. I will

17 review that because I did not see -- okay.

18 MEMBER WELCH: While you're talking,

19 I'll see if I can find it.

20 CHAIR REDLICH: Okay. And then, the

21 next one was another case that was accepted for

22 CBD. I wanted to mention this one. It was
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1 someone who had, again, in fact, in this case a

2 positive BeLPT. So, that was not the question.

3 The two questions I had, just the CT

4 scan was actually somewhat a typical pattern for

5 CBD in ground glass and NSIP. But the person did

6 have restriction and a low DLCO, what you would

7 expect with interstitial lung disease.

8 And so, I think the key point to me

9 was that it is going to have the positive BeLPT

10 and they have evidence of interstitial lung

11 disease, one, and functionally interstitial lung

12 disease, that one doesn't necessarily have to

13 worry that much about the exact -- you have met

14 the criteria and the policy. Because one could

15 have also said, well, it doesn't quite meet the

16 description of this or the pathology, but I think

17 that this was a correct decision.

18 And the other thing I thought was

19 notable, not so much as an immediate issue that

20 we address, was -- and there was another case, I

21 think, like this -- it was a very perceptive

22 pulmonary doctor who got the BeLPT findings after
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1 they had obtained the exposure history. So, this

2 person was not in a surveillance program at Brush

3 Wellman's or now Materion. So, I think it also

4 just raised the question of whether there was

5 adequate surveillance of current employees, which

6 may or may not be relevant to some other sites.

7 Because my understanding was that

8 surveillance was something that was supposed to

9 still be ongoing. So, if this pulmonary doctor

10 had not obtained the history and personally sent

11 off the BeLPT, then this person would not have

12 been recognized.

13 Am I correct in terms of what ongoing

14 surveillance is supposed to be happening? Is

15 that clear-cut?

16 MEMBER WELCH: I don't know the

17 answer.

18 CHAIR REDLICH: Steve, I don't know if

19 you know.

20 MEMBER MARKOWITZ: I'm not sure. You

21 know, not current worker, right, just former

22 worker?
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1 CHAIR REDLICH: For the current

2 worker?

3 MEMBER MARKOWITZ: Current worker? 

4 Yes, I don't know what goes on exactly.

5 CHAIR REDLICH: Okay. But, then, a

6 way to identify these would be more it is the

7 appropriate surveillance. Because I think it

8 also demonstrates that there are still ongoing

9 cases that have just been recently recognized

10 with -- you know, this is not super-historic,

11 someone who started working in 1992, not in 1960.

12 Okay. The next case I only listed for

13 -- someone was interested for historic goal or

14 interest. It was a very well-described case of

15 acute berylliosis in 1946, and CBD was diagnosed

16 a year later in 1947. It wasn't actually, a

17 claim, though, wasn't -- and then, the autopsy in

18 1989 that noted CBD -- a claim was not filed

19 until by the survivors in 2014.

20 But there was, I think, by probably

21 chance, the old records were still available. It

22 was a path that was very well-documented. I
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1 think it is probably somewhat unique, and it was

2 also Dr. Nancy Sprintis in Boston.

3 I could imagine the scenario if the

4 initial admission was more like a pneumonia, that

5 the person could have actually gone on record, if

6 they had not had that workup or been in that

7 location.

8 Okay. And then, the next one was

9 another one, was an example of sarcoid CBD. 

10 There may be confusion. In this case the person

11 had exposure that was not at Savannah River, a

12 BeLPT that was negative and was also on steroids. 

13 The person had a block in 1988 and a diagnosis of

14 sarcoid. So, the sarcoid diagnosis was years

15 before CBD was considered or recognized, and that

16 was in 2013. Sorry. At that point, a

17 pulmonologist wrote a strong letter that the

18 person had a diagnosis of CBD.

19 Actually, my notes, okay. So, the

20 question was -- let me just pull up my original

21 notes on this. Because there was an initial

22 acceptance -- let me just pull out this number. 
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1 Sorry.

2 I will say this: it raised with

3 several, the issue of extra-pulmonary disease. 

4 Sorry. Okay.

5 Oh, so what was accepted on -- let me

6 just clarify this. The claim, okay, I guess this

7 one was -- I'm just checking what was denied. 

8 Excuse me. Okay. So, this ended up being --

9 again, it took a strong letter from the

10 pulmonologist to explain the negative BeLPT and,

11 then, it was accepted because there was,

12 basically, pulmonary sarcoid.

13 The piece that actually was denied was

14 a little bit separate, which was the asthma, the

15 angio, the rhinitis folliculitis that had been a

16 prior claim. But, actually, there was a strong

17 letter and it did look work-related, but that one

18 was denied based on the CMC report. So, it was

19 another pulmonary condition, but the main one was

20 accepted. And so, this was a situation of Be

21 being accepted.

22 Okay. I think we should probably get
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1 to -- the sarcoid ones in that other list had

2 some of the problems where they were not

3 accepted. The silicosis ILD claims, I don't

4 think we necessarily need to go through all of

5 them, but there were several -- and I think we

6 raised this -- there was a consistent issue.

7 John, you, I think, got two of them. 

8 And if you wanted to comment on the issue of the

9 exposure, the case number under the silicosis

10 ILD, the second and the third ones?

11 MEMBER DEMENT: I did, Carrie, and I

12 reviewed all of these. And one of the issues

13 that I noted in sort of a consistency across some

14 of these is uranium mining in association with

15 silicosis.

16 There are sort of two issues that I

17 saw. One is, based on the job classification, in

18 some cases it went to the SEM. And the SEM

19 really didn't list silicon as an exposure in

20 uranium mining. It found aluminum exposure in

21 two of the cases.

22 Based on that, the CMC opined that
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1 aluminum, their condition wasn't related aluminum

2 exposure, even though chest x-ray information

3 showed in most cases both pleural and parenchymal

4 changes that would be consistent with

5 pneumoconiosis.

6 One of the other issues is -- and I

7 found this really strange -- because they did not

8 see specifically the term "silicosis," despite

9 the diagnosis of pneumoconiosis, then the CMC

10 opined that it was not related.

11 So, there are two issues for me, and

12 I think SEM Committee needs to take this up. One

13 is why -- silicosis associated with uranium

14 mining is a known associated -- why would not a

15 diagnosis of pneumoconiosis suffice with

16 silicosis when in many cases we know that these

17 individuals likely have mixed pneumoconiosis

18 anyway? And I guess it goes through at least the

19 first five of these cases.

20 CHAIR REDLICH: Yes, and I agree. I

21 reviewed the two. In this case, and I would say

22 as a general statement, for most of the most of
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1 the ones that I reviewed I was actually impressed

2 at the questionnaire that was provided and the

3 description of the job categories, the location,

4 the years of employment, additional comments

5 about whether a respirator was used or a Dust

6 Bee, and the like.

7 To me, I would say in almost all of

8 the pulmonary cases I reviewed that that

9 information was sufficient to come up with the

10 correct conclusion; and that what the SEM did --

11 and it was most notable for these cases and,

12 also, for a few of the others -- but was to

13 actually, it is a little bit counterproductive

14 because it was clear there was, you know, silica

15 exposure; there was a lot of dust exposure. But,

16 then, the SEM came up with the bizarre sort of

17 exposure to aluminum.

18 MEMBER DEMENT: This is a specific

19 case where the SEM really needs to be looked at

20 very closely with regard to uranium mining. And

21 most jobs that were uranium mines would have

22 exposure to silica. All you need to do is look
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1 at the published literature in this area and it

2 becomes quite clear the silica exposure is pretty

3 much across job categories in uranium mines.

4 CHAIR REDLICH: Yes, and I would guess

5 this is maybe for our Committee, but for the SEM,

6 but I would just weigh-in whether it is even

7 needed to go that step; that if you knew someone

8 worked as "X" job category, and the like, for "X"

9 number of years as a miner or some of these other

10 jobs, would that be sufficient information, given

11 the clinical picture and the question that you

12 are being asked? And I felt that all the cases I

13 reviewed I didn't think there was a need for SEM.

14 MEMBER WELCH: But, Carrie, one of the

15 problems is that the cases aren't being reviewed

16 by knowledgeable physicians. They are being

17 reviewed by the claims examiner. So, if the SEM

18 included silica and exposure, it would make the

19 whole process much easier.

20 It is obvious to you and it was

21 obvious to me that there are two things to do. 

22 One of them is to have uranium mining be
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1 associated, so they are in the SEM, and the other

2 is to stop relying so heavily on the SEM. But I

3 think in this particular case it is easy to add

4 it to the SEM and that that would kind of assure

5 the process for these cases. And you can make

6 that recommendation.

7 MEMBER DEMENT: Another issue with

8 these cases -- and it wasn't so much with the SEM

9 -- is that when you have a chest x-ray with a 

10 perfusion change of 1/1 or even higher, but the

11 specific term silicosis is not anywhere in the

12 medical record, I can't see why a uranium miner

13 with a 1/1 chest film and a diagnosis of

14 silicosis, it would not suffice to consider that

15 silicosis.

16 MEMBER WELCH: Absolutely. No,

17 absolutely. I mean, there are a couple of these

18 that I wasn't down as reviewing them, but I did

19 look at them. This is one of these ones that

20 makes me think, so where did they find these

21 CMCs?

22 CHAIR REDLICH: Yes, and I was going
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1 to bring this up later, but --

2 MEMBER WELCH: One other question I

3 had, though, that relates to that, John, is --

4 there are two things. One of them is you could

5 get accepted for silicosis or pneumoconiosis. 

6 You would be accepted for either one, I think.

7 So, for someone to kind of suffer with

8 their silicosis, you know, the B reads clearly

9 showed pneumoconiosis and the guy had duct

10 exposure. So, it doesn't seem important to

11 distinguish, although in one particular case they

12 turned him down altogether, even though, as he

13 pointed out, his ILS-1 showed markings and he had

14 restrictive lung disease.

15 CHAIR REDLICH: Yes, I think, at least

16 for me, part of the confusion was not necessarily

17 solely the issue of some of these had a prior

18 RECA claim that was accepted and others did not. 

19 I was not totally clear about that component.

20 MEMBER WELCH: You mean, if they had

21 a RECA claim, how that affected their review or?

22 CHAIR REDLICH: Yes.
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1 MEMBER WELCH: Because, I mean, what

2 they could get under this was supplemental to

3 what they would get under RECA.

4 CHAIR REDLICH: That's right. And so,

5 I think that, because some of them had a RECA

6 claim that was already accepted, so it was almost

7 a secondary question --

8 MEMBER WELCH: That's right.

9 CHAIR REDLICH: -- is it the cause of

10 death?

11 MEMBER MARKOWITZ: Hello. This is

12 Steven. I just have a question.

13 Under Part B, silicosis is covered for

14 Amchitka, I think, and Nevada Test Site as

15 specified locations. So, under RECA, is

16 silicosis covered under RECA?

17 MEMBER WELCH: I don't know. I think

18 we looked at that when we looked at the cases. I

19 will see what I can find right now.

20 MEMBER DEMENT: I think one of my

21 notes states for the one, two, three, four, the

22 fifth one down, it says it was accepted silicosis
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1 under RECA.

2 I think the other issue which I don't

3 think we necessarily have control over is there's

4 a specific timeframe for exposure, that it has to

5 be before a certain period of time in terms of

6 years and, then, that there is also a minimum

7 number of months in a mine. And I think that was

8 an issue for the third case down. It was 9.88

9 months, and there is a very specific way that the

10 number of months is defined.

11 I think, John, you know more about

12 that.

13 MEMBER DEMENT: That particular case,

14 you know, that was one that it is likely a

15 marginal case at best, the only exposure. But it

16 is perhaps a believable one if exposures are high

17 enough.

18 So, that was, to me, one of the cases

19 where it wasn't accepted under RECA, and I think

20 the RECA actually is based on working a number of

21 months, so a calculated radiation exposure. See,

22 this person did not meet that threshold, but,
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1 nonetheless, they had a subsequent B read many

2 years later that was consistent with at least

3 pneumoconiosis. I think it is a call based on

4 short exposure. It was denied. But the purpose

5 for denial, when I looked through it, was this

6 assessment of aluminum exposure, and not really a

7 consideration in great detail of silica and

8 silicosis.

9 CHAIR REDLICH: That's right, but if

10 a case is denied under RECA, can it be accepted

11 here?

12 MEMBER WELCH: Yes, absolutely.

13 MEMBER DEMENT: Yes. I think it has

14 to come mostly under the Part E, am I not

15 correct?

16 MEMBER WELCH: Yes.

17 CHAIR REDLICH: Right. Okay. So, my

18 understanding that it could be considered under

19 E, but not B, if it has been denied.

20 MEMBER WELCH: No, I don't think

21 that's true. It depends on where they worked. I

22 mean, if they are a uranium miner and meet the
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1 definition, then they should be covered. You

2 know, it is sort of if they qualified for RECA

3 and weren't accepted, then it suggests a problem

4 with the medical documentation and it might not

5 be accepted by the Department of Labor. But they

6 might not qualify in terms of some of the

7 employment characteristics. I think they're not

8 exactly the same, but I can't find it quickly

9 enough. So, I don't think we should speculate

10 about it. We need to know the answer.

11 MEMBER MARKOWITZ: Right, but, at any

12 rate -- this is Steven -- but, in any event, the 

13 essential limitation in some of these cases was

14 that silica wasn't properly identified in the

15 exposure assessment as being relevant.

16 CHAIR REDLICH: That's correct.

17 MEMBER WELCH: Neither in the SEM or

18 by the CMC.

19 MEMBER DEMENT: Right.

20 MEMBER WELCH: And these were cases

21 where you could see that process where the claims

22 examiner creates a statement of accepted facts
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1 and CMC relies on that, even though we would like

2 to think that a physician with occupational

3 training or pulmonary training who was hearing

4 these cases would think, well, a uranium miner

5 should have also had silica exposure, even if it

6 wasn't in the statement of accepted facts. But

7 it was, apparently, not part of their practice. 

8 But when they set the facts in and said it was

9 aluminum, he said, "Well, no, I don't think so."

10 MEMBER DEMENT: Yes, and I think

11 Carrie has also hit on an issue. In many of

12 these instances, when you look at the completed

13 occupational history questionnaire, most people

14 would look at the job and say, this job was a

15 mucker in a uranium mine for quite a number of

16 years; therefore, it is silica exposure.

17 CHAIR REDLICH: Yes. This is Carrie.

18 I sort of feel that there is one

19 particular CMC that has come up with a number of

20 these bad conclusions. I mean, if a CMC does not

21 know that working as a miner involves silica

22 exposure, then they are not qualified to be a
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1 CMC.

2 MEMBER WELCH: Well, then, why don't

3 you send a note over to the CMC Committee?

4 (Laughter.)

5 Really, they've got a big problem

6 because there is no quality review of the

7 opinions of CMC. The quality review, the review

8 of the contractor has to do with timeliness and

9 if the claim, then, they feel has answered their

10 question. But whether they got the answer right

11 is not part of their review.

12 CHAIR REDLICH: I understand. 

13 Actually, that is sort of a secondary issue I was

14 going to bring up later because there is one CMC

15 that has reviewed, I think, about half, you know,

16 a large number of these cases. And a number of

17 his reviews I think are quite problematic. And

18 no matter how many times you rewrite a manual, if

19 the person who is interpreting and using the

20 manual doesn't come up with the right conclusion,

21 rewriting the manual five more times won't

22 necessarily --
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1 MEMBER WELCH: Right.

2 CHAIR REDLICH: -- solve the problem.

3 MEMBER WELCH: Right. Yes, but I just

4 don't think we should get into that. We should

5 send it to their Committee.

6 CHAIR REDLICH: Exactly. I just want

7 them to be aware of it because I don't think that

8 they've necessarily reviewed as many cases, and

9 if they have come up with the same person's name,

10 and I pulled out a couple of examples of them,

11 that you realize it's a problem.

12 MEMBER DEMENT: This is Steven.

13 But isn't it a quicker or more

14 efficient solution that, for any number of job

15 titles that relate to this uranium mine work,

16 that if there is a certain number of years in

17 which they work, then it seems that silica

18 exposure is so common, that there would be the

19 presumption that job titles with a certain number

20 of years and the diagnosis of something related

21 to silicosis, that's simply --

22 CHAIR REDLICH: Right.
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1 MEMBER DEMENT: -- the presumption

2 they will hold, and we don't have to go through

3 the whole CMC process?

4 CHAIR REDLICH: I mean, that would be

5 my hope.

6 MEMBER WELCH: Yes, we can do that.

7 CHAIR REDLICH: That's exactly right. 

8 I feel that, if there was a presumption of "X"

9 number of years, exactly, then really in any

10 pneumoconiosis, whether it was, you know,

11 pulmonary fibrosis, silicosis, would be a

12 presumption, yes.

13 MEMBER DEMENT: I agree. This is

14 John. I think this is one where a presumption

15 would cut out a lot of this process, not to

16 exclude the possibility, for example, of 9.8

17 months' exposure as possible, but that would be

18 an unlikely person to be included in a

19 presumption.

20 MEMBER WELCH: So, adding in the SEM

21 and getting a good review would be important, but

22 I think that having a presumption might help this
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1 in a lot of other cases.

2 MEMBER DEMENT: Yes, I think the

3 tracking just by a good presumption and

4 correcting the SEM appropriately and educating

5 the physicians on the uranium mining would help.

6 CHAIR REDLICH: Okay. And, yes, a

7 presumption would help with that diagnosis.

8 The last two cases on the list are

9 "other issue," which was that the CMC was asked

10 not does this person have silicosis or

11 pneumoconiosis, but did that disease contribute

12 to their death. And the person, basically, sort

13 of said that the prior -- acknowledged that there

14 was, you know, a prior accepted claim for

15 pneumoconiosis and silicosis, then said pulmonary

16 function tests were not available.

17 And it also acknowledged that

18 pulmonary fibrosis increases the risk of ischemic

19 heart disease and various other diseases that

20 this person ended up dying of. But, then,

21 basically, said no pulmonary function tests were

22 available. And so, then, that person's pulmonary
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1 disease did not contribute to their death.

2 To me, this was going out of your way

3 to sort of deny a claim. To question, you know,

4 I mean, if it is an accepted

5 silicosis/pneumoconiosis and there were a uranium

6 worker and machine as well who, then, "dies," it

7 is a condition that is felt to be associated with

8 that, but no one has given you pulmonary function

9 tests. But that is a poor reason to deny the

10 claim.

11 So, I'm mentioning it not so much --

12 and there was another one similar to that where

13 they, basically, questioned the prior RECA B

14 determination that the person had pneumoconiosis. 

15 So, if you didn't have that, then you couldn't --

16 I think in this case where the lesion lies, to

17 me, is not necessarily something we could -- and

18 it is suggested the person doing, you know, the

19 CMC.

20 MEMBER WELCH: Right. So, if you want

21 to send those --

22 CHAIR REDLICH: Pass that on to the
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1 CMC. My thought was that some of these cases we

2 could pass on to the CMC Committee.

3 MEMBER WELCH: Yes, sure.

4 MEMBER DEMENT: I looked at these two

5 as well, Carrie. The last one on the list was a

6 question of whether or not pneumoconiosis

7 contributed to the cause of death. I think this

8 person already had acceptance under Part B of

9 pneumoconiosis.

10 When I look at this case, the person

11 actually had bladder cancer and pneumonia, and

12 the B read that was taken in this case was pretty

13 much at the time that the person was having

14 complications from the bladder cancer and

15 pneumonia. And so, the CMC, to the defense of

16 the CMC, looked at this and said, you know, all

17 along the way there have been different chest

18 films taken, not likely read by a B reader, but

19 none of them actually mention pneumoconiosis. 

20 And then, the cause of death really didn't, when

21 you look at the death certificate, it didn't

22 attribute that to pneumoconiosis. So, that, to
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1 me, was a problematic case.

2 MEMBER WELCH: And difficult to

3 discern.

4 MEMBER DEMENT: I'm sorry?

5 MEMBER WELCH: I mean, you think the

6 CMC has made a reasonable decision?

7 MEMBER DEMENT: You know, I don't

8 think it is unreasonable. I think this

9 individual likely -- you know, the chance the B

10 reading was taken within a few weeks, actually,

11 of the actual demise. And so, there are many,

12 many complications belonging there, including the

13 possibility of metastatic issues.

14 CHAIR REDLICH: I thought it had been

15 earlier. I thought it had been quite a bit

16 earlier. I may be wrong, but I'll check that

17 because I don't want to mix a line and I might be

18 -- but I thought that there was a tag lag and

19 that it had been an x-ray before the other

20 medical issues reared their head.

21 MEMBER WELCH: I think the question,

22 too, is whether -- you know, you are looking at
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1 death certificate for cause of death, and if the

2 cause of death was cardiopulmonary, then, how do

3 you say that -- you know, it can be difficult to

4 determine that something is a contributing cause

5 to a death.

6 CHAIR REDLICH: Yes, and I think the

7 other point, though, is also, if there is a prior

8 accepted case that has been reviewed and accepted

9 as just a process system, and we are trying to

10 sort of, hopefully, streamline the process, to

11 change the prior conclusion I think probably just

12 is not an optimal approach as the reason. I

13 think one could independently decide what you

14 thought was contributing or not, but to change a

15 prior final decision that had been made years

16 previously as a process I find questionable.

17 MEMBER MARKOWITZ: Carrie, this is

18 Steven.

19 It kind gives a whole new meaning to

20 the statement of accepted facts.

21 MEMBER WELCH: Yes. Or maybe it is --

22 CHAIR REDLICH: I mean, I think that
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1 could easily be solved. And again, I think this

2 is more of a CMC -- one could simply say, you

3 know, there was a prior decision that has been

4 finalized and accepted that this person has "X,"

5 you know, that qualifies.

6 I think the thing is you don't need to

7 readdress that question. Assuming that that is

8 the case, we would like you to answer this

9 additional question.

10 MEMBER WELCH: I guess I'm feeling a

11 little lost because I feel like, if we go through

12 all the cases -- I don't know if I'm finding this

13 helpful.

14 CHAIR REDLICH: Okay. Anyway, you

15 know what? Let's finish with this and go on to

16 the -- I mean, to me, I think the CBD cases, we

17 will get to the ones that I think were denied,

18 were a problem in the other group because they

19 were in the sarcoid. To me, the main take-home

20 point was that there were cases that were denied

21 because of the SEM problem that we already

22 discussed that could be fixed with, just to
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1 summarize, either a presumption in terms of

2 silicosis and pneumoconiosis, and Laura had

3 suggested the other way it could be fixed is the

4 SEM split out silica.

5 MEMBER WELCH: Right. It would

6 resolve --

7 CHAIR REDLICH: Yes, that is correct.

8 And then, the other issue as a general

9 issue was simply, I would say not the

10 qualifications, but the decision-making by

11 certain CMCs and whether there needs to be some

12 process to sort of review their decision-making

13 without the details of the given one. And I

14 think that was the key take-home messages of

15 these.

16 And I guess, then, the final one,

17 which sort of relates to the sarcoid, was

18 sometimes the delay in finally making the CBD

19 diagnosis, yes; and the beryllium sensitization

20 was generally reasonable and straightforward.

21 MEMBER WELCH: Uh-hum.

22 CHAIR REDLICH: So, I think that is
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1 sort of the bottom line for those. And so, if

2 anyone else has any comments -- and, Kirk, I

3 don't know if you have any before we move on to

4 the sarcoid cases, but on any of the other,

5 silicosis, ILD, or CBD, the ones that were in

6 those groups.

7 MEMBER DOMINA: Here we are just

8 talking about Case No. 12, is that correct, on

9 the pneumoconiosis?

10 CHAIR REDLICH: Yes.

11 MEMBER DOMINA: Well, that one is a

12 little confusing for me because for the simple

13 fact, as I am looking at my disk right now, and

14 there seems to be some confusion on the death

15 certificate on my desk is for a female, not for a

16 male. They are obviously related, but there is

17 some confusion when I go back and look at this

18 right now, as we are speaking. There is a

19 problem.

20 So, unless you guys got another

21 version, but, to me, when the case number is the

22 same and the death certificate is for a female
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1 and the case is talking about a male, there is an

2 issue with that for me.

3 CHAIR REDLICH: Okay. Let me just

4 quickly -- you are on top of things here. Hold

5 on. I'm just pulling up the death certificate.

6 MEMBER DOMINA: Because it's very

7 clear on the death certificate that the cause of

8 death is not what you guys were just talking

9 about.

10 MEMBER DEMENT: There's another file

11 in that case. It is the SOF plus the medical

12 records, and I think there is a different death

13 certificate in there.

14 MEMBER DOMINA: Okay.

15 CHAIR REDLICH: Yes.

16 MEMBER DEMENT: I think they are

17 different. I saw that, too, but --

18 MEMBER DOMINA: Okay. I just wanted

19 to make sure because of some other things that I

20 have seen on the third disk. I mean, I have to

21 bring up questions on the next meeting in a week

22 and a half. So, I'm just making sure because I'm
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1 trying to follow along because some of these I

2 didn't review because of computer issues and

3 workload.

4 CHAIR REDLICH: It appears that that

5 death certificate is a different person, but I

6 think there was, as John said, another death

7 certificate.

8 MEMBER DOMINA: Okay. All right. But

9 the case number shouldn't be the same.

10 MEMBER DEMENT: No.

11 CHAIR REDLICH: There were a few cases

12 where there were records of a different person in

13 a file. I think it happened relatively

14 infrequently when you consider how much scanning

15 and the like --

16 MEMBER DOMINA: Right.

17 CHAIR REDLICH: I have raised the

18 point that one has to carefully make sure that

19 all the documents relate to the proper person.

20 MEMBER DOMINA: Right, especially when

21 people have common names, or whatever. I mean, I

22 see that, too, but when it is the individual
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1 being involved, they are not so sensitive to

2 that --

3 CHAIR REDLICH: Yes.

4 MEMBER DOMINA: -- I mean as far as

5 wanting an excuse, or whatever the case might be.

6 CHAIR REDLICH: Okay.

7 MEMBER DOMINA: But I just wanted to

8 make sure because I was having a little confusion

9 here.

10 CHAIR REDLICH: Yes. Well, I did

11 notice one or two, but, generally, I thought the

12 right names were in the right places.

13 MEMBER DOMINA: Right.

14 CHAIR REDLICH: And there was also

15 some confusion, I think as people know, with some

16 numbers.

17 MEMBER DOMINA: Okay.

18 CHAIR REDLICH: Okay, but thank you. 

19 You've got good eyes there.

20 So, I think for me what was most

21 helpful was some of the sarcoid cases in terms of

22 addressing some of the issues as far as a
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1 presumption. And I think the ones that were

2 relevant, some of them, you know, it is a basic

3 question, which if you had a history of exposure

4 and you have granulomas, should that be presumed

5 and not have to have an BeLPT.

6 And then, the other was a couple

7 raised this issue of extrapulmonary versus

8 extrapulmonary and pulmonary sarcoid. And also,

9 you could have a scenario where it likely

10 involved the one, but the actual gran biopsy was

11 taken at another site because that may have been

12 more accessible. And so, I think there is

13 confusion around some of these issues.

14 So, the first case on the list, I

15 think, John, you looked at this. Did you want to

16 mention --

17 MEMBER DEMENT: I think I looked at

18 this. This was an accepted case. So, I don't

19 think I had a particular problem with myself the

20 way the determination was made.

21 CHAIR REDLICH: Yes. You know what? 

22 That is correct. I added it on for two reasons. 
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1 One, it basically used the sarcoid presumption. 

2 The biopsy of the granuloma was on a -- there

3 were four indeterminate, as you had noted,

4 BeLPTs.

5 MEMBER DEMENT: Yes.

6 CHAIR REDLICH: The other thing is

7 that this question, I raised it because there was

8 some confusing wording as far as the lymph nodes

9 versus lung tissue. So, this was an accepted

10 claim, that they should have normal lung

11 function. And it appeared that it was hilar

12 adenopathy, basically, and an indeterminate

13 BeLPT.

14 And so, in this case it was accepted. 

15 There has also been noted that you have to have

16 lung involvement, like the lung tissue versus the

17 lymph node in the chest. I personally think --

18 MEMBER DEMENT: I think one of the

19 other ones, I think it is the last one on the

20 list that I looked at, and that had to do with

21 primarily sarcoid involving the spine. And the

22 question for me -- and it is not a question that
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1 I can answer; I'm not a physician -- but to what

2 degree the sarcoid and the spine preclude also

3 involvement of the lung? Or are they completely

4 separate? You know, that is something we need to

5 consider as sarcoid is non-pulmonary.

6 CHAIR REDLICH: Yes, so I think that

7 is a question. Just getting to the one, I

8 thought that it would be helpful if we had

9 agreement -- and this may seem like a petty

10 point, but it was in one of the sideline

11 documents. To me, the actual wording in the

12 manual talks if it is a lung biopsy or a lung,

13 and I would consider it chest as part of the

14 lung, so we are not getting into whether it was a

15 hilar node that was biopsied or actual lung

16 tissue, because I would say that that is part of

17 the chest and the lungs. But I wanted to see if

18 other people agreed with that or had a problem

19 with that.

20 Because the reason I know this about

21 testing, this was one of the areas I had

22 highlighted in yellow in the actual, I guess it
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1 is called manual or instructions. And they

2 mentioned the mediastinal lymph node biopsy is

3 not the equivalent of a lung biopsy and does not

4 substitute for such in the assessment of a post5 1993 thing. The evidence has to be lung

6 pathology. A mediastinal lymph node is not a CBD

7 in the same way as a lung biopsy.

8 MEMBER MARKOWITZ: Carrie, this is

9 Steven.

10 So, you think that's wrong, right?

11 CHAIR REDLICH: I personally feel that

12 that's wrong. But we should get clarity among

13 ourselves about that question.

14 MEMBER MARKOWITZ: This is Steven.

15 But if the thinking is that it is

16 wrong, I think we should just tell them.

17 CHAIR REDLICH: Well, I just want to

18 see if Laura and everyone else agrees with that. 

19 That is why I am raising it.

20 MEMBER WELCH: Yes, a biopsy, a

21 mediastinal, well, I think a lymph node biopsy

22 that shows granulomas is indicative of sarcoid. 
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1 So, it should be accepted as done, not because of

2 them.

3 MEMBER MARKOWITZ: This is Steven.

4 That would pass the standard. That

5 would be the standard of proof in the practicing

6 pulmonary community, right?

7 CHAIR REDLICH: Yes.

8 MEMBER MARKOWITZ: Yes, okay.

9 CHAIR REDLICH: Okay. I just assumed

10 because it was made such a point of under No. 7

11 in the manual, I just wanted us to have a

12 discussion about that. So, what else? Because

13 they are distinguishing whether it is the lymph

14 node versus the lung. In this case, it was the

15 lymph node, and I just mention that.

16 Okay. So, that is something that I

17 think we could, then, address in terms of needing

18 some clarity as far as the workup and

19 interpretation.

20 MEMBER MARKOWITZ: Right. This is

21 Steven.

22 I'm just thinking. Actually, I'm
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1 trying to recall the language of the statute,

2 whether that is a problem. I will look it up as

3 we continue the call.

4 CHAIR REDLICH: Yes. You know, I was

5 thinking this question, like the language of the

6 statute and, then, sort of how it has been

7 interpreted. Because there are a number of

8 things that have sort of busted the language of

9 the statute. So, I thought we should give what

10 we think we would recommend based on our

11 expertise. And then, if it turns out that it is

12 an issue with the language of the statute, they

13 would let us know.

14 MEMBER MARKOWITZ: Well, yes. This is

15 Steven.

16 Also, if the concern is the statute,

17 obviously, that is a bigger hurdle, but, you

18 know, there may be a number of technical issues

19 like this that could be --

20 CHAIR REDLICH: But the thing is there

21 are already things. Let's say that you have to a

22 positive BeLPT. It is in the statute, but the
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1 document had --

2 MEMBER MARKOWITZ: Right.

3 CHAIR REDLICH: -- already has given

4 reasons not to have it.

5 MEMBER MARKOWITZ: Right. So, yes, we

6 will give our best scientific opinion and, then,

7 they figure out how to do it.

8 CHAIR REDLICH: That's right. Okay. 

9 Because all I'm saying is that there is,

10 basically, already given an interpretation of

11 that statute that is somewhat, you know, a little

12 bit different than the original wording.

13 MEMBER MARKOWITZ: Right.

14 CHAIR REDLICH: Okay. So, John, going

15 back, just so we clarify what was a part of the

16 diaphragm and, then, part of the chest, this is

17 helpful in terms of the adenopathy in the lung,

18 as far as CBD.

19 Then, the other question that you were

20 raising was the issue of extrapulmonary

21 sarcoidosis and pulmonary sarcoidosis. And a

22 couple of cases raised that question. Just in
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1 terms of my reading the literature and also

2 asking the opinion of several of our sarcoid ILD

3 specialists here about that question, I think the

4 feeling is that at least 90 percent of sarcoid

5 involves the lung. So, the great majority of

6 cases do.

7 Sometimes the pulmonary manifestation

8 may occur at a later point in time or the

9 extrapulmonary may be the most prominent

10 characteristic, so that is what is being focused

11 on. And also, there is nasal involvement or skin

12 involvement. That may be easier to actually

13 biopsy rather than going for something in the

14 lungs. So, the fact that one was diagnosed,

15 let's say, by a skin biopsy would not mean that

16 it wasn't pulmonary. It would mean that the skin

17 was the site of where they biopsied the

18 granulomas. I suspect that is a small

19 percentage, less than 10 percent, that may be

20 solely extrapulmonary.

21 And I think it is an issue because

22 there are claims that have been denied because of
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1 the feeling that they didn't have pulmonary

2 sarcoidosis. And so, it raises the question, to

3 have CBD, does sarcoid have to involve your

4 lungs? And I think most of us feel that CBD

5 involves pulmonary condition and that it should

6 involve the lungs.

7 MEMBER WELCH: Carrie, the thing is,

8 isn't it reasonable to presume that, if you have

9 a biopsy of the spinal cord or the skin that

10 shows granulomas and somebody has a positive LPT,

11 that they have, let's say, the diagnosis of

12 sarcoidosis based on that biopsy outside the

13 bone, that you can presume no involvement?

14 CHAIR REDLICH: Yes.

15 MEMBER WELCH: You know, you don't

16 have to have a --

17 CHAIR REDLICH: Yes, I think if there

18 is a positive BeLPT, wherever the biopsy is, then

19 it is chronic beryllium disease. I think the

20 more common scenario is, and where the questions

21 have come up is, where there is predominantly

22 extrapulmonary disease and the BeLPT is negative.
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1 The third case from the bottom is one

2 that falls into that category. And Laurie and I

3 have reviewed that. So, I think this just shows

4 what the problem is. And so, this was someone

5 who was diagnosed with skin sarcoid in 2012. 

6 They had worked starting in 1990 up until 2013 at

7 Savannah River Site at various locations.

8 And basically, the BeLPT was negative

9 by the nodes. There was a pulmonary diagnosis

10 for asthma. And so, this claim was denied.

11 Laura, you thought that was reasonable

12 because it appeared to be skin sarcoid. I looked

13 at the chest CT scan report that talked about

14 some slightly enlarged lymph nodes in the chest. 

15 I think these are the types of cases that bring

16 up, understandably, confusion. And the pulmonary

17 function testing was okay.

18 So, my take on this would be that,

19 yes, it is primarily skin sarcoid, and we have a

20 negative, we have a clear beryllium exposure

21 history and we have a negative BeLPT.

22 MEMBER WELCH: We don't have any
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1 evidence of any lung disease.

2 CHAIR REDLICH: Yes. And so, then,

3 what qualifies as -- I think where the gray zone

4 or the areas that get confusing, and where I

5 think it is worth discussing, is the

6 presumption -- you know, one option would be, and

7 I'm not advocating it, but the simplest option

8 would simply be to say sarcoid-confirmed

9 beryllium exposure diagnosis is CBD. That would

10 be the simplest, most straightforward. It could

11 conceivably include some people who had only, you

12 know, that small number of people with sarcoid,

13 that they had skin disease, but didn't have

14 actual pulmonary disease.

15 The other is try and define what we

16 mean by pulmonary involvement or pulmonary

17 disease.

18 MEMBER WELCH: I think whatever you

19 want to propose is fine. It is just there

20 probably won't be another case like this.

21 CHAIR REDLICH: There are a couple. 

22 Also, actually, Sue sent me a couple. So, I do
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1 think that the concept -- because I think it is

2 not that uncommon for the actual biopsy to be

3 taken from another site like the skin or the

4 nose.

5 MEMBER WELCH: Well, I think what I

6 would suggest is that it is the pulmonary doc, if

7 it is the doctor's diagnosis of lung involvement

8 in some way or another, they should accept it. 

9 They shouldn't require a biopsy of the lungs. 

10 But they do need something to say that there is

11 some involvement. But, then, they still have to

12 deal with CMC anyway. It is better that it comes

13 in with a note from the doctor. I don't think we

14 should say, if someone has a skin biopsy, you

15 automatically get accepted for a CBD claim. I

16 was going to use something else. That would be

17 my recommendation.

18 CHAIR REDLICH: Okay. Okay. And so,

19 the case that was shared with me and was actually

20 presented at last week at sort of a joint

21 conference was someone who had nasal sarcoid that

22 was biopsied, a negative BeLPT. Their BeLPT has
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1 been done on steroids. And the CT scan showed,

2 you know, hilar changes and some non-specific

3 stuff. The person's pulmonary function tests

4 were, quote, "normal". You know, a normal PFT,

5 you don't really know what the person was prior,

6 you know, whether it is truly normal for that

7 person.

8 But his feeling was that this was CBD

9 and that the person did have clear beryllium

10 exposure, the definite diagnosis of sarcoid, and

11 probable lung involvement, even though the PFTs

12 fell in the normal range. The case was denied

13 because the person didn't have -- the fallout was

14 that he didn't have pulmonary sarcoid. And it

15 does seem that whoever is reviewing the cases is

16 under the impression that the actual biopsy has

17 to be taken from the lung.

18 MEMBER MARKOWITZ: Well, this is

19 Steven.

20 Yes, I'm looking at the Act, the

21 statute, and it says that actually. It says "a

22 lung biopsy showing granulomas".
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1 But I think the general point you are

2 making is that finding of the typical granulomas

3 at other sites should be considered equivalent

4 finding the same in the lung, and I think that

5 that should be written up with a brief rationale

6 and unique, and submitted to them.

7 CHAIR REDLICH: Okay. I mean, I'm

8 okay with that. The issue that Laura raised I am

9 slightly ambivalent on in terms of, if we are

10 thinking about administering a claims program and

11 where there is a clear -- you know, there is a

12 diagnosis of sarcoid quite clear, but the

13 pulmonary component is less clear. A part of me

14 feels that, just from the simplicity of running

15 as a compensation system, if you just sort of

16 blanketly accepted all those, you probably would

17 have a few skin sarcoid cases that were not

18 beryllium disease versus all of the effort to go

19 through to educate people through all of the CT

20 scans, PFTs, and sort of argue about whether

21 there is actual pulmonary involvement.

22 So, I could actually argue both sides,
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1 that the time and cost involved in picking out

2 the few people who didn't have pulmonary

3 involvement just make it sort of a more general

4 presumption versus requesting documentation of

5 the pulmonary involvement.

6 MEMBER MARKOWITZ: Well, yes. This is

7 Steven.

8 But the problem, I might agree with

9 you, but the problem is being constrained by a

10 statute and what the statute says. So, the issue

11 of efficiency and cost-effectiveness, you know,

12 it is important, but there is this other

13 consideration. But I don't want to defend it.

14 CHAIR REDLICH: I think the fact is we

15 already have a problem with the issue of the

16 biopsy in the nose versus the lung, because how

17 do you interpret lung? So, that piece. You're

18 right, but I think what we could do is make

19 clear, because there is a misconception, and we

20 need to resolve that the lung actually has to be

21 what is biopsied versus --

22 MEMBER MARKOWITZ: I think we should
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1 move on.

2 CHAIR REDLICH: I think this is where

3 a lot of these cases run into issues because of

4 the sarcoid is diagnosed first. But, okay, and I

5 think that is about three or four of them on this

6 list.

7 Okay. The other cases, I would say

8 that there were several -- so, I would say the

9 number one, two, three, four, number five from

10 the bottom was an example of another issue that

11 came up on a couple. And Kirk has also reviewed

12 this one.

13 But it was basically where a diagnosis

14 of sarcoid had been made in the past, in 2008,

15 with a lung biopsy, and no BeLPT was done. The

16 person had worked at Savannah River Site from

17 1981 to 2005 as a clerical worker in multiple

18 different buildings.

19 The conclusion was that there was no

20 beryllium exposure. And so, that seemed that

21 there likely was beryllium exposure.

22 And I don't know if, Kirk, you wanted
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1 to comment on that one?

2 MEMBER DOMINA: Yes, I am trying to

3 pull it up here real quick, so I jar my memory.

4 CHAIR REDLICH: So, I think there were

5 several that fell into the category and where it

6 seemed pretty obvious that there should be

7 beryllium exposure. And these did not involve

8 SEM. One of them involved the same CMC.

9 So, I think that part, if we could

10 help clarify the beryllium exposure piece, that

11 would be helpful. So, maybe those cases should

12 also go to the Exposure Subcommittee.

13 MEMBER WELCH: Well, I don't know. I

14 don't think so. I mean, because beryllium

15 exposure is separate from the SEM discussions.

16 Do you know when that case was

17 reviewed?

18 CHAIR REDLICH: Yes, it was just in

19 like, it was recent, 2014. What I could do is

20 the ones that there was a question of no

21 beryllium exposure should be, you know, where it

22 seems like they are probably clearly was, to just
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1 be aware that that fell through the cracks;

2 that's all.

3 MEMBER WELCH: Yes, I don't know why

4 the CMC has concluded there is no beryllium

5 exposure at Savannah River. I don't know why.

6 CHAIR REDLICH: Yes.

7 MEMBER WELCH: John will remember it

8 better than me, but, you know, there wasn't a lot

9 of beryllium used at Savannah River. They didn't

10 have an issue, et cetera, et cetera. But, then,

11 we have had several people who were sensitized. 

12 Then, the staff within Savannah River did

13 identify some specific operations that used

14 beryllium for short periods of time. But I don't

15 think that it is reasonable to assume that the

16 people couldn't have been sensitized.

17 CHAIR REDLICH: Yes, because,

18 actually, there were several cases in this group

19 that were Savannah River with a positive BeLPT.

20 MEMBER WELCH: Actually, when I look

21 at it, most of these people are Savannah River. 

22 Almost every one of them who has got a job
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1 title --

2 CHAIR REDLICH: That's right.

3 MEMBER WELCH: -- for Savannah River

4 on the first page.

5 CHAIR REDLICH: Yes. Exactly. Okay. 

6 And so, I guess I think the ones that were denied

7 because of the beryllium piece, I mean, that has

8 to be, I think, an issue.

9 And then, as far as the presumption,

10 I think, how do people feel about simply the

11 option of -- at least what we recommend and sort

12 of the pulmonary involvement, or is simply a

13 diagnosis of sarcoid sufficient?

14 All right. And I think, then, we

15 would need to just define what we mean by

16 pulmonary involvement.

17 MEMBER WELCH: Well, to get a

18 diagnosis of CBD under the legislation, you have

19 to have lung involvement. And so, you have to

20 have --

21 CHAIR REDLICH: And is your

22 interpretation of lung involvement, okay, is your
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1 interpretation --

2 MEMBER WELCH: What I'm saying, not

3 where the biopsy comes from. To be accepted for

4 CBD, you have to have lung disease. That is

5 written right into the legislation; you have to

6 have lung disease.

7 And so, I don't think if you had a

8 skin biopsy that is sarcoid, I think it would be

9 a big stretch to get a presumption that turns

10 that into lung disease. I think it is possible

11 to say, if they have other lung disease and

12 sarcoid diagnoses from another location, you can

13 kind of make that case. But I think what you

14 were suggesting was that you could, if they had

15 sarcoid, wherever the biopsy was taken from, and

16 there is acceptance of their status, they should

17 be accepted CBD -- I think that can't happen,

18 given the legislation.

19 I don't think we should recommend

20 that, but I think you could recommend that a case

21 of -- that you could accept a diagnosis of

22 sarcoidosis is involved with the lung, even if
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1 the biopsy was from some other part of the body

2 if there is evidence of lung disease consistent

3 with charcoal of the lung.

4 CHAIR REDLICH: Okay, I'm fine with

5 that, but just the issue of -- just because of

6 this current being about the adenopathy, I think

7 a CT scan that showed hilar adenopathy that was 

8 consistent with sarcoid.

9 MEMBER WELCH: Yes, that's fine. And

10 I think the only way it is really going to work

11 is if there is a medical opinion that states

12 that. I mean, we can try to write it up as some

13 kind of presumption if it is worth doing. I

14 don't think that the way sarcoid and LPT has been

15 interpreted -- you know, generally, they want

16 somebody outside that says this is CBD.

17 CHAIR REDLICH: I reason is that I

18 think the current worry of lung involvement and

19 how they describe that is having involvement of

20 the lung parenchyma.

21 MEMBER WELCH: Not really.

22 CHAIR REDLICH: For post-1993, of all
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1 of the things that they describe as possible

2 patterns, they are interstitial things.

3 MEMBER WELCH: I think that we should

4 suggest that they interpret in the legislation

5 that, if there is a lung biopsy showing

6 granulomas, that lymph nodes that drain the lung

7 should be considered part of the lung.

8 CHAIR REDLICH: Yes, okay.

9 MEMBER WELCH: I think if you say it

10 that way -- don't say, you know, lymph nodes that

11 are by the chest -- just lymph nodes that drain

12 the lungs, it is going to be, don't you think? I

13 mean, that would be easier.

14 I got a case accepted, a case I opined

15 on, you know, to tell them that maybe a spinal

16 biopsy was the equivalent of a lung biopsy, and

17 they accepted in the case.

18 CHAIR REDLICH: Yes.

19 MEMBER WELCH: It was somebody who had

20 a possible --

21 CHAIR REDLICH: Okay. And I agree

22 with that. So, we're okay with the fact that
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1 adenopathy in the lung, because it is drains, it

2 is involved in the chest, is evidence of lung

3 involvement?

4 MEMBER WELCH: Yes.

5 CHAIR REDLICH: That would solve this

6 problem.

7 MEMBER WELCH: Because it would be

8 easier for them to be able to implement that if

9 we tried to say that those lymph nodes are really

10 part and parcel of the pathology in the lung.

11 CHAIR REDLICH: Okay. So, I think

12 that having that sort of one caveat about

13 pulmonary and, also, just clarify that the actual

14 diagnosis does not have to be based on lung

15 tissue if there is other evidence of lung

16 involvement which could be A, B, and C.

17 MEMBER MARKOWITZ: Well, you know, the

18 post-'93 criteria have these five variables that

19 you look at. You need three out of the five. 

20 One is lung pathology and the others rest on

21 other things which are reasonable.

22 CHAIR REDLICH: Yes, but none of those
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1 other things are, let's say, hilar adenopathy on

2 a chest x-ray.

3 MEMBER MARKOWITZ: I think one of them

4 is CT scan evidence. I'm trying to find it, but 

5 I think --

6 CHAIR REDLICH: It is, but it is other

7 things like diffuse nodules, tracheobronchitis. 

8 I am mentioning this because these are some cases

9 people brought to my attention that have been

10 denied because it might be the CT scan -- and

11 this was Dr. Sue's (sic) case -- said hilar

12 adenopathy, but not pulmonary fibrosis.

13 MEMBER MARKOWITZ: Well, you know --

14 this is Steven -- you know, DOL specifically

15 asked us for assistance in proper interpretation

16 of vague terms like "consistent with" and, yes,

17 "characteristic of," including some of those five

18 variables they looked at. So, that would be very

19 useful for us to focus on that.

20 CHAIR REDLICH: I'm good with that.

21 MEMBER MARKOWITZ: Yes.

22 CHAIR REDLICH: I think this would be
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1 simply solved by adding -- and that is actually

2 the most common thing that you see with sarcoid. 

3 So, that would just help simplify these, and it

4 would mean that there was pulmonary involvement. 

5 So, I think that would probably solve the great

6 majority of some of these what appear to be more

7 problematic cases.

8 MEMBER DEMENT: Yes, it will clarify

9 three of the ones that I flagged in my review.

10 CHAIR REDLICH: Okay. And everyone

11 else would be okay? We could clarify that the

12 biopsy could be from another site; there has to

13 be pulmonary involvement, which could be defined

14 by -- and the main additional criteria that would

15 be needed would be something like hilar

16 adenopathy.

17 Okay, great. And I think those and,

18 then, just the other issue that I think comes up

19 with some of these cases that could be addressed

20 in different ways is the scenario of the negative

21 BeLPT.

22 So, in thinking about this, if it is
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1 in a case that there is granulomas, one of the

2 ones we just discussed, the sarcoid diagnosis, we

3 have sort of dealt with that because, if there

4 was a presumption, you wouldn't need to have the

5 positive BeLPT.

6 The other scenarios I think right now

7 absolutely you have to, post-1993, the statute

8 about having positive beryllium incorporation

9 tests, they are sort of reading the wording there

10 two out, one being you are on steroids and the

11 other being you are dead and didn't have it done

12 or can't, you know, the blood test. And so, it

13 raises the question of adequate or are there

14 other reasons why there may be a negative test.

15 But, having said that, I think that issue comes

16 up more in the wording and not in the cases per

17 se.

18 So, are there any other issues that

19 anyone had that they want to discuss with any of

20 the particular cases that they reviewed?

21 MEMBER DEMENT: This is John.

22 I think one of the issues that was
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1 raised was the possibility of drilling exposure,

2 and I think was the very last case that I

3 reviewed. Or I think you reviewed it and I

4 reviewed it was well. I think that actually

5 hands down some of the language in the enabling

6 legislation about a covered facility. And we're

7 not going to have much impact on that one, you

8 know, the work at this Linde Ceramics Plant. I

9 think it was a question whether or not that was

10 truly a carbon facility for purposes of the

11 compensation program.

12 CHAIR REDLICH: Yes. You know what? 

13 I just turned that over, and you are correct. 

14 That person, this is someone, it was actually,

15 who was diagnosed in 1971 with sarcoids. The

16 description of the occupational history, when you

17 look at the questionnaire, it seems like there

18 was clearly beryllium exposure, but there was a

19 question, that's right, of whether -- that was my

20 interpretation of whether it was a covered

21 facility. I couldn't quite tell from the amount

22 of documentation we have whether someone thought
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1 there just wasn't any beryllium or it wasn't a

2 covered facility.

3 But it is, also, that he, then, died

4 and the death certificate, it was idiopathic

5 pulmonary fibrosis in 1992. And I think it is

6 clear that his sarcoid progressed to idiopathic

7 pulmonary fibrosis. So, by the time he died, it

8 was just labeled as that. It did raise the

9 question that IPS could be on a death

10 certificate. Okay.

11 MEMBER DEMENT: Yes, I think it is

12 probably, at least in mind, looking at it, there

13 is probably no question at least that he likely

14 at CBD. It is just I think the decision hinged

15 on the technicalities of the legislation.

16 CHAIR REDLICH: Okay. Yes, I've got

17 that. That is correct. I mean, I had the same,

18 and I don't think we can necessarily do anything

19 about that.

20 And then, just the one above that, two

21 above that is, again, the issue of the we already

22 discussed of it was denied because it was thought
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1 to be extrapulmonary sarcoid, but the CT scan

2 showed enlarged lymph nodes. So, that is another

3 example of the one that we just discussed.

4 And I think also what was clear was

5 that some of these were accepted because there

6 was a letter written that was by someone more

7 sort of knowledgeable that argued the case versus

8 someone that didn't specifically argue the case

9 in terms of sarcoid clear-cut exposure, but not a

10 sort of letter arguing for a diagnosis.

11 MEMBER MARKOWITZ: And this is Steven.

12 Was that variation among the CMCs or

13 was that there were differences between some

14 treating physicians and some CMCs, or some mix?

15 CHAIR REDLICH: Well, I think it was

16 more that there were people like National Jewish 

17 or Laura Welch, that those people could make the

18 case. And if someone like that didn't make the

19 case, then it wasn't made.

20 MEMBER MARKOWITZ: Okay.

21 CHAIR REDLICH: Because of the

22 probably confusion over the presumption. So, if
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1 the presumption, hopefully, could get clarified,

2 because it seems more the exception rather than

3 the rule that these cases were accepted.

4 Okay. What if we do this: I think

5 what happens is that sort of the sections that I

6 have highlighted in yellow on the actual manual,

7 we don't necessarily need to go through in

8 painful detail. But I think that that is why

9 some of them have been denied, because of this

10 lack of priority.

11 So, should we take -- it is already

12 four o'clock, after 4:00 -- should we take a

13 brief, five-minute break?

14 What I was hoping to do was to just

15 point out a couple of areas in these documents

16 that are just inconsistent, not that we are the

17 ones that want to rewrite that, but I think that

18 that may be part of what the problem is in sort

19 of implementing.

20 MEMBER MARKOWITZ: Why don't we take

21 a five-minute break?

22 MS. RHOADS: Okay, let's take a five-
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1 minute break. But it is not necessary for

2 anybody to disconnect or reconnect. Just put

3 your phones on mute and we'll come back at 4:20. 

4 All right?

5 CHAIR REDLICH: Okay. Okay.

6 MS. RHOADS: Thank you.

7 (Whereupon, the above-entitled matter

8 went off the record at 4:12 p.m. and resumed at

9 4:22 p.m.)

10 CHAIR REDLICH: The hour is already

11 late.

12 The other two items we have are as far

13 as the sarcoid presumption and the original

14 request.

15 I didn't end up sending around the

16 edited. I thought I had, but I realized before

17 this meeting that I don't believe I had sent it.

18 Our basic recommendation for a

19 presumption is already actually in the current

20 document, but where I wanted to see if we were

21 clear on was -- in the current, it is one of the

22 documents that was sent again, the presumption
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1 for B. I have to put it in front of me. It

2 basically says that it is a presumption of --

3 let's just read it, if someone has it.

4 It has sarcoid as the presumption of

5 beryllium disease, and that part is

6 straightforward. It, then, says, however, you

7 have to meet the requirement of either B or it,

8 basically, says, however, then, you have to

9 satisfy the criteria for pre- or post-CBD.

10 So, that is sort of a contradictory

11 statement. Because if you have a presumption,

12 then you don't necessarily need to fulfill the

13 criteria. To me, if you looked at the EEOICPA

14 circular from 2008, it basically says, the first

15 paragraph, the purpose of a circular is to notify

16 everyone that a diagnosis of sarcoid is not

17 medically-appropriate if there is a history of

18 beryllium exposure. In these situations it seems

19 to consider sarcoids to be a diagnosis of CBD.

20 And then, there is this sentence,

21 "However, the application of this presumption in

22 the adjudication of a claim will differ between
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1 Parts B and E of the Act." And then, it goes

2 through the B and the E.

3 So, from our discussions, my

4 understanding of presumption would be there was

5 beryllium exposure; there was a clear diagnosis

6 of sarcoids that involved the lung. And we

7 discussed how the lung was involved, period.

8 Does that seem reasonable to

9 everybody?

10 MEMBER WELCH: Medically, that would

11 be reasonable. Whether, given the statute, that

12 could be implemented -- I mean, I think what we

13 see is, bending over backwards, is how to get

14 around the requirements that beryllium

15 sensitivity be present to diagnose CBD. Because

16 the statute says beryllium sensitivity together

17 with lung pathology consistent with chronic

18 beryllium disease.

19 So, if it is in the statute, then they

20 have kind of come up with the roles in which, if

21 the LPT is negative, getting off into the history

22 of previous ones and, you know, make a good-faith
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1 effort to determine when the beryllium

2 sensitivity is present.

3 CHAIR REDLICH: So, what I am

4 wondering is if we would propose a presumption

5 that was a careful statement of sarcoid

6 exposure/lung involvement.

7 MEMBER WELCH: Beryllium

8 exposure/sarcoid diagnosis.

9 CHAIR REDLICH: Yes, and with some

10 evidence of the chest involved.

11 MEMBER WELCH: And that would be

12 accepted as CBD.

13 CHAIR REDLICH: Right, that that would

14 be if we are giving a recommendation.

15 MEMBER WELCH: Right. But I think

16 that to have that be accepted as CBD they have to

17 change the legislation.

18 CHAIR REDLICH: But I just think that

19 there is a difference between proposing that as a

20 presumption, because the amount of work to go

21 through what basically ends up -- I mean,

22 requesting a first be negative, then a second
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1 negative BeLPT with a letter from the doctor

2 stating you were on steroids. I mean, it seems

3 to me we could make a recommendation that we

4 think there should be this presumption. If the

5 lawyers, and whatever, feel that that is not

6 consistent, then, to me, that would be at least

7 worth trying. If they say, no, this doesn't meet

8 -- you know, we need A, B, and C, then we

9 could --

10 MEMBER WELCH: I think that is a good

11 idea.

12 CHAIR REDLICH: Because I think we had

13 talked about presumption would -- maybe there is

14 more openness now after 9/11 and other such

15 things to the process of a presumption.

16 MEMBER WELCH: I think you should --

17 why don't we write up the presumption? And then,

18 we could vote on it. And then, we will submit it

19 and find out what happens. Because, otherwise,

20 we will just talk about this forever.

21 CHAIR REDLICH: Okay. I would say

22 that the presumption would basically be the
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1 sentence that is already written. So, we could

2 just use what has already been written, but just

3 leave out it's Circular, you know, 8-07, and we

4 just stop the presumption with "however".

5 MEMBER WELCH: Can you write

6 something?

7 CHAIR REDLICH: Yes, I could, exactly. 

8 And then, I was going to say, if we try that

9 presumption and the fact, then, was not accepted,

10 then we could through the gyrations of how to get

11 around the negative BeLPT.

12 Because what I was unclear of -- and

13 maybe someone else on the phone knows -- I was

14 unclear of all this complicated wording about

15 having to redo the BeLPT and all of this, when in

16 the bottom line, if there was a way around it,

17 people would try to do that or is that merely

18 done to mandate as far as the law.

19 MEMBER WELCH: I don't really

20 understand what you just said.

21 CHAIR REDLICH: Well, the thing is the

22 extent of language that is so confusing to
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1 everyone about, you know, you could have a

2 negative if you document on steroids, but, first,

3 you have to get a second one and, then, document

4 you're on steroids. Was that really all put in

5 there because a lawyer or someone felt that was

6 the only way it would be in compliance with the

7 Act? Or was that just how this had evolved in

8 terms of direction for the --

9 MEMBER WELCH: We would have to ask --

10 MEMBER MARKOWITZ: This is Steven.

11 Let me just ask a process question for

12 a moment. So, we have about 30 minutes left. I

13 don't know how much more there is on the agenda. 

14 But, if there is other stuff we want to cover,

15 then maybe we should move on and just look at a

16 draft of the thinking.

17 CHAIR REDLICH: Okay. So, that's

18 fine. Why do we do this, then: I would favor us

19 doing a draft of what we think is the best thing. 

20 And whether it is in compliance with the Act, we

21 need that as a secondary condition. I mean, we

22 first just recommend what we think would be best
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1 and vote on that.

2 MEMBER MARKOWITZ: We will leave it as

3 consequential condition, right.

4 CHAIR REDLICH: But not presuming we

5 can't have a presumption ahead of time, right. 

6 Well, that won't be in compliance with the Act,

7 so we can't recommend that?

8 MEMBER WELCH: Well, I think we just

9 propose a presumption as you suggested and see

10 what happens.

11 CHAIR REDLICH: Okay. I'm sorry, my

12 screen froze in terms of bringing it up.

13 I think that at this point it was the

14 justification piece that we wanted clarification.

15 MS. RHOADS: Dr. Redlich, it sounds

16 like you're going in and out of the recording.

17 CHAIR REDLICH: Okay. Because I'm

18 having trouble hearing with the background noise.

19 MS. RHOADS: Yes. Does everyone have

20 their phones on mute?

21 CHAIR REDLICH: It's quieter now.

22 MS. RHOADS: All right. It sounds
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1 quieter to me, too.

2 CHAIR REDLICH: Okay. So, as a

3 process, I would suggest that I will send around

4 a presumption based on our discussion. And then,

5 the question is voting on that.

6 Steve, are you there?

7 MEMBER MARKOWITZ: Yes, I am here. I

8 am here. I was just on mute.

9 CHAIR REDLICH: Okay. So, could we

10 have voted on the presumption?

11 I'm freezing my computer.

12 But we had gotten, I think, in terms

13 of why to justify it as far as potentially the

14 Act.

15 MEMBER MARKOWITZ: Yes, I think you

16 should send around a draft.

17 CHAIR REDLICH: Okay.

18 MEMBER MARKOWITZ: And then, we come

19 to consensus about that. Then, we can figure out

20 the next step.

21 CHAIR REDLICH: I think, then, we

22 would be clearer on the presumption. The
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1 questions I have that I wanted on consensus on in

2 terms of, you know, I think we're clear on.

3 Then, the other piece, the questions

4 that this letter addressed that we had received

5 and our original document, the original

6 Subcommittee draft, I apologize because I thought

7 I had sent around the comments and

8 recommendations for those questions that had been

9 asked, and I did not.

10 So, I think that we have actually

11 discussed almost every point on the original

12 request. One that wouldn't come up that we

13 haven't, Laurie, was the indeterminate BeLPTs. 

14 And, Laurie, I was hoping you could address that

15 question.

16 MEMBER WELCH: Well, I had sent back

17 a note about the borderline.

18 CHAIR REDLICH: And that is

19 borderline, yes.

20 MEMBER WELCH: Borderline, because

21 indeterminates and uninterpretable are

22 definitions.
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1 The modeling done by -- I can't think

2 of his name -- Middleton --

3 MEMBER MARKOWITZ: Middleton, yes.

4 MEMBER WELCH: -- that suggested that

5 three borderlines is the equivalent of one

6 abnormal and one borderline. I mean, we could

7 recommend either three borderlines or two

8 borderlines -- we would have to just send the

9 paper around -- is the equivalent of a single

10 positive. Because, apparently, a number of

11 workers have multiple borderlines, and I think

12 those should be accepted as sensitive.

13 CHAIR REDLICH: That's right. And

14 there was one of the cases that we reviewed that

15 had that scenario, and there was a letter that

16 addressed it also that was effective.

17 MEMBER WELCH: Okay.

18 CHAIR REDLICH: And so, one of those

19 cases, just as you said, that other case was an

20 example of how to address it.

21 MEMBER WELCH: Yes. Do you know which

22 one it was, so I can take a look at that and see
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1 if it helps? Well, I will just write up

2 something and send it to you, Carrie.

3 CHAIR REDLICH: And I will send around

4 the document that addressed the other questions

5 that were asked, which I think we have really

6 been over just about every one of them.

7 To me, the problem that has happened

8 I think is that the description in the circular

9 of directions actually is internally sort of

10 inconsistent in the way that is written. And so,

11 I think we could just, I was thinking we could

12 point out the pieces that we found to be

13 inconsistent because I think that that is part of

14 the problem, and even the PowerPoint description

15 which has, then, created the confusion for a lot

16 of the cases.

17 MEMBER MARKOWITZ: This is Steven.

18 So, I had a question. In the draft

19 responses to the questions that DOL asked of us,

20 it seems like a bunch of the problems in the past

21 have stemmed from the language of the Act which

22 is transferred over to the Policy Manual, you
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1 know, words like "characteristic," characteristic

2 chest x-ray findings" or "clinical course

3 consistent with chronic respiratory disease,"

4 that these are very vague terms. But the

5 Procedure Manual puts some definitions to them,

6 but the question is, should the details be in

7 some sense modified, expanded? Are they too

8 restrictive in the way that these terms are

9 interpreted? So, my question really, Carrie, is

10 whether the draft response, whether we take on

11 that specific issue of the "consistent with" and

12 "characteristic" language.

13 CHAIR REDLICH: Well, the thing is I

14 looked over and, generally speaking, I think most

15 of the wording, there were just one or two areas,

16 such as like the CT scan that actually doesn't

17 mention hilar adenopathy. So, I think that there

18 are a few areas where there could be

19 clarification.

20 In looking over these cases, I think

21 where the problem is -- and I was trying to

22 think, if you are giving a manual, about to do
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1 this -- it is not so much finding 10 other things

2 to write down, there are already so many of the

3 characteristics of the CT scan. And I started to

4 make a little chart of this.

5 So, if you have, let's say, a positive

6 BeLPT and you've got abnormal restrictive low

7 BLCO, PFTs, with a positive BeLPT, there is a

8 comment you need A, B, and C, but there is,

9 actually, a caveat that you don't have to have

10 the biopsy.

11 In other words, I think the problem is

12 that you have got a clear positive BeLPT and you

13 have got a interstitial lung process. Then, that

14 is really enough in terms of -- and there is a

15 caveat for that, which is, you know, that

16 basically we already give this out. And so, in a

17 way, then, like the same thing with the sarcoid,

18 if there is a presumption that you don't have a

19 positive BeLPT, you don't have to get into all

20 the variations about that BeLPT. So, I think

21 that some of these cases have gotten lost in the

22 weeds of one little piece of it, which, if you
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1 step back, you actually met the criteria.

2 MEMBER MARKOWITZ: This is Steven.

3 I assume the problem in the past has

4 been where CBD claims have been denied because

5 their criteria haven't been met. And then, there

6 are different views of whether the criteria have

7 been met or not.

8 And I'm looking at the list, the

9 summary list of cases, and it looks like the

10 cases of the CBD cases that were provided, there

11 were a total of four, and all of them were

12 accepted. Then, I wonder whether we get some

13 insight if we looked at some CBD cases that were

14 refused, denied, and the issue was that they

15 didn't meet the -- the issue wasn't primarily

16 BeLPT, but it was these other problem areas of

17 "consistent with clinical course,"

18 "characteristic of".

19 CHAIR REDLICH: Yes. You know what? 

20 We had listed the ones that people felt were

21 worth discussing. There were some that were

22 denied because it was clear-cut.
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1 So, I think that a common denial,

2 looking at all them, is interstitial lung

3 disease, sarcoid, with a negative BeLPT. And

4 that one we discussed. So, I think that is the

5 biggest batch of the ones that are denied. And

6 so, that is how the presumption would help with

7 that.

8 And then, the other ones, when they

9 are in -- to clarify, it already gives the option

10 of where you may not have been able to get lung

11 tissue.

12 Meeting what they were wording, it

13 turns out that there is actually quite a list. I

14 think some of the cases it looked like it was

15 more of the CMC's interpretation of it rather

16 than what is in the wording. Because, currently,

17 other than I have added one or two words that

18 were just really to make that simpler, but it is

19 pretty much already a rather thorough list of

20 "characteristic of".

21 Okay?

22 MEMBER MARKOWITZ: Yes, yes, I hear
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1 you. I hear you.

2 CHAIR REDLICH: That's what I didn't

3 do -- there were two more words, but it is almost

4 like it is A, B, C, D, E, F, and G. And there

5 aren't that many other things that a biopsy could

6 look like. And then, it is how the CMC is, then,

7 interpreting that information.

8 So, I think part of that would be

9 helpful to send. I think that the oversight of

10 some of the CMCs is where part of the problem is.

11 MEMBER MARKOWITZ: So, you're saying

12 it was the way the CMCs applied the --

13 CHAIR REDLICH: That's right.

14 MEMBER MARKOWITZ: Right. Okay.

15 CHAIR REDLICH: And it leaves a number

16 if there were one single CMC.

17 But what if I send around -- I mean,

18 I have drawn the wording in one or two places. 

19 But, as you noted, already under CT scan there is

20 a long list of things.

21 MEMBER MARKOWITZ: Right.

22 CHAIR REDLICH: It is the same for
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1 chest x-ray.

2 And so, what is happening is just more

3 ability to put together these different pieces of

4 information in terms of some basic common sense.

5 Also, the cases that I have heard from

6 other physicians who put a complaint to me, and I

7 had asked them to send me cases that have been

8 denied, all of those have been in the setting of

9 a negative BeLPT. And so, I think that issue, I

10 personally feel like right now it already worded

11 you could have a negative BeLPT if you are on

12 steroids. And I think that that wording could be

13 slightly tweaked or this can happen in other

14 conditions such to open that opportunity. 

15 Because it may be that the person doesn't know

16 for sure whether the person was on steroids or

17 not at the time the BeLPT was done. So, I think

18 that, if all the other components were -- I think

19 that is really where the issue is there.

20 Then, the other issue is the cause of

21 the BeLPT where the evidence of actual lung

22 disease is very minimal. That, I think there is
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1 a category of beryllium sensitization. I think

2 that that goes into that bucket. If it

3 progresses to beryllium disease, then it would

4 create a claim. And so, someone who basically

5 has beryllium sensitization and no other lung

6 disease, it is denied. That I think is not an

7 understanding of it is sensitization and not CBD.

8 Okay. In terms of our agenda, I think

9 we have been over the presumption, the cases, the

10 original request. In terms of additional data or

11 information needs, I have heard from the field

12 that we have gotten a relatively good feel for

13 what is happening in many of these cases.

14 John, I don't know if you felt that

15 additional information or data on the data

16 side --

17 MEMBER DEMENT: I don't think it is

18 going to clarify anything for us. I think we

19 have got some issues that we need to really start

20 with developing some presumptions and clarifying

21 some categories of lung involvement. But, other

22 than that, I don't think the new data is going to
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1 help.

2 You know, where we have learned the

3 most is from the denied cases that we have gone

4 into detail, and not the ones that have been

5 approved. I think, for the most part, because I

6 went through the approved cases, I didn't have

7 any problem with most of the approvals.

8 CHAIR REDLICH: I think that what

9 might be helpful would be maybe 10 or 20 more

10 denied cases. We don't need any more approved

11 ones.

12 MEMBER DEMENT: I don't know if that

13 is going to help.

14 Laura, what do you think in terms of

15 reviewing additional cases? Is that going to

16 clarify issues for us?

17 MEMBER WELCH: No, I don't this so.

18 MEMBER DEMENT: I think we need to

19 start putting stuff on paper and --

20 CHAIR REDLICH: I'm okay with not

21 another, and I think I agree.

22 The other area that I think there is
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1 a problem with is -- and I think we should just

2 mention it -- just the denials because of the

3 question of really whether there was beryllium

4 exposure. But we could address by clarifying the

5 exposure side. But I agree; I think we can

6 define the presumption and clarify the "such

7 as...."

8 I also feel that, you know, that's

9 true; I was only thinking more cases, as some of

10 them are -- I somehow feel that it would be good,

11 that it is the education of the people carrying

12 it out, and that the cases, I think all of us

13 just putting in a bucket the cases that were

14 denied that we disagree with, I think that

15 whoever is actually doing the work or overseeing

16 it and the quality of it should review some of

17 the cases. And we could make that a

18 recommendation because I think the way to realize

19 is to give some examples of we disagree with this

20 final decision and these are the reasons.

21 MEMBER MARKOWITZ: Well, this is

22 Steven.
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1 So, that would be important to

2 articulate that as a recommendation, and not just

3 put it over onto the IH and CMC Subcommittees. 

4 Because if it is a finding of this Subcommittee,

5 you know, in addition to that Committee, it is a

6 little bit stronger.

7 Another separate point is that we have

8 skirted a little bit of this issue of documented

9 beryllium exposure. If we are not clear about

10 how they apply that, we should ask for

11 clarification.

12 CHAIR REDLICH: I just think, you

13 know, that clarification of --

14 MEMBER MARKOWITZ: You know, there is

15 a point at which they require documented

16 beryllium exposure. I can't remember where it is

17 exactly, but we saw it today. And then, we saw a

18 case in which a clerical worker was denied based

19 on no exposure. So, I think we should ask for

20 clarification about how they apply the term.

21 CHAIR REDLICH: Okay. And I was also 

22 unclear on a couple of them where the
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1 determination was no beryllium. I wasn't quite

2 clear where that came from, at which point.

3 MEMBER WELCH: That would be in the

4 statement of accepted facts or something. And

5 then, I think it is the claims examiner that

6 makes that determination.

7 CHAIR REDLICH: Okay.

8 MEMBER WELCH: But somebody may have

9 to go back and look at those files, I think. I

10 don't think I looked at those.

11 CHAIR REDLICH: Okay. It seems to me

12 personally that, again, I was under the

13 assumption that there was some presumptions with

14 beryllium, but I think is where the problem

15 arises, because, oh, this person worked in an

16 office, so they didn't have beryllium exposure. 

17 So, we probably want clarification of that

18 determination.

19 MEMBER MARKOWITZ: This is Steven.

20 A separate comment. So, how many

21 denied CBD cases have we had the opportunity to

22 look at?
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1 CHAIR REDLICH: I think there were 10,

2 some of which were sarcoid cases that were

3 denied. There was a total of 10. I had picked

4 out the ones that there was a question. I think

5 that the sarcoid and those have to be lumped

6 together with the sarcoid as denied CBD cases. I

7 could make a list of the reason for each denial

8 and whether we agreed with it. At least half of

9 them were sarcoids that the presumption was,

10 hopefully, addressed. And then, with the others,

11 some of them were probably appropriate and some

12 were the question of exposure.

13 MEMBER MARKOWITZ: This is Steven.

14 The other comment I have is one of the

15 other subcommittees focused in on kind of getting

16 a summary of the public comments in relation to

17 the issues they were looking at. And I know

18 there were a number of public comments on

19 beryllium, particularly at the first meeting. It

20 might be useful to get -- I don't know how we

21 achieve this exactly; I'm speaking to Carrie

22 Rhoads here -- but to get a summary of some of
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1 those comments, so that if there are issues that

2 have not yet been discussed that should be

3 discussed, we should make sure that we cover

4 them.

5 CHAIR REDLICH: Okay.

6 MS. RHOADS: Excuse me.

7 The other Subcommittee from last week

8 went over all the public comments from the

9 October meeting. Are you talking about the

10 public comments from the April meeting also? 

11 Because I don't think anybody has gone over them

12 from before.

13 MEMBER MARKOWITZ: Yes. I know there

14 were a bunch of comments --

15 MS. RHOADS: Yes.

16 MEMBER MARKOWITZ: -- in April about

17 beryllium.

18 MS. RHOADS: Okay. I can read over

19 those and send you a list or page numbers, or

20 something, of when people mentioned them, if you

21 would like.

22 CHAIR REDLICH: Okay.
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1 MEMBER MARKOWITZ: Yes, that would be

2 a good start, yes.

3 MS. RHOADS: Okay.

4 CHAIR REDLICH: Then, we can use the

5 ones that were similar and make sure we have

6 addressed them.

7 But your point I think is about the

8 CMC, I mean in terms of just not understanding. 

9 Like there was someone who wrote that, well, a

10 chest x-ray 10 years earlier didn't show

11 silicosis. Well, if it happened, it should have

12 been present 10 years earlier because that was

13 closer to when they were at work. That is just

14 not understanding chronic pneumoconiosis. So,

15 the problem there isn't what is written in any of

16 the sort of guidance, but it is the person giving

17 the opinion.

18 MEMBER MARKOWITZ: Right. This is

19 Steven. So, yes, if that is a finding of the

20 group, incompetence on the part of the CMCs for

21 this application, then that should be pointed

22 out.
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1 CHAIR REDLICH: Okay. Or the concept

2 that there was misconception on several of them

3 that, if you had extrapulmonary sarcoid, it could

4 not be CBD. So, that is different, having

5 extrapulmonary and pulmonary, meaning, well, the

6 extrapulmonary just excludes you. So, that is

7 something that could be clarified. But I have

8 started to feel like clarifying every one of

9 these, I think if you had a process where you

10 reviewed the quality of the CMCs and got rid of

11 the bad ones, that that would be more effective

12 than anticipating everything that they might do

13 that doesn't necessarily make sense.

14 MEMBER MARKOWITZ: Sure.

15 CHAIR REDLICH: I had requested -- and

16 I guess this is not available -- I was sort of

17 curious, for this whole group of diseases, my

18 understanding is questions we have asked about

19 the CMCs, we haven't gotten a lot of information

20 on. Because if you look at the total number of

21 cases in the pulmonary realm, it is not that

22 huge.
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1 And if they had three or four good

2 CMCs that could handle that volume of claims, but

3 if we knew how many they were using, and even if

4 you looked at if they had these 10, I understand

5 you can't give a percentage acceptance rate for

6 each one because of the conditions, the questions

7 that are asked. But you could ask, on the basis

8 of their report, was it accepted or denied, and

9 someone could review as a group, you know, this

10 A, B, C from those A, B, C different CMCs.

11 So, we could put that in a

12 recommendation, because I really feel that the

13 review of the CMCs' disease conditions, if there

14 were problems with them, then one could educate

15 that person and, then, the oversight of that,

16 because they are really a little bit more

17 formulaic if the person sort of understands the

18 disease process.

19 MEMBER VLIEGER: Dr. Redlich, this is

20 Faye here. I have been listening in the whole

21 time, and I beg the Committee's indulgence.

22 I did present Kirk and my findings of
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1 the review of the first two disks, and that one

2 particular doctor was being sent the CBD cases,

3 and his usual answer was no. And I presented

4 that information at the October meeting.

5 So, I think they are trying to funnel

6 them to one or two doctors. Unfortunately, the

7 outcome from those doctors presently is not what

8 we would expect.

9 CHAIR REDLICH: Exactly.

10 MEMBER VLIEGER: And then, one final

11 thing and, then, I'll give you back to your

12 Committee work. In my discussions with claims

13 examiners, when they referred to a CMC for a lung

14 condition or for CBD, I asked them, are they made

15 aware of the provisions in the law and in the

16 Procedure Manual? And I'm always told they get

17 training to be a CMC; it's not our job to tell

18 them how to do their job.

19 So, many times what we see in the CBD

20 decisions is that they are following their

21 medical school training and not the provisions

22 under the law, in that they are requiring four or
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1 five conditions in order to be diagnosed versus

2 the positive blood test and two items.

3 So, I think part of it is you may have

4 good CMCs out there, but they are not given all

5 the guidance they need in order to do the

6 adjudication under this program.

7 CHAIR REDLICH: Thank you. I agree.

8 So, I guess we could make a

9 recommendation with the other Subcommittee on the

10 specific areas that we are concerned about the

11 CMCs as it relates to the Part B condition.

12 MEMBER VLIEGER: Yes, I would think

13 that would be appropriate.

14 CHAIR REDLICH: Okay. And any that I

15 had collected I think the ones where there was a

16 problem -- but, if anyone else has one where they

17 are concerned about the CMC, I think we could

18 flag those because I may omit some.

19 Would it be okay if we passed those to

20 the CMC Committee?

21 MEMBER MARKOWITZ: I'm sorry, what do

22 you want to pass off to them?
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1 CHAIR REDLICH: Would that be okay to

2 show them which of the CMC reports that we have

3 concerns about?

4 MEMBER MARKOWITZ: Sure. That would

5 be great.

6 This is Steven.

7 CHAIR REDLICH: Okay. So, I will do

8 that. If anyone could just email me the number

9 of the ones, in case I missed any of them that

10 they noticed, because there could have been a

11 problem with that where you didn't flag the whole

12 chart?

13 Okay. I think we have covered -- so,

14 I will send out the draft responses that I have

15 later today and, also, the sarcoid presumption

16 draft.

17 And then, Carrie, you're going to sum

18 up the different comments?

19 MS. RHOADS: Yes, I will take a look

20 at the public comments from the April meeting and

21 send you a list of where they talk about CBD.

22 CHAIR REDLICH: Okay. And right now,
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1 for now, we have sufficient data. Okay.

2 Other new items, anyone?

3 (No response.)

4 Okay. Thank you. I know this was

5 very long and it got a little detailed, but it

6 was helpful for me to see where I think we got

7 consensus on what the issues are with the cases

8 that we reviewed.

9 Okay. Any other issues/comments?

10 (No response.)

11 So, should we just go, then -- people,

12 we could do edits to the draft as far as the

13 sarcoid and the response to their initial

14 comments? And do that, all right, we send it by

15 email to Carrie?

16 MEMBER WELCH: You mean for the

17 presumption proposal?

18 CHAIR REDLICH: That's right. Carrie

19 will send it out and, then, we could just

20 circulate edits to it.

21 MEMBER WELCH: Okay.

22 CHAIR REDLICH: And the same with the
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1 response, initial response to their questions

2 that they had asked.

3 And I think what would be helpful for

4 me is if people just add any areas that they feel

5 we need much further explanations, because some

6 of them I was just brief on.

7 Okay. Any other? Any other comments?

8 (No response.)

9 Carrie, are you here?

10 MS. RHOADS: Yes.

11 CHAIR REDLICH: Okay. Does anyone

12 have any other items?

13 (No response.)

14 So, we are done? Last chance.

15 Steve?

16 (No response.)

17 Oh, Carrie, still working on Carrie?

18 (Interruption by phone.)

19 MS. RHOADS: I think we just heard Dr.

20 Markowitz's hold music.

21 MEMBER MARKOWITZ: I'm sorry. Yes. 

22 No, I'm sorry. I'm sorry. I'm back. I made a
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1 mistake.

2 (Laughter.)

3 CHAIR REDLICH: Okay. Okay. So, I

4 guess we're done. I just wanted to check if you

5 have anything else.

6 MEMBER MARKOWITZ: No. Sorry about

7 that. No, it's fine.

8 CHAIR REDLICH: Okay. I think we have

9 a plan. I thank everybody for all the time.

10 MEMBER MARKOWITZ: Thank you.

11 CHAIR REDLICH: And I would just

12 reiterate the problem of the CMCs. I don't know

13 how it gets fixed, but we can raise that.

14 MEMBER MARKOWITZ: Right.

15 CHAIR REDLICH: Okay. Thank you.

16 MEMBER MARKOWITZ: Okay. Bye now.

17 MS. RHOADS: Thanks, everybody.

18 (Whereupon, the above-entitled matter

19 went off the record at 5:12 p.m.)

20

21

22
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A

ability 94:3

able 69:8 92:10

abnormal 87:6 90:6

above-entitled 77:7

110:18

absolutely 26:16,17

30:12 72:7

accept 58:8 66:21

acceptance 20:22 38:8

66:16 104:5

accepted 12:17 14:15

15:18,21 16:21 21:5

21:11,20,21 22:3 27:5

27:6,18 28:6,22 29:19

30:10 31:3,5,22 32:6

36:14 37:4 40:8,8,20

41:4 47:18 48:9,14

51:1 58:15 60:16 66:3

66:17 68:14,17 75:5

76:3 80:12,16 82:9

87:12 91:12 99:4

104:8

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accurate 8:3

achieve 100:21

acknowledged 36:13

36:17

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84:6 85:14 88:21

actual 11:8 39:11 47:10

49:11,15,22 57:14

58:2 59:16 60:21

69:13 76:6 94:21

acute 19:15

add 26:3 109:4

added 47:22 92:17

adding 35:20 71:1

addition 98:5

additional 24:4 41:9

71:14 95:10,15 96:15

address 10:16 17:20

51:17 86:14 87:20

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addressed 71:19 86:4

87:16 88:4 100:10

102:6

addresses 9:9

addressing 46:22

adenopathy 48:12

53:17 67:6,7 69:1

70:1,12 71:16 89:17

adequate 18:5 72:13

Adjourn 3:16

adjudication 78:22

106:6

administering 60:10

admission 20:4

advance 6:21

Advisory 1:3 2:11 4:6

7:16 8:21 9:12

advocating 57:7

agenda 7:2 10:1 83:13

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68:21 96:21 97:5

106:7

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agreed 49:18 100:8

agreement 49:9

agrees 50:18

ahead 84:5

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allows 6:2

altogether 27:12

aluminum 22:20 23:1,1

24:17 30:6 32:9

ambivalent 60:9

Amchitka 28:14

amount 10:10 73:21

80:20

angio 21:15

answer 18:17 31:10

33:10 41:8 49:1 105:3

answered 33:9

anticipating 103:12

anybody 77:2 101:11

anyway 23:18 41:14

58:12

apologize 86:6

apparently 32:7 87:10

appear 71:6

appeared 48:11 56:12

appears 45:4

application 78:21

102:21

applied 14:8 93:12

apply 98:10,20

appreciate 4:11

approach 40:12

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100:11 106:13

appropriately 36:4

approvals 96:7

approved 96:5,6,10

April 7:16 101:10,16

107:20

area 1:6 25:1 96:22

areas 49:21 57:4 76:15

89:15,18 91:16

106:10 109:4

argue 60:20,22 75:8

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arguing 75:10

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articulate 98:2

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70:15 86:9 88:5,19

94:7 103:18 104:7

105:14 109:2

asking 54:2

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assessment 30:6 31:15

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associated 23:13,14

26:1 37:7

association 22:14

assume 64:15 91:3

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Assuming 41:7

assumption 99:13

assure 26:4

asthma 21:14 56:10

Atomic 5:7

attention 70:9

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automatically 58:15

autopsy 19:17

available 6:9 8:10,18

19:21 36:16,22

103:16

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B 1:6 3:6,9 4:8 9:13

16:5 27:8 28:13 30:1

30:19 37:13 38:8,12

38:18 39:9 69:16 78:1

78:7 79:1,2 81:8 90:8

93:4 104:10,10

106:11

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77:3 86:16 91:1 99:9

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backwards 79:13

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based 12:4 21:18 22:17

22:22 29:20 30:3

52:10 55:12 69:14

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basic 47:2 77:18 94:4

basically 21:12 36:12

36:21 37:13 48:1,12

53:10 56:8 62:13 78:2

78:8,14 80:21 81:22

90:16 95:4

basis 104:7

batch 92:5

Bee 24:6

beg 104:21

believable 29:16

believe 77:17

belonging 39:12

BeLPT 14:9,11 15:21

17:2,9,22 18:11 20:12

21:10 47:5 48:13

52:22 55:18,22 56:8

56:21 58:22,22 62:15

64:19 71:21 72:5 81:1

82:11,15 90:6,7,12,19

90:20 91:16 92:3 94:9

94:11,17,21

BeLPTs 48:4 86:13

bending 79:13

berylliosis 19:15

beryllium 10:18 12:20

14:1 42:19 55:19

56:20 57:9 59:9 60:18

62:20,21 63:7,10,14

63:21 64:4,9,14 65:7

72:8 73:18 74:1 78:5

78:18 79:5,14,16,18

80:1,7 95:1,3,5 97:3

98:9,16 99:1,14,16

100:19 101:17

beryllium-sensitive

12:13

best 10:2 16:6 29:15

53:6 83:19,22

better 58:12 64:8

big 33:5 66:9

bigger 52:17

biggest 92:5

biopsied 49:15 54:17

58:22 61:21

biopsy 47:10 48:2

49:12 50:2,3,7,20,21

54:13,15 55:9,12,18

58:2,9,14 59:16,22

61:16 62:15 66:3,8,15

67:1 68:5,16,16 71:12

90:10 93:5

bit 10:19 12:1 13:19

21:14 24:13 39:15

53:12 98:6,8 104:16

bizarre 24:16

bladder 38:11,14

blanketly 60:16

BLCO 90:7

block 20:13

blood 72:12 106:2

Board 1:3 2:11 4:6,12

4:15,17 5:17 6:9,14

7:9,16,20 8:11,21 9:2

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borderline 86:17,19,20

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Boston 20:2

bottom 43:1 56:1 62:10

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brief 60:5 76:13 109:6

bring 27:1 33:14 44:21

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brought 70:9

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buildings 5:12 62:18

bunch 88:20 101:14

busted 52:8

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C

C 69:16 81:8 90:8 93:4

104:10,10

calculated 29:21

calendar 8:11

call 3:2,4 4:17 5:15 15:2

30:3 52:3

call-in 7:12

called 50:1

cancer 38:11,14

capacity 9:1

carbon 73:10

cardiopulmonary 40:2

careful 80:5

carefully 45:18

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4:4,19 15:10 22:11

25:14 32:11,17 38:5

40:17 50:8 55:7 88:2

89:9 100:21 107:17

108:15,18 109:9,17

109:17

carrying 97:11

case 9:9 11:12 12:11

13:11,13,21 14:19,21

15:7,12,17,18,21

16:21 17:1,20 19:12

19:14 20:10 22:9

23:21 24:19 26:3

27:11 29:8,13,15

30:10 37:16 38:10,12

39:1 40:8 41:8 43:8

43:21 44:1,11 45:9

46:5 47:14,18 48:14

51:14 56:1 57:20

58:19 59:12 63:16

66:13,20 68:14,14,17

70:11 72:1 73:2 75:7

75:8,18,19 87:19

98:18 107:9

cases 3:6,7 10:8,11,21

11:2 12:21 13:6,14

19:9 22:18,21 23:3,16

23:19 24:8,11 25:12

25:15 26:5,8 28:18

29:18 31:13,20 32:4

33:16 34:8 36:1,8

38:1 41:12,16,20 43:4

45:11 46:21 53:22

54:6 56:15 59:15

60:17 62:3,7 63:11

64:18 70:8 71:7,19

72:16,20 76:3 87:14

87:19 88:16 89:20

90:21 91:9,10,10,13

92:14 94:5,7 95:9,13

96:3,6,10,15 97:9,12

97:13,17 99:21 100:2

100:6 103:21 105:2

108:7

categories 24:3 25:3

95:21

category 25:8 56:2 63:5

95:1

cause 28:9 38:7,20 40:1

40:2,4 44:7 94:20

caveat 69:12 90:9,15

CBD 13:14 14:8 15:18

16:22 17:5 19:15,18

20:9,15,18 41:16

42:18 43:5 50:6 53:18

55:3,4 57:9 58:15

59:8 65:18 66:4,17

67:16 74:14 78:19

79:15 80:12,16 91:4

91:10,13 95:7 99:21

100:6 103:4 105:2,14

105:19 107:21

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certain 29:5 34:16,19

42:11

certificate 38:21 40:1

43:15,22 44:5,7,13

45:5,7 74:4,10

certified 8:9

cetera 64:10,10

chance 19:21 39:9

109:14

change 26:10 40:11,14

80:17

changes 23:4 59:2

characteristic 54:10

70:17 89:1,1,12 91:18

92:20

characteristics 31:7

90:3

charcoal 67:3

chart 90:4 107:12

check 11:7 39:16 110:4

checking 21:7

chest 23:2 26:9,13

38:17 48:17 49:13,17

53:16 56:13,14 68:11

69:2 70:2 80:10 89:2

94:1 102:10

chronic 55:19 79:17

89:3 102:14

chronologic 11:5

chronological 11:7

circular 78:14,15 82:3

88:8

circulate 108:20

City 5:20

claim 12:16 19:17,18

21:6,16 27:18,21 28:6

33:9 36:14 37:3,10

48:10 56:10 58:15

78:22 95:4

CLAIMANT 2:7

claims 22:3 25:17 31:21

54:22 60:10 91:4 99:5

104:2 105:12

clarification 84:14

89:19 98:11,13,20

99:17

clarified 76:1 103:7

clarify 21:6 53:15 63:10

69:13 71:8,11 92:9

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clarifying 95:20 97:4

103:8

clarity 50:12 51:18

classification 22:17

clear 24:14 25:2 27:19

44:7 56:20 59:9 60:11

60:12,13 61:19 74:6

75:4 77:21 79:5 86:2

90:12 98:9 99:2

clear-cut 13:17 15:6

18:15 75:9 91:22

clearer 85:22

clearly 7:22 16:5 27:8

63:22 73:18

clerical 62:17 98:18

clicking 6:18

clinical 25:11 89:2

91:17

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closer 102:13

CMC 21:18 22:22 23:9

31:18 32:1,19,20 33:1

33:3,7,14 35:3 36:9

37:19 38:1,2,15,16

39:6 41:2 58:12 63:8

64:4 93:6,16 98:3

102:8 105:13,17

106:17,20 107:2

CMC's 92:15

CMCs 26:21 42:11

75:12,14 93:10,12

102:20 103:10,19

104:2,10 106:4,11

110:12

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come 24:9 30:14 32:19

33:20 34:9 55:21 77:3

79:20 85:18 86:12

comes 58:12 66:3

71:18 72:15

comment 7:11 22:8

63:1 90:8 99:20

100:14

comments 6:9 24:4

43:2 86:7 100:16,18

101:1,8,10,14 107:18

107:20 108:14 109:7

Committee 23:12 25:5

33:3 34:5 38:2 98:5

105:12 106:20

Committee's 104:21

committees 10:10

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45:21 55:20 71:2 92:1

94:4

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compensation 60:15

73:11

complaint 94:6

completed 32:12

completely 49:3

compliance 83:6,20

84:6

complicated 82:14

complications 38:14

39:12

component 27:19

60:13

components 94:18

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conceivably 57:11

concept 58:1 103:1

concern 52:16

concerned 12:6 106:10

106:17

concerns 11:14 107:3

concluded 64:4

conclusion 24:10 33:20

40:11 62:19

conclusions 32:20

condition 16:5 21:19

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conference 58:21

confusing 10:20 16:10

43:12 48:8 57:4 82:22

confusion 10:7 20:10

27:16 43:14,17 46:8

46:15 47:13 56:16

75:22 88:15

consensus 85:19 86:1

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consideration 30:7

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consistent 22:6 23:4

30:2 67:2,8 70:16

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91:17

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continue 9:5 52:3

contractor 6:4 33:8

contradictory 78:10

contribute 36:11 37:1

contributed 38:7

contributing 40:4,14

control 29:3

convene 9:11

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24:10 30:15 31:16

42:7 43:8 47:22 73:13

74:17

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correctly 15:19

cost 61:1

cost-effectiveness

61:11

Council 5:7

counterproductive

24:13

couple 26:17 34:10

47:6 53:22 57:21,22

62:11 76:15 98:22

course 89:2 91:17

cover 83:14 101:3

covered 28:13,16 31:1

73:6,20 74:2 107:13

cracks 64:1

create 95:4

created 10:7 88:15

creates 31:22

criteria 17:14 69:18

71:14 78:9,13 91:1,5

91:6

cryptic 12:1

CT 17:3 56:13 59:1

60:19 67:7 70:4,10

75:1 89:16 90:3 93:19

curious 103:17

current 18:5,21 19:1,3

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currently 92:16

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D

D 2:8 93:4

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data 95:10,15,15,22

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day 8:14

days 8:11,19

dead 72:11

deal 58:12

dealt 72:3

death 28:10 36:12 37:1

38:7,20,21 40:1,1,2,5

43:14,22 44:5,7,8,12

45:5,6 74:4,9

DECEMBER 1:11

decide 40:13

decision 11:15 17:17

39:6 40:15 41:3 74:14

97:20

decision-making 42:10

42:12

decisions 105:20

dedicated 6:19

defend 61:13

defense 38:15

define 57:15 65:15 97:6

defined 29:10 71:13

definite 59:10

definition 31:1

definitions 86:22 89:5

degree 49:2

delay 42:18

Dement 2:3 5:2,3 22:11

24:18 26:7 28:20

29:13 30:13 31:19

32:10 34:12 35:1,13

36:2 38:4 39:4,7

44:10,16 45:10 47:17

48:5,18 71:8 72:21

74:11 95:17 96:12,18

demise 39:11

demonstrates 19:8

denial 30:5 92:1 100:7

denials 97:2

denied 14:9,21 21:7,13

21:18 30:4,10,19

41:17,20 54:22 56:10

59:12 65:6 70:10

74:22 76:9 91:4,14,22

92:5 94:8 95:6 96:3

96:10 97:14 98:18

99:21 100:3,6 104:8

deny 37:3,9

Department 1:1 4:6

31:5

depends 30:21

describe 67:19 68:1

description 17:16 24:3

73:16 88:8,14

Designated 2:17 3:3

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desk 43:15

despite 23:8

detail 6:5 11:12 30:7

76:8 96:4

detailed 8:17 108:5

details 42:13 89:6

determination 37:14

47:20 99:1,6,18

determine 40:4 80:1

developing 95:20

DFO 4:9 8:8

diagnose 79:15

diagnosed 14:4 19:15

54:14 56:5 62:4 73:15

106:1

diagnoses 66:12

diagnosis 12:14 13:20

15:7,20 20:13,14,18

23:9,15 26:13 34:20

36:7 42:19 55:11 56:9

57:9 58:7 59:10 60:12

62:13 65:13,18 66:21

69:14 72:2 75:10

78:16,19 79:5 80:8

diaphragm 53:16

died 74:3,7

dies 13:10 37:6

differ 78:22

difference 80:19

differences 75:13

different 16:8 38:17

44:12,17 45:5,12

53:12 62:18 71:20

91:6 94:3 103:4

104:10 107:18

difficult 39:2 40:3

diffuse 70:7

direction 83:8

directions 88:9

Director 9:20

Director's 14:14 15:12

15:15 16:10

disagree 97:14,19

discern 39:3

disclosure 9:3

disconnect 77:2

discuss 72:19

discussed 9:3,6,10

41:22 72:2 74:22 75:3

79:7 86:11 92:4 101:2

101:3

discussing 57:5 91:21

discussion 6:2,13 7:14

11:22 51:12 85:4

discussions 7:20 8:3

63:15 79:3 105:12

disease 17:7,11,12 21:3

27:14 36:11,19 37:1

55:19,22 57:1,13,14

57:17 60:18 66:4,6,10

66:11 67:2 78:5 79:18

89:3 92:3 94:22 95:3

95:6 104:13,18

diseases 36:19 103:17

disk 43:13 44:20

disks 105:1

distinguish 27:11

distinguishing 51:13

DLCO 17:6

doc 58:6

doctor 17:22 18:9 58:13

81:1 105:2

doctor's 58:7

doctors 105:6,7

document 53:1 77:20

83:2,3 86:5 88:4

documentation 31:4

61:4 73:22

documented 98:8,15

documents 6:12 9:10

45:19 49:11 76:15

77:22

doing 6:5 37:18 67:13

83:19 97:15

DOL 70:14 88:19

dol.gov/owcp/energy...

6:15

Domina 2:8 5:5,6,6 43:7

43:11 44:6,14,18 45:8

45:16,20 46:4,7,13,17

63:2

Dr 1:18 4:19,21 5:2,9,16

9:14 20:2 70:11 84:15

104:19 109:19

draft 83:16,19 85:16

86:6 88:18 89:10

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drain 68:6,11

drains 69:1

drawn 93:18

drilling 73:1

duct 27:9

Duke 5:3

dust 24:5,15

dying 36:20

E

E 30:14,19 79:1,2 93:4

earlier 39:15,16 102:10

102:12

easier 11:4 25:19 54:12

68:13 69:8

easily 41:1

Eastern 1:18 6:1

easy 26:3

edited 77:16

edits 108:12,20

educate 60:19 104:14

educating 36:4

education 97:11

EEOICPA 78:13

effective 87:16 103:11

efficiency 61:11

efficient 34:14

effort 14:17 15:5,8

60:18 80:1

either 14:22 27:6 42:1

78:7 87:7

email 7:5 107:8 108:15

employee 6:5

employees 9:1 18:5

employment 24:4 31:7

enabling 73:5

encourage 6:17

ended 11:2 14:21 21:8

36:20

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energyadvisoryboar...

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enlarged 56:14 75:2

entirely 6:19

Environmental 9:21

Epidemiology 5:19

equivalent 50:3 60:3

68:16 87:5,9

especially 8:1 45:20

essential 31:13

et 64:10,10

event 31:12

eventually 14:13

everybody 4:3 79:9

110:9,17

everyone's 12:5

evidence 17:10 50:5

57:1 67:2 69:2,15

70:4 80:10 94:21

EVIDENTIARY 1:5

evolved 83:7

exact 17:13

exactly 19:4 31:8 34:6

35:7,9 65:5 82:7

98:17 100:21 105:9

examiner 25:17 31:22

99:5

examiners 105:13

example 13:13,14

14:15 15:3,5 20:9

35:16 62:10 75:3

87:20

examples 34:10 97:19

exception 76:2

exclude 35:16

excludes 103:6

excuse 21:8 46:5 101:6

exists 10:5

expanded 89:7

expect 17:7 105:8

expertise 52:11

explain 16:6 21:10

explanations 109:5

exposure 14:1 18:1

20:11 22:9,19,20 23:2

24:15,15,17,22 25:2

25:18 27:10 29:4,15

29:21 30:4,6 31:15

32:5,16,22 34:18

35:17 47:3 56:20 57:9

59:10 62:20,21 63:7

63:10,12,15,21 64:5

73:1,18 75:9 78:18

79:5 97:4,5 98:9,16

98:19 99:16 100:12

exposure/lung 80:6

exposure/sarcoid 80:8

exposures 29:16

extent 82:22

extra-pulmonary 21:3

extrapulmonary 47:7,8

53:20 54:9,20 55:22

75:1 103:3,5,6

eyes 46:19

F

F 93:4

FACA 8:12

facilities 9:9

facility 73:6,10,21 74:2

fact 17:1 43:13 54:14

61:14 68:22 82:9

facts 31:22 32:6,8

40:20 99:4

fallout 59:13

falls 56:2

far 10:1 11:17 12:16

46:4,22 48:8 51:18

53:18 65:9 77:12

82:18 85:13 108:12

favor 83:18

Faye 2:14 104:20

Federal 2:17 3:3 4:9

feel 32:18 33:9 35:8

41:11 50:11 55:4

65:10 81:5 94:10

95:12 97:8,10 103:8

104:12 109:4

feeling 41:10 54:4 55:1

59:8

feels 60:14

fell 59:12 63:5 64:1

felt 25:12 37:7 83:5

91:20 95:14

female 43:15,22

fibrosis 35:11 36:18

70:12 74:5,7

field 95:11

fifth 28:22

figure 53:7 85:19

file 44:10 45:13

filed 19:18

files 99:9

filled 12:5

film 26:13

films 38:18

final 11:15 40:15 42:16

97:20 105:10

finalized 41:4

finally 14:15 42:18

find 7:1 16:19 26:20

28:19 31:8 40:16 70:4

81:19

finding 41:12 60:2,4

90:1 98:4 102:19

findings 17:22 89:2

104:22

fine 12:4 57:19 67:4,9

83:18 110:7

finish 41:15

first 4:11 12:11 23:19

47:14 62:4 65:4 78:14

80:22 83:2,22 100:19

105:1

five 23:19 33:21 62:9

69:18,19 70:17 106:1

five- 76:22

five-minute 76:13,21

fixed 41:22 42:3 110:13

flag 106:18 107:11

flagged 71:9

focus 70:19

focused 54:10 100:15

folliculitis 21:15

follow 6:13 45:1

following 15:9 105:20

forever 81:20

form 12:5

formal 8:15

former 18:21

formulaic 104:17

forward 14:18 15:1

found 14:7 16:7 22:20

23:7 88:12

four 28:21 48:3 62:5,9

76:12 91:11 104:1

105:22

freezing 85:11

front 78:1

froze 84:12

fulfill 78:12

function 36:16,21 37:8

48:11 56:17 59:3

functionally 17:11

funnel 105:5

further 109:5

G

G 93:4

general 9:7 23:22 42:8

60:1 61:3

generally 12:22 42:20

46:11 67:15 89:14

getting 35:21 49:7,14

79:21 100:15

give 52:9 53:6 90:16

97:19 104:5 105:11

given 6:21 13:6 25:10

37:8 42:13 53:3,10

66:18 79:11 106:4

gives 40:19 92:9

giving 80:14 89:22

102:16

glass 17:5

goal 19:13

good-faith 79:22

gotten 85:12 90:21

95:12 103:19

government 9:1

gran 47:10

granuloma 48:2

granulomas 14:7,11

47:4 50:22 54:18

55:10 59:22 60:2 68:6

72:1

gray 57:3

ground 17:5

group 6:6 13:14 41:18

64:18 102:20 103:17

104:9

groups 43:6

guess 15:2 21:6 23:18
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106:8 110:4

guidance 102:16 106:5

guide 11:22

gyrations 82:10

H

half 33:15 44:22 100:8

handle 104:2

hands 73:5

Hanford 5:6

happen 66:17 94:13

happened 45:13 88:7

102:11

happening 18:14 94:2

95:13

happens 76:5 81:19

84:10

head 39:20

heading 6:10

Health 1:3 4:7 9:13

hear 92:22 93:1

heard 94:5 95:11

109:19

hearing 8:6 12:16 32:3

84:18

heart 36:19

heavily 26:2

Hello 4:3 28:11

help 35:22 36:5,7 63:10

71:3 92:6 96:1,13

helpful 10:12 13:18

41:13 46:21 49:8

53:17 63:11 93:9 96:9

108:6 109:3

helps 88:1

Hi 5:18

high 29:16

higher 26:10

highlighted 49:22 76:6

hilar 48:11 49:15 59:2

67:7 70:1,11 71:15

89:17

hindsight 13:9

hinged 74:14

historic 19:13

history 14:1 18:1,10

32:13 47:3 56:21

73:16 78:17 79:21

hit 32:11

hold 35:2 44:4 109:20

hoops 14:16

hope 35:5

hopefully 14:17 40:10

76:1 100:10

hoping 76:14 86:14

hour 77:10

huge 10:10 103:22

hurdle 52:17

I

idea 81:11

identified 31:14

identify 19:6 64:13

idiopathic 74:4,6

IH 98:3

ILD 3:7 22:3,10 43:5

54:2

illustrates 13:16

ILS-1 27:13

imagine 20:3

immediate 17:19

immunosuppressive

14:5

impact 73:7

implement 69:8

implementation 10:6

implemented 79:12

implementing 76:19

important 27:10 35:21

61:12 98:1

impressed 24:1

impression 59:16

include 9:7 57:11

included 12:19 25:18

35:18

including 9:4 39:12

70:17

incompetence 102:20

inconsistent 76:16

88:10,13

incorporation 72:8

increases 36:18

independently 40:13

indeterminate 13:4

48:3,12 86:13

indeterminates 86:21

indicated 10:22

indicative 50:22

individual 39:9 45:22

individuals 23:17

indulgence 104:21

information 7:12 9:8

12:7 23:2 24:9 25:10

93:7 94:4 95:11,15

103:19 105:4

infrequently 45:14

initial 20:4,21 108:13

109:1

initially 14:9

insight 91:13

instances 32:12

instructions 7:2 50:1

interactive 7:8

interest 19:14

interested 19:13

internally 88:9

interpret 15:4 61:17

68:4

interpretation 51:19

53:10 65:22 66:1

70:15 73:20 92:15

interpreted 52:7 67:15

89:9

interpreting 33:19 93:7

Interruption 109:18

interstitial 17:7,10,11

68:2 90:13 92:2

introduce 4:15

introduction 4:18

Introductions 3:4

involve 55:3,6 63:7

involved 46:1 47:10

61:1 63:8 66:22 69:2

79:6,7 80:10

involvement 48:16 49:3

54:11,12 55:13 57:16

58:7,11 59:11 60:21

61:3,5 65:12,16,19,22

67:18,19 69:3,16 71:4

71:13 80:6 95:21

involves 32:21 54:5

55:5

involving 48:21

IPS 74:9

ischemic 36:18

issue 8:6 13:3 17:19

21:3 22:6,8 26:7

27:17 29:2,8 32:11

33:13 36:9 42:8,9

44:2 47:7 52:12 53:20

54:21 60:8 61:10,15

62:10 64:10 65:8 67:5

71:18 72:15 74:21

89:11 91:14,15 94:9

94:19,20 98:8

issues 10:17 13:7 22:12

22:16 23:6,11 39:13

39:20 45:2 46:22

47:13 52:18 62:3

72:18,22 95:19 96:16

100:17 101:1 108:7

issues/comments

108:9

items 3:14 77:12 106:2

108:2 109:12

J

James 5:14

jar 63:3

Jewish 75:16

job 22:17 24:3 25:3,8

32:14,14 34:14,19

64:22 105:17,18

jobs 24:21 25:10

John 2:3 5:2 22:7 27:3

29:11 35:14 45:6

47:15 53:14 64:7

72:21 95:14

joining 7:6 9:17,22

joint 58:20

justification 84:14

justify 85:13

K

keep 11:6

key 10:17 17:8 42:14

Kirk 2:8 5:5,6 43:2

62:11,22 104:22

knew 25:7 104:3

knowledgeable 14:22

25:16 75:7

known 23:14

knows 82:13

L

labeled 74:8

Labor 1:1 31:5

Labor's 4:6

lack 76:10

lag 39:18

laid 15:19 16:4

language 16:8,12 52:1

52:5,8,12 73:5 82:22

88:21 89:12

large 33:16

late 77:11

Laughter 33:4 110:2

Laura 2:6 5:9 42:2

50:18 56:11 60:8

75:17 96:14

Laurie 5:10 11:19 12:12

13:12 15:11 56:2

86:13,14

law 82:18 105:15,22

lawyer 83:5

lawyers 81:5

layout 16:11

lays 15:13

learned 96:2

leave 13:5 82:3 84:2

leaves 93:15

left 83:12

legislation 65:18 66:5

66:18 68:4 73:6 74:15

80:17

Leiton 15:16

lesion 37:16

let's 41:15 52:21 54:15

55:11 70:1 76:22 78:3

90:5
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lies 37:16

limitation 31:13

Linde 73:8

line 4:21 5:17 7:21

39:17 43:1 82:16

list 11:6,9 13:12 22:1,19

36:8 38:5 47:14 48:20

62:6 91:8,9 92:13,19

93:20 100:7 101:19

107:21

listed 12:12 13:13

19:12 91:20

listen-in 7:13

listening 104:20

listing 6:11

literature 25:1 54:1

little 10:19 12:1 13:19

21:14 24:13 41:11

43:12 46:8 53:11 90:4

90:22 98:6,8 104:16

108:5

location 20:7 24:3

66:12

locations 28:15 56:7

long 93:20 108:5

look 11:8 16:3 21:17

24:22 26:19 32:12,14

38:10,21 43:17 52:2

64:20 69:19 73:17

83:15 87:22 93:6 99:9

99:22 103:20 107:19

looked 24:19 28:18,18

30:5 38:4,16 47:15,17

48:20 56:12 70:18

78:13 89:14 91:13

92:14 99:10 104:4

looking 39:22 43:13

59:20 74:12 89:20

91:8 92:2 100:17

looks 91:9

Los 14:3

loss 12:16

lost 41:11 90:21

lot 10:7 24:15 35:15

36:1 62:3 64:8 88:15

103:19

low 17:6 90:6

LPT 55:10 67:14 79:21

lumped 100:5

lung 1:6 4:8 9:13 17:7

17:10,11 27:14 48:9

48:10,16,16 49:3,12

49:12,14,15 50:3,5,7

51:14 53:17 54:5 57:1

58:7 59:11,17,22 60:4

61:16,17,20 62:15

65:19,22 66:4,6,10,11

66:22 67:2,3,18,20

68:5,6,7,16 69:1,2,10

69:14,15,20 79:6,7,17

90:13 92:2,10 94:21

95:5,21 105:13

lungs 49:17 54:14 55:4

55:6 58:9 68:12

lymph 48:8,17 50:2,6

50:21 51:13,15 56:14

68:6,10,11 69:9 75:2

M

M 2:3

machine 37:6

main 21:19 41:19 71:14

majority 54:5 71:6

making 42:18 44:22

60:2

male 43:16 44:1

mandate 82:18

manifestation 54:7

manual 16:9 33:18,20

33:21 49:12 50:1

51:11 76:6 88:22 89:5

89:22 105:16

marginal 29:15

marker 12:20

markings 27:13

Markowitz 2:13 5:16,18

5:19 18:20 19:3 28:11

31:11 40:17 50:8,14

51:3,8,20 52:14 53:2

53:5,13 59:18 61:6,22

69:17 70:3,13,21

75:11,20 76:20 83:10

84:2 85:7,15,18 87:3

88:17 91:2 92:22

93:11,14,21 97:21

98:14 99:19 100:13

101:13,16 102:1,18

103:14 106:21 107:4

109:21 110:6,10,14

110:16

Markowitz's 109:20

material 6:20

materials 6:8,22 8:22

9:6

Materion 18:3

matter 33:18 77:7

110:18

mean 16:3,14 26:17

27:20 28:1 30:22

32:20 35:4 37:4 39:5

40:22 41:16 44:20

45:21 46:4 54:15,16

57:16 60:7 63:14 65:7

65:15 67:12 68:13

71:4 74:17 79:12

80:21 81:2 83:21 87:6

93:17 102:8 108:16

meaning 40:19 103:5

meant 15:15

mediastinal 50:2,6,21

medical 2:4 5:4,12 9:21

26:12 31:4 39:20

44:11 67:11 105:21

Medically 79:10

medically-appropriate

78:17

medicine 5:19 9:19

meet 5:22 17:15 29:22

30:22 78:7 81:7 91:15

meeting 1:8 4:5,10,13

6:7,8,11,18,19,21

7:16,19 8:2,10 9:4,5

9:11 44:21 77:17

92:12 100:19 101:9

101:10 105:4 107:20

meetings 6:10 7:15,17

Melissa 6:3

members 2:1,11 4:12

4:15 5:1 7:9 8:21 9:2

memory 63:3

mention 16:22 38:19

47:16 51:15 89:17

97:2

mentioned 50:2 101:20

mentioning 37:11 70:8

merely 82:17

messages 42:14

met 1:17 17:13 91:1,5,7

Metal 5:7

metastatic 39:13

Middleton 87:2,3

mind 74:12

mine 29:7 32:15 34:15

miner 25:9 26:12 30:22

32:4,21

mines 24:21 25:3

minimal 94:22

minimum 29:6

mining 22:14,20 23:14

24:20 25:22 36:5

minute 77:1

minutes 7:18 8:8,10,15

83:12

misconception 61:19

103:2

missed 15:20 107:9

mistake 110:1

mix 39:17 75:14

mixed 23:17

modeling 87:1

modified 89:7

moment 83:12

months 29:7,9,10,21

months' 35:17

move 15:1 43:3 62:1

83:15

moving 14:17

mucker 32:15

multiple 62:17 87:11

music 109:20

mute 77:3 84:20 85:8

muted 7:9

N

name 4:4 8:2 34:9 87:2

named 9:10

names 9:9 45:21 46:12

Nancy 20:2

nasal 54:11 58:21

National 75:16

nature 8:18

necessarily 17:12 22:4

27:16 29:3 33:22 34:8

37:17 74:18 76:7

78:12 103:13

necessary 77:1

need 22:4 24:22 25:13

31:10 41:6 49:4 58:10

61:20 65:15 69:19

72:4 76:7 78:12 81:8

83:21 90:8 95:19

96:10,18 106:5 109:5

needed 25:7 71:15

needing 51:17

needs 23:12 24:19

42:11 95:11

negative 13:2 14:10,12

20:12 21:10 55:22

56:8,20,21 58:22

71:20 72:14 79:21

80:22 81:1 82:11 83:2

92:3 94:9,11

Neither 31:17

Nevada 28:14

new 3:14 5:20 40:19

95:22 108:2

node 48:17 49:15 50:2

50:6,21 51:14,15

nodes 48:8 56:9,14

68:6,10,11 69:9 75:2

nodules 70:7

noise 84:18

non-Advisory 7:9

non-pulmonary 49:5

non-specific 59:2

normal 15:21 48:10

59:4,4,6,12

Norman 6:4
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notable 17:19 24:11

note 7:7,10 33:3 58:13

86:17

noted 19:18 22:13 48:3

48:15 93:19

notes 11:22 20:19,21

28:21

notice 46:11

noticed 107:10

notify 78:15

NSIP 17:5

number 10:7,11 11:8,13

14:20 20:22 22:9 25:9

29:7,10,20 32:15,19

33:16,16 34:14,16,19

35:9 43:21 45:9 52:7

52:18 57:12 62:9,9

87:10 93:15 100:18

103:20 107:8

numbered 11:6

numbers 46:16 101:19

O

o'clock 76:12

obtained 18:1,10

obvious 25:20,21 63:6

obviously 8:17 43:16

52:17

occupational 5:11,19

9:19,20 32:2,13 73:16

occur 54:8

October 101:9 105:4

office 99:16

Officer 4:9

Official 2:17 3:3

old 19:21

omit 106:18

ones 10:14,21 12:21

22:1,10 24:1 26:19

41:17 43:5 47:1 48:19

63:20 65:6 71:9 72:2

76:17 79:22 91:20

92:5,8 96:4,11 100:4

102:5 103:11 106:15

107:9

ongoing 18:9,13 19:8

open 7:17 94:14

Opening 3:2,5

openness 81:14

operations 64:13

opined 22:22 23:10

68:14

opinion 53:6 54:2 67:11

102:17

opinions 33:7

opportunity 94:14

99:21

optimal 40:12

option 57:6,7 65:11

92:9

order 3:2 11:5,7 106:1,5

organizationally 10:13

organize 10:13

original 11:9 20:20

53:12 77:13 86:5,5,11

95:10

outcome 105:7

outside 55:12 67:16

overlap 11:2

overseeing 97:15

oversight 93:9 104:15

OWCP 6:5

P

P-R-O-C-E-E-D-I-N-G-S

4:1

p.m 1:18 4:2 77:8,9

110:19

page 6:19 65:4 101:19

painful 76:8

paper 87:9 96:19

paragraph 78:15

parcel 69:10

parenchyma 67:20

parenchymal 23:3

part 1:6 3:6,9 4:8 9:13

27:16 28:13 30:14

32:7 33:11 38:8 49:13

49:16 53:15,16 60:13

63:9 67:1 68:7 69:10

76:18 78:5 88:13 93:8

93:10 96:5 102:20

106:3,11

participate 7:14

participating 7:3,3

particular 26:3 27:11

29:13 32:19 47:19

72:20 105:2

particularly 100:19

Parts 79:1

pass 12:17 37:22 38:2

51:4 106:22

passed 106:19

path 19:22

pathology 17:16 50:6

69:10,20 79:17

patient 12:14 14:5

pattern 17:4

patterns 68:2

people 10:22 32:13

45:21 46:15 49:18

57:11,12 60:19 61:2

64:11,16,21 65:10

70:9 75:16,17 82:17

91:20 97:11 101:20

108:11 109:4

percent 54:4,19

percentage 54:19 104:5

perceptive 17:21

perfusion 26:10

period 29:5 79:7

periods 64:14

person 14:19 17:5 18:2

18:11 20:5,10,13,18

29:22 33:19 35:18

36:10,12,20 37:14,18

38:8,10,13 41:4 45:5

45:12,19 59:5,7,9,13

62:16 73:14 94:15,16

99:15 102:16 104:15

104:17

person's 34:9 36:22

59:3

personally 18:10 48:17

50:11 94:10 99:12

personally-identifiable

9:8

petty 49:9

PFT 59:4

PFTs 59:11 60:20 90:7

phone 82:13 109:18

phones 7:8 77:3 84:20

physician 5:11 9:20

32:2 49:1

physicians 25:16 36:5

75:14 94:6

pick 10:14

picked 100:3

picking 61:1

picture 25:11

piece 21:13 61:17 63:10

65:7 84:14 86:3 90:22

pieces 88:12 94:3

placeholder 16:15

places 46:12 93:18

plan 11:18 110:9

Plant 73:8

please 7:4,6,10,21 8:2,5

9:4

pleural 23:3

plus 44:11

pneumoconiosis 23:5

23:9,15,17 27:5,9

30:3 35:10 36:11,15

37:14 38:6,9,19,22

42:2 43:9 102:14

pneumonia 20:4 38:11

38:15

point 11:12 17:8 20:16

40:7 41:20 45:18

49:10 51:10 54:8 60:1

76:15 84:13 86:11

88:12 98:7,15 99:2

102:7

pointed 27:13 102:21

points 10:16

policy 16:5 17:14 88:22

poor 37:9

positive 13:1 17:2,9

52:22 55:10,18 64:19

72:5,8 87:10 90:5,7

90:12,19 106:2

possibility 35:16 39:13

73:1

possible 35:17 66:10

68:1,20

post- 50:4

post-'93 69:18

post-1993 67:22 72:7

post-CBD 78:9

posted 7:12

potentially 85:13

PowerPoint 88:14

practice 32:7

practicing 51:5

pre- 78:9

preclude 49:2

predominantly 55:21

prepared 7:19 8:9,16

preparing 4:12

present 2:11 79:15 80:2

102:12 104:22

presented 58:20 105:3

presently 105:7

presiding 1:19

presume 55:8,13

presumed 47:4

presuming 84:4

presumption 3:10 10:3

10:5,6,17 13:15,18

15:3,6,22 16:9 34:19

35:1,8,12,14,19,22

36:3,7 42:1 47:1 48:1

57:6 61:4 65:9 66:9

67:13 72:4 75:22 76:1

77:13,19,22 78:2,4,11

78:21 79:4 80:4,20

81:4,13,15,17,22 82:4

82:9 84:5,9 85:4,10

85:22 90:18 92:6 95:9

97:6 100:9 107:15

108:17

presumptions 95:20

99:13

pretty 25:2 38:12 63:6

92:19

previous 79:22

previously 40:16

primarily 48:21 56:19

91:15

prior 21:16 27:17 36:13
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21:22 40:11 57:20

60:16 63:22 71:5

74:12,13 75:22 99:17

100:11

problem 7:4 13:17 31:3

33:5 34:2,11 41:18,21

43:19 47:19 49:18

52:2 56:4 61:8,9,15

69:6 76:18 88:7,14

89:21 90:11 91:3,16

93:10 96:7 97:1 99:14

102:15 106:16 107:11

110:12

problematic 33:17 39:1

71:7

problems 22:2 25:15

88:20 104:14

Procedure 16:8 89:5

105:16

process 11:15 25:19

26:5 31:21 35:3,15

40:9,10,16 42:12

81:15 83:11 85:3

90:13 103:9 104:18

program 5:12 9:21 18:2

60:10 73:11 106:6

progressed 74:6

progresses 95:3

prominent 54:9

proof 51:5

proper 45:19 70:15

properly 31:14

proposal 108:17

propose 57:19 80:4

84:9

proposing 80:19

provided 6:22 8:22 24:2

91:10

provisions 105:15,21

public 6:8 7:11,13,18

9:2 100:16,18 101:8

101:10 107:20

publically-available

6:20

publicly 9:4

publish 6:22

published 8:13 25:1

publishing 8:16

pull 20:20,22 63:3

pulled 34:10

pulling 44:5

pulmonary 9:19 14:6

17:22 18:9 21:12,19

24:8 32:3 35:11 36:15

36:18,21,22 37:8 47:8

51:6 53:21 54:7,16

55:1,5 56:9,16 57:14

57:16,16 58:6 59:3,14

60:13,21 61:2,5 65:12

65:16 69:13 70:12

71:4,13 74:5,7 103:5

103:21

pulmonologist 15:1

20:17 21:10

purpose 30:4 78:15

purposes 73:10

put 4:12 16:7 77:2 78:1

83:4 94:3,6 98:3

104:11

puts 89:5

putting 96:19 97:13

Q

qualifications 42:10

qualified 31:2 32:22

qualifies 41:5 57:3

qualify 31:6

quality 33:6,7 97:16

103:10

question 12:13,15 13:5

17:2 18:4 20:20 25:11

27:2 28:7,12 33:10

37:3 38:6 39:21 41:7

41:9 47:3 48:7,22,22

49:7 50:13 52:5 53:19

53:22 54:3 55:2 63:20

72:13 73:9,19 74:9,13

83:11 85:5 86:15

88:18 89:6,9 97:3

100:4,12

questionable 40:16

questioned 14:2 37:13

questionnaire 24:2

32:13 73:17

questions 17:3 44:21

55:20 86:1,3,8 88:4

88:19 103:18 104:6

109:1

quick 4:16 63:3

quicker 34:13

quickly 31:8 44:4

quieter 84:21 85:1

quite 17:15 25:2 32:15

33:17 39:15 60:12

73:21 92:13 99:1

quote 59:4

R

Rachel 15:16

radiation 29:21

raise 74:8 110:13

raised 12:13,15 18:4

21:2 22:6 45:17 47:7

48:7 53:22 60:8 73:1

raises 55:2 72:13

raising 50:19 53:20

range 59:12

rate 31:12 104:5

rationale 60:5

read 30:1 38:12,18 78:3

101:18

readdress 41:7

reader 38:18

reading 39:10 54:1 72:9

reads 27:8

ready 8:13

real 63:3

realize 10:4 34:11 97:18

realized 77:16

realm 103:21

reared 39:20

reason 15:18 37:9

40:12 49:20 67:17

100:7

reasonable 39:6 42:20

55:8 56:11 64:15

69:21 79:8,11

reasons 47:22 53:4

72:14 97:20

RECA 27:18,21 28:3,5

28:15,16 29:1,19,20

30:10 31:2 37:13

recall 52:1

received 86:4

recognized 18:12 19:9

20:15

recommend 52:10

65:11 66:19,20 83:22

84:7 87:7

recommendation 3:9

26:6 58:17 77:18

80:14 81:3 97:18 98:2

104:12 106:9

recommendations 3:12

86:8

reconnect 77:2

record 8:3 20:5 26:12

77:8 110:19

recording 8:7 84:16

records 19:21 44:12

45:12

redo 82:15

referred 105:13

refers 16:9

reflect 10:8

refused 91:14

regard 24:20

Regarding 6:7

regulations 8:12

reiterate 110:12

relate 34:15 45:19

related 13:7 23:1,10

34:20 43:16

relates 27:3 42:17

106:11

relation 100:16

relatively 45:13 95:12

relevant 18:6 31:15

47:2

relies 32:1

relying 26:2

Remarks 3:2,5

remember 15:19 16:3

64:7 98:16

remind 8:20

remotely 7:3,4

report 21:18 56:13

104:8

reports 107:2

request 77:14 86:12

95:10

requested 103:15

requesting 61:4 80:22

require 58:9 98:15

requirement 78:7

requirements 1:5 79:14

requiring 105:22

resolve 42:6 61:20

resolved 15:8

respirator 24:5

respiratory 89:3

response 89:10 108:3

108:10,13 109:1,1,8

109:13,16

responses 88:19

107:14

rest 69:20

restriction 17:6

restrictive 27:14 89:8

90:6

result 4:14

resumed 77:8

review 10:15,22 16:17

27:21 33:6,7,7,11

35:21 42:12 45:2 71:9

97:16 104:9,13 105:1

reviewed 10:12 13:12

22:12 23:21 24:1,8

25:13,15,17 33:15

34:8 40:8 56:3 62:11

63:17 72:20 73:3,3,4

87:14 103:10 108:8

reviewing 10:2 26:18

59:15 96:15

reviewing-only 7:7

reviews 33:17

rewrite 33:18 76:17
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rewriting 33:21

rhinitis 21:15

Rhoads 2:19 3:2 4:3,4

5:1,5,9,13,21 76:22

77:6 84:15,19,22

100:22 101:6,15,18

102:3 107:19 109:10

109:19 110:17

Richland 5:7

rid 103:10

risk 36:18

River 20:11 56:7 62:16

64:5,9,12,19,21 65:3

roles 79:20

roll 3:4 4:16

room 6:3

rule 76:3

run 62:3

running 60:14

S

sarcoid 3:10 10:3,17

13:15,20 14:4 15:3

16:9 20:9,14,14 21:12

22:1 41:19 42:17 43:4

46:21 47:8 48:1,21

49:2,5 50:22 54:2,4

55:3 56:5,12,19 57:12

58:21 59:10,14 60:12

60:17 62:4,14 65:13

66:8,12,15 67:8,14

71:2 72:2 74:6 75:1,9

77:13 78:4,16 80:5

90:17 92:3 100:2,5,6

103:3 107:15 108:13

sarcoid-confirmed

57:8

sarcoidosis 15:20

53:21,21 55:2,12

66:22

sarcoids 73:15 78:19

79:6 100:9

sat 10:9

satisfy 78:9

Savannah 20:11 56:7

62:16 64:5,9,12,19,21

65:3

saw 22:17 44:17 98:17

98:17

saying 53:9 66:2 93:11

says 28:22 59:21,21

61:10 67:16 78:2,6,8

78:14 79:16

scan 17:4 56:13 59:1

67:7 70:4,10 75:1

89:16 90:3 93:19

scanning 45:14

scans 60:20

scenario 13:20 20:3

47:9 55:20 71:20

87:15

scenarios 72:6

scheduled 7:11

school 105:21

Schroeder 6:4

scientific 2:2 53:6

screen 6:12 84:12

se 72:17

second 22:10 80:22

83:3

secondary 28:7 33:13

83:21

sections 76:5

seen 44:20

selected 10:21

SEM 22:18,18 23:12

24:10,16,19 25:5,13

25:17 26:1,2,4,8

31:17 35:20 36:4

41:21 42:4 63:8,15

send 11:5 12:4 33:3

34:5 37:21 85:3,16

87:8 88:2,3 93:9,17

94:7 101:19 107:14

107:21 108:14,19

sending 12:6 77:15

sense 89:7 94:4 103:13

sensitive 46:1 87:12

sensitivity 79:15,16

80:2

sensitization 12:21

42:19 95:1,5,7

sensitized 64:11,16

sent 18:10 57:22 77:17

77:22 86:7,16 105:2

sentence 78:20 82:1

separate 21:14 49:4

63:15 98:7 99:20

session 7:7,11

set 32:8

setting 94:8

shared 9:3 58:19

short 4:17 6:1 30:4

64:14

show 102:10 107:2

showed 23:3 27:9,13

59:1 67:7 75:2

showing 59:22 68:5

shows 50:22 55:10 56:3

sic 70:11

side 95:16 97:5

sideline 49:10

Sidem 6:4

sides 60:22

silica 24:14,22 25:2,18

30:7 31:14 32:5,16,21

34:17 42:4

silicon 22:19

silicosis 22:3,9,15 23:8

23:13,16 26:11,14,15

27:5,8 28:13,16,22

30:8 34:21 35:11

36:10,15 42:2 43:5

102:11

silicosis/pneumocon...

3:7 37:5

similar 14:20 37:12

102:5

simple 43:12

simpler 92:18

simplest 57:7,10

simplicity 60:14

simplify 71:3

simply 34:21 41:2 42:9

57:8 65:10,12 71:1

single 87:9 93:16

site 28:14 47:11 54:17

56:7 58:3 62:16 71:12

sites 18:6 60:3

situation 14:10 21:20

situations 78:18

skin 54:11,15,16 55:9

56:5,12,19 57:13 58:3

58:14 60:17 66:8

skirted 98:8

slightly 56:14 60:9

94:13

small 54:18 57:12

SOF 44:11

solely 27:17 54:20

solution 34:14

solve 34:2 69:5 71:5

solved 41:1 71:1

somebody 13:10 14:12

55:10 67:16 68:19

99:8

somewhat 13:15 14:20

15:4 17:4 20:1 53:11

soon 8:13

sorry 20:16 21:1,4 39:4

84:11 106:21 109:21

109:22,22 110:6

sort 10:14 11:14 12:19

22:13,16 24:16 31:2

32:18 33:13 36:12

37:3 40:10 42:12,17

43:1 52:6,8 58:20

60:15,20 61:3 65:11

69:12 72:3,9 75:7,10

76:5,18 78:10 88:9

102:16 103:16 104:17

sound 14:2

sounds 84:15,22

speak 7:21

speaking 8:1 43:18

89:14 100:21

special 9:1

specialists 54:3

specific 9:9 24:18

26:11 29:4,9 64:13

89:11 106:10

specifically 23:8 70:14

75:8

specified 28:15

speculate 31:9

spent 15:8

Spicer 6:5

spinal 55:9 68:15

spine 48:21 49:2

split 42:4

Sprintis 20:2

staff 64:12

standard 51:4,5

start 8:1 10:2 95:19

96:19 102:2

started 19:11 90:3

103:8

starting 56:6

state 8:2

statement 23:22 31:22

32:6 40:20 78:11 80:5

99:4

states 1:1 28:21 67:11

stating 81:2

status 66:16

statute 52:1,6,9,12,16

52:22 53:11 59:21

61:10,10 72:7 79:11

79:16,19

stemmed 88:21

step 25:7 85:20 91:1

steroids 14:12 20:12

59:1 72:10 81:2 83:2

83:4 94:12,16

Steve 5:18 18:18 85:6

109:15

Steven 2:13 5:16 28:12

31:12 34:12 40:18

50:9,14 51:3,21 52:15

59:19 61:7 70:14

75:11 83:10 88:17

91:2 97:22 99:19

100:13 102:19 107:6

stop 26:2 82:4

straightforward 12:14

12:22 42:20 57:10

78:6

strange 23:7

streamline 40:10

stretch 66:9

strong 20:17 21:9,16

stronger 98:6
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stuck 15:17

stuff 59:3 83:14 96:19

Subcommittee 1:5,17

4:7,16,20 5:15 6:11

7:1,17 9:13 63:12

86:6 98:4 101:7 106:9

Subcommittee's 7:14

subcommittees 98:3

100:15

submit 81:18

submitted 60:6

subsequent 30:1

Substances 1:3 4:7

9:12

substitute 50:4

successful 15:2

Sue 57:22

Sue's 70:11

suffer 27:7

suffice 23:15 26:14

sufficient 24:9 25:10

65:13 108:1

suggest 58:6 68:4 85:3

suggested 37:18 42:3

84:9 87:4

suggesting 66:14

suggests 31:3

sum 107:17

summarize 42:1

summary 91:9 100:16

100:22

super-historic 19:10

supplemental 28:2

supposed 18:8,14

surveillance 18:2,5,8

18:14 19:7

survivors 19:19

suspect 54:18

system 40:9 60:15

T

TABLE 3:1

tag 39:18

take-home 41:19 42:14

taken 38:12,18 39:10

47:11 58:3 59:17

66:15

talk 81:20 107:21

talked 56:13 81:13

talking 16:18 43:8 44:1

44:8 101:9

talks 49:12

technical 52:18

technicalities 74:15

teleconference 4:5

7:21

telephonically 1:17

tell 50:16 68:15 73:21

105:17

term 23:8 26:11 98:20

terms 10:11 13:1,4

18:13 29:5 31:6 42:1

46:21 51:17 53:17

54:1 60:9 70:16 75:9

83:8 84:12 85:12 86:2

89:4,8 90:14 94:4

95:8,10 96:14 102:8

test 13:1 28:14 72:12

72:14 106:2

testing 49:21 56:17

tests 36:16,21 37:9

59:3 72:9

thank 5:13 9:16,22

46:18 77:6 106:7

108:4 110:9,10,15

Thanks 5:21 110:17

therapy 14:6

things 16:7 25:21 27:4

44:4,19 52:8,21 68:1

68:2 69:21 70:1,7

81:15 90:1 93:5,20

third 22:10 29:8 44:20

56:1

thorough 92:19

thought 10:1 11:11,13

13:4 17:18 38:1 39:14

39:15,18 40:14 46:11

49:8 52:9 56:11 73:22

74:22 77:16 86:6

three 14:13 28:21 62:5

62:9 69:19 71:9 87:5

87:7 104:1

threshold 29:22

timeframe 29:4

timeliness 33:8

times 33:18,21 105:19

timing 15:17

tissue 14:6,11 48:9,16

49:16 69:15 92:11

title 65:1

titles 34:15,19

today 5:15,22 6:3,7

7:11,20 8:12 9:6

98:17 107:15

today's 4:5,9 6:18,19

7:2,19 8:10

told 105:16

top 44:4

total 91:11 100:3

103:20

totally 27:19

Toxic 1:3 4:6 9:12

tracheobronchitis 70:7

tracking 36:3

Trades 5:7,12

training 5:12 32:3,3

105:17,21

transcriber 7:22 8:5

transcript 7:18 8:18

transcripts 7:15 8:17

transferred 88:22

treated 14:5

treating 75:14

trial 12:1

tried 10:13 69:9

trouble 84:18

true 30:21 97:9

truly 59:6 73:10

try 57:15 67:12 82:8,17

trying 40:9 45:1 52:1

63:2 70:4 81:7 89:21

105:5

turned 27:12 73:13

Turner 5:14

turning 9:14

turns 52:11 66:9 92:13

tweaked 94:13

two 15:9 17:3 22:7,16

22:21 23:11,21 25:21

27:4 28:21 36:8 38:4

46:11 47:22 62:9

72:10 74:20 77:12

87:7 89:15 92:17 93:3

93:18 105:1,6 106:2

types 56:15

typical 17:4 60:2

U

Uh-hum 42:21

unclear 82:12,14 98:22

uncommon 58:2

understand 7:22 33:12

82:20 104:4

understandably 56:16

understanding 18:7

30:18 79:4 95:7 102:8

102:14 103:18

understands 104:17

Unfortunately 105:6

uninterpretable 86:21

unique 20:1 60:6

UNITED 1:1

University 5:4,20

unreasonable 39:8

unsuccessful 15:4

uranium 22:14,20 23:13

24:20,21 25:3,22

26:12 30:22 32:4,15

34:15 36:5 37:5

use 58:16 82:2 102:4

useful 10:15 70:19

100:20

usual 105:3

V

vague 70:16 89:4

variables 69:18 70:18

variation 75:12

variations 90:20

various 36:19 56:7

verbatim 8:16

version 43:21

versus 47:7 48:9,16

51:14 60:18 61:4,16

61:21 75:7 106:1

views 91:6

visited 6:16

VLIEGER 2:14 104:19

105:10 106:12

volume 104:2

vote 81:18 84:1

voted 7:16 85:10

voting 85:5

W

wanted 16:22 22:8

44:18 46:7 49:17

51:11 62:22 77:20

84:14 86:1 110:4

wanting 46:5

Washington 5:8

wasn't 11:11 14:22

19:16,17 23:1 26:8,18

29:19 31:14 32:6

54:16 64:8 74:1,1

75:19 91:15 99:1

way 9:7 16:6 19:6 29:9

37:2 38:17 42:3 47:20

50:7 58:8 67:10,14

68:10 82:16 83:6

88:10 89:8 90:17

93:12 97:18

ways 16:3 71:20

WebEx 6:12 7:6

webpage 6:20

website 6:10,14,17 7:13

8:11,19

WEDNESDAY 1:10

weeds 90:22

week 44:21 58:20 101:7

weeks 39:10

weigh-in 25:6

Welch 2:6 5:9,10,11

11:19,19 12:8 13:8

15:10,16 16:2,14,18

18:16 25:14 26:16

27:2,20 28:1,8,17

30:12,16,20 31:17,20

33:2 34:1,3 35:6,20

37:20 38:3 39:2,5,21

40:21 41:10 42:5,21

50:20 55:7,15 56:22
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57:18 58:5 63:13 64:3

64:7,20 65:3,17 66:2

67:9,21 68:3,9,19

69:4,7 75:17 79:10

80:7,11,15 81:10,16

82:5,19 83:9 84:8

86:16,20 87:4,17,21

96:17 99:3,8 108:16

108:21

welcome 4:5

well-described 19:14

well-documented

19:22

Wellman's 18:3

went 10:20 22:18 77:8

96:6 101:8 110:19

weren't 31:3

wonder 91:12

wondering 80:4

word 9:18

worded 94:10

wording 48:8 49:11

53:12 72:9,16 82:14

89:15 92:12,16 93:18

94:12

words 89:1 90:11 92:17

93:3

work 4:13 10:11 34:15

34:17 67:10 73:8

80:20 97:15 102:13

105:12

work-related 21:17

worked 25:8 30:21 56:6

62:16 99:15

worker 1:3 4:7 9:12

18:21,22 19:2,3 37:6

62:17 98:18

workers 87:11

working 19:11 29:20

32:21 109:17

workload 45:3

workup 20:6 51:18

worry 17:13 67:18

worth 57:5 67:13 81:7

91:21

worthwhile 10:22

wouldn't 72:4 86:12

write 67:12 81:17 82:5

88:1 90:2

written 6:8 60:5 66:5

75:6 82:1,2 88:10

102:15

wrong 39:16 50:10,12

50:16

wrote 20:17 102:9

X

X 25:8,8 35:8 41:4

x-ray 23:2 26:9 39:19

70:2 89:2 94:1 102:10

Y

Yale 9:20

year 19:16

years 13:21 14:13 15:9

20:14 24:4 25:9 29:6

30:2 32:16 34:16,20

35:9 40:15 102:10,12

yellow 49:22 76:6

York 5:20

Z

zone 57:3

0

1

1/1 26:10,13

10 54:19 90:1 96:9

100:1,3 102:10,12

104:4

108 3:14

110 3:16

12 3:6 43:8

1946 19:15

1947 19:16

1960 19:11

1971 73:15

1981 62:17

1988 20:13

1989 19:18

1990 56:6

1992 19:11 74:5

1993 50:5

2

2:30 1:18 5:22

2:35 4:2

20 96:9

2005 62:17

2008 62:14 78:14

2010 13:22 14:4

2012 15:6 56:5

2013 20:16 56:6

2014 14:14 19:19 63:19

2016 1:11 7:16

21 1:11

22 3:7

3

3 1:6

3:30 6:2

30 8:19 83:12

4

4 3:2,4

4:00 76:12

4:12 77:8

4:20 77:3

4:22 77:9

47 3:10

5

5 3:2

5:00 5:22

5:12 110:19

6

7

7 51:10

8

8-07 82:3

9

9 3:5

9.8 35:16

9.88 29:8

9/11 81:14

90 8:11 54:4

90th 8:14

98 3:12
NEAL R. GROSS

COURT REPORTERS AND TRANSCRIBERS 

1323 RHODE ISLAND AVE., N.W. 

(202) 234-4433 WASHINGTON, D.C. 20005-3701 www.nealrgross.com 

C E R T I F I C A T E

This is to certify that the foregoing transcript 

In the matter of: 

Before: 

Date: 

Place: 

was duly recorded and accurately transcribed under 

my direction; further, that said transcript is a 

true and accurate record of the proceedings. 

 

 ----------------------- Court Reporter 

122

Evidentiary Requirements for

Part B Lung Conditions (Area #3)

Toxic Substances and Worker Health Adv. Comm.

12-21-16

teleconference