there was an administrative error on the part of the
DO in mailing a recommended decision, FAB must
coordinate with the DO to have it reissue the decision
to all claimants with an effective date that
corresponds with the new mailing date. Should the FAB
CE or HR determine that the claimant’s mailing address
is not valid, he or she evaluates the case evidence to
identify any information that could help locate the
claimant. The investigation should include making a
reasonable effort to obtain new information that may
assist in identifying the claimant’s valid mailing
address. For example, the FAB should request a
forwarding address from the Post Office closest to the
claimant’s last known address. See Exhibit 25-8. Once
FAB has undertaken development, but is unable to
obtain the claimant’s current address, it places a
memorandum in the file listing the actions taken to
locate the claimant. It then administratively closes
the effected claim. In a single claimant case, FAB
returns the file to the jurisdictional office
responsible for case management. For a multiple
claimant case, FAB must proceed to finalize the
recommendation to any remaining claimants for which a
valid mailing address exists. FAB is to reference the
administrative closure of any claim with an invalid
mailing address. For compensable claims, FAB must also
explain that the allocation of any payable
compensation to a claimant for which the FAB does not
have a valid address is held in abeyance until the
claimant provides written confirmation of his or her
correct mailing address.

a. In the event the DO obtains information on the
claimant’s current address after FAB
administratively closes the claim, the assigned
CE must ensure that the claimant submits a
written notice of his or her address change (See
Exhibit 25-9). Once received, the CE resumes
development of the claim.

(1) In a claim with a single claimant, the CE
notifies the claimant in writing that the
claimant did not provide proper notification
of an address change, and that for this
reason, FAB administratively closed its
review of a pending recommended decision.
The CE explains that action on the


PM v2.3 reads:

b. Consequential illness acceptance (including
reverse consequential illness acceptance).

o Added content at Ch. 24.10.f to add new basis for
issuing a letter decision:

ray Acceptance of additional cancers under Parts B
and E following a NIOSH POC equal to or greater
than 50% by letter decision.

e Chapter 25 - FAB Review Process:
o Removed all content related to former CE2 Unit

o Ch. 25.12 has been revised to outline new procedures
for duties previously performed by the former CE2 Unit
and clarify processing of claims with incorrect
mailing addresses

PM v2.2 read:

12. CE2 Designated to the FAB. FAB offices are
geographically located as noted in section 3 above.
However, since DO adjudicatory functions are sometimes
required while a case is at FAB, each DO assigns
certain CEs to handle DO development and adjudication
while the case is at FAB. This process eases the
burden of file sharing and allows for case files to be
maintained in one central location while RDs are
pending review or FAB is addressing objections by
hearing or review of the written record and further
DO-level development is required.

a. Reporting and Roles. These CEs are called Co-
Located Secondary CEs (CE2s) because the FAB CE
(or HR) is considered the primary CE while the
case is in FAB’s jurisdiction. This group of CE2s
is referred to as the “Co-Located Unit.” The Co-
Located Unit reports to either the DO or to the
Policy Branch.

b. Assign CE2 Role. To enable the CE2 role, the DD
or designee e-mails the Unit Chief of the Policy,
Regulations and Procedures Unit, with a copy to
Energy Technical Support, requesting the role


fe}

medical evidence is insufficient, he or she
issues a letter decision denying the
authorization request. The letter decision
is to include a narrative as to why the
evidence is insufficient to warrant
authorization. The CE is to send a copy of
the letter decision to the provider, if
applicable. The letter decision is to
include the following language:

If you disagree with this decision
and wish to request a formal
decision, please immediately advise
this office, in writing, that you
wish to have a Recommended Decision
issued in this case, providing you
with your rights of action.

Once the CE determines to approve or deny
the request, the CE sends an email to the
FO, who prepares and sends a thread to the
medical bill processing contractor,
authorizing or denying the enteral formula
request. The CE creates a correspondence
entry in the Correspondence screen of ECS,
documenting the decision, and bronzes the
letter along with the supporting
documentation into OIS.

An employee, a designated AR or a medical
provider must request a renewal of an
expiring authorization or modification of an
existing authorization for enteral formula.
In either of these situations, a LMN
documenting the medical necessity of
prescribed formula must accompany the
request. A CE may authorize enteral formula
in ongoing six-month increments, so long as
the requestor continues to submit sufficient
evidence of medical necessity.

New Ch.29.19, Rehabilitative Therapy, incorporates
content of Bulletin No. 18-01, as outlined below:

19.

Rehabilitative Therapy Services. The DEEOIC

requires prior authorization for the therapy services
outlined below.


United States production of benzidine, and it has not
been produced for commercial sale in the United States
since 1974; however, benzidine can be imported and
small amounts are still used to make benzidine-based
dyes.

Exhibit 15-4, Section 8c has been edited to add two
new toxins:

PM v2.2 read:

c. Exposure: Evidence in the file must not only
establish that the employee worked within a certain
job category listed above, but that the employee was
concurrently exposed to at least one of the specified
organic solvents listed below:

* Ethyl Benzene

* Methyl Ethyl Ketone

* Methyl Isobutyl Ketone
* Styrene

* Toluene

* Trichloroethylene

* Xylene

It has been edited in PM v2.3 to read:

c. Exposure: Evidence in the file must not only
establish that the employee worked within a certain
job category listed above, but that the employee was
concurrently exposed to at least one of the specified
organic solvents listed below:

* Carbon Disulfide

* Ethyl Benzene

* Methyl Ethyl Ketone

* Methyl Isobutyl Ketone
+ n-Hexane

* Styrene

* Toluene

* Trichloroethylene

° Xylene

Exhibit 15-4 adds a new Section 12, presumptive
criteria for lung cancer:

12. Lung Cancer: Part E causation can be presumed
for lung cancer when all of the following criteria


claimant’s file is resuming based on the
status of the claim at the time of
administrative closure. The CE is to
reissue the previously undeliverable
recommended decision with a new date. The CE
then forwards the claim to FAB, for it to
proceed with finalization of the recommended
decision.

(2) For a claim with multiple claimants, if
resumption of development occurs on an
ineligible claimant, the CE is to issue a
new recommendation to the claimant denying
his or her claim. However, in the
circumstance where resumption of development
occurs involving a claimant who is eligible
for compensation benefit, it is necessary to
first reopen all claims to allow for a newly
issued recommendation that comprehensively
addresses the entitlement for all claimants
with an interest in the claim.

FD Returned by Postal Service. If the FAB has
issued a FD and the Postal Services returns it as
undeliverable, the responsible FAB staff person
is to ascertain the correct mailing address for
the effected claimant. In such instances, the DO
is to transfer the case back to FAB so that the
responsible FAB staff may complete these actions.
If the assigned FAB staff person obtains written
confirmation of a new address from the claimant,
he or she is to mail a copy of the FD to the
claimant’s new address. In the event that the
assigned staff person is unable to obtain a
written confirmation of a new address, he or she
is to refer the claim to the appropriate DO
contact to initiate an administrative reopening.
The assigned DO staff will draft a Director’s
Order for the file explaining that the mailing
address of the claimant is invalid, attempts to
obtain a valid address were unsuccessful, and
that a reopening is necessary to allow for an
administrative closure. In a multiple claimant
situation, reopening and administrative closure
will apply only to those claims where the DO
cannot confirm an address. However, later, if the
DO receives written confirmation of a valid


If medical documentation or a signed
physician’s prescription is not received
within 30 days, the CE/MBE must deny the
request. The CE/MBE sends an email to the WCA
who then notifies the BPA to deny the
request. The CE/MBE sends a letter to the
requestor with a copy to the employee denying
the request and providing instruction to
resubmit the request once the treating
Physician submits a signed prescription.

Requests for rehabilitative therapy must be
substantiated by the results of the initial
evaluation by the applicable therapy
specialist and a LMN from the employee’s
treating physician. The LMN must provide a
description of the employee’s medical need
for the requested rehabilitative therapy
based on the results of the initial
evaluation and the physician’s face-to-face
examination of the employee occurring within
sixty days of the date of the LMN.

The physician must provide a description of
the type of rehabilitative therapy he or she
is prescribing, along with a discussion of
the specific quantity, frequency and duration
of the therapeutic service. DEEOIC considers
rehabilitative therapy services medically
appropriate only if a qualified physician
describes, with appropriate medical
rationale, how the prescribed rehabilitative
therapy will lead to an expected measurable
improvement in one or more activities of
daily living within a reasonable period. The
LIMN signed by the treating physician must
include his or her official practice address,
telephone and fax number.

When the CE/MBE receives a request for
authorization of rehabilitative therapy
accompanied by an appropriate LMN, the
CE/MBE prepares a decision letter to the
employee authorizing the requested therapy.
The initial authorization period may be fewer
than, but must not exceed 3 months (90 days).
The assigned CE/MBE may approve up to 3


necessary in the care of the covered
employee’s accepted work-related medical
condition(s).

(1) Requests for enteral formula must be
substantiated by a LMN from the
employee’s treating physician. The LMN
must provide a description of the
employee’s medical need for enteral
formula based on a face-to-face
examination of the patient occurring
within 60 days of the date of the LMN.
In addition, the physician must
identify the accepted work-related
medical condition (preferably with a
specific diagnosis code) that is
necessitating the need for enteral
formula. The physician must provide a
description of the type of formula he
or she is prescribing, along with a
discussion of the specific quantity,
frequency and duration of use. The
physician may also provide guidance on
how the patient receives the formula
(orally or via feeding tube). The LMN
signed by the treating physician must
include his or her official practice
address, telephone and fax number.

When the CE receives a request for
authorization of enteral formula accompanied
by an appropriate LMN, the CE prepares a
decision letter to the claimant authorizing
the enteral formula at the prescribed level.
The CE grants authorization of enteral
formula in six-month increments.

Upon receipt of requests for enteral formula
unaccompanied by a sufficient LMN, the CE
undertakes development by contacting the
prescribing physician and the claimant to
request evidence necessary to allow for
authorization. A CE can refer requests with
unclear medical support to a DEEOIC nurse
consultant for review and expert advice on
the proper course of action. If, after
development, the CE determines that the


(3)

(4)

allow 30 days for the claimant to submit
written confirmation of his or her address
change. The CE then files a memorandum into
the case describing the actions taken
regarding the address problem, and transfers
the case file back to the FAB. The FAB does
not issue the FD until receipt of a written
confirmation from the claimant of the
correct mailing address. If the claimant
does not submit a written confirmation of
his or her address change within the 30 days
requested, the FAB administratively closes
the claim.

Correct Address Found, Claimant Notified Do.
In the event the CE2 obtains written
confirmation of the claimant’s proper
address, and the wrong-address problem was
not the claimant’s fault, the CE2
coordinates with the DO to re-issue the RD
to the claimant with a new issuance date. In
a multiple person claim, the CE must reissue
the RD to all claimants, with a brief
explanation of the matter contained in the’
RD cover letter. The CE2 spindles a
memorandum explaining the situation into the
case file. The CE2 then transfers the case
file back to the assigned FAB CE/HR.

Multiple Claimants. If a case has multiple
claimants, and the Postal Service returns
one or: more claimants’ RDs because of an
incorrect address, the CE2 undertakes
development individually for each returned
RD in accordance with the instruction
provided above. At the conclusion of the
CE2’s development, he or she prepares a
memorandum for the case describing the
outcome of development, which could include
administrative closure for claimants with an
invalid address. The CE2 then returns the
case to the FAB. The FAB CE or HR may then
proceed to issue a FD to all claimants for
which a valid and confirmed mailing address
exists. Claims administratively closed due
lack of correct mailing address, or failure
to return written confirmation of a new


presumed. The earlier receipt by the employee of
monetary benefits under Part E for wage-loss
and/or impairment does not negate the
availability of this election for any subsequent
amount of monetary benefits claimed by the
survivor.

e Chapter 21 - Impairment Ratings:

°

Ch. 21.16 has been updated to clarify the correct
forms needed for additional filings for an increased
impairment benefit and to provide new clarifying
guidance regarding a waiver of the two-year waiting
period on claims for increased impairment.

PM v2.2 read:

16. Additional Filings for Increased Impairment
Benefits. An employee previously awarded impairment
benefits may file a claim for increased impairment
benefits for the same covered illness included in the
previous award. For such a claim, the claimant must
file using Form EN-10. When a claim for increased
impairment is developed but the medical evidence
establishes lower whole person impairment than
previously determined, the CE denies the claim for
increased impairment. The CE takes no action to
reopen a prior impairment determination in these
circumstances because a claim filed for increased
impairment after the two-year waiting period is a new
claim.

a. Timeframe. The employee may not submit a
Form EN-10 for an increased impairment
rating earlier than two years from the date
of the last FD on impairment, except for the
following reasons.

(1) New Covered Illness, The CE waives the
two-year time period requirement if
the CE adjudicates an additional
impairment claim based upon new covered
illness not included in the previous
award. A new covered illness must
involve a different disease, organ,
body function, illness, or injury that


Once the CE/MBE decides to approve or deny
the request, he/she sends an electronic mail
message to the WCA/FO, who prepares and
sends a thread to the BPA, authorizing or
denying the rehabilitative therapy request.
The CE/MBE creates a correspondence entry on
the correspondence screen of ECS,
documenting the decision and bronzes the
letter along with the supporting
documentation into OIS.

An employee, an authorized representative,
treating physician, or rehabilitative
therapy provider must request a renewal of
an expiring authorization or modification of
an existing authorization for rehabilitative
therapy and should do so prior to the
expiration date of the existing
authorization, to allow care to continue
uninterrupted. In either of these
situations, the requestor must submit a LMN
documenting the continuing medical necessity
of the request. Requests for rehabilitative
therapy outside of this guidance must be
evaluated on a case-by-case basis, including
possible consultation with the DEEOIC
Medical Director. The employee, or his or
her AR, has final responsibility regarding
the amount or type of rehabilitative therapy
sought. :

Rehabilitative therapy providers must
conduct services in an appropriate setting;
(i.e., in a clinic, professional office, or
other similar location). If the CE/MBE
receives a request for in-home professional
therapy, the employee must be homebound to
receive such authorization. Medical evidence
from the treating physician must demonstrate
that the employee is medically unable to
travel to obtain the therapy outside the
home. Once the CE/MBE receives convincing
medical evidence that the employee is not
able to travel for therapy, and sufficient
documentation exists regarding the medical
necessity for care, the CE/MBE may authorize
in-home rehabilitative therapy. Provider


Cc.

Latency: The diagnosis of mesothelioma was made
at least 30 years after initial exposure to
asbestos in covered employment.

It has been edited in PM v2.3 to read:

b.

Cc.

Exposure: The employee was employed in a job that
would have brought the employee into contact with
significant exposure to asbestos on a day-by-day
basis for at least 30 or more aggregate workdays.
This can be determined by existing asbestos
exposure presumptions or an IH assessment.

Latency: The diagnosis of mesothelioma was made
at least 15 years after initial exposure to
asbestos in covered employment.

o Renumbered Exhibit 15-4, Section 15c (Ovarian
Cancer)and made changes to the latency period:

PM v2.2 (Section 14c) read:

c.

Latency: The diagnosis of ovarian cancer was made
at least 20 years after initial exposure to
asbestos in covered employment.

It has been edited in PM v2.3 to read:

cn

Latency: The diagnosis of ovarian cancer was made
at least 15 years after initial exposure to
asbestos in covered employment.

o Renumbered Exhibit 15-4, Section 17c (Pleural Plaques)
and made changes to the latency period.

PM v2.2 (Section 16c) read:

Cc.

Latency: The diagnosis of pleural plaques was
made at least 20 years after initial exposure to
asbestos in covered employment

It has been edited in PM v2.3 to read:

c.

Latency: The diagnosis of pleural plaques was
made at least 10 years after initial exposure to
asbestos in covered employment.


have been satisfied. If the case does not meet the
causation presumption as stated below but the case
involves a diagnosis of lung cancer, development is to
include an IH referral if appropriate (e.g., there are
no established exposure presumptions), and obtaining a
medical opinion on causation.

a. Medical: The file contains a diagnosis of
lung cancer.

b. Exposure: The employee was employed in a
job that would have brought the employee into
contact with significant exposure to asbestos on
a day-by-day basis for at least 250 aggregate
workdays. This can be determined by existing
asbestos exposure presumptions or an IH
assessment.

Ch Latency: The diagnosis of lung cancer was
made at least 15 years after initial exposure to
asbestos in covered employment.

Exhibit 15-4, Section 12-18 renumbered:

12. Meningioma changes to 13. Meningioma

13. Mesothelioma changes to 14. Mesothelioma

14. Ovarian Cancer changes to 15. Ovarian Cancer
15. Parkinsonism changes to 16. Parkinsonism

16. Pleural Plaques changes to 17. Pleural Plaques
17. Radiation Induced Cataracts changes to 18.
Radiation Induced Cataracts

18. Radiation Sickness (Acute) changes to 19.
Radiation Sickness Acute.

Renumbered Exhibit 15-4, Section 14c (Mesothelioma) and
made changes to the exposure and latency period:

PM v2.2 (Section 13b-c) read:

b. Exposure: The employee was employed in a job that
would have brought the employee into contact with
significant exposure to asbestos on a day-by-day
basis for at least 250 aggregate work days. This
can be determined by existing asbestos exposure
presumptions or an IH assessment.


address within a 30 days, are referenced in
the FD; however, the effected claimants are
not party to the decision. The FAB explains
in the FD that any shares of payable
compensation on an administratively closed
claim is held in abeyance until the claimant
provides written confirmation of his or her
correct mailing address.

Ah. FD Returned by Postal Service. If the FAB has
issued a FD and the Postal Services returns it as
undeliverable, the responsible CE or CE2 staff
person is to ascertain the correct mailing
address for the effected claimant. If the
assigned staff person obtains written
confirmation of a new address from the claimant,
he or she is to mail a copy of the FD to the
claimant’s new address. In the event that the
assigned staff person is unable to obtain a
written confirmation of a new address, he or she
is to refer the claim to the appropriate DO
contact to initiate an administrative reopening.
The assigned DO staffer will draft a Director’s
Order for the file explaining that the mailing
address of the claimant is invalid, attempts to
obtain a valid address were unsuccessful, and
that a reopening is necessary to allow for an
administrative closure. In a multiple claimant
situation, reopening and administrative closure
will only apply to those claims where the DO
cannot confirm an address. However, later, if the
DO receives written confirmation of a valid
address on an administratively closed claim, it
may then become necessary to reopen the other
claims to permit for a reissuance of a unified
FD.

It has been edited in PM v2.3 to read:

12. Decisions Returned by Postal Service. [In those
instances where a case file is at the FAB for review
of a RD, and the Postal Service returns a RD sent toa
claimant as undeliverable, the assigned FAB CE or HR
should ascertain whether a simple mailing mistake
(e.g., typographical error, unprocessed address change
request) occurred that is easily rectified, or whether
the claimant’s mailing address is no longer valid. If



Section 17 Parkinsonism changes to Section 18

Section 18 Other conditions changes to Section 19

e Exhibits 19-1, 19-2 and 19-4, have been updated to include
the new mailing address for the U.S. Department of Justice

(DOJ),

RECA.

e Chapter 20 - Establishing Survivorship

o Ch. 20.12b has been edited for clarity.

PM v2.2 read:

b.

Death Due to Non-Covered Illness, Part E. If a
covered Part E employee dies after filing a claim
but before any payment is received, and if the
employee’s death was caused solely by a non-
covered illness, the survivor (any survivor
including the spouse) has the election of
benefits option. The survivor may elect to
receive compensation (wage-loss and/or
impairment) that the employee would have received
had he not died prior to payment. It is not
necessary for the employee to have filed a claim
specifically for wage-loss or impairment in order
to have the election of benefit option available.
As long as the employee filed a Part E claim,
claims for impairment and wage-loss are assumed.

It has been edited in PM v2.3 to read:

b.

Death Due to Non-Covered Illness, Part E. Ifa
covered Part E employee dies after filing a claim
but before the claimed payment is received, and
if the employee’s death was caused solely by a
non-covered illness, the survivor(s) has the
option to elect to receive the payment that the
covered Part E employee would have received, had
he/she not died prior to payment, rather than
survivor benefits. It is not necessary for the
employee to have filed a claim specifically for
wage-loss or impairment benefits for the election
option to be available to the survivor(s). As
long as the employee filed a Part E claim, claims
for wage-loss and impairment benefits are


Types of Therapy Requiring Prior
Authorization.

(1) Physical Therapy is the treatment of
injuries or disorders using physical
methods, such as exercise and massage.
The goal of physical therapy is to
relieve pain and to help the patient
attain his or her maximum functional
motor potential.

(2) Occupational Therapy involves treatment
that helps develop adaptive or physical
skills that will help the claimant to
return to the ordinary tasks of daily
living. Occupational therapy focuses on
the use of hands and fingers,
coordination of movement, fine motor
skills and self-help skills such as
preparing meals and dressing.

(3) Speech Therapy is the treatment of
defects and disorders of speech and
swallowing.

(4) Other rehabilitative therapy services
is defined as a therapeutic service for
which a provider charges a fee to
render care outside of the scope of
routine and customary medical care
generally provided by a qualified
Physician.

The recommended other therapeutic service
must be considered safe and effective by the
medical community and intended to improve
the health of the patient.

An appropriately licensed (in accordance with
relevant state requirements) or credentialed
specialist must perform the prescribed
rehabilitative therapy.

Requests for the authorization of
rehabilitative therapy, including physical
therapy, occupational therapy, speech therapy


U.S. Department of Labor Office of Workers’ Compensation Programs
Division of Energy Employees
Occupational Illness Compensation
Washington, DC 20210

RELEASE - TRANSMISSION OF FEDERAL (EEOICPA) PROCEDURE MANUAL
VERSION 2.3:

EEOICPA TRANSMITTAL NO. 18-04 July 24, 2018

EXPLANATION OF MATERIAL TRANSMITTED:

The Division of Energy Employees Occupational Illness
Compensation (DEEOIC) is issuing this transmittal to notify
staff of the publication of Version 2.3 of the Federal (EEOICPA)
Procedure Manual (PM). Version 2.3 (v2.3) replaces Version 2.2
(v2.2), effective the date of publication of this transmittal.

Following are the content edits that make up Federal (EEOICPA)
PM v2.3:

e Chapter 2 - The EEOICPA:

o Ch. 2.4b(1) has been edited to remove reference to
Secondary Claims Examiner (CE2) unit.

o Ch. 2.4b(1)(b) has been edited to remove content
relating to functions of CE2 unit. New content added
to explain role of the CE while a case is undergoing
review by FAB.

PM v2.2 read:

(b) The CE2 Unit handles DO development and
adjudication required while a case is pending
review at the FAB. The CE2 Unit only adjudicates
issues that are outside the scope of the issue(s)
being addressed by the FAB. In particular, CE2
staff:

(i) Conduct all necessary development on
outstanding claim elements not related to
the RD currently in front of the FAB for
review, and appropriately reflecting those
actions in the Energy Compensation System
(ECS) for the duration of the FAB review
process;

(ii) Prepare a memorandum for the case file
explaining what development actions have


ii.

already rated for a pulmonary
condition, but now has an
approval for a newly diagnosed
skin cancer.

The claimant requests a waiver
of the two-year rule and submits
medical evidence, documenting
since the last impairment
rating, that the accepted
condition(s) has caused a
substantial detrimental effect
to the claimant’s living
circumstances, one or more ADLs,
or medical status. The effect
should represent a change
unlikely to improve. For
example, an employee previously
vated for lung cancer, who was
mobile and able to perform most
ADLS, has a sudden degradation
of their accepted condition to
the point where they are
rendered bedbound. No other
treatment modalities are
available. Under this
circumstance, the CE could grant
a waiver of the two-year waiting
period for a new impairment, if
requested. Alternatively, an
employee who has had an
impairment rating performed for
multiple skin cancers receives
approval for two new skin
cancers. There is no documented
change to the employee’s
lifestyle or ADLs. Under this
circumstance, a waiver is
inappropriate because the new
conditions relate to the organ
system previously rated and
there is no evidence of a
substantial detrimental effect
to the claimant’s living
circumstance. The CE may seek
the input of a DEEOIC nurse
consultant or CMC to assist in


was not the basis of the original
impairment rating.

It has been edited in PM v2.3 to read:

16. Additional Filings for Increased Impairment
Benefits. An employee previously awarded impairment
benefits may file a claim for increased impairment
benefits for the same covered illness included in the
previous award. The DEEOIC will accept the submission
of the EN-10, EN-11A or words of claim to initiate a
claim for increased impairment; however, the DEEOIC
must receive a completed EN-11A to allow the claimant
to communicate his or her choice as the physician to
perform the rating for increased impairment.

When a claim for increased impairment is developed but
the medical evidence establishes lower whole person
impairment than previously determined, the CE denies
the claim for increased impairment. The CE takes no
action to reopen a prior impairment determination in
these circumstances because a claim filed for
increased impairment after the two-year waiting period
is a new claim.

a. Timeframe. The employee may not submit a
claim form for an increased impairment
rating earlier than. two years from the date
of the last FD on impairment.

(1) Waiver of the Two-Year Waiting Period.
The CE has discretion to ascertain the
circumstance warranting the waiver of
the two-year waiting period. The CE may
consider waivers under the following
circumstances.

i. The CE accepts a new covered
illness since a previous final
decision awarding impairment and
the condition relates to an
organ system (in accordance with
the AMA’s Guides to the
Evaluation of Permanent
Impairment, 5th Edition) that was
not included in a prior rating.
For example, an employee was


travel to and from an employee’s residence
is not a billable service.

1. Rehabilitative therapy providers must submit
appropriate clinical notes to the BPA, along
with their bill, describing in detail the
Particular therapeutic care provided during
each visit, and the time spent providing
that care. The therapy notes must document
compliance with the LMN. The notes should
describe the effect of the rehabilitative
therapy specific to unique features of the
employee, including any specific
improvements in functionality or in
achieving relief from the symptoms of a
compensable illness. The CE/MBE may refer
claims to the Program Integrity Unit for
investigation of those situations where an
applicable therapy provider does not provide
an employee specific description of the
services provided, lists vague or non-
descriptive services or conducts therapy
services that do not comply with the
prescribing physicians LMN.

e Appendix 3 ~- Index of Archived Bulletins and Circulars, has
been updated to include the following items which have been
incorporated into the PM:

o Bulletin No. 17-02, Prior Authorization Required for
Enteral Formula

o Bulletin No. 18-01, Rehabilitative Therapy
o Circular No. 18-01, Idiopathic Disease Diagnosis

Bat P Seite

Rachel P. Leiton
Director, Division of
Energy Employees Occupational Illness Compensation


e Chapter 18 - Eligibility Criteria for Non-Cancerous
Conditions:

o Ch. 18.15, Idiopathic Disease Diagnosis, has been
added, and reads:

15. Idiopathic Disease Diagnosis. “Idiopathic” means
that the causative agent is unknown. However, in the
case of pulmonary fibrosis, peripheral
neuropathy/polyneuropathy, and interstitial
pneumonitis, DEEOIC maintains health effect data for
these commonly referenced idiopathic conditions that
could allow a physician to render an opinion on the
potential work-relatedness of the underlying medical
condition.

In claims that present with medical evidence
characterizing one of the above medical conditions as
idiopathic, the CE is to treat those illnesses as
potentially work-related and he or she is to evaluate
the condition without consideration given to the
idiopathic designation. With the identification of any
potential exposures associated with the employee's
work at a covered site, an Industrial Hygienist's
referral, followed by a review of the claim by the
claimant's treating physician or a Contract Medical
Consultant, as appropriate, must occur.

Regardless of whether or not DEEOIC maintains health
effect data on a medical condition labeled as
idiopathic, CEs may not presume that the condition is
unrelated to toxic substance exposure and deny it
without development. For a medical condition labeled
as idiopathic, with no available health effect data
relating to the underlying condition, the CE is to
undertake development as outlined in Chapter 15 -
Establishing Toxic Substance Exposure and Causation,
including asking the claimant to submit any medical or
health effect information that could associate the
claimed medical condition to the employee's exposure
to a toxic substance.

o The remaining sections of Chapter 18 are renumbered:

Section 15 Medical Conditions Associated with Asbestos
Exposures changes to Section 16.

Section 16 COPD changes to Section 17


address on an administratively closed claim, it
may then become necessary to reopen the other
claims to permit for a reissuance of a unified
FD.

e Chapter 26 - FAB Decisions:

° Correction to outline format. Accordingly, what was
Ch. 26.3b(3) (a) (iv) has been renumbered Ch. 26.3b(4)

e Chapter 29 - Ancillary Medical Services and Related
Expenses.

o What was Ch. 29.18, Ancillary Services or Expense
Authorization RD, in PM v2.2, is renumbered Ch. 29.20.

o New Ch.29.18, Enteral Formula, incorporates content of
Bulletin No. 17-02, as outlined below:

18. Enteral Formula. Enteral formula is a
nutritional replacement for patients who are unable to
get enough nutrients in their diet. Patients
prescribed enteral formula consume it by mouth or
through a feeding tube. The DEEOIC requires prior
authorization for enteral formula.

a. Requests for the authorization of enteral
formula may originate from an employee, a
designated AR or a medical provider. The
DEEOIC medical bill processing contractor is
tasked with registering all authorization
requests for enteral formula in its
electronic case tracking system. If the
contractor receives the authorization
request directly, they will record it and
forward the request, as a thread, to the
appropriate DO for processing. If the DO
receives the authorization request via mail
or fax, it is routed through the FO to the
medical bill processing contractor for
record creation and thread initiation.

b. Once the assigned CE receives a thread for
authorization of enteral formula, he or she
must undertake a review of the evidence in
the case file to make a determination as to
whether or not the request is medically


visits per week by therapy discipline. Each
visit is equal to a maximum of 1.5 hours (6
units). PT, OT, or ST services are limited to
one hour (4 billable units) when the provider
bills with combined codes. The CE/MBE may not
authorize therapy for any one discipline more
than 60 visits per calendar year. The
approval letter must contain the following
information:

(1) Covered medical condition(s) for the
rehabilitative therapy.

(2) Number and frequency of visits approved
(e.g., 3 visits per week for 12 weeks).

(3) Authorized billing code(s) relevant to
the approval.

(4) Dates for the authorized period.

(5) Statement to indicate that
corresponding medical notes must be
provided for each service date.

(6) Statement advising that fees are
subject to the OWCP fee schedule.

Upon receipt of requests for rehabilitative
therapy unaccompanied by a sufficient LMN,
the CE/MBE undertakes development by
contacting the prescribing physician and the
employee to request evidence necessary to
allow for authorization.

(1) After 30 days has passed with no
satisfactory response from the treating
Physician, or no response from the
employee, the CE/MBE prepares a second
letter to the employee (accompanied by a
copy of the initial letter), advising
that following the previous letter, no
additional information has been
received from the treating physician.
The CE/MBE advises that an additional
period of 30 days will be granted for
the submission of necessary evidence,


It has been edited in v2.3 to read:

b. A medical diagnosis for asthma should be made
when the physician is able to identify the
presence of intermittent respiratory and
Physiologic evidence of reversible or variable
airways obstruction including post-bronchodilator
reversibility on spirometry or a positive
methacholine challenge test. However, a physician
can also rely on other clinical information to
substantiate his or her diagnosis of asthma, such
as the findings from a detailed medical history
and physical examination. Documentation of
recurrent symptoms of airflow obstruction or
airway hyper-responsiveness, such as episodic
cough, chest tightness or shortness of breath, or
symptomatic improvement following treatment for
asthma (e.g., inhaled bronchodilator or steroids)
supports a diagnosis of asthma. Physical
examination findings such as wheezing on lung
examination, nasal swelling and drainage, or use
of chest muscles to breath also support a
diagnosis of asthma. The response to inhaled
bronchodilator administration has also been used
as a measure of airway hyperresponsiveness. A 12%
improvement in FEV1 of at least 200 mL after
inhaled bronchodilator is how the American
Thoracic Society defines a significant
improvement indicative of hyperresponsive
airways. However, a negative bronchodilator test
does not rule out a diagnosis of asthma,
especially if the patient is on medical treatment
for asthma.

o Exhibit 15-4 Section 5c outline numbering is changed
for consistency

o Exhibit 15-4, Section 6b has been updated to include a
subsection (5) to add Benzidine as an agent known to
be causally related to bladder cancer. The new content
added with v2.3 reads:

(5) Benzidine: This substance has been used at DOE
sites for activities associated with painting,
predominantly used in the production of dyes.
Benzidine can be absorbed into the body by inhalation,
skin absorption, ingestion, and skin and/or eye
contact. In 1973, OSHA regulations effectively banned


change. The e-mail contains the name of the CE
and the reason for the request. The FAB manager
to which the CE2 is co-located is also copied on
the e-mail, so that FAB is aware of personnel
changes that affect FAB workflow.

Development Memorandum for Co-Located Unit. A DO
CE who prepares a RD must be aware of any
outstanding claims issues not addressed in the RD
and requiring further development. If more
development is needed concurrent with FAB’s
review of the case, the CE prepares a memorandum
on gold-colored paper addressed to the FAB
manager from the Senior CE, Supervisor, or DD who
is the final reviewer of the RD. The subject
line should read: “Co-Located FAB Development for
File No. [file number].”

The body of the memorandum addresses any
outstanding claim issues that require development
by the Co-Located Unit while the case is being
reviewed by the FAB. When the RD is reviewed and
signed, the memorandum is also reviewed and
signed. Once this is done, the original
memorandum is spindled on top of the case file
documents.

Receipt of Case by the FAB. The FAB CE or HR
reviews any co-located development memorandum and
notes any further development needed. The FAB CE
or HR may also become aware of issues during
their review.

If DO development is required where no co-located
memorandum exists in the case file, FAB writes a
memo to the CE2 outlining the issues that must be
developed and sends the file to the co-located
unit. The FAB CE or HR must not assign any
development actions to the CE2 regarding matters
before the FAB for review. The FAB CE or HR
conducts any development necessary about matters
before the FAB.

CE2 and FAB Coordination. The FAB CE or HR and
the CE2 should coordinate their work to ensure

that the file is where it is needed and the work
can be completed. If both the FAB CE or HR and


been taken and what future actions are
required. The memorandum is spindled on top
of the case file. Throughout the time the
case is in FAB, the CE2 continues
development and issues RDs on approved claim
elements as the requisite evidence is
received and evaluated.

RD Returned by Postal Service. If the case file
is at the FAB for review of a RD, and the Postal
Service returns the RD sent to a claimant as
undeliverable, the assigned FAB CE or HR should
quickly ascertain whether a simple mailing
mistake (e.g. typographical error) occurred that
is easily rectified, or whether the claimant’s
mailing address is no longer valid. If the FAB
CE or HR determines that the claimant’s mailing
address is invalid, he or she transfers the case
record to a CE2 for development. Once the CE2
receives the transfer; he or she evaluates the
case evidence to identify any information that
could help locate the claimant. The CE2
investigation should include making a reasonable
effort to obtain new information that may assist
in identifying the claimant’s valid mailing
address. For example, the CE2 should request a
forwarding address from the Post Office closest
to the claimant’s last known address. See Exhibit
25-8.

(1) Correct Address Not Found. If the CE2
cannot obtain the claimant’s current
address, the CE2 places a memorandum in the
file listing the actions taken to locate the
claimant, and then administratively closes
the claim until receipt of the claimant’s
valid mailing address.

(2) Correct Address Found, Claimant Did Not
Notify DO. In the event the CE2 obtains the
claimant’s current address, and the claimant
did not notify the DEEOIC in writing of that
change, the CE2 sends the claimant a copy of
the RD from the file. The CE is to prepare
a separate request to the claimant asking
for written notice of his or her address
change (See Exhibit 25-9). The letter is to


Uranium Workers. All claims for uranium workers (or
their survivors) who may have been awarded benefits
under Section 4 or 5 of RECA are within the
jurisdiction of the Denver DO.

Chapter 8 - Case Maintenance:

o Ch. 8.6a(2) edited to remove reference to CE2 unit

Chapter 9 - Transfers and Loans:

o Chapter edited to remove all references to CE2 Unit

Chapter 13 - Establishing Covered Employment:

o Ch. 13.10a(2) has been edited to update the fax number
for the Social Security Administration (SSA)

Chapter 14 - Establishing Special Exposure Cohort Status:
o Chapter edited to remove all references to CE2 Unit

Exhibit 15-4 - Exposure and Causation Presumptions with
Development Guidance for Certain Conditions:

o Exhibit 15-4, Section 5b has been edited for clarity.
PM v2.2 read:

b. A qualified physician has diagnosed the employee
with asthma. A medical diagnosis for asthma
should be made when the physician is able to
identify the presence of intermittent respiratory
and physiologic evidence of reversible or
variable airways obstruction including positive
methacholine challenge test or post-
bronchocodialator reversibility. However, a
Physician can also rely on other clinical
information to substantiate his or her diagnosis
of asthma. For example, spirometry for
measurement of FEVi and FVC is the most reliable
method for assessing airway obstruction. The
response to inhaled bronchodilator administration
has been used as a measure of airway
hyperresponsiveness. A 12% improvement in FEVi of
at least 200 mL after inhaled bronchodilator is
how the American Thoracic Society defines a
significant improvement indicative of
hyperresponsive airways


or other rehabilitative therapy, may
originate from an employee, a designated
authorized representative or a medical
provider.

The DEEOIC Bill Processing Agent (BPA) must
register all authorization requests for
rehabilitative therapy services in its
electronic case tracking system. The BPA will
record authorization requests it receives and
then forward the request, as a thread, to the
Workers’ Compensation Assistant (WCA)/FO for
processing. Authorization requests received
at the DO via mail or facsimile must be
routed through the WCA/FO to the BPA for
record creation and thread initiation.

Once the assigned CE/MBE receives a thread
for authorization of a rehabilitative
therapy, he or she must undertake a review of
the evidence in the case to make a
determination as to whether or not the
request is medically necessary in the care of
the covered employee’s accepted work-related
medical condition(s).

The CE/MBE must approve requests for a
rehabilitative therapy initial assessment as
long as the employee’s treating physician
prescribes it. The CE/MBE approves the
request and sends an email to the WCA who
then notifies the BPA to authorize an initial
therapy assessment. The CE/MBE sends a letter
authorizing the initial assessment to the
requestor with a copy to the employee. If the
CE/MBE receives a request for an initial
rehabilitative therapy assessment without a
physician’s prescription, he or she sends a
letter to the employee (with a copy to the
therapy provider) requesting a signed
prescription for the initial assessment. In
the letter, the CE/MBE advises that the
employee has 30 days within which to submit a
signed physician’s prescription for an
initial therapeutic evaluation.


(iii) been taken and what future actions are
required to address any outstanding
issues;

(iv) Issue a RD whenever the case record
contains enough evidence on file to
support a RD on any of the outstanding
claim elements.

It has been edited in PM v2.3 to read:

(b) A separation must exist between the district
offices and FAB to maintain impartiality in case
adjudication functions. The designated CE
assigned to a case handles all necessary
development on outstanding claim elements not
related to the RD currently in front of the FAB
for review, and may issue a RD whenever the case
record contains enough evidence on file to
support a RD on any of the outstanding claim
elements. While the CE may concurrently work on a
case assigned to FAB, the CE may not engage in
any case adjudication activity relating to a
claim under evaluation by FAB. Moreover, FAB may
not seek CE assistance with regard to its
evaluation or development of a claim under
consideration for finalization.

o Ch. 2.6b has been edited to reconcile instructions on
the jurisdiction and handling of Section 4 and 5
Radiation Exposure Compensation Act (RECA) claims with
guidance outlined in Chapter 19 - Eligibility
Requirements for Certain Uranium Workers.

PM v2.2 read:

Uranium Workers. Normally, all claims for uranium
workers (or their survivors) who may have been awarded
benefits under Section 5 of RECA are within the
jurisdiction of the Denver DO. (However, if a worker
filed for both RECA Section 5 and silicosis benefits,
and the Nevada Test Site was the last place of
employment, the case would go to the Seattle DO rather
than the Denver DO).

It has been edited in PM v2.3 to read:


(2)

and if the information is not received
in that time, the request for
rehabilitative therapy may be denied by
the DEEOIC.

If the employee or the physician does
not provide a response to the second
request for information within the 30-
day period allowed, the CE/MBE issues a
letter decision to the employee denying
the claim for rehabilitative therapy.
The CE/MBE further sends an email to
the FO, who sends a thread to the BPA
for system update.

A CE/MBE can refer requests with
unclear medical documentation to a
DEEOIC nurse consultant or CMC for
review to obtain expert advice on the
recommended course of action. Once the
CE/MBE has undertaken development,
including allowance for the treating
physician to provide further support
for an unsubstantiated request for
rehabilitative therapy, he or she can
issue a letter decision denying the
authorization if sufficient medical
justification has not been forthcoming.

The letter decision is to include a
narrative as to why the evidence is
insufficient to warrant authorization.
The CE/MBE is to send a letter to the
employee along with a copy of the
letter decision to the provider, if
applicable. The letter decision is

to include the following language:

If you disagree with this decision and
wish to request a formal decision,
Please immediately advise this office,
in writing, that you wish to have a
Recommended Decision issued in this
case, providing you with your rights of
action.


assessing whether a substantive -
basis exists for granting a
waiver of the two-year rule.

o Exhibit 21-5: Title changed from “Required Medical
Evidence for Specific Conditions” to “Evidence to
Support Impairment Rating for Specific Conditions.”
Exhibit content edited to include updated guidance
related to classification of voice/speech impairment,
specifically referencing Table 11-8 of the AMA’s
Guides to the Evaluation of Permanent Impairment, 5t®
Edition.

e Chapter 22 - Wage-Loss Determinations:

o Ch. 22.10a(4) has been edited to correct the fax
number for resubmissions to the SSA.

e Chapter 23 - Consequential Conditions:

fe}

Ch. 23.12 edited for clarity.
PM v2.2 read:

12. SWC Claims, Lawsuits and Fraud. For each
consequential injury that is to be accepted, the CE
may need to obtain a newly signed Form EN-16
SWC/Tort/Fraud affidavit from the claimant.

It has been edited in PM v2.3 to read:

12. SWC Claims, Lawsuits and Fraud. For each
consequential injury that is to be accepted, the CE
must obtain a newly signed Form EN-16 SWC/Tort/Fraud
affidavit from the claimant.

e Chapter 24 - Recommended Decisions:

o All references to former CE2 Unit removed

o Ch. 24.10.b has been updated to include reverse
consequential illness acceptance by letter decision.

PM v2.2 read:

b. Consequential illness acceptance


the CE2 need the actual file, the needs of the
FAB CE or HR take precedence.

Development by CE2. When the FAB completes its
initial review, the CE2 may request the case to
determine whether the evidence of file is
sufficient to issue a RD on an outstanding claim
element. The CE2 inputs the appropriate action
status in ECS. Jurisdiction should remain in the
appropriate FAB office and not be changed to the

DO.

(1)

(2)

Issuing a RD. Should the record contain
enough evidence to support a RD on any of
the outstanding claim elements, the CE2
issues a RD. The Senior or journey level CE
in the DO (or DD designee) reviews and signs
the decision before issuance. Once the
decision is reviewed and approved by the
appropriate individual at the DO, the CE2
returns the case to the FAB and reflects the
transfer of the case in ECS. It is
particularly important to issue a RD if the
claim element is in posture for acceptance.

If additional elements of the claim require
development, the CE2 prepares a memorandum
as outlined below. There is no need to rush
to issue a RD denying a claim element if
alternate elements are being deferred. [In
such a situation, the CE2 should wait until
the deferred elements are resolved before
proceeding with a RD. An exception to this
rule is if a hearing date has been requested
or scheduled. In these cases, the CE2
proceeds with any appropriate denial prior
to a hearing so that objections to all
outstanding RDs can be entertained at one
time, thus avoiding multiple hearings.

Further Development Required. If the DO
development does not permit the CE2 to issue
an additional RD, he or she completes
whatever development is possible and returns
the case to FAB. The CE2 prepares a
memorandum on gold-colored paper to the DD
explaining what development actions have