UNITED STATES DEPARTMENT OF LABOR

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ADVISORY BOARD ON TOXIC SUBSTANCES AND WORKER HEALTH

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SUBCOMMITTEE ON MEDICAL ADVICE FOR CEs REGARDING WEIGHING 

MEDICAL EVIDENCE (AREA #2)

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MEETING MINUTES

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TUESDAY

JULY 12, 2016

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

Eastern Time, Victoria A. Cassano, Subcommittee Chair, 

presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

KENNETH Z. SILVER

LESLIE I. BODEN

MEDICAL COMMUNITY:

STEVEN MARKOWITZ, Board Chair

VICTORIA A. CASSANO, Subcommittee Chair

CLAIMANT COMMUNITY:

DURONDA M. POPE

KIRK D. DOMINA

FAYE VLIEGER
DESIGNATED FEDERAL OFFICIAL:

CARRIE RHOADS
Introduction and scope

Ms. Rhoads called the meeting to order at 1:07 p.m. Chair 

Cassano said that the purpose of the day's meeting was to 

lay a roadmap for the subcommittee and determine how to 

proceed. The subcommittee focused on four documents during 

the meeting: 1) the Procedural Manual, Chapter 2, Section 

0800; 2) contracted medical professional statement of work;

3) claims examiner (CE) job description; 4) final 

adjudication board claims examiner job description. DOL is 

asking the subcommittee for clarification and 

recommendations regarding the assessment of medical 

opinions, methodologies for improving physician 

responsiveness, training resources for improving the 

quality of medical review of medical evidence, and 

application and guidance relating to assessing contribution 

or aggravation of office questions.

Procedure Manual

Member Silver took issue with the wording of 2(b) Medical 

Monitoring Programs such as the Former Worker Program. 

Former Worker Programs are not administered by DOE 

facilities; many are run by universities. A claims examiner 

might give privileged consideration to a company doctor and 

not appreciate the independence of the Former Worker 

Program. Chair Cassano said that the language on the 

Contract Medical Consultants (CMCs) – in order to form a 

truly reasoned decision the CMCs should be looking at all 

of the medical evidence that is presented whether or not 

the CE thinks it's reasonable or not. Member Vlieger wanted 

the CEs to go into the medical records from the sites. 

Member Boden said that published studies are also a 

potential source of information. However, it's not the 

place of the CE to be able to figure out what learned 

bodies or what peer reviewed papers should be used in the 

claim evaluation process. 

Medical Evidence

On the issue of medical evidence, Member Vlieger wanted to 

see something about the valid diagnostic tests that are 
used for various portions of claim evaluations. Chair 

Cassano had an issue with using death certificates because 

death certificates are inaccurate when it comes to the 

secondary cause of death. In terms of a hierarchy of data, 

healthcare providers have acquired that hierarchy through a 

lot of experience and claims examiners may not be 

sophisticated enough to understand a hierarchy of medical 

evidence and apply it to the claims process. 

Member Markowitz wanted the subcommittee to formally look 

at the issue of affirmative assistance in the claims 

process. In many cases, the CE may not be aware of what 

evidence he needs. This issue can be examining along with 

the notion of creating a training document for the CEs. The 

subcommittee wanted clarification on wage loss and how it 

relates to the diagnosing physician's medical evaluation of 

a claimant. Member Vlieger said that it is out of scope of 

the job of the CE to assign weight to medical evidence. The 

CE is in a tough spot and the question from the 

subcommittee is, how does a CE apply the guidance for

weighing medical evidence? How does someone without the 

proper training evaluate who is telling the truth and how 

convincing is the rationale that is used? If the CE 

determines that the evidence they are provided does not 

rise to the level of a rationalized opinion, then that 

information is provided to a CMC within the guidelines of 

some very restrictive questions. The CMC then opines on 

those particular questions. Whether or not a CE sends 

information to a CMC hinges on the CE determining that a 

physician's statement does not meet what the CE considers 

the level of evidence.

There do not seem to be audits on CMC reports to check for 

validity and medical accuracy. The CE does not have any 

guidelines on how to evaluate the report coming from the 

CMC. 

It might be good to put together a focus group of CEs and 

ask them how they deal with particular situations. It would 

be helpful to have a couple of members of the subcommittee 

sit down with a CE and go through a claim. The subcommittee 

also wanted to work through a small percentage of claims to 

get a sense of the process that is used when a CE decides 

to use a CMC. Member Boden thought that paying physicians 
for their time might be a good way of improving physician 

responsiveness to data requests. Member Silver wanted to 

get the quarterly management reports from DOL that track 

the CMC process. Getting the four most recent reports would 

be a good start.

Work Plan and Time Table

Chair Cassano said that the other documents that need to be 

reviewed, like the job descriptions, the statement of work, 

and other sections of the Procedure Manual – those can be 

discussed in another subcommittee telephone meeting prior 

to the October full board meeting. 

Member Markowitz wanted to get data from DOL that would 

give the subcommittee a closer look into the process of 

decisions that the CEs are making. The list of reasons to 

send things to a CMC includes: clarification of diagnosis, 

causation and care, onset date, consequential injury 

treatment, clarification of conflict. Including the 

weighing of exposure information as part of the evaluation 

of medical evidence needs to be on the mind of the 

subcommittee. Another subcommittee is looking at the 

exposure matrices. DOL does not always differentiate 

between diagnosis and causation. Looking at how the DOL 

includes exposure is part of looking at how DOL weighs 

medical evidence. The subcommittee will also look at 

whether the CMC actually weights the industrial hygienist 

report. Finding out how much discernment the CE has in 

ignoring some evidence and moving other evidence forward to 

the industrial hygienist or CMC in order to get a valid 

opinion is a critical issue before the subcommittee.

As far as a formal recommendation to the DOL, the 

subcommittee thought it best to take its time to develop an 

approach that is useful instead of just trying to rewrite 

the Procedure Manual. The subcommittee will ask the DOL to 

provide them with the materials that they specifically 

requested the advisory board to review. These items include 

department letters, outreach efforts, development letters, 

etc. There is no standardized letter written by CEs 

requesting information. Each one is done on a case-by-case 

basis.
The subcommittee will look at the issue of aggravation. 

Aggravation is not just a causation issue, but it's a preexisting condition that's been aggravated by exposure, the 

new disease, or the treatment of the new disease. One 

significant problem is how one differentiates between 

aggravation of a disease by exposure versus a natural 

progression of a disease. Member Vlieger asked if the DOL 

could assign a well-qualified claims examiner supervisor to 

the subcommittee calls. Member Silver said that a way out 

of the aggravation problem might be to list diseases like 

asthma and the things that can aggravate it and develop 

“slam dunk” presumptions. Getting the sentinel health 

event/occupational lists developed by Hawthorne and Melius 

in the 1980s and updated by Mullan in the 1990s would be a 

very useful tool for the subcommittee to have at its 

fingertips. 

Member Boden wanted to know what are the exposures and/or 

diseases that people are submitting their requests to. If 

the subcommittee or full board is going to think about 

presumptions, it would be good to know which 

substances/diseases combination were high on the list. The 

frequency of diagnoses in claims has been requested by 

another subcommittee, there has not been a request to look 

at the frequency of exposures. 

The occupational history questionnaire is something that 

the subcommittee is going to look at carefully during the 

course of its deliberations and whether it can be improved 

to help the claims examiner. If the occupational history 

questionnaire is going to be changed, the subcommittee 

wants to first look at the reports that come from the 

interviews of the workers to the Former Worker Medical 

Screening Program.