Opinion ID: 1280719
Heading Depth: 2
Heading Rank: 2

Heading: DRE versus ROM Impairment Ratings

Text: The next grievous error committed by the majority concerns its mistaken interpretation of the American Medical Association's Guides to the Evaluation of Permanent Impairment (4th ed.1993, reprinted 1995) [hereinafter referred to as the  Guides ] adopted by the Commissioner and its ultimate conclusion that such Guides are much more restrictive than their plain language would suggest insofar as they apply to compensable spine injuries. In its decision, the Court correctly states that early editions of the Guides authorized examiners to use the ROM model in making their disability determinations. See generally Guides ง 3.3, at 94. Beginning in the 1993 edition of the Guides, however, upon which edition the Commissioner relies in W. Va.C.S.R. ง 85-16-4.1, the Guides abandoned the predominance of the ROM model in favor of the DRE model, which is considered to be a more reliable indicator of an individual's actual degree of impairment resulting from work-related spinal injuries. Therefore, at present, under the Guides the only reason to utilize the [ROM] model [i]s if an injury [i]s not clearly enough defined in the DRE model. Thomas v. United Parcel Serv., 58 S.W.3d 455, 457 (Ky.2001) (per curiam). Armed with this knowledge, the majority abruptly halts its investigation into the validity of the DRE model versus the ROM model. Further review of the actual language employed in the Guides, however, suggests that the ill-informed decision to completely abandon any reference to the DRE model in disability evaluations was perhaps too hastily made. In its most basic and rudimentary sense, in simplistic and uncomplicated language, the Guides specifically advocate the employment of both methodologies to evaluate a claimant's degree of spinal impairment, rather than the wholesale adoption of the DRE model to the complete exclusion of the ROM methodology as suggested by the majority. One of the purposes of the Guides is to lead to similar results when different clinicians evaluate illnesses and impairments. For evaluating spine impairments, past Guides editions have used a system based on assessing the degree of spine motion and assigning impairment percents according to limitations of motion. Impairment percents related to the range of motion were to be combined with percents based on diagnoses or therapeutic approaches and neurologic impairments. One concern with the range of motion system has been that in applying it, other clinical data and diagnostic information tend to be ignored. Also, some physicians are concerned about the accuracy and reproducibility of mobility measurements, while others believe the system fails to account for the effects of aging. .... [A] recent study of objective methods for examining patients with chronic low-back pain and self-reported, everyday disabilities identified seven clinical measurements that distinguish well between the patients with pain and normal subjects.... In this edition of the Guides, the contributors have elected to use two approaches. One component, which applies especially to patients' traumatic injuries, is called the Injury Model [or Diagnosis-Related Estimates (DRE) Model]. This part involves assigning a patient to one of eight categories, such as minor injury, radiculopathy, loss of spine structure integrity, or paraplegia, on the basis of objective clinical findings. The other component is the Range of Motion Model, described above and recommended in previous Guides editions. .... If none of the eight categories of the Injury [DRE] Model is applicable, then the evaluator should use the Range of Motion Model. All persons evaluating impairments according to Guides criteria are cautioned that either one or the other approach should be used in making the final impairment estimate.... However, if disagreement exists about the category of the Injury Model in which a patient's impairment belongs, then the Range of Motion Model may be applied to provide evidence on the question. Guides ง 3.3, at 94 (endnote omitted) (emphasis in original). Thus, it is apparent that the Guides advocate the use of the DRE model because it is more reliable than the former ROM model, which yields inconsistent results that are difficult to reproduce when a claimant is examined by a variety of physicians and fails to account for non-compensable conditions that may aggravate the compensable injury. In spite of the Guides ' efforts to promote accurate and reliable disability ratings, the majority forsakes such principles and adopts the ROM model because, they claim, the rule of liberality dictates such a result. Reaching such a conclusion, however, the majority fails to appreciate the very direct and concise language of the Guides which counsels examiners to employ either one or the other approach ... in making the final impairment estimate and permits reference to be made to the ROM model where disagreement exists as to a definite DRE diagnosis. Guides ง 3.3, at 94 (emphasis in original). Thus, it is apparent that, insofar as the majority of the Court is concerned, accuracy and reliability have no place in rating back impairments if the evaluation criteria leading thereto does not consistently award the injured claimant the highest disability rating and, consequently, the biggest workers' compensation benefits check. The majority additionally, and incorrectly, argues that the DRE model can only be used prior to a claimant reaching his/her maximum medical improvement [hereinafter referred to as MMI]. To support this assertion, the majority has taken a passage from the Guides out of context. In this respect, my colleagues contend that the Guides ' statement that surgery to treat impairment does not modify the original impairment estimate under the DRE model actually means that the DRE model can only be used prior to a claimant reaching MMI. This is absurd. The Guides explicitly, unequivocally, and repeatedly emphasize that the claimant must reach MMI prior to being evaluated for impairment. See, e.g., Guides ง 3.3, at 94 (It is emphasized that if an impairment evaluation is to be accepted as valid under the Guides criteria, the impairment being evaluated should be a permanent one, that is, one that is stable, unlikely to change within the next year, and not amenable to further medical or surgical therapy[.] (emphasis in original)). In fact, the Guides specifically contemplate that the claimant not receive a rating unless and until his/her condition has stabilized, is unlikely to change within the next year, and is not amenable to further medical or surgical therapy. See id. The passage relied upon by the majority was extrapolated from a larger discussion which elucidates that the DRE model attempts to document physiologic and structural impairments relying especially upon evidence of neurologic deficits and uncommon, adverse structural changes according to clinical findings that are verifiable using standard medical procedures. In the same context, the Guides intend that common developmental findings which affect the general public should not be included in a DRE impairment rating, nor should changes in signs or symptoms that do not result from the injury but rather from the individual claimant's subjective response to the injury. In other words, the DRE model intends to remove from impairment consideration those conditions that vastly affect the general population, as a natural result of non-work related factors such as aging, obesity, and lethargy. The majority, however, fails to appreciate this distinction.