Opinion ID: 1280719
Heading Depth: 2
Heading Rank: 3

Heading: Conflict with Statute

Text: The Guides, Fourth is far more than a chart or reference table consulted by doctors; it is a complete set of extremely detailed instructions as to how a doctor should evaluate a claimant's injury. Of particular importance in the instant case is that the Guides, Fourth mandates the use of the DRE model for most back injuries. The evaluator assessing the spine should use the Injury Model [the DRE], if the patient's condition is one of those listed in Table 70 (p. 108). That model, for instance, would be applicable to a patient with a herniated lumbar disk and evidence of nerve root irritation. If none of the eight categories of the Injury Model is applicable, then the evaluator should use the Range of Motion Model. Guides, Fourth, ง 3.3, p. 94. Implicit in this instruction is that very few claimants would ever be evaluated under the ROM Model, since most would fall into one of the eight categories. The Guides, Fourth, goes on to list other specific instructions as to not only how a doctor should perform an examination, but what sort of data a doctor should consider, and in some cases, what weight the doctor should give that data. Again, we stress that, by virtue of incorporation by rule, the Guides, Fourth section on spinal injuries is far more than a guide, model, or illustration; it is a mechanical set of rules that compels a doctor to consider x but exclude y. It is with this controlling aspect of the Guides, Fourth that appellants most strongly disagree. Appellants point out that several commands of the Guides, Fourth appear to be in conflict with specific dictates of the Legislature, and that the spine injury section of the Guides, Fourth is also internally inconsistent. In essence, appellants echo the logic expressed in a policy memorandum issued by the then-chief administrative law judge, which rejected the DRE Model. Chief Administrative Law Judge Robert Smith issued the policy memorandum shortly after rendering a decision in the case of Thelma Cottrell v. Workers' Compensation Division and Community Health Associates, Claim No. 92-56811 (August 22, 1997). In that case, the chief administrative law judge determined that the DRE Model ran afoul of several Code provisions, and as a result, reports conducted in accordance with the DRE are unreliable and thus should not be considered in a determination of disability. Appellees argue that the decision of the chief administrative law judge was in excess of his statutory authority, and cannot bind either the Division or the Appeal Board. Before reaching the question of the administrative law judge's authority, we examine appellants' argument that the DRE conflicts with our workers' compensation statutes. First, appellants point out that the text of the Guides, Fourth states that the DRE Model considers a claimant's impairment at the time of the injury, not the time of evaluation, that the text of the DRE Model excludes consideration of occupational wear and tear or so called developmental findings, and finally, that the Guides, Fourth, rates one specific injury, but cannot be used where there are sequential injuries to the same body part or when an injury grows worse over time. It is clear that several statutes and opinions of this Court are in apparent conflict with the Guides, Fourth. First, we note that the section we quoted, supra, states that the degree of permanent disability other than permanent total disability shall be determined exclusively by the degree of whole body medical impairment that a claimant has suffered.  W. Va.Code ง 23-4-6(i) (1999) (emphasis added). We believe has suffered implies that any rating of permanent partial impairment must be made when the claimant has healed as much as possible. Furthermore, the Code suggests that the permanent partial impairment rating of an injured worker must be made after he or she has reached the maximum degree of improvement. (c) When the authorized treating physician concludes that the claimant has either reached his or her maximum degree of improvement or is ready for disability evaluation, or when the claimant has returned to work, such authorized treating physician may recommend a permanent partial disability award for residual impairment relating to and resulting from the compensable injury. W. Va.Code ง 23-4-7a(c)(1995); accord, Dalton v. Spieler, 184 W.Va. 471, 473, 401 S.E.2d 216, 218 (1990). Clearly, this Code section does not contemplate an impairment rating made based upon the claimant's condition at the time of injury, or even at some time after injury that is prior to reaching the maximum degree of improvement. However, on its face, the DRE Model suggests that once an estimate of impairment is made, subsequent treatment or improvement of the injury should not change the initial estimate. With the Injury Model [the DRE], surgery to treat an impairment does not modify the original impairment estimate, which remains the same in spite of any changes in signs or symptoms that may follow the surgery and irrespective of whether the patient has a favorable or unfavorable response to treatment. Guides, Fourth at ง 3.3d, p. 100. Although this statement seems at odds with other language in the spine section of the Guides, Fourth, [9] it nonetheless directs a physician to ignore the outcome of a claimant's treatment, and to rely upon the first estimate of impairment. By virtue of the Commissioner's decision to incorporate the Guides, Fourth, we are left with a nonsensical command that conflicts with the statute. Although during oral argument before this Court, certain parties intimated that this command is, in practice, ignored, we note that ignoring it doesn't make it disappear. Thus, we believe that this aspect of the DRE Model conflicts with W. Va.Code งง 23-4-7a (1995) and 23-4-6(i) (1999). Appellants also argue that the DRE Model, as set forth in the Guides, Fourth, is geared more toward rating single incident traumas to the spine, and purports to exclude any injury that appears over time. The Injury Model [the DRE] attempts to document physiologic and structural impairments relating to insults other than common developmental findings, such as (1) spondylolysis, found normally in 7% of adults; (2) spondylolisthesis, found in 3%; [10] (3) herniated disk without radiculopathy, found in more than 30% of individuals by age 40 years; and (4) aging changes, common in 40% of adults after age 35 years. Guides, Fourth, ง 3.3d, p. 100 (footnotes omitted) (footnote added). This sort of analysis would be inappropriate where a workers' injury has occurred over time. We have made clear that: An employee who is injured gradually by reason of the duties of employment and eventually becomes disabled is, under our workmen's compensation law, no less the recipient of a personal injury than one who suffers a single disabling trauma. Syl. pt. 3, Lilly v. Workmen's Compensation Commissioner, 159 W.Va. 613, 225 S.E.2d 214 (1976); accord, Syl. pt. 2, Sansom v. Workers' Compensation Commissioner, 176 W.Va. 545, 346 S.E.2d 63 (1986). We have also stated that: A compensable injury which does not initially or of itself produce a permanent total disability may become progressively worse over time or combine with prior impairments under the second injury statute, W. Va.Code, 23-3-1, so as to result in a permanent total disability..... Syl. pt. 1, Lambert v. Workers' Compensation Division, 211 W.Va. 436, 566 S.E.2d 573 (2002) (quoting Miracle v. Workers' Compensation Commissioner, 181 W.Va. 443, 383 S.E.2d 75 (1989)). Obviously, our law contemplates that an injury is not necessarily static, and can become worse over time, a concept to which the DRE is at odds, and to which it must yield. Another argument advanced by appellants is that W. Va.Code ง 23-4-16 (1995) allows a claimant to re-open his or her claim if a compensable injury worsens. The Code provides that in any claim in which an award of permanent disability was made, any such request must be made within five years of the date of the initial award. During that time period, only two such requests may be filed. As we noted above, the authors of the DRE state that the original impairment estimate remains the same, even if a claimant's condition worsens or improves. Thus, a claimant who attempts to reopen a claim would appear to be blocked by this language. Moreover, even if we accept the appellees' argument that this language can be ignored or explained, a claimant evaluated under the DRE Model who attempts to reopen still faces the enormous challenge of getting out of the box or category of his or her initial rating. This same problem also befalls a claimant who does not attempt to reopen for a change in an injury, but is simply injured a second time in a separate incident. The Code provides for additional compensation for claimants who become further impaired as a result of a second injury. See, W. Va.Code ง 23-4-6(d) (1999). Because the DRE puts a claimant in one category or another, his or her rating will be 5 percent, 10 percent, 15 percent, etc. Once rated at 5 percent, for example, a claimant must suffer a severe enough second injury to make the quantum leap between the 5 percent category and the 10 percent category. Thus, a claimant whose second injury under the ROM Model would have moved him or her from 5 percent to 7 percent, would remain stuck at 5 percent under the DRE Model. Thus, there is effectively no compensation for a second injury under this scenario, which we believe conflicts with our law.