"Documented Dysfunction" (California)

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"Documented Dysfunction" (California)

Postby angelinlaw on Thu Apr 23, 2009 12:30 pm

"Documented Dysfunction" :?

Facts: I have an Internist who determined that the applicant falls under Table 13-4 category II with a sleep impairment 10% WPI (psyche, shoulder and lumbar claim)

So Chapter 13 intro states that this section is to be used when there is a "documented dysfunction" of the:
-cranial nerves
-spinal cord
-nerve roots
-peripheral nerves

1) What is your understanding/interpretation of "documented dysfunction"?

I was initially thinking a traumatic injury to the head or traumatic injury to the spine

2) Then section 13.3c assessing impairment due to arousal and sleep disorder goes on to provide

Impairment categories hat may arise from sleep disorders relate to
-the nervous system, with reduced daytime attention, concentration, and other cognitive abilities
-mental and behavioral factors, including depression, irritability, interpersonal difficulties an d social problems

This leads me to believes as long as a person has reduced daytime attention or concentration, etc and or has mental behavioral factors such as depression, irritability, then they can be rated per Table 13-4, even if no documented dysfunction to the enumerated body systems?

Any opinions on this?????????????????? :?: :?:

I know there needs to be sleep study test if the applicant is considered to have excessive daytime sleepiness, but would one even need to proceed with the test to access this if there is no “documented dysfunction?”

Or is the sleep study test considered to be the “documented dysfunction?” :?:

Think I’m going around in circles ( and maybe unnecessarily)……??? :geek:

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Re: "Documented Dysfunction" (California)

Postby denyse on Tue Apr 28, 2009 4:36 pm

In order to define arousal disorder under table 13-4, one must have a neurologically assessed disorder to the Central Nervous System (brain). Your doc is giving impairment for symptoms not a valid diagnosis under chapter 13, which is inappropriate.

You have also introduced a potential issue, and that is sleep (insomnia) can be defined under chapter 14, or in the case of Cali, GAF. Mild insomnia is a 61-70 GAF, or 0-14% WPI before the 40% increase for FEC. Not saying that will happen, but it is within the realm of possibility (exposure). No testing required underr GAF. All based on patient complaints unless you have film or conflicting testimony. Still surprized at the lack of play by CAAA. Maybe the are waiting for the inevitable Almaraz reversal (Almaraz II).
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Re: "Documented Dysfunction" (California)

Postby shalom1 on Wed Jan 13, 2010 1:28 pm

The applicant does not need to have a neurologically based disorder in order to refer him/her for a sleep evaluation and/or study. According to the DWC unit, (see 2/27/09 "DWC unit emphasizes Sleep Study, Diagnosis as Basis for Disorders), the applicant can develop "obstructive sleep apnea " due to weight gain because of theui industrial injury. In addition, the DWC refers to impaired ADL's as a basis for sleep evaluation
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Re: "Documented Dysfunction" (California)

Postby kkingdon@kingdonrating.net on Thu Jan 14, 2010 8:45 am

Although Table 13-4 is located in the Central Nervous System section of the Nervous System Chapter, it rates sleep disorders irregardless of etiology.

Master the Guides notes at page 155 that sleep disorders secondary to nervous system, mental, cardiovascular, or respiratory diseases are ratable under this section.

Example 13-17 in the Guides rates obstructive sleep apnea, which is not a nervous system disorder, under this section.

In most cases, there will be an issue of duplication.
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Re: "Documented Dysfunction" (California)

Postby denyse on Thu Feb 04, 2010 4:30 pm

My 2 cents:

Arousal is apart of the CNS chapter. Specifically 13.3 (Cerebral Impairment). The following is presented:

1. Section 13.1 (Principles of Assessment) states, “This chapter emphasizes the deficits or impairments that may be identified during a neurologic evaluation.”
2. Section 13.2 (Criteria for Rating Impairment Due to Central Nervous System Disorders) states, “The central nervous system (CNS) consists of the brain and spinal cord. When injury or illness affects the CNS several areas of function may be impaired.
3. Section 13.3c (Arousal and Sleep Disorders) states, “Impairment categories that may arise from sleep disorders relate to (1) the nervous system, with reduced daytime attention, concentration, and other cognitive abilities; (2) mental and behavioral factors, including depression, irritability, interpersonal difficulties, and social problems; (3) the cardiovascular system, with systemic and pulmonary hypertension, cardiac enlargement, congestive heart failure, or arrhythmias; and (4) the hematopoietic system. The Respiratory System (Chapter 5) also discusses impairment as it relates to obstructive sleep apnea.
4. 13.10 (Nervous System Impairment Evaluation Summary) and table 13-25, require an assessment of function (CT Scan, MRI, EEG, etc.).

My take is that the primary condition that arousal impairment is rated on is neurological (CNS), and must be assessed (assessment of function) to make a valid diagnosis. This is consistent with the other 13.3 impairments. You must rate a condition, not a symptom. That said, line items 3 appears to suggest arousal can be rated for mental, cardio, hematopoietic or respiratory conditions. I note that obstructive sleep apnea is an example, but is also referenced on page 105 in the respiratory section. As such, this would appear consistent with the line item 3 exceptions. As such, I would strongly argue that you can't rate sleep disorders "irregardless of etiology". You don't rate arousal because your toe hurts. I would also suggest that most GAF's subsume (duplicative) any class 1 or 2 sleep disorder. Lastly, it is expected that a diagnosis of daytime sleepiness should be supported by a formal sleep study (see obstructive example). Now if you want to give 3% as a basis for pain add on (toe pain keeps me up at night), I am not sure the IC would be wise to mandate a test.

Quite frankly, I don't see an internal play here unless you also commenting on the exceptions (conditions).
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