FOLIO

GQ Corner

Apr 22, 2021 | by FOL

Q. I have a claim that has a PLN-11 filed regarding EOI. The injury does not extend to or include lumbar radiculopathy. We requested DDE to address MMI/IR for the CP diagnoses. The DWC-32 clearly only reflects MMI/IR are to be addressed. I received the DDR DWC-69 and report.  He found the claimant not at clinical MMI. I reviewed the report, and he opines that he feels the compensable injuries are lumbar strain, lumbar radiculitis and lumbar radiculopathy. Since he gave his opinion on what he feels the CP injury is, do I need to take any action regarding that? Do I now have to accept lumbar radiculopathy?

A. The DWC’s position is that where a DD is addressing only MMI and IR, they are not restricted to what is indicated as accepted on the DWC-32. The DD is permitted to independently assess the scope of the injury as part of the evaluation. That opinion on extent; however, is not afforded presumptive weight. You would still need to comply with the MMI/IR findings. If you want the DD to provide alternative MMI/IR certifications, you have to also ask for extent to be addressed on the DWC-32.

1. 1. 1. You can continue to dispute the lumbar radiculopathy. However, you will need to get that extent issue addressed in dispute resolution if you want any closure on MMI/IR.
      2. I would recommend a post DD RME on the MMI/IR and that you develop extent evidence through peer review, either by the same doc as your RME or another doc. If you request a DD on extent, it is likely to be the same DD so you know what that opinion would be. If Claimant request a DD on extent, you can also have the post-DD address extent.

Q. Claimant was overpaid in TIBs.  Voluntary reimbursement was requested from the claimant via the PLN-9; however, reimbursement was not received. We have now received a DWC-69 with impairment.  Are we allowed to take credit for the TIB overpayment against IIBs  –  OR  –  do we first have to send notification to the claimant of the overpayment and our intentions of recoupment of same against IIBs and allow the time period (no sooner than 2nd check) to elapse before we begin taking credit?

A. It depends on whether the overpayment of TIBs occurred in the weeks immediately following the MMI date, or whether the overpayment occurred prior to the MMI date. If it occurred in the weeks immediately following the MMI date, then you can convert those TIBs to IIBs. If not, then you must send the letter and comply with Rule 126.16.