🙌 Our team at PeakEvals wrapped up an incredible few days in Monterey! Here are the Key Takeaways from Day 1! Stay tuned for Day 2!
1. Substantial medical evidence standard: Opinions must be based on reasonable medical probability, accurate and relevant history, and a clear explanation of the “how and why” behind every conclusion (not just bare conclusions).
2. PTP, QME, and AME roles: Primary treating physicians and QMEs are held to the same substantial evidence standard; AME opinions carry weight but can be rebutted with a clear, well-reasoned comprehensive med-legal opinion.
3. Attorney–physician interface: When rebuttal is needed, attorneys should formally identify a medical-legal dispute and request a comprehensive report; PTPs may speak with attorneys but must keep interactions professional and within appropriate boundaries.
4. Impairment vs. disability: The AMA Guides rate impairment (a medical measurement focused on ADLs), while disability is a legal/vocational construct; it is inconsistent to assign 0% impairment yet impose work restrictions.
5. Central role of ADLs: Evaluations should begin and end with ADLs as the anchor for understanding functional impact, selecting the correct tables, and choosing where within an impairment range the rating should fall.
6. Beyond Table 1-2 and use of clinical judgment: Reliance solely on Table 1-2 is inadequate; physicians must integrate ADL effects, interpolate between categories when appropriate, and explain their reasoning, especially when subjective reports and objective findings diverge.
7. Use of other experts and information: The Guides allow reliance on both medical and non-medical experts (e.g., vocational) and support using home healthcare or ADL assessments when needed to fully document functional impact.
8. New diagnoses and communication limits: Examiners have an obligation to address newly discovered diagnoses, and while there is a limited exception to ex parte rules, applicants should be discouraged from bringing written materials directly to evaluations.
9. Violent act and catastrophic injury analysis: Loss of consciousness is often accepted as evidence of a “violent act” and may support a finding of “catastrophic” injury, but significant brain injury can exist without LOC; the Wilson case outlines multiple factors for catastrophic determinations, including sequelae.
10. Chapter 2 and CVC v. Vigil principles: AMA Guides Chapter 2 provides the roadmap for rating, with jurisdictional law controlling where definitions differ; under CVC v. Vigil, opinions must be ADL-driven, sustainable, and supported by explicit “how and why” reasoning throughout, not only in apportionment.
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