The AMA Guides and Almaraz Guzman from an Orthopedic perspective

Peter M Newton, MD

Newton Medical Evaluations, Inc

The AMA Guides provides a reliable and repeatable method for assigning impairment for injured workers who have suffered a loss of bodily function or loss of a body part. The impairment determination is performed once the injured worker has reached maximum medical improvement (MMI). MMI is where additional treatment is unlikely to lead to an improvement symptoms.

The AMA Guides is a work in progress that is improved with each updated edition. Over the years since introduction, the Guides has provided a science and consensus-based standard to evaluating injured individuals. The 5th edition of the Guides used in California since 2005, and 11 other states, was published in 2000. The 6th edition published in 2007 is used in another 19 states. Each new edition attempts to update the ratings method based on current evidence-based science. Use of an outdated version of the guides may result in ratings that are not based on current science and may result in inequitable results.

It was an impossible task for the authors include all orthopedic diagnoses in merely 3 orthopedic chapters 15, 16 and 17 of the Guides. Many important and common diagnoses and conditions are not included. Some of these common injuries/conditions cause significant pain and limitations and permanent loss of function. If rating by analogy is not used, then many of these unlisted conditions would be assigned a 0% whole person impairment. Because impairment reflects a loss of function, assigning a 0% WPI to those conditions/injuries is not realistic when that injury has resulted in a permanent loss of function.

The Almaraz Guzman decision not only allows rating by analogy but also the more controversial aspect of this decision, allowing physicians to assign ratings based on an “accurate reflection of the injured workers loss of function” and allowing use of the “4 corners of the Guides” to assign a whole person impairment. The physician must take into consideration the affected Activities of Daily Living (ADL’s) when opining on Whole Person Impairment (WPI). The more the ADL’s are affected, the higher the WPI that can be assigned.

ADL’s do not contemplate work restrictions and often to not consider functional loss. This is the reason that Almaraz Guzman expanded a physician’s ability to assign WPI. Almaraz Guzman requires the physician to assign the straight rating under the AME Guides and then explain why further impairment may be assigned. The standard of employing this technique is to be “accurate.”

The Almaraz Guzman Court cautioned that the physician should only use the rating by analogy method in rare circumstances. First of all, it is this physician’s opinion that Almaraz Guzman should not be used where the patient has returned to work, retains function, or has pain that is easily manageable. It is also rare that an orthopedic condition cannot be rated using the 3 respective orthopedic chapters in the AME Guides.

The examiner should always assign a rating for conditions discussed in the respective chapters and only assign a rating by analogy where the applicant’s condition is not accurately rated per the strict interpretation of the Guides or has not been included.

Any rating by analogy or rating outside of the strict interpretation of the Guides, must be supported by abnormal objective findings including physical exam, diagnostic study findings, or anatomical changes from surgery or trauma . An alternate Almaraz Guzman rating is not valid if based solely on subjective complaints that are not supported by significantly abnormal objective findings. The physician must always support its decision to use Almaraz Guzman by stating “how and why” it leads to greater accuracy. This standard is similar to assigning apportionment. Medical opinions that use Almaraz Guzman should always be challenged where the physician does not provide sufficient justification. The courts have rejects medical opinions that fall short of the Almaraz Guzman analysis.