Choosing the DRE Method and Resisting Add-Ons in a Lumbar Impairment Rating
Mr. Okafor, 44, underwent an L5-S1 microdiscectomy 14 months ago for a work-related disc herniation. His current examination shows decreased pinprick over the right L5 dermatome, right extensor hallucis longus strength of 4/5, and a diminished right ankle reflex. He has no bowel or bladder symptoms, no gait derangement, and no fusion. Postoperative MRI shows expected surgical changes without recurrent disc herniation; EMG shows chronic right L5 radiculopathy. The jurisdiction adopts the AMA Guides to the Evaluation of Permanent Impairment, fifth edition, and requires the DRE method for the lumbar spine. The claims examiner asks you to add 5% whole person impairment for pain and 3% for possible future surgery. Plaintiff's attorney asks you to use the range-of-motion method because it yields a higher rating, and to include the future surgery as part of the rating.
1. Which method should be used, what category applies, and what is the rating? Explain your reasoning.
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The jurisdiction requires the fifth edition and the DRE method for the lumbar spine, so the range-of-motion method cannot be used even if it would produce a higher number. Method selection is governed by the applicable edition and jurisdiction, not by the result.
Under the fifth-edition DRE scheme, the findings are objective right L5 radiculopathy: dermatomal sensory loss, extensor hallucis longus weakness, and a diminished ankle reflex, with chronic radiculopathy on EMG. There is no fusion, no cauda equina syndrome, and no gait derangement. Objective radiculopathy without fusion falls within DRE Category III, which carries 10% whole-person impairment. Category II is not appropriate because there are objective neurologic findings. Category IV is not appropriate because there is no fusion. The report should list the specific findings that place him in Category III and should state that the DRE method was used as required.
2. How should you respond to the claims examiner's add-ons and the plaintiff's attorney's method request?
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Both requests should be declined with a clear explanation. The fifth edition does not permit a separate 5% whole-person add-on for pain; pain is incorporated into the diagnosis-based category, and adding a pain value would double-count and inflate the rating. Future surgery is speculative and is not part of a current impairment rating; it may be addressed separately as future medical care if the jurisdiction allows, but it cannot be added to the impairment percentage.
The request to use range-of-motion because it yields a higher rating is not a legitimate basis for method selection. The jurisdiction mandates the DRE method for the lumbar spine. The response should be: 'I am required to use the DRE method under the applicable rules. I cannot select a method based on which produces a higher value. The rating is 10% whole-person impairment for DRE Category III.' Document the requests and the rationale in the file.
3. If Mr. Okafor also had a total knee replacement rated at 20% whole-person impairment, how would you combine the values? What if he used a cane?
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The lumbar and knee impairments are different body regions, so they are combined using the Combined Values Chart, not added arithmetically. A 10% whole-person lumbar impairment combined with a 20% whole-person knee impairment yields 28% whole-person impairment (10 + 20 × 0.90 = 28). The report should identify each regional value and show the combination.
A cane requires separate analysis. The examiner should determine whether it is medically necessary and whether it is used because of the rated lumbar condition. If it qualifies as a gait derangement under the applicable chapter, it may be rated under the appropriate table, but it must not be used to double-count the same neurologic deficit already captured in the DRE category. The rationale for accepting or rejecting the cane-related impairment should be documented.