Ask the Rating Experts
iRatings, LLC would like to thank all those who submitted questions to our “Ask the Rating Experts” series. In this periodical, we will continue to answer your questions on the rating issues of the day. Topics include, but are not limited to, the proper application of any edition of the AMA Guides, common errors we see, and the assessment of impairment under Almaraz/Guzman in California.
As always, we invite you to submit your questions online, or via email.
This issue’s question deals with a familiar problem – when to use the Range of Motion method for the spine under the 5th Edition.
The Range of Motion (ROM) Method
Q: I received a report where the physician cited imaging findings of “multilevel degenerative disc disease” as the basis for using the Range of Motion method. I was surprised to see the ROM method being used in this case, as there was only a history of a single level diskectomy based on a disk herniation at L5-S1 and electrodiagnostic findings of a left S1 radiculopathy. At the time of MMI, there were still complaints of radicular pain and the physician did document residual motor and sensory deficits in the left S1 distribution. Since there was no history of bilateral or multilevel radiculopathy, I thought the ROM method could not be used. However, the physician pointed to Section 15.2, Number 2, which states that the ROM can be used “When there is multilevel involvement in the same spinal region.” Is this correct?
A: No, this does not appear to be correct based on the history presented, and this is a very common error we see when rating the spine. Remember that the Guides state in Section 15.2 that “The DRE method is the principal methodology used to evaluate an individual who has had a distinct injury.” (p. 379) There are several situations where the Guides indicate the use of the ROM method, and multilevel involvement is the first criteria that must be met. It is not, however, the only criteria.
While the Guides do note in Section 15.2, Number 2, that the ROM can be used “When there is multilevel involvement in the same spinal region,” they clarify this to mean“fractures at multiple levels, disk herniations, or stenosis with radiculopathy at multiple levels or bilaterally.” The Guides break this down further in Section 15.2a, Number 4, which states the following:
Determine whether the individual has multilevel involvement or multiple recurrences/occasions within the same region of the spine. Use the ROM method if:
a. there are fractures at more than one level in a spinal region,
b. there is radiculopathy bilaterally or at multiple levels in the same spinal region,
c. there is multilevel motion segment alteration (such as a multilevel fusion) in the same spinal region, or
d. there is recurrent disk herniation or stenosis with radiculopathy at the same or a different level in the same spinal region; in this case, combine the ratings using the ROM method.
In this case, if there were findings of “multilevel degenerative disc disease” that would meet the first criteria. However, based on the findings you noted (electrodiagnostic evidence of single level radiculopathy, motor and sensory deficits of left S1 only), none of the other criteria are met. Remember that the Guides note that there are common developmental findings on imaging studies, and state that “the presence of these abnormalities on imaging studies does not necessarily mean the individual has an impairment due to an injury.” (p. 383) In order for there to be ratable impairment under any method, the Guides state that “clinical symptoms and signs must agree with the imaging findings.” (p. 378) Therefore, while there are imaging findings of multilevel involvement, the clinical signs and symptoms would not support the presence of a bilateral or multilevel radiculopathy. As such, the ROM method is not supported in this case.
Given the history of single level diskectomy and findings noted in this case, the injured worker would meet the criteria for rating under DRE Lumbar Category III, as there is both surgery and “Significant signs of radiculopathy.” This allows for a rating range of 10%-13% whole person. Based on the residual symptoms noted in this case and residual radicular findings, a rating of 13% whole person would be appropriate (see Ex 15-4).
Sincerely,
iRatings LLC