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Federal Workers' Compensation

The Office of Workers' Compensation Programs administers four major disability compensation programs which provide wage replacement benefits, medical treatment, vocational rehabilitation and other benefits to certain workers or their dependents who experience work-related injury or occupational disease.

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Topeka  
#1 Posted : Friday, April 23, 2010 4:10:01 AM(UTC)
Topeka

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Topeka  
#2 Posted : Friday, April 23, 2010 4:12:30 AM(UTC)
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I don't know why this didn't post the first time, probably user error - LOL!  I
fell on the stairs at work over 2 years ago and hit my kneecaps on concrete floor.  I was diagnosed by Occ. Health as bilateral knee sprains and contusions.  Since they diagnosed sprains, I waited for them to heal for about 6 months
and finally went back to OH, had my case reopened, and was referred to a sports med doctor.  He has been treating me for about 1-1/2 years and recently referred me to an orthopedic surgeon.  I spoke to OWCP a couple of months back and
was told me sent a letter when the case was reopened but I never received it, so I requested a copy.  The copy states
that since I had an old knee injury 16 years ago with a diagnosis of
chondromalacia, the only diagnosis code they would accept was for bilateral contusions (bruises) of the knees.  That
old injury was treated and I recovered within a year afterward with no really significant problems until I fell at work 2 years ago.   I saw the orthopedic surgeon
today and he says I have bad arthritis in both knees and need bilateral knee replacements.  He said I may have had
arthritis for years but if it wasn’t bothering me before I fell (which it wasn’t), the fall aggravated it and caused my current problems.  I’m expecting a battle with OWCP to get my diagnosis code changed and get approval for surgery.  Anyone have experience with this type of situation?

stapler  
#3 Posted : Friday, April 23, 2010 4:34:35 AM(UTC)
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Hi Topeka,

According to the FECA Manual, "Aggravation of a pre-existing condition by employment is compensable." I'm posting the link to the FECA Manual Part 2, which is online. Read chapter 2 for more info on pre-existing conditions.

http://www.dol.gov/owcp/dfec/regs/compliance/DFECfolio/FECA-PT2.pdf


You're right to expect a battle with OWCP. It's very important to have your doctor write a thorough medical report that addresses all the points OWCP requests. You should have received a letter stating what is needed: history of injury, exam, pre-existing conditions,diagnosis, treatment, work-status, etc.

Just so you know, OWCP will try to accept a claim for the least significant diagnosis. They seem to love using the word sprain as a way of diminishing the severity of injuries, particularly when surgery is needed. Sometimes doctors will use the term "sprain" when referring to ACL tears as knee sprains, or rotator cuff tears as shoulder sprains, etc. It can pose a big problem for you when you request treatment or claim expansion, or apply for a scheduled award. Make your doctor aware.

OWCP will reject his report if he doesn't provide a "rationalized medical opinion," and provide "causal relationship." Your doctor needs to be as explicit as possible in connecting the dots between the work injury and the problem you're having now, as well as whether or not he feels that your pre-existing condition is a factor.

Hope this gives you a place to start. Good luck.
Topeka  
#4 Posted : Friday, April 23, 2010 6:19:53 AM(UTC)
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I actually had shoulder surgery performed by this surgeon years ago.  I wrote OWCP and requested change of physician and they approved, and the letter they sent did indeed outline exactly what they want from the doctor's report.  He has a copy of the letter.  I also told him about the whole sordid mess with the diagnosis code and past injury and he stated we would, "get this straightened out." He also mentioned the causal relationship between the fall and aggravating the knees.  He did knee replacement for a co-worker who also suffered a fall and wrote and asked to see this doctor.  Hopefully he'll do a good job on the initial report.  I just wondered if anyone else experienced this type of dodgeball from OWCP.
jesse slade  
#5 Posted : Friday, April 23, 2010 7:24:27 AM(UTC)
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Pretty much all of us have experienced the crazy ways of the OWCP.

hadenough  
#6 Posted : Friday, April 23, 2010 10:17:37 AM(UTC)
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Topeka, my case is similar and I have had nothing but problems with OWCP. They would not change my diagnosis code. At one point my CW even laugh that I needed any kind of treatment for bilateral contusions. I suffer from chondromalacia and moderate arthritis due to a head-on vehicle accident in a LLV. I will also need bilateral knee replacements sometime in the future. But because of the code they slapped on it before I saw my orthopedic surgeon they will not change it. Now, OWCP won't even pay me because of the LWEC rating I received in 1998.  Then there's the NRP. Finally, I am trying the disability route. Just plain tired of fighting this crap.
jesse slade  
#7 Posted : Friday, April 23, 2010 10:44:14 AM(UTC)
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Hadenough: You'll need to get your ICD-9 codes changed through consequential injuries. Same rules apply as when you're first applying, statement from you, good report from your doctor with job descriptions, how the injuries are caused by your employment, diagnosis, etc...Here's the case law for consequential injuries:
It is an accepted principal of Workers' Compensation law, and the Board has so recognized that when the primary injuries are shown to have arisen out of and in the course of employment, every natural consequence that flows from the injury is deemed to arise out of the employment, Charlet Garrett Smith 47 ECAB Docket No. 94-1421 (1996), Charles J. Jenkins 40 ECAB Docket No. 88-1369 (1988), Stuart K. Stanton 40 ECAB 89-1766 (1989), Carolyn King Palermo (Travis Palermo) 45 ECAB Docket No. 91-1736 (1994), Clement Jay After Buffalo 45 ECAB Docket No. 93-667 (1994).
Snowed  
#8 Posted : Saturday, April 24, 2010 12:25:12 AM(UTC)
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This is just a thought, but I think it would be eassier to file a NEW occupational disease for the arthritis than to try and upgrade diagnosis of old injury.  Arthritis can be caused by repetative motion injuries and repetative injuries to the area.  You do have 3 years from the date you realized it was work related.
 
Since you had additional WORK EXPOSURE after the original injury, I believe a new claim to be appropriate.
 
I think this would work for you too hadenough.
March for Justice!
Ruuth_Less  
#9 Posted : Wednesday, April 28, 2010 9:55:00 AM(UTC)
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Snowed...

I'm thinking this is the way to go for me too..

My current dx's are sprains and strains and bilateral contusions about both knees.

However almost 20yrs later, there is so much more.
hadenough  
#10 Posted : Wednesday, April 28, 2010 10:34:20 AM(UTC)
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jesse what do you mean by consequential injuries. I am 14 years on my knees and they are only deteriorating with wear, age, increasing pain but my case worker refuses to accept that. I have sent in medical and explained in a letter to him but there is never any action. Steer me in the direction if you could. Frankly, they have worn me down and with the NRP, EEO, loosing my dental and vision, etc it just seems to be something every day. I just want to cut my ties completely from the USPS and will never look back.

ICE_lady  
#11 Posted : Sunday, May 02, 2010 8:34:29 AM(UTC)
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Wow, I'm reading this post to find that OWCP likes to downgrade the severity of claimants conditions all the time.
I'm a LEO, who had surgery to correct a work related injury. OWCP approved my claim indicating that my injuries were accepted as sprain of foot and osteoarthritis of ankle. Hmm, funny how I had a fracture and ligament injury that required surgical intervention which my doctors report clearly states such facts. I even went to the federal workers compensation doctor and he agreed with my doctors findings! How does a claimant get them to change those codes?
Wish I could afford a lawyer but one guy wanted $500 an hour!

stapler  
#12 Posted : Sunday, May 02, 2010 11:55:49 AM(UTC)
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Hi ICE,

The first thing I would do is look at the actual report from your doctor. You wrote "my doctors report clearly states such facts." If he wrote a soap note or narrative report, what specifically does he list as your diagnosis under assessment?

This may seem tedious. Your doctor may discuss the fracture and ligament in the body of the report, but may have used different terminology in the "assessment" or "diagnosis" section. Make sure that the fracture and ligament injuries are listed there. Sometimes doctors even use terms like sprain to refer to tears, etc. Don't count on OWCP to interpret MRI reports or doctor notes in any way that would expand your claim.

If you find that your doctor wrote "fracture" in the diagnosis, you can follow up with a letter to your claims examiner asking that your diagnosis codes be corrected and/or to provide you with an explanation if she/he is unwilling to do so. At least this is where I'd start.     
jesse slade  
#13 Posted : Sunday, May 02, 2010 12:33:54 PM(UTC)
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hadenough wrote:

jesse what do you mean by consequential injuries. I am 14 years on my knees and they are only deteriorating with wear, age, increasing pain but my case worker refuses to accept that. I have sent in medical and explained in a letter to him but there is never any action. Steer me in the direction if you could. Frankly, they have worn me down and with the NRP, EEO, loosing my dental and vision, etc it just seems to be something every day. I just want to cut my ties completely from the USPS and will never look back.

Hadenough: what is your claim actually accepted for?? Was it a knee injury??
 
I know exactly what you mean about something every day...they've been on the attack last week with me too and I'm not looking forward to the results of their latest. If you figure out a way to cut the ties...let me know!! 
jesse slade  
#14 Posted : Sunday, May 02, 2010 12:41:24 PM(UTC)
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ICE_lady wrote:
Wow, I'm reading this post to find that OWCP likes to downgrade the severity of claimants conditions all the time.
I'm a LEO, who had surgery to correct a work related injury. OWCP approved my claim indicating that my injuries were accepted as sprain of foot and osteoarthritis of ankle. Hmm, funny how I had a fracture and ligament injury that required surgical intervention which my doctors report clearly states such facts. I even went to the federal workers compensation doctor and he agreed with my doctors findings! How does a claimant get them to change those codes?
Wish I could afford a lawyer but one guy wanted $500 an hour!
Hey Ice Lady...was your surgery approved and paid for by the OWCP? If so, that is a plus in your favor. For example, why are they approving and paying for a surgery for conditions they claim you don't have? If your doctor and the OWCP doctor agree then you have those tools at your disposal. You will never get your codes changed, but it is possible to have new codes added. Persistence and paitence is what it will take along with using the FECA manual and case law. Give us more information and we'll try to help you more.
 
As far as a lawyer goes, there's no guarantee that you'll get anything other than your checks cashed from a lawyer. A lot of them know less than the people on this board which is proven almost every time they post or by other people's experience. If at some point you do decide to go with a lawyer, post his/her name here and see who else has used them.
Topeka  
#15 Posted : Sunday, May 02, 2010 12:54:57 PM(UTC)
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ICE_lady wrote:
You will never get your codes changed, but it is possible to have new codes added.

Now that's exactly what I need to do.  I'm fine if they keep my existing code, I just need to get them to add osteoarthritis of the knee, since that's what resulted from the original injury.  How does one go about doing this?
stapler  
#16 Posted : Sunday, May 02, 2010 1:30:44 PM(UTC)
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Jesse,

I can think of a few reasons OWCP would allow treatment for claims they haven't acccepted.

I seem to recall reading an ECAB case (I'll try and find the cite) where a man had an ACL tear, but the claim was accepted for "knee sprain." OWCP authorized the surgery for the ACL repair. Some time later, he experienced a re-tear. Because the claim was accepted for knee sprain, the burden was placed on him to show that the ACL re-tear was related to the work injury. Totally crazy. Typical game playing.

It's not unusual for OWCP to allow the appropriate medical procedure without formally accepting a claim for the same diagnosis codes. My guess is that they're hedging their bet that it will be cheaper to permit one invasive surgery to fix everything rather than having to accept/justify multiple and more serious medical codes in the event other procedures are needed. I imagine other money issues come into play as well when they want to terminate benefits, send people back to work, minimize scheduled awards, etc.

It's easier to cut a claimant off and place the burden on them to justify continued disability with a diagnosis of "sprain" than it is to do the same to someone who has a claim accepted for rotator cuff tear or ACL tear, etc.

jesse slade  
#17 Posted : Sunday, May 02, 2010 4:53:39 PM(UTC)
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Topeka wrote:
ICE_lady wrote:
You will never get your codes changed, but it is possible to have new codes added.

Now that's exactly what I need to do.  I'm fine if they keep my existing code, I just need to get them to add osteoarthritis of the knee, since that's what resulted from the original injury.  How does one go about doing this?
It's easier to give you specific information if you give us specific information...but generally...
 
First, you need a narrative from your doctor. S/he would have to relate the facts of your employment, physical requirements, etc...the facts of the original injury (Since it's arthritis, the OWCP will only accept that as a pre-existing condition, that's just the way it is) Your doctor should say you had no symptoms of osteoarthritis prior to the employment event. If you weren't taking meds, s/he should also say you were not taking any medication for osteoarthritis prior to the employment event that you weren't being treated for osteoarthritis that there are no xrays or MRI showing osteoarthritis prior to the employment event (obviously, this is if these things are true). If you weren't having any medical problems at the time of the employment event, s/he should say that as well. There should be examination results including range of motion, etc...Basically, you need a report that explains every little detail so that a four year old can understand what you did for a living, how you got hurt and what diagnosis you have and how the injury affects your body.
 
The doctor needs to basically explain how the injured part of the body works and how it doesn't when it's injured. For example a shoulder allows the arm to move in various directions, and is the most used joint in the body, but it is also the most easily damaged part of the body due to the fact the outer ball is larger than the socket it fits in to. When it's injured, you lose use of the arm because the joint doesn't work properly and when it's damaged, it's painful whenever you move the arm because the joint is injured.
 
Precipitation may be the best way for your doctor to explain it to them. Work related precipitation is when employment brings out a latent condition that would not have been manifested itself but for the employment.  In other words, you were going along just fine, say you fell or were in an accident and that brought out the symptoms and diagnosis of the arthritis. So your doctor would say that whatever employment event it was caused a precipitation of the arthritis and now you have an aggravation of the underlying (which ever arthritis you have) related to your employment as a consequential injury of the original employment event.
 
S/he needs to give the ICD-9 code of the diagnosis and say how s/he came to the conclusion...for example an MRI. When that first report is done, you should write a statement that goes with it explaining what your job was, how long you did it, the physical requirements, what happened to injure you, when you first noticed it, why you noticed it, your symptoms, how if effects you, what meds you take, why you believe the injuries are consequential to the original injuries, etc...If you have an MRI or other diagnostic test, you'd send that too.
 
Doctors rule the OWCP. Although your claims examiner will have you believe they are the ones in charge of everything, it's the quality of your medical reports and the physician's that make things happen. Most doctors assume when they say so and so has arthritis diagnosed by MRI because an employee fell or was in an accident, that covers it, but in the OWCP that is not enough. Again, think explaining it to a four year old.
 
Be forwarned, this does not happen overnight. Your doctor will have to push the issue and continue to write narrative reports stating the same facts over and over and over and over....Once it goes on for a couple of months, you can write your claims examiner and ask why they have not added the injuries as consequential and to give you specific information required from you. If you get a letter where the OWCP is asking you questions, you'll know you're doing your job to get new codes accepted. Stick to the facts, keep your emotion out of it and don't give up. There's no guarantee, but you'll get nothing if you fight for nothing.
jesse slade  
#18 Posted : Sunday, May 02, 2010 4:56:23 PM(UTC)
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Good points Stapler...but it seems to me you could use that information against them (?) I will go out on a limb and say that we've all experienced the totally crazy game playing!
leftylouie  
#19 Posted : Monday, May 03, 2010 2:38:58 AM(UTC)
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Jesse Slade- Excellent! You have more patience than I do when explaining things.  While I love being helpful, sometimes I can't give the blow by blow as well as you due to pain meds Embarrassed  It is key that you have a doctor that can articulate the Biomechanics !!! Some just do not want to take the time but if the narratives are written as you say - in a way children can understand - you have more sucess in the approval process.leftylouie2010-05-03 10:46:43
Just want to be free....
jesse slade  
#20 Posted : Monday, May 03, 2010 5:04:42 AM(UTC)
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Leftylouie-sometimes if you do the research, your doctor who is probably nearly as frustrated as you, will write what you need. Usually the problem is they have no idea what is required. It should be as easy as diagnostic tests and the doctor saying what is wrong with you, how it happened...but we all know that's just not the case in OWCP claims. Yes, BIOMECHANICS, it's extremely hard for them to discount you if you've got that. It's sad but true, it has to be explained for the children we call claims examiners...And believe me, I know exactly what you mean about the pain meds! Pinch
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