1
Q
Escobedo Standard for Asymptomatic Pathology
A
Apportionment is permissible to asymptomatic pathology (e.g., DDD on MRI) if the QME medically explains how it currently contributes to the disability.
2
Q
Difference between Aggravation and Exacerbation
A
Aggravation = permanent increase in pathology/disability. Exacerbation = temporary flare-up that returns to baseline.
3
Q
Anderson Rule (Injury vs. Disability)
A
You apportion permanent disability (limitations), NOT the cause of the injury (e.g., hypertension causing a stroke).
4
Q
LC 4664 Overlap Rule (Cup Analogy)
A
If a new finding (e.g., 15%) is less than or equal to a prior award (e.g., 20%) for the same region, the new industrial award is 0%.
5
Q
Milpitas Standard (Independent Reasoning)
A
A QME cannot simply ‘adopt’ another doctor’s findings; they must provide independent clinical reasoning for every conclusion.
6
Q
Benson Rule (Intertwined Disabilities)
A
Requires separate ratings for separate dates of injury unless inextricably intertwined; requires a specific logic bridge to deviate.
7
Q
Initial Comprehensive Report Deadline
A
30 days from the date of the evaluation.
8
Q
Supplemental Report Deadline
A
60 days from the date of the written request.
9
Q
Factual Correction (Form 37) Response Window
A
10 days for a worker request; 15 days if the insurer is involved or joint.
10
Q
Mandatory Face-to-Face Floor: Psychiatry
A
60 minutes.
11
Q
Mandatory Face-to-Face Floor: Neurology (Non-ortho)
A
45 minutes.
12
Q
Mandatory Face-to-Face Floor: Cardiovascular/Internal Med
A
30 minutes.
13
Q
Mandatory Face-to-Face Floor: Ortho/Neuromusculoskeletal
A
20 minutes.
14
Q
LC 3208.3(d) Psychiatric 6-month rule exception
A
Sudden and extraordinary employment events (e.g., violence, catastrophic accidents) waive the 6-month tenure requirement.
15
Q
“Substantial Cause” threshold (Personnel Action Defense)
A
35% to 40%. If a good faith action is >= this amount, the whole psych claim is barred.
16
Q
“Predominant Cause” threshold (General Psych Claims)
A
At least 51% (more than 50%).
17
Q
Lumbar Structural Instability (DRE IV) Threshold
A
Translation > 5 mm OR Angular Motion difference > 11 degrees at a single level.
18
Q
Cervical Structural Instability (DRE IV) Threshold
A
Translation > 3.5 mm.
19
Q
Ratable Atrophy Threshold (Thigh/Calf)
A
A difference in circumference of 2 cm or more compared to the unaffected side.
20
Q
Range of Motion (ROM) Consistency Standard
A
Measurements must be repeated until three consecutive readings are within 5 degrees or 10% of each other.
21
Q
Grip Strength Validity Standard (Trials)
A
Average of 3 trials; all trials must be within 20% of the average to be valid.
22
Q
GAF Score to WPI Conversion Source
A
The Permanent Disability Rating Schedule (PDRS) conversion table (NOT the AMA Guides).
23
Q
Labor Code 4060 vs. 4061 vs. 4062
A
4060 = Compensability (Denied). 4061 = Rating/PD. 4062 = Catch-all (TD, P&S date, restrictions, new body parts).
24
Q
QME Unavailability (Form 109) Reporting Floor
A
Absences of 14 to 90 days require 30 days advance notice to the Medical Director.
25
Maximum Annual Unavailability Limit
90 days per calendar year (without good cause) may lead to denial of reappointment.
26
Maximum Certified Office Locations
10 locations.
27
Medical-Legal Record Retention Rule
5 years from the date of the evaluation.
28
Unrepresented Record Service "Wait Window" (LC 4062.3b)
Information must be served on the worker 20 days BEFORE it is sent to the QME.
29
Appointment Notification (Form 110) Deadline
Must be served within 5 business days of scheduling the appointment.
30
Conflict of Interest Disclosure Deadline
Must be disclosed in writing to all parties within 5 business days of discovery.
31
Replacement Panel Relocation Threshold
If the selected QME moves > 20 miles from the zip code used to generate the panel.
32
SB 863 Secondary Condition Ban (LC 4660.1)
No ratings for secondary Psych, Sleep, or Sex dysfunction unless the injury was a Catastrophe or a Violent Act.
33
SB 863 Physical Secondary Exceptions
Secondary physical pathology (e.g., Liver or GI damage from meds) remains fully ratable.
34
Acupuncturist QME Appointment Requirement
5 years of active clinical practice.
35
Chiropractor (DC) QME Specialized Requirement
100 hours of post-graduate course work in disability evaluation.
36
1/3 Direct Treatment Alternative
Served as an AME on 8 or more occasions in the 12 months prior to application.
37
Prohibited Advertising Terms
"State-Appointed" or "Government-Approved" (misleadingly implies state employment/endorsement).
38
PDRS Age Adjustment Midpoint
39 years old (impairment is neither increased nor decreased).
39
PDRS Occupational Group Baseline
Group 111 (standard laborer).
40
PDRS Occupational Variants (Letters)
F, G, H, I, J (ascending order of physical demand and adjustment magnitude).
41
CVC Combination Formula and Sequence
A + B(1-A). Combine two largest first, then iterate. Round ONLY the final result.
42
Chapter 18 Pain Add-on Requirements
Max 3% WPI; only if base objective rating is > 0% and pain is clinically excessive.
43
Duty for Missing Records (Skill 29)
Identify missing data and medically explain why it is pertinent to an objective evaluation.
44
Duty for Psychiatric Collateral Data (Task 15)
Evaluator must seek and integrate co-worker statements, personnel records, or family interviews.
45
Treatment of Non-industrial Barriers
Employer is liable if a non-industrial condition (e.g., obesity/diabetes) prevents implementing the industrial cure (surgery).
46
QME Diagnostic Authority
May order/perform any test (X-ray, MRI, Labs) incidental to the report to resolve the dispute.
47
Return of Original Physical Evidence
Must return original physical records/films to the supplier upon written request.
48
Evaluator Due Process (Discipline)
Formal discipline (not summary) entitles the QME to a hearing under the Administrative Procedure Act (APA).
49
DEU Summary Rating Deadline
20 days from the receipt of the QME report and DEU Form 101.
50
QME Signage Font Rule
The "QME" designation must be proportional and no larger than the physician's name.
51
Initial Physical Aggressor Rule
Injuries from workplace fights are barred if the worker was the initial physical aggressor.
52
Post-Termination Psych Exception
Claims filed after notice are barred unless pre-existing medical evidence exists or it was a Sudden/Extraordinary event.
53
Gait Derangement: Cane vs. Crutches
Cane = 20% WPI; Crutches/Walker = 35% WPI.
54
Almaraz-Guzman Analogy Prerequisite
The physician must first state that the standard rating is 'inaccurate' and explain why.
55
Vaira/Ricken Rule (Genetics/Habits)
You cannot apportion to risk factors (age, genetics, smoking habits); you must apportion to pathology (disease).
56
DRE Spinal Hierarchy
DRE is primary; switch to ROM for multilevel fractures, instability, or if pathology is not captured by DRE.
57
Psychiatrist Record Cancellation Rule
Mental health QMEs can cancel if records are missing and they certify it's needed for a 'Full and Fair' evaluation.
58
Summary Suspension Trigger (Immediate)
License revocation/suspension or failure to pay annual fee (no hearing required).
59
QME Form 115 Signatory
The Certified Interpreter must sign this to verify credentials and participation.
60
QME Form 111 Purpose
Findings Summary for unrepresented workers; served on parties and the DEU.
61
QME Form 122 Purpose
Proof of Service for represented cases.
62
Required Vehicle Exception
Commute is industrial if employer requires worker to have personal vehicle at work for duties.
63
Personal Comfort Doctrine
Brief acts for comfort (water, restroom, rest) on premises are industrial.
64
ML-104 Complexity Factors
Multiple sources of history, high record volume (over threshold), or multiple body systems.
65
ML-202 Increments
15-minute units for record review documentation.
66
ML-201 Purpose
Testimony at a deposition or trial.
67
10-Day Cooling Off Period
Working-day wait period after mailing objection before requesting a represented panel.
68
Reschedule Window for QME Cancellation
If a QME cancels, they must offer a new date within 30 days.
69
Ex Parte Permissible Contact
Oral contact for logistics (scheduling, address, status) is OK.
70
Ex Parte Forbidden Contact
Oral contact for merits (medical findings, causation) is forbidden.
71
Zip Code Anchor Error
Panels must be generated using worker residence; employer zip code usage requires replacement panel.
72
DWC-AD 10133.36 (Voucher Report)
Mandatory service when permanent partial disability is found to trigger retraining benefits.
73
DRE Category II Sign
Guarding or Spasm observed by the evaluator.
74
DRE Category V Sign
Cauda Equina Syndrome or neurogenic bladder/bowel dysfunction.
75
Acupuncturist Ad Restriction
Defined as 'Physician' for treatment but cannot advertise as a 'Physician' (LC 3209.6).
76
Informal Rating Source
I&A Unit estimate based on Treater records (PTP).
77
Summary Rating Source
DEU calculation based on a formal QME report (unrepresented).
78
Board Rejection Denial
More than 5 reports found to be 'not substantial evidence' can trigger denial of reappointment.
79
Conflict Discovery Window
Must be disclosed in writing within 5 business days of discovery.
80
Dorsett Rule (Inability to Apportion)
Must state specific reasons why the prior condition's effect cannot be determined.
81
Primary Treating Physician (PTP) Priority
If PTP finds worker P&S, parties must wait 20 days to object and request a QME panel.
82
Re-evaluation Window
If a worker returns for re-evaluation, the QME has 20 days to issue the follow-up report.
83
ML-102 (Basic) Evaluation
Standard evaluation with minimal record review and single body system.
84
ML-103 (Complex) Evaluation
Evaluation involving 3 or more body systems or complex medical-legal issues.
85
Mandatory Service List (Represented)
Attorneys for both sides must be served; the DEU is NOT served in represented cases.
86
Mandatory Service List (Unrepresented)
Worker, Insurer, and the DEU must all be served.
87
QME Fee Schedule Language Requirement
QME must state in the report if an interpreter was used and for how long.
88
Proof of Service (POS) Legal Effect
An unsigned or missing POS makes the report technically inadmissible in court.
89
Self-Referral Financial Threshold
Prohibited if physician has > 5% interest or receives any financial kickback.
90
Acupuncturist Scope of QME Work
May evaluate neuromusculoskeletal conditions but cannot perform surgical assessments.
91
Psychiatry: 51% Causation Standard
Work must be the predominant cause (at least 51%) of the psychiatric disability.
92
Violence Exception for Psychiatry
Substantial cause threshold is 35-40% if injury resulted from a violent act.
93
Good Faith Personnel Action Defense
No compensation for psych injury if >= 35% cause was a lawful, nondiscriminatory personnel action.
94
Post-Termination Claim Restriction
Psych claims filed after notice of layoff are barred unless sudden/extraordinary event occurred.
95
Commercial Traveler Rule
Injury is industrial if it occurs while worker is on business travel (door-to-door).
96
Special Mission Rule
Injury is industrial if worker is on a special errand for employer outside normal duties/hours.
97
Bunkhouse Rule
Injury is industrial if worker lives on employer premises and is injured during reasonable use of premises.
98
Horseplay Rule
Injuries from horseplay are generally non-industrial if the injured worker was an active participant.
99
Intoxication Defense
Injury is barred if the primary cause was the worker's intoxication by alcohol or illegal drugs.
100
Willful Misconduct of Employer
If employer is at fault, benefits are increased by 50%.
101
Willful Misconduct of Employee
If employee is at fault, benefits may be reduced by 50% (unless injury is severe/fatal).
102
Permanent Disability (PD) Rating Steps
Impairment (WPI) -> Occupation Adjustment -> Age Adjustment -> Final PD %.
103
Impairment vs. Disability
Impairment is medical (what is broken); Disability is economic (loss of earning capacity).
104
DRE Method Prerequisite
Diagnosis-Related Estimate is used for most spinal injuries where pathology is local.
105
ROM Method Use Case
Range of Motion is used for multilevel fractures, instability, or non-local spinal pathology.
106
Analogous Rating Requirement
Physician must identify the most similar condition in the Guides and explain the comparison logic.
107
Excessive Pain (Chapter 18)
Defined as pain that significantly exceeds the expected level for the objective pathology.
108
Apportionment to Age
Strictly prohibited; must apportion to underlying disease processes, not chronological age.
109
Escobedo vs. Anderson
Escobedo = Apportioning to disease; Anderson = Apportioning to disability, not just cause. Employers vs employee it prevents apportioning to cause vs disability
110
Rice/Ricken Logic
You cannot apportion to the 'person' or their 'habits'; you must find a 'medical disease' (pathology).
111
Prior Awards Conclusivity
Prior legal awards for the same body part are legally binding on the current QME.
112
Substantial Evidence: Foundation
The report must list all records reviewed to provide a factual foundation for the opinion.
113
Substantial Evidence: Reasoning
The physician must explain 'How and Why' the findings lead to the conclusion.
114
ML-202 Increments
Must be documented in 15-minute blocks for all record review time.
115
Face-to-Face Definition
The time spent in the physical presence of the worker, including history and physical exam.
116
Ex Parte Sanctions
Physicians who engage in prohibited ex parte contact may be fined or removed from the QME list.
117
Communication with PTP
QME may contact the PTP for clinical records or clarification without ex parte violations.
118
Service of Supplemental Request
Parties must serve the other side with the request for a supplemental report at the same time it is sent to the QME.
119
Panel Replacement: Unavailability
Grounds for replacement if QME cannot see worker within 60 days of the request.
120
Panel Replacement: Conflict
Grounds for replacement if QME has an undisclosed financial or personal conflict.
121
Annual QME Fee Deadline
Failure to pay the annual fee results in immediate summary suspension of QME status.
122
QME Competency Exam Standard
The passing score is determined by the Angoff method (standardized testing science).
123
Continuing Education (CME) Requirement
12 hours of specialized medical-legal education every 2 years for reappointment.
124
Reporting Bias
Pattern of reports favoring one side (e.g., always finding 0% or always 100%) is grounds for discipline.
125
Consultation Authority
QME may consult with other specialists but must maintain final responsibility for the report.
126
Referral for Treatment
QMEs are strictly prohibited from referring the worker to themselves or their clinic for treatment.
127
Initial Evaluation Fee (ML-102/103)
Flat fee based on complexity; includes the exam and standard report writing.
128
Supplemental Report Fee (ML-106)
Flat fee for responding to questions that do not require a new physical exam.
129
Record Review Fee (ML-202)
Hourly rate for reviewing records in excess of the threshold included in the base fee.
130
Missed Appointment Fee (ML-200)
Allowed if worker fails to show or cancels < 6 business days before exam.
131
CVC Math: 30 and 10
37% (not 40%).
132
CVC Math: 20 and 20
36% (not 40%).
133
CVC Math: 50 and 50
75% (not 100%).
134
Rounding 43.4
43% (Standard rounding to nearest whole number).
135
Rounding 43.5
44% (Round up from 0.5).
136
PDRS Age Adjustment Direction
Older workers get higher ratings; younger workers get lower ratings.
137
PDRS Occupational Variant G
.represents the first step above average , since F represents average
138
PDRS Occupational Variant F
Decreases the rating (usually for sedentary or low-demand jobs).
139
PDRS Occupational Variant H-J
Increases the rating (usually for high-demand or heavy-labor jobs).
140
Permanent and Stationary (P&S)
Medical status where the worker has reached maximum improvement and is not expected to change for 1 year.
141
Ratable Scarring (Skin)
Must have functional impact or significant aesthetic disfigurement to be ratable.
142
Neurological Deficit: Reflexes
+2 is normal; +1 is diminished; 0 is absent (ratable).
143
Neurological Deficit: Strength
5/5 is normal; 4/5 is weak (ratable); 0/5 is paralysis.
144
Subjective Factors of Disability
Complaints of pain, numbness, or stiffness that cannot be measured objectively but are medically credible.
145
Objective Factors of Disability
Measurable findings like atrophy, loss of motion, or diagnostic imaging results.
146
Reasonable Medical Probability
More likely than not (> 50% certainty).
147
Inadmissible Evidence
Information sent to the QME that was not served on the opposing party (Ex Parte).
148
Administrative Director (AD)
The head of the DWC who oversees the QME program and discipline.
149
Medical Director
The physician who oversees the QME Medical Unit and panel generation.
150
Specialty Substitution
A party cannot request a different specialty once the panel is issued (must use the replacement rules).
151
Form 109: Unavailability
Must be filed if QME will be away from office for > 14 days.
152
Form 105: QME Appointment
The initial application for QME certification.
153
Form 106: QME Reappointment
The bi-annual application to remain a QME.
154
Substantial Evidence: Speculation
Reports based on 'I think' or 'Maybe' are speculative and inadmissible.
155
Substantial Evidence: Factual Error
Reports based on an incorrect history (e.g., wrong date of injury) are not substantial evidence.
156
Milpitas: The 4-Part Test
Foundation, Logic, Evidence-Based, Independent Reasoning.
157
Benson: Intertwined Example
A back injury and a secondary psych injury from the same event are usually intertwined.
158
Benson: Separate Example
A 2010 back injury and a 2020 neck injury are separate dates and require separate ratings.
159
Almaraz-Guzman: Analogies
Allows using a different chapter of the Guides if the standard chapter is clinically inaccurate.
160
Vaira: Apportionment Detail
Requires the physician to explain the 'Pathology' of the pre-existing condition.
161
Ricken: Risk Factor Exclusion
Explicitly bans apportioning to 'Smoking' or 'Age' as causative factors.
162
Escobedo: Asymptomatic Rule
Confirms that a condition does not have to be symptomatic before the injury to be apportionable.
163
Dorsett: Missing Data Rule
If you can't determine the percentage of apportionment, you must explain why (often results in 0% apportionment).
164
Form 115 Signatory
The Certified Interpreter must sign this to verify their role in the exam.
165
Form 111 Recipient
Mandatory for unrepresented workers; sent to the DEU.
166
Form 122 Recipient
Mandatory for represented cases; sent to attorneys.
167
Proof of Service: Mandatory Content
Who was served, how they were served, and the date of service.
168
Declarations of Participation
Must list everyone who performed any part of the evaluation or report writing.
169
Face-to-Face Duration Documentation
Must state the exact start and stop times of the clinical encounter.
170
Record Review Documentation
Must list every record reviewed by date, author, and type.
171
Ex Parte: The 20-Day Rule
Applies to unrepresented workers objecting to non-medical records.
172
Ex Parte: The 10-Day Rule
Applies to represented attorneys objecting to a proposed QME panel.
173
Conflict: Financial Interest
Defined as > 5% ownership or any direct referral-for-profit arrangement.
174
Conflict: Personal Relationship
Includes treating the worker, the worker's family, or the attorney's family.
175
Conflict: Professional Bias
Having a primary practice that only serves one side (e.g., 100% defense or 100% applicant).
176
Summary Suspension: License
Immediate suspension if state medical license is inactive, suspended, or revoked.
177
Summary Suspension: Fees
Immediate suspension if annual QME fee is not paid by the deadline.
178
Formal Discipline: APA
Requires a hearing before an Administrative Law Judge for complex ethical or quality violations.
179
Probationary Status
QMEs on probation must disclose their status to the worker at the start of the exam.
180
Termination for Cause: Threat
Evaluator may end exam if worker makes credible threats of physical violence.
181
Termination for Cause: Recordings
Evaluator may end exam if worker/attorney attempts to record without prior legal notice.
182
Certified Interpreter: State List
Must be from the DWC's approved list of certified medical interpreters.
183
Required Vehicle Exception
Commute is industrial if employer mandates the worker bring a car to use during shift.
184
Personal Comfort Exception
Using a restroom or getting water during shift is industrial.
185
Initial Physical Aggressor
No benefits if worker started the fight (first physical act).
186
Self-Inflicted Injury
No benefits if worker intentionally harmed themselves.
187
Felony Rule
No benefits if injury occurred during the commission of a felony by the worker.
188
Psychiatry: 6-Month Rule
General psych claims barred if worker has < 6 months tenure (with exceptions).
189
Psychiatry: Violence Exception
Sudden/Extraordinary event or violence waives the 6-month rule.
190
Personnel Action: 35% Rule
Psych claim barred if >= 35% cause was a good faith personnel action.
191
Secondary Psych Ban
Cannot rate psych as secondary to physical injury (e.g., depression from back pain) per SB 863.
192
Secondary Physical Ratability
Can rate physical pathology secondary to industrial meds (e.g., ulcer from NSAIDs).
193
DRE IV Translation
> 5mm in Lumbar; > 3.5mm in Cervical.
194
DRE III Atrophy
Circumferential difference of >= 2cm in Thigh or Calf.
195
ROM Consistency
Measurements must be within 5 degrees or 10% across 3 trials.
196
Grip Validity
Trials must be within 20% of the average of 3 attempts.
197
CVC Math: 30 + 10
37% (Iterative formula).
198
Rounding 43.5
44% (Round half up).
199
Rounding 43.4
43% (Round half down).
200
PDRS Base Age
39 years old.
201
PDRS High Demand Variant
Variants H through J (Increase the rating).
202
PDRS Low Demand Variant
Variants C through F (Decrease the rating).
203
Permanent and Stationary (P&S)
Medical status where condition is stable and not expected to change for 1 year.
204
Chapter 18 Pain Cap
Maximum of 3% WPI add-on for pain.
205
Gait: Crutches/Walker WPI
35% WPI (Whole Person Impairment).
206
Gait: Single Cane WPI
20% WPI (Whole Person Impairment).
207
Almaraz-Guzman Analogy
Using a different AMA chapter to accurately reflect impairment if standard chapter fails.
208
Vaira Rule
Apportionment must explain how the pre-existing pathology currently causes disability.
209
Ricken Rule
You cannot apportion to risk factors like 'Age' or 'Smoking'.
210
Milpitas Standard
QME must provide independent reasoning and cannot simply adopt another doctor's findings.
211
Psychiatrist Cancellation Rule
Can cancel if records are missing and they certify it's needed for a 'Full and Fair' exam.
212
Summary Suspension
Immediate loss of QME status for license issues or fee non-payment.
213
Form 115
The mandatory form for Certified Interpreters.
214
Form 111
The Findings Summary for unrepresented cases.
215
Form 122
The Proof of Service for represented cases.
216
Special Mission Exception
Commute is industrial if worker is on a special errand for the boss.
217
Bunkhouse Rule
Injury is industrial if worker is required to live on-site and is injured during reasonable use of premises.
218
Horseplay Defense
Employer not liable if worker was the one who started the horseplay and it was a major deviation from work.
219
Intoxication Defense
Employer not liable if injury was primarily caused by worker's drug/alcohol intoxication.
220
Willful Misconduct (Employer)
Serious/Willful misconduct by boss leads to 50% increase in benefits.
221
Willful Misconduct (Employee)
Serious/Willful misconduct by worker leads to 50% reduction in benefits (if not severe/fatal).
222
PD Rating Components
WPI % -> Occupational % -> Age % -> Final PD %.
223
Impairment vs. Disability
Impairment = medical loss; Disability = economic loss of earning capacity.
224
Chapter 18 Pain Prerequisite
Must have a base objective rating > 0% to add a pain percentage.
225
Gait Derangement Table
Used if injury causes a functional mobility deficit requiring assistive devices (cane/crutches).
226
Substantial Medical Evidence
Opinion must be based on facts, list all records, and explain the 'How and Why'.
227
Ex Parte: Unrepresented Records
20-day wait period for worker to object before QME sees non-medical records.
228
ML-202 Increments
Must be tracked and documented in 15-minute intervals.
229
QME Conflict Disclosure
Must be made in writing within 5 business days of discovery.
230
Unavailability Notice
Form 109 must be filed if away for > 14 days; max 90 days total per year.
231
Replacement Panel: Relocation
Granted if QME moves > 20 miles from the original zip code anchor.
New QME study 2026
flashcards
Decks in class (3)
# Cards
