New QME study 2026 > New QME study deck > Flashcards

New QME study deck Flashcards

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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.

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2
Q

Difference between Aggravation and Exacerbation

A

Aggravation = permanent increase in pathology/disability. Exacerbation = temporary flare-up that returns to baseline.

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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).

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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%.

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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.

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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.

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7
Q

Initial Comprehensive Report Deadline

A

30 days from the date of the evaluation.

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8
Q

Supplemental Report Deadline

A

60 days from the date of the written request.

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9
Q

Factual Correction (Form 37) Response Window

A

10 days for a worker request; 15 days if the insurer is involved or joint.

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10
Q

Mandatory Face-to-Face Floor: Psychiatry

A

60 minutes.

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11
Q

Mandatory Face-to-Face Floor: Neurology (Non-ortho)

A

45 minutes.

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12
Q

Mandatory Face-to-Face Floor: Cardiovascular/Internal Med

A

30 minutes.

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13
Q

Mandatory Face-to-Face Floor: Ortho/Neuromusculoskeletal

A

20 minutes.

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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.

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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.

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16
Q

“Predominant Cause” threshold (General Psych Claims)

A

At least 51% (more than 50%).

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17
Q

Lumbar Structural Instability (DRE IV) Threshold

A

Translation > 5 mm OR Angular Motion difference > 11 degrees at a single level.

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18
Q

Cervical Structural Instability (DRE IV) Threshold

A

Translation > 3.5 mm.

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19
Q

Ratable Atrophy Threshold (Thigh/Calf)

A

A difference in circumference of 2 cm or more compared to the unaffected side.

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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.

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21
Q

Grip Strength Validity Standard (Trials)

A

Average of 3 trials; all trials must be within 20% of the average to be valid.

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22
Q

GAF Score to WPI Conversion Source

A

The Permanent Disability Rating Schedule (PDRS) conversion table (NOT the AMA Guides).

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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).

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24
Q

QME Unavailability (Form 109) Reporting Floor

A

Absences of 14 to 90 days require 30 days advance notice to the Medical Director.

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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.
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