ADJ10809397 · September 17, 2021

Dr. Lineback's reports and opinions on applicant's disability rating constitute substantial evidence, properly applying Almaraz/Guzman and AMA Guides by analogy due to lack of specific AMA criteria for chest wall pain.

From the decision · page 4First, Dr. Lineback clearly stated that "Unfortunately, no AMA criteria address chest wall pain" (Joint Exh. 1, p. 3), and "... no AMA Guidelines exist for chronic injuries to the chest wall." (Joint Exh. 5, p. 2.) Based on our review of the AMA Guides, we agree with Dr. Lineback that they do not contain any criteria for addressing applicant's chest injury. Thus, there is no means by which the doctor could provide a strict rating and in turn he could not explain why a strict rating would not be accurate. Under these circumstances, Dr. Lineback must exercise his professional skill and judgment to determine an accurate rating of applicant's disability. Also, Dr. Lineback did provide an alternative rating "within the four corners of AMA Guides" by analogizing applicant's chest injury with "the AMA Guidelines pertaining to the respiratory system" (Joint Exh. 5, p. 2.) He then explained why applicant's symptoms were consistent with "the criteria for Class 2 (15%) impairment of the whole person..." (Joint Exh. 5, p. 2.) For these reasons, we agree with the WCJ

No AMA criteria exist for chronic chest wall pain injury, requiring rating by analogy.

Favours Applicant prevailed

This fact justified Dr. Lineback's use of analogy to respiratory system AMA Guidelines for disability rating, which was accepted as substantial evidence.

From the decision · page 4First, Dr. Lineback clearly stated that "Unfortunately, no AMA criteria address chest wall pain" (Joint Exh. 1, p. 3), and "... no AMA Guidelines exist for chronic injuries to the chest wall." (Joint Exh. 5, p. 2.) Based on our review of the AMA Guides, we agree with Dr. Lineback that they do not contain any criteria for addressing applicant's chest injury. Thus, there is no means by which the doctor could provide a strict rating and in turn he could not explain why a strict rating would not be accurate. Under these circumstances, Dr. Lineback must exercise his professional skill and judgment to determine an accurate rating of applicant's disability. Also, Dr. Lineback did provide an alternative rating "within the four corners of AMA Guides" by analogizing applicant's chest injury with "the AMA Guidelines pertaining to the respiratory system" (Joint Exh. 5, p. 2.) He then explained why applicant's symptoms were consistent with "the criteria for Class 2 (15%) impairment of the whole person..." (Joint Exh. 5, p. 2.) For these reasons, we agree with the WCJ

Applicant has chronic chest pain and chest wall injury from industrial trauma with 15% whole person impairment rating by analogy to AMA respiratory system guidelines due to lack of specific AMA criteria for chest wall pain.

No AMA criteria for chest wall pain; rating by analogy to respiratory system per Almaraz/Guzman en banc decision.

From the decision · page 3As I stated in my initial report from this office dated April 12, 2018, this gentleman continues to experience chronic chest pain that is associated with shortness of breath. His exercise tolerance is limited as a result of that chest pain which can be duplicated by palpation of the chest on physical exam. He also has a surgical scar from previous chest tube placement in the left thorax that is moderately tender to palpation. Unfortunately, no AMA Guidelines exist for chronic injuries to the chest wall and so a rating using the principles of the Almaraz Guzman decisions is in order; the only possible way to rate his disability is by analogy. Therefore, the use of the AMA Guidelines pertaining to the respiratory system seems to [be] the most logical substitute.

Almaraz v. Environmental Recovery Services / Guzman v. Milpitas Unified School District (2009) 74 Cal.Comp.Cases 1084 (Appeals Board en banc)

Four requirements to rebut strict AMA Guides application under Almaraz/Guzman: strict rating, explanation of inaccuracy, alternative rating within AMA Guides, explanation of alternative rating accuracy.

Applied to evaluate Dr. Lineback's rating methodology and substantial evidence status.

From the decision · page 4Defendant argues that Dr. Lineback failed to address the four requirements, stated in Almaraz/Guzman, necessary to rebut the strict application of the AMA Guides: (1) provide a strict rating per the AMA Guides; (2) explain why the strict rating does not accurately reflect the applicant's disability; (3) provide an alternative rating using the four corners of the AMA Guides; and (4) explain why that alternative rating most accurately reflects the applicant's level of disability. Defendant is correct that Almaraz/Guzman specifies the four requirements. However, defendant is incorrect in its argument that Dr. Lineback did not address those factors in reaching his conclusion as to rating applicant's disability.

Dr. Lineback's clinical judgment and analogy rating based on examination and medical record review

From the decision · page 5As discussed above, Dr. Lineback appropriately exercised his clinical judgment in rating applicant's disability by analogy based on his examination of applicant and his review of the medical record. His reports constitute substantial evidence and we see no basis for disturbing the WCJ's F&A.