Attachment A Medical Contractor Review Questions.docx

ATTACHMENT A - Physician Questions for Initial Disability Decision Quality Assurance Review

1. Type of Disability Entitlement?

The physician selects one of the following drop down menu options:

· Occupational

· Total Disability

· Widow(er)

· Child

2. What was the initial disability determination?

The physician selects one of the following drop down menu options:

· Grant

· Denial

3. What was the basis for the grant/denial?

The physician selects one of the following drop down menu options:

· Continued in compensated railroad service

· Impairment met/equaled Listing level severity

· Adopted an SSA decision based on Listing level severity

· Disqualified from regular railroad job

· Occupational Tables

· Independent Case Evaluation (ICE) – limitations provided in an RFC

· ICE - Adopted an SSA decision based upon limitations in an RFC

· ICE - Objective findings – no RFC

· ICE – Objective findings – RFC not used

4. Limitations Used in the Initial Disability Decision

The physician selects one of the following drop down menu options:

· Less than Sedentary

· Sedentary

· Sedentary Framework/Narrow Range of Light Work

· Light Work

· Light Framework (Medium to approaching Light)

· Medium

· Heavy Work

· Non exertional limitations

5. Were the limitations identified by the examiner and used in the initial disability determination supported by the medical evidence of record at the time of the determination?

The physician selects one of the following drop down menu options:

· Yes

· No

6. Does the medical evidence that the limitations were based upon come from an accepted medical source?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

7. Was the medical evidence that the limitations were based upon current? For denials medical evidence must be within the past 12 months. Older medical evidence may be used for allowances provided that it is complete and detailed enough to allow a disability determination. If it is not, then was development of more current medical warranted?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

8. Did the medical evidence that the limitations were based upon have objective medical findings?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

9. Were there inconsistencies in the medical evidence used to establish the limitations that warranted the ordering of exams or opinions and exams or opinions were not secured?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

10. If the decision was based upon Listing Level severity rather than upon limitations, did the medical evidence support this finding?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

11. For occupational decisions, based upon your review, did the limitations identified in the decision preclude the individual from performing the essential functions of his/her regular railroad job?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

12. Did the medical evidence in file support the RFC limitations that were established?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

13. Complete only if a Child decision -- did the medical evidence establish limitations/Listing level severity before age 22?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

14. Complete only if there was an RFC from a consultative exam in file that was not used in the decision -- Does the medical evidence in file support the RFC?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

15. Did the medical evidence of record support the onset date that was established?

The physician selects one of the following drop down menu options:

· Yes

· No – if answered no, the physician provides additional comments in a separate database field.

16. During your review, did you notice any unusual patterns or inconsistencies in objective findings in the medical evidence submitted in support of the disability application? Some examples: indications that a template was used where medical information from the doctor or information provided by the claimant seemed structured, formatted, or cookie cutter’, the information may have been typed out or photocopied, the claimant may have heavily used technical medical terminology on the application, or anything that just seems out of the ordinary?

The physician selects one of the following drop down menu options:

· Yes - if answered no, the physician provides additional comments in a separate database field.

· No

17. Do you have any additional, final comments concerning this case that were not covered in the criteria above?

Prepared by PEMS 10/21/19 1