Simply by being in the workers’ compensation arena allows most everyone involved to have a general understanding of maximum medical improvement (MMI). In Pennsylvania, MMI does not hold as much weight as it does in other states because Pennsylvania is not a true “permanency state.” However, in the context of Impairment Rating Evaluations (IREs), MMI does come into play.

Claimants’ attorneys have developed numerous defenses against efforts to limit indemnity exposure at 500 weeks using the IRE process. One of these arguments is that a claimant has not reached MMI, which is a prerequisite for the performance of an IRE.

The Pennsylvania Commonwealth Court recently reversed the Appeal Board’s affirmance of a workers’ compensation judge’s Order, setting aside an IRE because the claimant had not reached MMI when the IRE was performed. The Commonwealth Court confirmed that substantial, competent medical evidence must be offered by a claimant in opposition to an IRE physician’s finding that the claimant was at MMI at the time of the IRE. In order for an IRE to be valid, the IRE physician must use the American Medical Association (AMA) Guides, 6th Edition. The AMA Guides indicate that MMI “refers to a status where the person is as good as he/she is going to get from the medical and surgical treatment available to him/her. It can also be conceptualized as a date from which further recovery or deterioration is not anticipated, although over time (beyond 12 months), there may be some unexpected change.”

The Commonwealth Court determined that the claimant’s medical expert did not offer an opinion regarding whether the claimant had reached MMI at the time the IRE was performed, let alone make reference to the definition of MMI as set forth in the AMA Guides. On the other hand, the IRE physician provided detailed testimony regarding why he found the claimant to be at MMI based on the AMA Guides, 6th Edition.

What It Means to You

There are various definitions of MMI. However, the only one that matters in the context of an IRE is the definition set forth in the most recent edition of the AMA Guides. If a claimant has received 104 weeks of total disability benefits and his or her condition is fairly stable, request that an IRE physician be designated and proceed with an IRE. If the IRE physician does not believe that the claimant is at MMI—specifically as defined in the AMA Guides—he will not proceed with the evaluation. You will get back only the Impairment Rating Determination Face Sheet, indicating that the claimant has not reached MMI. If the IRE physician proceeds with the evaluation, you have the evidence that you need to seek a modification of the claimant’s benefit status from a total to a partial claim.

If you have any specific claim-related questions regarding MMI in the context of IREs, contact one of Cipriani & Werner’s workers’ compensation attorneys.