Incapacity Determination - PEP Step I
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Incapacity Determination - PEP Step I


Revised December 30, 2013


Review of medical evidence


WAC 388-447-0030Progressive Evaluation Process Step I - How does the department review the medical evidence required for an incapacity determination?

<p>WAC 388-447-0030

WAC 388-447-0030

Effective January 1, 2014

WAC 388-447-0030 Progressive Evaluation Process Step I - How does the department review the medical evidence required for an incapacity determination?

(1) When we receive your medical evidence, we review it to see if it is sufficient to decide whether you meet the incapacity requirements. It must:

(a) Contain sufficient information under WAC 388-447-0010;

(b) Be written by an authorized medical professional described in WAC 388-447-0005;

(c) Document a potentially incapacitating condition; and

(d) Indicate an impairment is expected to last at least ninety days from the application date.

(2) If the information received isn't clear, we may require more information before we decide if you are incapacitated. As examples, we may require you to get more medical tests or be examined by a medical specialist.

(3) We deny incapacity if:

(a) The reported impairment isn't expected to last ninety days or more from the date of application;

(b) We don't have the medical evidence detailed in WAC 388-447-0010, which is necessary to determine incapacity.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Worker Responsibilities

1. Determine if there is sufficient medical evidence:

a. Review available medical evidence to determine if it is sufficient to determine incapacity. Sufficient medical evidence must meet all requirements outlined in WAC 388-447-0010.

b. If the medical evidence is not sufficient to determine incapacity, pend the incapacity determination and request additional medical evidence.

 


2. Determine Duration:

a.  If the provider's assigned duration is consistent with the medical evidence provided, accept it.

b.  If the provider fails to assign duration or the provider's assigned duration is not consistent with available objective medical evidence, use reference sources and your professional judgment to assign duration. Clearly document what evidence was used to adjust the duration.

c.  When the provider identifies a condition as chronic, you may consider the condition to meet the 90-day duration requirement even when qualified as episodic or in remission if this determination is consistent with the objective medical evidence.

 


EXAMPLE

Dale is diagnosed with chronic rapid-cycling bi-polar disorder.  The most significant impairment on work activities is due to psychotic symptoms which, according to his psychiatrist, are episodic in nature.  Although not currently psychotic, he has had 3 major psychotic episodes within the last 2 months.  He has not yet been stabilized on medication.  Accept this as meeting the 90-day duration requirement.


3. PEP Step 1 Determination:

a.If available medical evidence meets the requirements outlined in WAC 388-447-0010 and the duration supported by objective medical evidence is at least 90 days, proceed to PEP Step 2. 

b. If it is clear the impairment will not last at least 90 days or available medical evidence does not meet the requirements outlined in WAC 388-447-0010, deny incapacity.

Modification Date: December 30, 2013