Incapacity Determination - PEP Step I

Created on: 
Oct 21 2014

Review of Medical Evidence 

WAC 388-447-0030 Progressive evaluation process step I - How does the department review the medical evidence required for an incapacity determination?

Worker Responsibilities

  1. Determine if there is sufficient medical evidence:
    1. 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.
    2. If the medical evidence is not sufficient to determine incapacity, pend the incapacity determination and request additional medical evidence.
  2. Determine Duration:
    1. If the provider's assigned duration is consistent with the medical evidence provided, accept it.
    2. 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.
    3. 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 bipolar disorder. The most significant impairment on work activities is due to psychotic symptoms which, according to their psychiatrist, are episodic in nature. Although not currently psychotic, they have had 3 major psychotic episodes within the last 2 months. They have not yet been stabilized on medication. Accept this as meeting the 90-day duration requirement.

  3. PEP Step 1 Determination:
    1. 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.
    2. 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.