Matrix for Confirming Sufficient Evidence of Non-Cancerous Covered Illnesses

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Applicable dates

Any one of the following two criteria:

a. A written diagnosis of acute silicosis made by a medical doctor; or

b. Death certificate or other acceptable documentation of death due to acute silicosis

And

The medical record contains no other diagnoses, such that would otherwise account for the acute sudden severe lung illness, such as other infection or ARDS.

Additional considerations

for causation

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A written diagnosis of accelerated silicosis made by a medical doctor

And

Any one of the following three criteria:

a. A chest radiograph, interpreted by NIOSH certified B reader classifying the existence of pneumoconiosis of category 1/0 or higher;

b. Results from a chest x-ray or computer assisted tomography (CT) or other imaging technique that are consistent with silicosis; or

· Such as nodules or fibrosis usually with upper lung zone predominance

c. Lung biopsy findings consistent with silicosis

· Such as silicotic nodules.

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A written diagnosis of progressive massive fibrosis (PMF) or complicated silicosis made by a medical doctor

And

Results from a chest x-ray or computer assisted tomography (CT) or other imaging technique that are consistent with PMF

· Progression and coalescence of the upper lung zone nodules to form masses (conglomerate lesions)

· When they cause contraction of the lobes, an “angel wing pattern” can be seen.

Additional considerations

for causation

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Written evidence of one of the following two criteria:

a. A written diagnosis of pneumoconiosis made by a medical doctor; or

b. Results of breathing tests (PFTs or spirometry) showing a restrictive lung pattern FVC < 80% predicted

And

Any one of the following three criteria:

a. A chest radiograph, interpreted by NIOSH certified B reader classifying the existence of pneumoconiosis of category 1/0 or higher;

b. Results from a chest x-ray or computer assisted tomography (CT) or other imaging technique that are consistent with asbestosis and/or findings of pleural plaques or rounded atelectasis; or

c. Lung biopsy findings consistent with pneumoconiosis.

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A written diagnosis of mesothelioma made by a medical doctor

And

Pathology report consistent with mesothelioma from surgical or biopsy specimen.

Additional considerations

for causation

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Pleural plaques: 20 or more years

Pleural effusions: 5-30 years

A diagnosis of pleural plaques or pleural effusions made by a medical doctor

And

Results from a chest x-ray or computer assisted tomography (CT) or other imaging technique that are consistent with these disorders

· Pleural plaques

· Pleural thickening, not associated with an area of prior surgery or trauma

· Rounded atelectasis

· Bilateral pleural effusions, also called benign asbestos related pleural effusion.

Additional considerations

for causation

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A written diagnosis of lung fibrosis made by a medical doctor

And

Any one of the following three criteria:

a. Results from a chest x-ray or computer assisted tomography (CT) or other imaging technique that are consistent with fibrosis;

· Such as small lung fields or volumes, minimal ground glass opacities, and/or bibasilar reticular abnormalities

b. Results of breathing tests (PFTs or spirometry) showing a restrictive or mixed pattern; or

· Such as FVC <80% predicted

c. Lung biopsy findings consistent with fibrosis

And

There is no evidence in the medical record that the lung fibrosis is present due to another disease process.

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A written diagnosis of COPD or chronic bronchitis made by a medical doctor

· Chronic bronchitis is defined as the presence of chronic productive cough for 3 months in each of two successive years and other causes of cough have been excluded

And

Any one of the following four criteria:

a. Abnormal results from Arterial Blood Gas (ABG) Testing

b. Results from a chest x-ray or other imaging technique that are consistent with COPD

· Such as air trapping, flattening of diaphragms, enlarged lung fields, interstitial patterns, scarring, or other abnormalities

c. Results of PFTs or spirometry showing an obstructive or mixed pattern

· FEV₁/FVC< 70% and FEV₁<80% predicted.

d. Results from Bronchoscopy showing obstruction

And

The employee has a history of being a never smoker***

And

There is no other lung disease present that would account for the findings.

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Any one of the following two criteria

a. A written diagnosis of kidney disease made by a medical doctor

· Other terms are chronic renal disease, chronic renal failure, renal insufficiency

b. The worker required dialysis

And

The worker does not have high blood pressure or diabetes

And

The type of kidney disease diagnosed is consistent with one known to be caused by the identified toxic substance.

Additional testing may be required to help establish a causal link between a toxic substance and a specific kidney disease. This may include additional urine testing, such as β ₂-microglobulin or retinol binding protein and/or biological tests to detect residual evidence of the toxic substance in the body. The need for this additional testing should be determined by the reviewing physician.

Physician review is required.

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A written diagnosis of occupational asthma or asthma caused by toxic substance made by a medical doctor

And

The diagnosis of asthma was made based on any one of the following criteria

a. Methacholine challenge test results showing a PC₂₀ ≤ 8 mg/ml;

b. Post-bronchocodialator reversibility of FEV₁ ≥ 12% and 200 ml; or

c. Post-bronchocodialator reversibility of FEV₁ ≥ 12% , but <20 ml, with subsequent improvement in FEV₁ ≥ 20% after steroid trial

And

An association between symptoms of asthma and work, including wheeze and/or shortness of breath that are better on days away from work, especially on holiday or vacation

And

One or more of the following criteria:

a. work-related change in FEV₁ or PEF rate; or

b. work-related change in bronchial hyperresponsiveness; or

c. positive response to specific inhalation challenge test (note this is not recommended if not already performed).

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A written diagnosis of peripheral neuropathy, toxic neuropathy, or neuropathy due to a toxic substance

And

The physician’s diagnosis was made by all three of the following criteria. Note: the definition of the classic syndrome will vary among the different toxic substances

a. Symptoms consistent with the classic syndrome caused by the specific toxic substance

· Sensory;

· Motor; or

· Sensorimotor

b. Signs consistent with the classic syndrome caused by the specific toxic substance

· Decreased or abnormal distal sensation

a. Such as stocking-glove numbness, allodynia, and/or hyperalgesia

· Decreased or absent distal reflexes

· Distal muscle weakness and/or atrophy

c. Results of electrodiagnostic studies consistent with a neuropathy caused by the specific toxic substance

· Should include both needle EMG and nerve conduction studies (NCS).

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A written diagnosis of chronic toxic encephalopathy (or analogus condition) made by a medical doctor

And

A formal neuropsychological assessment that included a battery of neurobehavioral tests is consistent with the diagnosis.

Appropriate neuroimaging studies (e.g., brain MRI, head CT) have been performed to investigate findings consistent with the diagnosis, or suggestive of unrelated causes.