Chapter E-500 Evidentiary Requirements for Causation

1. Purpose and Scope. This chapter describes the evidentiary requirements for causation under Part E of the EEOICPA and serves as a tool to describe the various methods by which causation is developed and evaluated. The chapter outlines the means by which DEEOIC determines whether the claimant has met his/her burden of proof to establish that it is “at least as likely as not” that exposure to radiation and/or a toxic substance during covered Part E employment aggravated, contributed to, or caused the illness or death of an employee. Additionally, this chapter provides an explanation of the Site Exposure Matrix (SEM) and guidance regarding the use of the SEM in Part E claim development.

2. Developing for Causation. When developing Part E cases the District Office (DO) Claims Examiner (CE) uses established development techniques in addition to certain other steps unique to the Part E adjudication process. The FAB develops medical conditions and employment where possible to avoid issuing a remand order for further development if such development can be conducted at the FAB with little additional effort. Three major elements must be developed and evaluated when making a causation determination under Part E: medical evidence of an established condition; evidence of covered Part E employment; exposure to a toxic substance at a covered Part E facility. While certain sources of information will provide evidence to establish one piece of the causation puzzle, some sources (i.e. Document Acquisition Requests (DAR) responses, Department of Energy (DOE) Former Worker Program (FWP) records, facility records) might contain a mixture of medical, employment, and exposure data and must be analyzed accordingly.

a. Medical. Overall, the CE develops medical evidence in line with EEOICPA PM 2-300 as revised by this chapter. Medical evidence required to establish certain specific conditions is outlined in this chapter and the CE should consult each respective part of the EEOICPA Procedure Manual (PM) for guidance where available. Unlike Part B, there is no set universe of covered illnesses under Part E and the CE develops for all claimed conditions when evaluating causation under Part E. The CE consults the Matrix Confirming Sufficient Evidence of Covered Illness (Exhibit 2) when evaluating medical evidence for causation.

The Matrix will be continually updated and provides information regarding occupational exposure requirements, onset and latency period requirements, and medical diagnostic requirements to establish a given illness.

b. Employment. In order to establish causation between specific conditions and employment exposure, certain criteria must be satisfied. These criteria are addressed in this chapter (see Exhibit 2) and include: onset of condition, period of exposure, and latency periods. Verification of employment must be sought and employment periods evaluated and verified by the CE in order to address the causation requirements.

(1) DOE Contractor Employment. DOE contractor employment will be established as it is under Part B of the EEOICPA and the methods outlined in EEOICPA PM 2-400 and 2-500, as well as EEOICPA Bulletin 03-27 and Chapter E-400 to this Part.

(2) Radiation Exposure Compensation Act (RECA) Employment. Verification of employment for Section 5 RECA uranium workers is addressed in Chapter E-700 of this Part.

(3) RECA 4 Awardees and/or Eligible Claimants. Eligibility criteria for certain RECA 4 claimants are outlined in EEOICPA Bulletin 06-07, to be incorporated into Chapter E-700.

c. Exposure. Establishing exposure to a toxic substance is a key element in developing and evaluating causation for claims filed under Part E. Developing for exposure to a toxic substance can be complex, and a multitude of tools have been developed to assist the CE in this endeavor. As noted, the CE must review all of the evidence of file when evaluating a claim for exposure, because certain documents will contain a mixture of medical, employment, and exposure information. As discussed below, if upon exhaustion of all reasonable development the CE cannot render a decision regarding the causal nexus on a claim file, a referral to either an Industrial Hygienist (IH)/Toxicologist, or a District Medical Consultant (DMC) may be made.

d. Major Sources of Development Evidence. As noted above, diagnostic medical evidence, medical records, test results, and other medical evidence is requested, obtained, and thoroughly reviewed with all the evidence as a whole in an attempt to establish an employee’s covered illness. In addition, other sources of information may contain medical evidence that is reviewed on the whole with the rest of the evidence of file. Other sources of evidence will provide information relating to one or all of the required elements: medical, employment, and/or exposure. For claims filed under Part D, the CE thoroughly reviews the case file and examines the contents before requesting information, as it may already be contained in the old Part D file. The following list is not exhaustive of all evidentiary sources, and NO will make it known when other outlets are uncovered or new development tools are made available.

(1) Document Acquisition Request (DAR) records are obtained by the CE from DOE and contain a wealth of employment and exposure evidence. The CE prepares a DAR to DOE pursuant to the guidance set out under Chapter E-400 and a full discussion of the DAR is available in that Chapter.

(a) What DAR records contain. DAR records contain radiological dose records, incident and accident reports, industrial hygiene (IH) records, safety and personnel records, job descriptions, medical records and other records which may prove useful to develop the basis for a determination of causation. The information contained in these records may vary from site to site, depending on site policies. Industrial hygiene and safety records can encompass a number of forms. These can range from formal exposure monitoring records (substance monitored and exposure measured, work location and duties, protective equipment worn) to copies of urinalysis results, descriptions of toxic substance releases or complaints of possible exposure (smells, leaks, rashes, etc.).

For a number of sites, industrial hygiene records (exposure monitoring, respirator fit testing, medical monitoring data, etc.) might only be found in a worker’s site medical records. Incident/Accident reports might contain specific details about the incident, who was exposed and what substances the worker was exposed to (chemicals, radioactive substances, certain biological hazards, etc.). Sometimes those reports may not name those involved (but should be treated as a part of that employee’s exposure and work records). Job descriptions might be found throughout an employee’s DAR and may note which building or part of a site the employee worked. Job descriptions may change due to change in job title (temporary or longer term), reassignment to another building or facility, renaming of job categories, change of employer, etc. Some changes in job descriptions will be found on time cards; others may be found by reviewing medical, radiation, IH and other records.

(b) What the CE looks for in DAR records. The CE reviews the DAR records in light of the claimed illness and exposure to determine what information may be relevant in determining causation. Reviewing DAR records is relatively simple where the employee’s job, work location and potential exposures are easily found. In many cases, however, finding work location and exposure to toxic substances requires searching for building aliases and job duties, the mention of toxic substances from incident reports, IH and safety records, radiological dose records (which may mention some non-radiological substances) and medical records. The CE uses the evidence as a whole, including SEM, to assist in the deciphering of the DAR records. In some cases, the mention of spills, toxic “clouds” or releases, medical conditions (acute or chronic) may assist the CE in determining exposure potential. It is important to note that these records contain a mixture of employment, medical, and exposure evidence when evaluating them for causation.

(2) The DOE FWP is an ongoing program designed to evaluate the effects of occupational exposures (i.e. beryllium, asbestos, silica) on the health of DOE workers. The surveillance programs test individuals to screen for certain illnesses, but the findings do not necessarily constitute a diagnosis, unless the specific test result is accompanied by a physician’s interpretation (i.e. beryllium sensitivity established by a beryllium lymphocyte proliferation test [BeLPT]). These records contain employment, medical, and exposure information. Exposure information obtained from FWP work history interviews taken after the enactment of the EEOICPA, October 2000, should be used only when corroborated by other evidence that supports the claimed exposure (i.e., DAR information, SEM). See Chapter E-300 for a full discussion on how to obtain and evaluate these records.

(3) Center to Protect Workers’ Rights (CPWR) is utilized under Part B and Part E to assist in contractor/subcontractor employment verification. Employment and exposure information is available through CPWR. (See EEOICPA Bulletin 04-09 for complete instructions and authorized referral forms).

(4) Employment and exposure evidence obtained from the claimant or other sources, verified affidavits, facility records, and other evidence is weighed by the CE along with the evidence of the whole.

(5) The SEM (discussed in detail below) provides site-specific exposure information, information regarding toxic substances and employment processes at a given site, and some limited information concerning potential adverse health effects produced by exposure to certain toxic substances.

(6) The Building Trades National Medical Screening Program maintains a database regarding medical evidence largely pertaining to construction workers and contractors, and the database is available on the Shared Drive. (See Chapter E-300 for a complete discussion).

(7) DOE Physician Panel findings are also a source of employment, medical, and exposure information. As discussed below, only those findings officially approved by DOE are given full credence when evaluating for causation, but even unofficial panel finding reports are reviewed for potentially valuable evidence to weigh against the evidence as a whole.

(8) Occupational History Questionnaire (OHQ) performed by the Resource Center (RC) staff to determine the workplace exposure experienced by an employee. (See Chapter E-400 for a complete discussion).

e. Development Using Existing Case File Materials. In many instances a Part E claim has a corresponding Part B and/or D case file already in existence. When an existing B and/or D case file exists, the CE examines the case file materials for medical, employment, and exposure evidence to assist in the causation development process. Under Part D, DOE collected exposure and employment data through DARs. The CE must examine all existing D case file material for DAR records to develop for causation. The CE must review all documentation presented with the new E claim filing and any corresponding B or D case file in existence to render a causation determination. The CE reviews for exposure, employment and medical evidence and weighs all the pertinent documentation to reach a conclusion regarding causation that conforms to the instructions outlined in this chapter. Note: a filing under Part D is automatically considered a filing under Part E, without a requirement for the filing of another claim form.

f. A General Rule about Reasonable Development. Given the complex nature of claim file development under Part E, it is necessary for the CE to judiciously determine whether or not the facts warrant concluding development and issuing a decision or whether additional development is necessary. As a general rule, the CE utilizes the tools outlined in this chapter to the fullest extent possible and issues a decision once all development avenues have been reasonably explored. While the CE issues decisions accepting claims for benefits as soon as the evidence support an acceptance and all statutory criteria are met, denial situations must be heavily weighed and decisions issued only when additional development is unlikely to produce the evidence needed to reach a decision. In essence, the CE evaluates all of the evidence of file to determine whether or not it is plausible that, given the evidence at hand, the claimed illness arose out of the claimed occupational exposure to a toxic substance at a covered facility.

When attempting to determine whether or not sufficient development has been conducted, the CE can look to the claimed condition and the evidence at hand to make an informed determination. If the claimed condition is generally a condition that arises out of occupational exposure, it is incumbent upon the CE to pursue additional development whenever possible. However, if the condition is one that is less likely caused by occupational exposure, the CE can be more certain that additional development might not be necessary and a decision can be issued.

The CE can perform an Internet search of the Haz-Map database (http://hazmap.nlm.nih.gov) to get an idea of the likelihood that a certain illness is occupational in origin. Haz-Map, also contained in and accessed through SEM, is a relational toxicology database designed for various health professionals and industrial hygienists to assist them in recognizing the diseases that may be related to occupational exposure to toxic substances. Haz-Map links jobs to work processes which are potentially linked to occupational diseases and their symptoms, and is a valuable tool when developing for exposure to a toxic substance and determining the possible health effects of that exposure. Information available in Haz-Map is utilized as the primary basis of information concerning toxic exposures housed in the SEM. Haz-Map also contains causal effects that are not related to occupational exposure (i.e. certain mercury-related diseases may arise from non-occupational exposures), and the CE consults the Matrix Confirming Sufficient Evidence of a Covered Illness (Exhibit 2) when evaluating a claim for a potential occupational link.

(1) Example: If the claimed illness is chronic silicosis, chronic beryllium disease (CBD), asbestosis, or some other condition that is known to arise almost exclusively out of occupational exposure but the evidence is not sufficient to accept the claim, the CE refrains from issuing a denial if additional development might establish the employee’s claim for benefits. However, if the claimed illness is heart disease, diabetes, arteriosclerosis, thrombosis, or some other disease that is less likely to derive from occupational etiology, the CE can send a development letter and allow the claimant an opportunity to present evidence. If no evidence is received, the CE may issue a decision after weighing the evidence as a whole and determining that no causal link exists between the claimed illness and the covered Part E employment.

(2) Burden of Proof. If no medical evidence is submitted that would lend any support to a connection between the claimed condition and potential exposure to a toxic substance (and no such evidence is available from the DOL sources referred to in the previous section), the CE requests such evidence before issuing a denial. While the CE must exhaust all reasonable development prior to issuing a denial, the claimant does bear the overall burden of proving his or her claim.

3. Causation Test for Toxic Exposure. The CE must develop the requisite employment and exposure evidence to render a causation determination. Specific causation requirements for cancer and other conditions are outlined below. In general, the CE develops the evidence of file and a determination is made based upon the “at least as likely as not” causation test. While resources are provided to assist the CE, there is no simple one-step tool for making this determination. Instead, the CE must base the determination on the totality of evidence in the case file. The CE does not use the Internet or other references to justify case decisions, unless such usage has been specifically authorized by National Office (NO). In addition, the CE may not base a decision on a vague reference to “medical literature.”

a. Establishing Exposure to a Toxic Substance. To establish that an employee was exposed to a toxic substance, the case file must show evidence of exposure to a toxic substance and evidence of covered DOE contractor/subcontractor or RECA employment at a covered DOE/RECA facility during a covered time period. Exposure to a toxic substance can be established by the submission of any appropriate document that is evidence that such substance was present at the facility in which the employee was employed and that the employee came into contact with such substance, and that there was a reasonable likelihood for employee exposure. Whenever possible, the CE considers such issues as whether the substance was present in not only the facility, but in the specific building(s) and/or areas in which the employee worked, and whether the substance was used during the processes involved as part of the employee’s job duties and exposure routes were likely (i.e. a welder exposed to fumes). The SEM (discussed below) will be especially helpful in evaluating for the presence of a toxic substance in a certain building/area/work process.

(1) Presence of toxic substance. The CE may look to the SEM, facility exposure records, DAR records, the OHQ, employee records, verified affidavits, DOE FWP screening records, NIOSH site profiles, and other evidence that establishes a toxic substance was present at the facility in which the employee was employed.

(2) Employee contact with a toxic substance. The CE review of the evidence described in (1) above may be sufficient to establish the employee came in contact with the toxic substance. Information such as the claimant’s response to the OHQ performed by the RC, reviewed in conjunction with DAR records and the SEM, may help the CE decide what further development may be necessary (i.e. to determine whether contact was likely given the employee’s labor category, labor process, or given safety controls or risk factors that may have been present at the worksite).

(3) Plausibility. When evaluating the evidence as a whole to determine whether or not a toxic substance was potentially present at a given facility (i.e. by building, area, work process, labor category [see discussion below]) and that it is likely that an employee came into contact with a toxic substance in the course of his or her employment at a covered facility, the CE must determine whether or not such contact is plausible. In essence, the CE must review all the evidence of file and determine whether or not it makes sense that the claimed toxic substance exposure could have potentially occurred. Sometimes this evaluation will require a referral to an Industrial Hygienist (discussed at length in section 6 below) as to the plausibility based upon the route of exposure. For example, if an employee is claiming lung cancer due to exposure to uranium metal maintained exclusively in a glove box (an enclosure to protect the worker from uranium exposure) the CE must examine whether or not an exposure route is plausible.

Without evidence that the employee was involved in machining uranium or cleaning out the glove box, no exposure route (inhalation which would potentially be linked to lung cancer) is plausible. Of course, the CE reviews all evidence of file to render such determinations and seek an Industrial Hygienist opinion if the occupational exposure evidence is unclear.

(4) Example Evaluation of Presence and Contact. A chemical operator involved in cascade operations at K-25, claims peripheral neuropathy. His responses to the OHQ show he worked with a variety of toxic substances on a routine basis, including mercury. Information obtained through the DAR request confirms his worksite (K-33) and job duties. The CE searches SEM (see below) and confirms the presence of mercury at the K-33 cascade building. Further, SEM supports a link between mercury and peripheral neuropathy. A physician report in the case file indicates a diagnosis of peripheral neuropathy and mentions that the employee has had tingling in his arms for approximately a year. An accident report notes a major mercury spill during the time in which the claimant worked at K-33. The evidence is sufficient to establish that the employee had peripheral neuropathy and potential exposure to mercury in the course of his employment at a covered DOE facility. The CE reviews all the evidence of file as a whole and determines that the exposure to a toxic substance (mercury) was a significant factor in causing, aggravating, or contributing to the covered illness (peripheral neuropathy). The mercury spill accident report lends support to the finding that it is plausible, given the facts, that the claimant did indeed encounter an occupational exposure to a toxic substance in the course of his work. Any question as to route of exposure (contact) even if presence is established, should be referred to an Industrial Hygienist (IH) as outlined in section 6 below.

b. Causation Test for Toxic Exposure. Evidence must establish that there is a relationship between exposure to a toxic substance and an employee’s illness or death. The evidence must show that it is “at least as likely as not” that such exposure at a covered DOE facility during a covered time period was a significant factor in aggravating, contributing to, or causing the employee’s illness or death, and that it is “at least as likely as not” that exposure to a toxic substance(s) was related to employment at a DOE facility.

(1) “At Least as Likely as Not.” The claims examiner does not need to establish with 100% certainty that the work-related exposure is related to the claimed condition. Rather, the claims examiner reviews the evidence to determine the likelihood of such a connection. Part E requires proof that established exposure “at least as likely as not” was a significant factor in aggravating, contributing to or causing the employee’s illness, impairment, disease or death. As with Part B, “at least as likely as not” means 50% or greater likelihood.

When a referral to NIOSH for a cancer claim related to radiation results in a probability of causation of greater than 50%, this requirement has clearly been met. However, when the claims examiner is basing a determination on a review of the evidence of file as a whole, ensuring that the “at least as likely as not” standard has been met requires more consideration. The CE weighs all of the evidence available and provides a clearly written rationale supporting his/her findings in the recommended decision.

(2) Significant factor. The CE evaluates the evidence as a whole when attempting to determine whether or not exposure to a toxic substance was indeed a significant factor in contributing to, aggravating, or causing the claimed illness or death of the employee. In most instances this evaluation will be done on a case-by-case basis. Nonetheless, the CE must weigh all available evidence and make a determination. In some cases a DMC evaluation will be necessary. The CE looks at the claimed exposure, the presence of such exposure, the duration of the verified employment, and any other important exposure/employment factors when ascertaining the possible role the potential toxic substance exposure played in the onset of the covered illness.

(3) Resources. As noted above, the SEM is designed to assist in determining the relationship between a specific toxic substance and a covered illness whenever possible. The CE also searches the Haz-Map website (searchable through SEM) for assistance in determining this relationship. In addition, as discussed below, the CE reviews policy statements in the form of Bulletins and the Covered Illness Matrix (Exhibit 2) in conjunction with SEM and the evidence of file as a whole in order to make the required causal determination.

4. Site Exposure Matrices (SEM). The SEM is a web based tool designed to assist the CE in developing for exposure to a toxic substance. While the information available in SEM is helpful in assessing exposure to a toxic substance, the SEM is not used alone to establish causation unless specific procedural guidance authorizes such action. Likewise, the SEM is not used as the sole basis to deny causation, but as a tool when evaluating the evidence as a whole. The SEM identifies the toxic substances that were commonly used in each DOE facility, uranium mine, or uranium mill, and contains two general categories of information that may be searched: chemical profiles and site-specific information tailored to the covered facility or site.

The SEM includes health effects and occupational diseases associated with a toxic substance as identified by the National Institutes of Health (NIH) Haz-Map database and contains a link directly to Haz-Map (other sources are utilized, but Haz-Map is the primary source of this type of information). For a given covered facility or site, the SEM provides information about the nature and location of work processes performed (i.e. fuel separation, instrument maintenance, or welding); the work groups involved (i.e. first line supervisor, instrument mechanic, or welder); the toxic substances used (i.e. plutonium nitrate, arsenic, mercury); and site-specific aliases and potential exposure information regarding work processes, work groups, toxic substances, buildings, and areas.

Data gathered from SEM is interpreted to mean that a worker had a potential for exposure to a toxic substance. The CE is required to review the information yielded from certain other development actions (i.e. DAR responses, DOE FWP records searches, and the OHQ prepared by the RCs) to hone the SEM search. The CE must obtain as much information as possible to determine the type of work or process the employee performed, the dates of such work or process, the building(s) or area(s) involved, and the toxic substance(s) alleged to have been present to determine through SEM the type of chemicals an employee could potentially have been exposed to while working in a particular building and/or performing a certain job or process. SEM also provides an indication of possible association between a toxic substance and an illness. All information listed in SEM is considered valid and factual. The toxic substance, work process, and facility information contained in SEM is deemed verified by DOE or other sources and if a certain toxic substance is listed as present in a given building or facility the data is accepted as fact and no additional confirmation from DOE or any other source is necessary.

The SEM is a living document and does not contain all information for every covered facility and site. The SEM is updated as information comes available and is intended to be as comprehensive as possible. The SEM serves as a repository of information drawn from many different sources for use as an exposure development tool when evaluating causation on the whole. The CE must be aware when using SEM that SEM is continually being updated and is not necessarily expected to represent 100% of the toxic substances potentially present at a given facility. As a result, simply because certain information is absent in SEM does not warrant a claim denial and also does not warrant delaying adjudication until SEM is completed. The CE conducts reasonable development by reviewing the evidence as a whole and issues decisions once such reasonable development allows the CE to adjudicate a claim for benefits.

This section provides a basic outline of the SEM and its use as a developmental tool when evaluating evidentiary requirements for causation. Please see the “Site Exposure Matrices Website User Reference Guide” (available on the Shared Drive, Part E folder, SEM subfolder, or accessed through the SEM menu) for complete and detailed instructions as to the use of SEM.

a. Policy. As a matter of policy, SEM is used as a tool when evaluating the evidence of file as a whole in rendering a determination as to the existence of a causal link between covered employment, exposure to a toxic substance during such covered employment, and a resultant illness arising out of such exposure. In most instances the SEM is not used solely to accept or deny a claim for benefits. However, in certain cases it will be possible to accept or deny a claim based upon the information contained in SEM if such information can be coupled with approved policy guidance as outlined below. Under no circumstances is a claim for benefits denied solely due to a lack of information contained in SEM, because the data for each facility will never be considered 100% uploaded.

(1) Bulletins Issued by National Office (NO). Whenever overwhelming authoritative scientific and medical evidence mounts to support a certain causal presumption (positive or negative) the Director of DEEOIC issues a Bulletin. The Bulletin will outline certain factual and evidentiary scenarios whereby a CE may either accept or deny a claim based upon commonly accepted scientific and medical findings. The CE uses the Bulletin guidance when it fits the approved scenario based upon the evidence of file. Evaluations of evidence will be on a case-by-case basis to determine whether or not the Bulletin guidance applies to the fact scenario at hand. In all cases where NO approves/denies causation in this manner, SEM will provide a link to the Bulletin language to assist the CE in claim file development and adjudication.

(2) The CE may also accept a claim for causation when using SEM if all the criteria (i.e. duration of employment, onset and latency periods, medical diagnostic requirements) outlined in the Matrix Confirming Sufficient Evidence of Covered Illness (Exhibit 2) is met and the potential for exposure to a toxic substance that is known to produce the health effect under development is found in SEM. The Matrix Confirming Sufficient Evidence of Covered Illness, like the SEM, is a living document and will be updated as new medical and exposure information is developed.

(3) Authorized Sources of Information. As noted above, the SEM acts as a repository of information gathered from a variety of sources. While one source is information gathered during an onsite review of records at a given facility, other sources exist and will be evaluated for authenticity by the NO. Website links used to support the SEM are to be used exclusively and no other website searches are authorized in support of a SEM search or causation development on the whole.

b. Management of SEM at NO. A NO SEM Point of Contact (POC) manages all issues arising out of SEM usage. SEM implementation questions, requests for access/denial of access to SEM, and any new evidence that might warrant inclusion into SEM are forwarded to the NO SEM POC.

(1) As a corollary to the NO SEM POC, each respective DO DD appoints a qualified individual to act as the DO SEM POC for interaction with NO. When evidence of an exposure not listed in SEM is verified or strongly alleged (supported by documentation) at a facility, the DO SEM POC prepares a memorandum to the NO SEM POC (for signature by the DD or the designee of the DD) requesting IH review for possible inclusion of the toxic substance in SEM. All associated evidence of the presence of the toxic substance is attached to the memorandum. The NO SEM POC will review the evidence with the NO IH and other NO staff (i.e. Medical Director, Toxicologist, and Health Physicists) to determine whether or not the evidence requires possible inclusion in SEM. In instances where the evidence is deemed to warrant inclusion into SEM, the NO POC advises the Web Site Administrator or appropriate individual to add the information to the database.

Additionally, as noted below, the DO SEM POC acts as the DO gate keeper to obtain/disable SEM access for DO staff. In general, the DO SEM POC interacts with the NO SEM POC on all issues arising out of SEM operations.

(2) Granting/Disabling SEM Access. The DO SEM POC obtains SEM access for DO staff by emailing the NO SEM POC with a request that staff members be granted access to the system and providing the employee’s name, job title, and email address. This email request must come from the DO SEM POC. Once received and reviewed, the NO SEM POC advises the Web Site Administrator through email to grant access to the requested individual. The Web Site Administrator contacts all individuals with newly granted access through email, providing access information such as a user name and a temporary password. Access is disabled (i.e. employee termination or resignation) by an email from the DO SEM POC providing the name of the employee whose access is being disabled and the precise date upon which access must be denied. The NO SEM POC emails the Web Site Administrator requesting that the access be disabled on the requested date and access is terminated.

c. Navigating Searchable Fields. The CE reviews all evidence of file to properly craft his/her SEM query, evaluating all evidence in conjunction with SEM. The CE reviews employment evidence for job description and facility. Employment and exposure evidence in the case file (i.e. facility records, DAR records, OHQ responses, NIOSH/PHS/DOJ data regarding RECA claims) is reviewed to determine as best as possible exactly where the employee worked and what processes or toxic substances were used in the building or area in which the employee worked. Medical evidence is evaluated to determine the diagnosed condition to be evaluated for causation. The CE also uses SEM to assist in the evaluation and understanding of other pieces of evidence and information contained in the DAR response, OHQ and summary, DOE FWP documents and other evidence of file.

Various searchable fields within SEM hold an array of valuable data viewable by site: the number of toxic substances present (with information regarding each substance); health effects or diseases known to be associated with a toxic substance; site history; buildings; processes; labor categories; known incidents; and exposure factors. All fields contain references to the document utilized by SEM to provide the given reference. The CE navigates the search fields based upon the known evidence of file, triangulating on the necessary information required to assist in the development and determination of causation. A search based upon facility-wide information (i.e. all toxic substances known to have been present at the Nevada Test Site) generally will not be a specific enough search without other qualifiers such as work category and/or work process, and may not produce usable information for a causation determination. At a minimum, (especially when searching DOE sites) the CE establishes the employee’s job category, work process, and/or building/area or employment before performing a SEM search. The more information a CE has about an employee’s occupational history when searching SEM, the more likely it is that the SEM search will prove useful in helping the CE determine causation.

d. Searches of Universal Information. This set of searchable fields in SEM contains the most recent scientifically based evidence regarding toxic substances and their relation to illnesses.

(1) Toxic Substance Information. This search field is useful when the evidence of file (i.e. OHQ, DAR, DOE FWP records) indicates which toxic substance(s) that the claimant was potentially exposed to. When a toxic substance is selected, SEM provides a “chemical profile” of the substance including its Chemical Abstracts Service (CAS) number that identifies the chemical, aliases for the substance name, chemical and physical properties(i.e. liquid or gas, odor, and color), and health hazard ratings assigned by sources routinely used by industrial hygienists for evaluation of workplace substances.

(2) Toxic Substance by Alias or Property. The CE uses this search field to find a toxic substance using an unofficial name, or by a physical or chemical property. Using this link allows the CE to find the identity of toxic substances by keying in part or all of the name, unofficial name (alias), or description of a toxic substance using a physical or chemical property. The result may be no match, one match, or multiple matches. For example, searching for “yellow” will return a list which includes uranium dioxide, and searching for “yellowcake” will return a shorter list which still includes uranium dioxide.

(3) Toxic Substance by Chemical Category. The CE uses this search field to find a toxic substance by category, such as gases or metals. If the claimant is not specific about the substance to which he/she was exposed, but describes it in general terms, this link will allow the CE to review a list of substances to which the employee may have potentially been exposed. After selecting a chemical category from the drop down menu (gases, metals, acids, etc.), a listing of all toxic substances within that category at the site is displayed.

For instance, the CE knows that the employee worked as a laborer in the pilot plant at the Feed Materials Production Center (Fernald) and is claiming chronic bronchitis. The OHQ indicates that the claimant does not recall exact exposures, but does recall a sharp, pungent odor and states that “breathed in this gas all the time.” The CE selects “Gasses” from the chemical category drop down menu and all gasses known to have been present at Fernald are listed. The CE searches each gas and finds that sulfur dioxide was present in the pilot plant and that laborers are a labor category of possible exposure and that the gas has a pungent odor and that chronic bronchitis is a health effect of exposure. If the overall evidence of file supports the claimed employment and the relationship between the disease and the employment, the CE can accept this claim for causation based upon the exposure information contained in SEM and the case file evidence.

(4) Health Effects. SEM provides a list of known health effects produced by a given toxic substance. In addition, SEM can also be searched to determine whether or not a given facility contained a toxic substance that could produce the health effect claimed. When searching this way, the CE searches by the claimed illness (i.e. asthma, skin cancer) to determine what toxic substances at a given site could have potentially caused, contributed to, or aggravated the claimed condition.

(a) Toxic substance by health effect. This section displays the toxic substances that could cause the health effect or disease. For instance, the above-listed laborer from the Fernald Pilot Plant claims chronic sinusitis as a result of his/her employment at Fernald. A search of the condition “chronic sinusitis” shows that no toxic substances contained within the Fernald database match the search criteria, meaning that no known substances involved in a work process at Fernald could have induced chronic sinusitis. While this is not sufficient evidence to deny causation, the CE must evaluate other evidence to determine whether or not the employee’s condition was caused, contributed to, or aggravated by his/her employment.

(b) The CE also can search SEM for toxic substances that cause a health effect by searching with a disease or health effect alias. In other words, if the CE does not know the official name of the disease (i.e. chronic obstructive pulmonary disease [COPD] a general term for lung ailments that can include emphysema, chronic bronchitis, and in some cases asthma) the CE can search by the word “lung.”

This generates a search of all toxic substances present at a given facility that could affect lung function. The CE can review the list of substances to determine if they were present in the employee’s work process or building and determine whether or not these substances could potentially cause one of the lung diseases commonly referred to as COPD.

(c) Disease or Health Effect by Alias. The CE uses this search if the organ affected by the disease is known. Using this link opens a page which allows the CE to find health effects or diseases by keying in all or a portion of the formal name of a health effect or disease. The SEM provides a list of health effects or diseases, which contain the search text in their formal names. For example, searching for “liver” returns Hemangiosarcoma of the liver.

e. Searches Specific to the Selected Site. This section of searchable fields contains the most recent information regarding covered DOE facilities, uranium mines, uranium mills, and uranium transport operations. The CE searches these site fields for specific information about a facility, the work processes performed there (i.e. PUREX fuel separation, instrument maintenance, welding), and the toxic substances involved in those work processes broken down by labor category (i.e. welder, yellow cake operator, electrician).

This collection of searchable fields assists the CE in rendering an overall evaluation as to whether or not the employee’s work history meets the presence and contact standard in the causation test for toxic substance exposure set out above. The CE searches site-specific fields when the CE knows the site of employment and also when the CE knows the building/area of employment, the work process performed and/or the labor category claimed.

When searching for a specific RECA location (mine or mill), the CE either locates the facility by the state in which it operated, by its name, or by its alias. For instance, the uranium mill “Durango” can be found by searching mills in Colorado, by the name “Durango,” or by searching the site alias: Vanadium Corp of America; VCA. RECA mines are also located in SEM by the county in which they operated. RECA mine and mill work process categories are more general than the DOE work process categories. As discussed below, the CE attempts to determine the exact labor category (specific job title or activity) whenever possible when conducting a SEM search regarding a RECA facility. Uranium mines are categorized as being either underground or surface mines, and typical mining operations include the following: drilling; blasting; shovel/machine digging; and hauling materials.

(1) Site History. This section is a repository of unclassified references from official DOE or DOE contractor websites providing a description of the DOE facility or uranium mine or uranium mill. This section provides dates of operation, known owners/operators, and historical reference data regarding the site. This description is available in SEM for both DOE facilities and uranium mines and mills.

(2) Areas. This section is only displayed if the selected site has defined areas. All defined areas are viewable by selecting a drop down menu identifying each known area by number and/or title. This searchable section is used when the CE knows the area in which the employee worked. Work processes, labor categories, toxic substances and incidents will be listed for each specified area at the site.

For instance, the employee claims to have worked on the bull gang in Area 16 at the Nevada Test Site from 1966 to 1970 and is claiming occupational asthma. The CE searches the Nevada Test Site facility by Area and queries Area 16, which shows all known potential toxic substances in that area, all labor categories, and work processes. A search of the toxic substances present at the time of the claimed employment shows that of all substances present cobalt can cause occupational asthma. A further search indicates that the bull gang labor category, involved in the labor process of reentry and mineback operations, is shown as a risk factor for cobalt exposure during the time in which employment is claimed. Verification of the claimed employment by DOE is sufficient to establish potential exposure and the medical evidence is reviewed in light of the evidence of file to evaluate causation based upon all known facts.

(3) Buildings. This section is searchable when the CE knows the official or unofficial name of the building in which the employee worked. This section lists all historical references to the building, hazardous chemicals present, the area in which the building was located, work processes, labor categories, and known incidents involving the building. This search category is only available for DOE sites. Uranium mines and mills will simply state the site history, processes, and searchable labor categories.

(a) Building information. This subsection lists all the major buildings (by number and title) at the site (i.e. the K-33 Process Building within the K-25 East Tennessee Technology Park).

(b) Building by Alias. The CE enters an alias or common name for a worksite used by a claimant that does not appear in the searchable buildings list (i.e. the K-33 Process Building above is also known as the “Cascade Building”). The SEM lists the proper names and numbers of buildings to which the slang or common name could refer. This search capacity assists the CE in locating a building in which the employee worked when no formal building name is identified in the employment history.

(4) Processes. This section lists all known processes at the site (i.e. carpentry, ash crushing, crane operations) and contain the related labor categories, timeframes, and toxic substances related to the process. This category is searchable for DOE facilities and uranium mines and mills. When searching for a labor process, the CE knows what type of process the employee was involved in (i.e. welding, drillback core sampling, solvent recovery).

Knowing the work process the claimant was involved in can assist the CE in conducting a search for potential exposure to toxic substances, because sometimes several different job categories can be involved in one work process and a process might be spread out among several different buildings within a facility (i.e. a process operator at Portsmouth GDP involved in cascade operations could have worked in X-326, X-330 and X-333, all buildings in which the work process “cascade operations” took place).

(a) DOE facilities list all processes known to have occurred at the site. For instance, if the CE knows an employee worked in Building 202-A at the Hanford Site, SEM indicates that the process in that building was PUREX fuel separation, lists all labor categories involved in this operation, and the toxic substance present during the timeframe in which this operation took place.

This assists the CE in determining which toxic substances an employee could potentially have been exposed to based upon the process listed and the timeframes in which the employee may have been involved in such processes.

(b) RECA mills list as many as three process categories: laboratory, maintenance, and all other than laboratory and/or maintenance. Some mills did not have a laboratory component and therefore list less than three processes (i.e.

Slick Rock in Colorado lists only maintenance and all processes other than maintenance). As such it is critical that the CE identify the labor sub category (actual work performed) whenever possible.

For example, if the CE knows that an employee worked as a bull dozer operator at Grand Junction in Colorado, the CE searches the labor sub category field to identify that job title. Once identified, the CE clicks on the bull dozer labor sub category and finds that a bull dozer operator is classified in the labor process “all other than laboratory and maintenance.” All potential toxic substance exposure for that sub category and labor process group are listed and the CE can match the findings against the claimed/verified illness and exposure.

(c) Much of the work performed at RECA mines was fairly uniform and easily categorized with regard to process. While no work processes are listed in SEM for a RECA mine, labor categories exist as outlined below. It is important to note that only exposure arising from processes and work that actually took place at a uranium mine or mill is taken into account when evaluating a claim for causation.

(d) Individuals employed in the transport of uranium ore or vanadium-uranium ore to and/or from covered RECA mines or mills are covered under the EEOICPA. However, when developing exposure for an ore transporter, the CE only counts exposure that could potentially have taken place on the premises of a covered RECA mine or mill. Exposure that could have potentially occurred during the time in which the ore transporter was in transit is not covered under the EEOICPA and is not considered by the CE when developing for causation. Please see Chapter E-700 for a greater discussion of covered exposure for RECA claimants.

(5) Labor Categories. The CE can search by labor category if the employee’s job title or job title alias specific to a certain facility is known. It is important to narrow down employment verification requests and information obtained on the EE-3 to ascertain the exact labor function performed by an employee if possible. The RC staff must make certain to obtain the most specific employment information that is available from the employee/survivor and the employment verifier entity when conducting initial employment verification. The CE must conduct additional development where necessary to further identify the exact definition of the employee’s functions and the timeframe(s) of those functions at a given site seeking the greatest specificity possible.

(a) Labor category information lists all the labor classifications or work group titles at the site (i.e. electrician, crane operator, barrier operator).

(b) Labor category by alias. If the employee’s job title does not appear on the drop down list of labor categories above, the entry on the claims form may be a slang or unofficial title. The CE may be able to find the official labor category, e.g., maintenance mechanic, by keying in the slang or commonly used title, e.g., pipe fitter.

(c) Searching SEM for Construction Trades. Construction worker exposures are separated into two exposure categories: exposures due to toxic substances inherent to the construction craft, and exposures to toxic substances caused by performing the construction work on a DOE site. The CE must consider both exposure categories when assessing exposure for construction workers, considering which toxic substances are known to be associated with construction in general, and which toxic substances are associated with certain construction work processes.

Construction exposure is searched as its own category outside of the facility lists. As such, it does not matter where the construction took place. If the CE is searching SEM regarding a construction worker’s claim, the CE searches by toxic substance (employing the methods outlined above) and by work process (i.e. adhesive work, brazing, carpentry) and labor category (i.e. electrician, millwright, iron worker). Searches for construction trade exposures contain the same toxic substances, work processes, and labor categories for all covered facilities.

(d) RECA mines list three labor categories: prospecting, mining, and support/maintenance. The CE determines the duty performed (i.e. mining or maintenance) when searching SEM for information regarding a site listing more than one process. Some sites list only one possible work process and the CE need only confirm that employment is claimed or verified at the given site. Once the work process is identified at the mine where employment took place, the CE can search a list of toxic substances to determine which one(s) an employee could have potentially been exposed to while working at the mine.

For instance, the Arrowhead # 1 mine located in Eagle County, Colorado, lists “prospecting, no mining” as the only work process performed at that site. This means that the only work process performed at the Arrowhead # 1 site was prospecting for uranium and that no actual uranium mining operations took place at that site. The Bay Mule mine located in San Miguel County, Colorado, lists “mining” as its only work process. A mixture of possible work processes will be listed for the RECA facilities depending upon what type of work activities actually transpired at the site.

(6) Incidents. The incident information field lists known major incidents and accidents experienced at the site. The entries provide a brief descriptive title of the incident, the year the incident occurred, the location of the incident (building or area) on the site. An example would be: Uranium cylinder rupture and release, 1976, Building X-344.

This information may assist in corroborating a claim if the claimant has referred to a particular accident or incident as having caused acute or extreme exposure to a toxic substance. Facility incident and accident information may be found in DAR responses, employment records, DOE FWP records, and OHQ summaries.

(a) The CE must evaluate incidents and accidents with regard to the evidence of file as a whole. Simply corroborating a claimed exposure is not sufficient to establish causation. The CE must review the medical evidence and, if necessary, seek the opinion of an IH or DMC regarding the possibility as to whether or not the type of incident or high exposure event (as viewed in association with the evidence as a whole) could prove a significant factor in causing, contributing to, or aggravating the claimed illness. Further, certain incidences of high or extreme exposure should be considered when evaluating whether or not a required disease latency period can be eased or waived entirely (more on latency periods below).

(7) Exposure Factors. This section lists the safety programs, risk factors and timeframes used to gauge an employee’s potential exposure as it relates to work process, labor category, building, and area.

(a) Safety programs are controls that may have reduced the likelihood of employee exposure to toxic substances (i.e. use of respirators, protective clothing).

(b) Risk factors are conditions or practices that may have increased the likelihood of employee exposures to toxic substances, such as periods of time when employees were not properly protected.

(c) Timeframes reflect known periods within which a known correlation exists. For example, certain timeframes outline the period in which it is known that a certain toxic substance was present in a certain building (i.e. from 1956 to 1988 ammonium fluoride was present in Area 200 East and involved in the work process of PUREX fuel separation activities). Additionally, timeframes outline periods in which certain safety programs or measures were in place at a given building or area. This information may assist the CE when evaluating the likelihood that a claimant was exposed to a toxic substance.

(i) Safety Control Example: In 1999 DOE enforced beryllium controls in that work could only be performed in certain buildings. The employee claims beryllium illness from beryllium exposure in 2000, yet the employment evidence shows that he/she worked in a building where beryllium was never present due to DOE controls. It is important to note that when dealing with beryllium the CE must be cognizant of the potential for residual contamination and in this instance it must be unequivocally verified that beryllium was never present at the facility in question.

f. Links within the Searchable Fields. Within SEM the various areas, facilities, buildings, processes, activities, labor categories, incidents and toxic substances which are known to have existed or occurred onsite are related (linked) to one another. For example, such relationships expressed in the matrices might be:

(1) “Toxic xxx was in building aaa at some time;”

(2) “Activity bbb was performed by Labor Category ddd and involved work with Toxic yyy in Building lll;”

(3) “Activity bbb was performed during Labor Process ddd and involved work with Toxic zzz in Building lll;” and

(4) “Labor category ppp involved work at all parts of the site”).

g. Example SEM Search # 1. A claim for benefits is filed and DOE verifies employment at the Portsmouth GDP from 1955 to 1960. The EE-3 indicates that the employee worked as an instrument mechanic in Building X-333 from 1955 to 1960. The verified diagnosed medical condition is aplastic anemia. A search of the SEM by Health Effect shows that aplastic anemia can be caused by arsenic, benzene, and plutonium exposure. The CE further consults the Haz-Map database link which provides a description of aplastic anemia and indicates that arsenic, benzene, and plutonium are among the hazardous agents that can cause the disease. A latency period of weeks to years is indicated.

The Building information for Building X-333 lists all known chemicals utilized at that site and arsenic, benzene, and plutonium are among them. The SEM further shows that the Labor Process of Instrument Maintenance took place in Building X-333 from 1953 to 1957 and lists the Labor Category Instrument Mechanic as involved in this process during this timeframe. The CE reviews the SEM findings with the evidence of the whole (medical opinions provided by qualified physicians that opine a link between the occupational exposure and the aplastic anemia, DAR records showing definite arsenic and benzene exposure, DOE FWP records, and OHQ results supporting a finding of potential occupational exposure to benzene, arsenic and plutonium) to determine whether or not sufficient evidence as a whole exists to accept the claim. In this instance, the evidence as a whole supports accepting the claim.

h. Example SEM Search # 2. An employee claims employment as a chemical operator in Building X-705 at the Portsmouth GDP from 1966 to 1982. DOE confirms the employment. The employee is claiming asthma and chronic bronchitis and medical evidence diagnosing COPD has been received. The CE reviews the OHQ and finds that the claimant indicated in his interview that he does not know specifically what chemicals he was exposed to, but does recall working with an acidic substance with a sour, vinegar-like odor. The CE reviews SEM searching by labor category and building, and finds that acetic acid was used in the employee’s work process in Building X-705 and that it has a sour, vinegar-like odor. A SEM search for health effects for acetic acid shows that it is known to be associated with occupational asthma. The DAR record response does not show that the claimant worked with acetic acid in the course of his employment, but that he did come into contact with various solvents. The CE should follow up with the treating physician to clarify the diagnosis. The CE may consider referral to a DMC to review the evidence and determine whether or not the potential for acetic acid exposure caused the claimant’s lung condition. The CE will also want the DMC to try and specify the lung condition.

i. Using SEM to Evaluate Causation in General. As noted above, absent specific policy guidance in the form of a Bulletin from the Director, the SEM is not used to establish causation by itself (unless used in conjunction with the Matrix Confirming Sufficient evidence of Covered Illness [Exhibit 2] discussed below), but is used as a tool of evaluation for causation in light of the evidence as a whole. The purpose of this searchable database is twofold. First, the database details many possible toxic substances that may have been present at a given facility. Second, the database describes the relationship between a specific toxic substance and a covered illness.

The CE reviews the database to assist in a determination of whether the claimed toxic substance was present at the facility where employment occurred and whether or not a relationship exists between exposure to a toxic substance and a particular covered illness. However, the database does not serve as a comprehensive list of all possible toxic substances that could be present at a facility, and the CE must confirm additional claimed toxic substances if necessary through employment records, DAR records, DOE FWP records, and other means. Finally, once the CE completes all reasonable development and carefully weighs the evidence on the whole, including the SEM findings, the CE must determine whether or not a referral is needed to a DMC or Industrial Hygienist/Toxicologist to further evaluate causation. Procedures for this action are outlined below.

(1) Part E causation is largely evaluated on a case-by-case basis by weighing the evidence of file on the whole. As noted above, absent policy guidance in the form of a Bulletin, the CE may only accept a claim for causation when using SEM if all the criteria (duration of employment, latency periods, diagnostic requirements) outlined in the Matrix Confirming Sufficient Evidence of Covered Illness (Exhibit 2) are met and the potential for exposure to a toxic substance that is known to produce the health effect under development is found in SEM.

j. Documenting the Case File Record and Issuing Decisions. In all instances where a SEM query is conducted, the CE must document the case file record to show that a SEM search took place and enter the corresponding ECMS coding.

(1) ECMS Coding for SEM. When the CE searches SEM for the first time to establish causation, the CE enters the following claim status code into ECMS: SM – ‘Site Exposure Matrix Searched’. Entering this code into ECMS verifies that the CE searched SEM as a part of causation development and the date the code is entered into ECMS is the date of the search. The date of the search is the date printed on the bottom right hand corner of the paper copy of the search finding. This code is only entered the first time SEM is searched for causation on a claimed condition and no coding is required for additional SEM searches unless SEM is consulted to develop causation for another claimed condition. Regardless of the outcome of the SEM search, the CE places the search results in the case file to show that the search was conducted.

(2) Prior to issuing a recommended decision denying benefits, the CE must ensure that the most updated version of the SEM data is contained in the case file and referenced properly in the decision. This is done by double checking the search initially conducted to make certain that an element not found in the initial search (i.e. a toxic substance) has not been added to the SEM since the date of the initial search. There is no need to print a copy of this search, or enter the coding in ECMS. The CE places an entry into ECMS Notes that indicates the follow-up search was conducted and that no new evidence has been added to SEM that will change the outcome of the decision. It is the CE’s responsibility to make certain that the SEM record is properly preserved in the case file for FAB review. SEM will show the latest date on which an update was made to the system that changes the data available regarding a given facility. If the date listed in SEM remains the same as it was when the original search was conducted, the CE will know that no new information has been added to SEM and no new search is required. However, if the date has been changed since the date of the last search, the CE must search SEM again to determine whether or not additions or changes will change the outcome of the SEM search and potentially affect the outcome of the claim file adjudication.

(3) Decisions Issued As Needed. Because SEM is a living document that is updated as data comes available, the CE does not wait for information in SEM to be updated before issuing a decision. If a SEM search is conducted and no information is available, or the site is not yet complete or searchable in the database, the CE issues a decision pursuant to normal procedures. The CE does not wait until a SEM update to issue the decision.

(4) FAB ensures that the SEM search was conducted, where applicable, during the FAB review of the recommended decision. FAB may remand the case to the DO if a SEM search was needed but not conducted, or if the search was conducted improperly, or if the SEM data relied upon by the DO was changed or updated significantly to warrant additional development or a potentially different adjudicatory outcome. Before issuing the FAB decision, the FAB must ensure that the SEM record is the most complete and updated data available in SEM and that no significant changes (additions of toxic substances or changes in work process definitions or timeframes) have been made since the issuance of the recommended decision. This checking of the SEM search data to determine whether or not a new data element was added that will alter the outcome of the decision is conducted in the same manner as set out above for denied recommended decisions. The FAB CE/HR does not print out a copy of a new search, but places an entry into ECMS Notes indicating that no new evidence exists in SEM to alter the findings in the recommended decision. Of course, if new evidence is uncovered that does alter the findings of the RD, a remand order may be necessary. However, if the SEM data is updated after the issuance of the recommended decision or the DO SEM search, and such update does not affect the outcome of the decision, a remand is not warranted.

(5) When using SEM as a finding in a recommended decision or a decision of the FAB, the CE/HR cites the technical document upon which the SEM data search result is founded and SEM in the decision. As always, the DO CE or FAB CE/HR clearly outlines the rationale behind accepting/denying causation based upon all of the evidence weighed as a whole. See Chapter E-1100 for a full discussion of Part E decisions. Below is an example of the language approved for use in a decision when referencing SEM.

Example: Source documents used to compile the U. S. Department of Labor Site Exposure Matrices (SEM) establish that the labor category of “Operator” at the Savannah River Site could potentially be exposed to the toxic substance asbestos. The SEM lists asbestosis as a possible specific health effect of exposure to asbestos and contains a list of the buildings at the Savannah River Site where that particular toxic substance is or was present during the years that the claimant worked there. The employment record provided by the Department of Energy (DOE) contains several numbers that appear to reference the employee’s work location including a number G160-235. The most comparable building listed in the SEM was 235F. Data contained in SEM for 235F establishes that asbestos was used in this building and that the labor category of “Operator” is associated with this building.

5. Statement of Accepted Facts (SOAF). There are certain instances where the evidence of file will require the CE to refer a case file to a specialist for review. The SOAF is a stand-alone document outlining accepted facts in a case and is not altered depending upon the specialist being queried or the issue at hand (i.e. causation, impairment, wage loss linked to a covered illness). Specific questions posed to a DMC or IH are placed in a separate memorandum accompanying the SOAF. While the reasons for referring a case file to an IH or a DMC are addressed below, the same well-reasoned, thorough, and clearly written SOAF is prepared for use by a specialist of any discipline. As noted below, a SOAF is not always necessary in instances where issues are referred to NO for IH review. However, a SOAF is always required for DMC referrals.

a. The SOAF is an outline of the CE’s factual findings relative to medical and/or causation development. All facts are stated clearly and concisely in chronological order so as to tell the full and complete story of the case file to the reviewer. The length of the SOAF is dictated by the complexity of the case file and the issue being forwarded for review. The SOAF serves as the basic story of the case and is written so that any audience can read it and immediately know what facts have been accepted.

b. A SOAF is prepared when all reasonable development actions relative to the matter of expertise (medical or exposure) is complete and referral to an expert is required to resolve a medical diagnosis, causation, impairment, wage loss causation, or exposure question, or some other vital issue that must be decided prior to adjudication.

c. Contents of the SOAF. Regardless of the type of specialist or issue involved, a SOAF must contain certain key elements in order to effectively serve its purpose.

(1) Employee information, such as name, social security number, date of birth, and date of death, if applicable.

(2) Claimed and verified employment is provided with timeframes of employment, job title(s) and description(s), facility, building/area where employed, processes involved in, and any other relevant information regarding potential exposure. The CE differentiates the claimed employment from the employment period(s) actually verified by DOE or a CV.

(3) The CE outlines exposure identified through DAR responses, employment records, DOE FWP records, DOJ, the OHQ and summary, medical or other employment records, or SEM (evidence on the whole) to assist the specialist in understanding the types of toxic substances the employee was potentially exposed to (both claimed and verified). While the CE does not need to state specifically where exposure data was found, the exposure information is clearly outlined for the specialist’s review.

(4) Medical Information in the SOAF. List all claimed condition(s), the cause(s) of death and contributing factors, where applicable, the diagnosed (verified) condition(s), and any other relevant information as it pertains to the question being posed. The CE does not provide any personal comment or opinion regarding the medical evidence. If medical reports/test results are attached, they may be summarized here and do not need to be listed out separately if evidence voluminous. The CE delineates between accepted/not accepted medical conditions.

(5) Case History. The CE outlines the case history contemporaneous with the referral, including past adjudication. Prior accepted conditions are also outlined.

d. The CE prepares a memorandum attached to the SOAF that summarizes the exact issue(s) the expert is to address. What is the issue that requires resolution?

6. National Office Specialist Review. If the CE identifies that an exposure issue requires review by an IH, the CE alerts his/her supervisor. Prior to seeking NO assistance, the CE must exhaust all reasonable exposure development pursuant to the tools and guidance set out in this Chapter. The supervisor reviews the issue at hand and must grant approval for the referral. If the issue is deemed to warrant NO referral for IH review, the CE prepares an email to the Health Services Program Analyst requesting such review. The Health Services Program Analyst forwards the email to the Health Services Manager who reviews the contents and assigns the question to an IH. However, if the Health Services Manager determines that the issue does not warrant a referral, the email is returned instructing the CE to pursue further development. Once the issue is assigned to an IH for review, the IH conducts such review and responds to the CE in a timely manner.

a. The issue framed by the CE will outline succinctly what information is known about the issue being referred (i.e. the employee was a stainless steel welder working at Savannah River from 1982 to 1985 who is diagnosed with asthma) and what is needed from the expert (could the employee have been exposed to nickel?). The CE will use the information contained in SEM and the case file as a whole to frame the question as carefully as possible based upon the claimed employment, process and illness.

(1) The facility in question (narrowed down to building and area where possible) and the work performed will always be a critical factor when querying the IH regarding exposure. The CE will use SEM whenever possible to assist in this narrowing process, but if no information exists in SEM, the CE will craft the question as best as possible based upon whatever evidence is available in the case file.

(2) In certain instances the CE may also forward a generalized question regarding a facility when information cannot be found in SEM and the facility in question is either not yet uploaded to SEM or the data is incomplete. For instance, a CE may need to know whether or not asbestos was present as a general rule in the Clarksville facility. The CE may ask a general question such as this of the IH, but should make certain to contain as much specificity in the query as possible, especially labor category, processes, and time periods.

b. The IH reviews the issue framed by the CE and determines whether or not more information from the case file is required to answer the question, or if the entire case file is needed. The IH role is to anticipate, recognize, and evaluate hazardous conditions in occupational environments and opines based upon his/her specialized knowledge regarding the question posed. The IH strives to answer the question based upon the information outlined in the CE’s email. However, if additional information is required, the IH may request whatever documentation from the case file that is necessary to answer the query. If required, the IH will request the entire case file if individual pieces of information from the file will not suffice to answer the question posed by the CE.

(1) The IH mainly addresses issues regarding routes of exposure (i.e. whether or not a welder at a given facility could have been exposed to nickel). IH review can also attempt to verify whether or not a toxic substance was/could have been present during a certain work process (i.e. welding, or instrument maintenance) at a given site, or if a certain labor category (i.e. welder, or instrument mechanic) could have come into contact with a given toxic substance in the performance of his or her duty at the site. The IH may also be asked to determine the plausibility that a certain toxic substance was present or that a claimed exposure could have occurred based upon the work history and/or accident/incident report.

(2) The IH also reviews SEM searches performed by the DO to determine whether or not they were performed correctly and accurately.

c. If the IH requests the entire case file, the CE prepares the WS/WR memorandum for the DD’s signature. Please see ECMS coding section below for coding instructions when referring files to NO for such review. The WS/WR memorandum is addressed to the Branch Chief of the Branch of Policies, Regulations, and Procedures (BPRP) at NO. Upon receipt of the case file, the BPRP Branch Chief forwards the case file to the IH for review.

d. The IH reviews the issue at hand and any other documents (including the case file) and renders an expert opinion in the form of a memorandum that addresses the issue as specifically as possible. The IH crafts a reply memorandum to address the specific question posed by the CE in the email/SOAF/WS/WR memorandum, and employs his/her specialized training to make findings based upon the evidence of file and clearly rationalized science.

e. Some referrals to NO will be of such a complex nature as to require IH and medical or possibly toxicology review. In these instances, the NO Medical Director and/or the NO Toxicologist may also review the case materials/case file to assist in addressing the CE’s inquiry. The proper specialist will be determined by the Health Services Manager at NO upon review of the query and/or case file materials. The NO Medical Director and/or Toxicologist will provide expert opinions in such cases where a review is necessary by more than one specialist at the same time. IH/Toxicologist/NO Medical Director review will sometimes result in policy Bulletins (see section 4a(1) above) that outline scenarios when a CE can accept/deny a claim for benefits based upon an established/lack of an established causal relationship between toxic substances and a certain covered illness. If an issue being sent to NO for assistance contains elements that might require expertise in the field of occupational exposure, medicine, and/or toxicology, the issue is forwarded to NO as outlined above with an initial email query. The appropriate specialist(s) will review the query and determine what additional information (including the case file) is necessary to resolve the issue at hand.

7. DMC Referral. DMC referral to address causation from a medical standpoint or render an opinion as to medical diagnosis can be made either to NO or to a DMC, based upon the issue at hand and the type of medical expertise sought. In general, the CE refers cases to a physician uniquely qualified to review medical evidence relevant to occupational exposure to certain toxic substances and a medically diagnosed or claimed disease or illness. When making a referral to the NO for review as outlined above (referral requires IH/toxicologist review and possibly a medical opinion or involves a potential policy decision), the CE utilizes the guidance set forth in section 6 above. If the case file does not require NO review, DMC referrals are conducted pursuant to established procedural guidance. As with IH/Toxicology referrals, the CE ensures that all reasonable medical development is conducted before seeking the expert medical opinion of a DMC.

a. The CE reviews medical evidence of file to determine whether or not a DMC referral is necessary. If no clear medical finding is available in the case file or from the treating physician, a DMC referral should be considered. A DMC referral may be required to determine whether or not an illness is indicative of toxic substance exposure or a natural medical process, to determine the causal relationship between all claimed conditions and the occupational exposure history, to determine cause of death, to determine a medical diagnosis, and to evaluate impairment. Generally, when developing for causation, a DMC referral may be necessary to render a medical opinion as to diagnostic evidence. DMC referrals will also be necessary for impairment ratings and opinions regarding the causal relationship between a covered illness and claimed wage loss.

b. The DMC determines medical causation by reviewing medical, employment, and exposure evidence to determine if the medical history is indicative of toxicity (arising out of exposure to a toxic substance) or of an organic/other nature (arising out of a natural medical occurrence, such as a hereditary or lifestyle illness).

(1) Indicative of Toxicity (illness related to exposure to a toxic substance). If the medical evidence supports that the origin of the illness is shown to be indicative of toxicity, the medical opinion is rendered as to causation. For example, if the verified illness is kidney disease and the overall weight of the exposure evidence shows the employee was potentially exposed to cadmium during the course of his/her work as a Flange Grinder in Building X-326 at the Portsmouth GDP and other risk factors are negligible, this is indicative of a finding of toxicity as the root cause of the illness. The finding must show that the potential toxic substance exposure(s) relates to causing, contributing to, or aggravating the illness, and such exposures are a significant factor in causing, contributing to, or aggravating the illness.

(2) If the medical evidence supports that the origin of the disease/illness is shown to be of a nature other than toxicity (exposure or potential exposure to a toxic substance at a covered facility), it is not as likely that exposure to a toxic substance was a significant factor that caused, contributed to, or aggravated the employee’s disease. This finding is evidenced by a medical opinion based upon the medical evidence that the disease/illness has its origin in a natural process. For example, the same employee as above with kidney cancer shows no occupational history of exposure to a toxic substance known to be associated with kidney cancer. The employee’s medical record does exhibit a family history of kidney disease, and a personal medical history of high blood pressure and obesity. Absent a direct link to a toxic substance, the medical evidence supports a finding of other causes and does not establish a causal link between the kidney cancer and a toxic substance.

c. DMC referrals are sought to evaluate medical evidence when no concrete diagnosis exists in the case file or from another knowledgeable source. In this instance the DMC reviews the medical evidence of record as a whole and opines with the greatest medical certainty possible whether or not the medical evidence meets the diagnostic test for the claimed illness.

d. The CE may also use the physician opinion and the evidence of record to render a determination as to whether it is “at least as likely as not” that exposure at a DOE/RECA facility was/was not a significant factor in aggravating, contributing to, or causing the employee’s illness or death.

e. The CE refers cases to a DMC in instances where a medical diagnosis already in the case file requires clarification. DMC opinions may also be sought when there are multiple diagnosed conditions and it is necessary to ascertain which conditions, if any, are potentially related to exposure to a toxic substance at a covered facility. DMC opinions may also be sought as to other causes of a claimed illness (i.e. natural causes as noted above that do not arise out of occupational exposure to a toxic substance).

(1) A DMC referral is not required for every case file. In each instance the CE must review the evidence of file carefully and make a determination based upon the medical evidence whenever possible. If the medical evidence is sufficient to reach a determination, no referral is necessary.

(2) Under no circumstances does the CE send a general question as to causation to a DMC. The CE must undertake all reasonable development prior to any referral. The CE only refers case files to the DMC when there is an actual medical question that must be answered by a physician in order to determine causation. For example, if there is no evidence of exposure or there is no medical evidence in the case file suggesting a connection between covered employment and a claimed medical condition, no referral is necessary. In such cases, the CE advises the claimant of the deficiency in the evidence, allows the claimant to support his/her claim, and proceeds with adjudication if no compelling evidence is received.

f. Once the referral is made, the physician reviews all pertinent evidence and prepares a medical opinion as to causation or medical diagnosis. The CE reviews the physician’s findings and may use the findings in support of the adjudication of the claim under review. Should the CE require clarification of the findings, the matter is referred to the same DMC for clarification. If upon clarification some doubt as to the findings exist, a second opinion may be sought.

8. DOE Physician Panels. Cases with positive DOE physician panel findings approved by DOE (signed by a DOE official) under the old Part D are accepted for causation on the basis of those findings for all conditions claimed under Part E that are approved by the panel. The CE uses the DOE physician panel finding as the basis for the decision and no further development for causation is required.

If the positive physician panel decision is not approved by DOE (not signed by a DOE official) it is not an approved finding. While positive panel findings not officially approved by DOE do not serve as causation under Part E, the reports themselves still might contain useful information regarding causation development. The CE thoroughly reviews the panel report and looks for medical and exposure evidence that might prove useful in reaching a causation decision based upon all of the other evidence of file. The CE weighs the report (i.e. reviews for rationale) just as he/she would any other medical reports of file.

Negative panel reports, whether approved by DOE or not, may also include useful information for the CE to consider. The CE reviews negative panel reports like any other piece of medical evidence in light of the weight of the evidence of file as a whole.

9. Treating Physician. The CE develops medical evidence for causation by requesting evidence from the claimant and/or treating physician. If the treating physician submits a report that meets all necessary criteria (i.e., is from an appropriate specialist, is not equivocal [concrete in its findings and based on clearly rationalized medical science], and provides sound rationale) explaining how it is at least as likely as not that the specified toxin was a significant factor that aggravated, contributed to, or caused the claimed illness and/or death, the CE accepts the claim. However, if such a report is not received, or if the report and/or diagnosis received is unclear, the CE may refer the case to a DMC.

10. Approved Part B Conditions. Conditions approved under Part B (cancer, beryllium illness, silicosis, and RECA Section 5 illnesses) are given a presumption of causation under Part E. In all instances when issuing recommended decisions on approved Part B acceptances, the CE must use only the findings of the original Part B final decision. The CE bears in mind that Part B acceptances for atomic weapons employees, beryllium vendor employees, and DOE federal employees are not covered under Part E. In addition, survivors approved under Part B must establish eligible survivorship under Part E and that it is at least as likely as not that the employee’s covered illness was a significant factor that caused, aggravated, or contributed to the employee’s death.

11. Special Exposure Cohort (SEC) Employment and Specified Cancers. If it is established under Part B that an employee was diagnosed with a specified cancer and his/her employment is considered as included in the SEC, the causation determination between the cancer and the employment is established. Development and adjudication of SEC specified cancer claims conforms to the guidance set out under EEOICPA PM 2-600. Accepted SEC claims under Part B are accepted for causation of the same illness (but not necessarily the employee’s death, if applicable) under Part E.

12. Consequential Conditions. For all accepted covered illnesses under Part E, claimed consequential illnesses must be established by a fully rationalized physician’s medical report that shows the relationship of the claimed consequential condition(s) and the accepted covered illness. Neither the fact that the illness manifests itself after the accepted covered illness was diagnosed, nor the belief of the claimant that the illness was caused by the accepted covered illness, is sufficient in itself to prove a causal relationship. Consequential conditions are adjudicated under the guidance available in EEOICPA PM 2-1000. Consequential illnesses may cause additional impairment or wage loss, but do not result in an additional $150,000 lump sum award under Part B.

13. Evidentiary Requirements for Survivor Claims. The CE uses any and all of the medical evidence of file in order to develop for causation in a survivor claim. Not only must the evidence of file establish that it is at least as like as not that toxic exposure caused, contributed to, or aggravated a covered illness, the evidence must also establish that the covered illness caused or contributed to the death of the covered employee.

a. Death Certificate. If a death certificate lists a covered illness as the cause of death, and is signed by a physician, the CE accepts this as causation. In this situation, the CE uses information contained on the death certificate to form a rationalized conclusion that a covered illness contributed to the death based on the medical evidence contained in the file.

b. Evidence as a Whole. For every claimed condition, the CE must review all medical evidence in the case file for adjudication regarding cause of death. Even in instances where there is no diagnosis on the death certificate or there is a diagnosis of a condition other than the condition(s) claimed, the CE must review the evidence of file and/or pursue further development to determine whether or not the death was caused or contributed to by a covered illness.

(1) Referral to a DMC. If the medical evidence is insufficient to establish that the covered illness caused or contributed to the employee’s death, the CE may refer the case to a DMC. If the DMC provides an opinion that it is at least as likely as not that the covered illness caused or contributed to the death, the claims examiner accepts the survivor’s claim. If the DMC cannot provide such an opinion, the CE advises the claimant of the need for rationale. If sufficient medical rationale is not received the CE denies the claim.

(2) Possible scenarios.

(a) Probability of causation 50% or greater on one cancer, but the death caused by a cancer which has not yet been accepted. As under Part B, once the probability of causation reaches 50%, all cancers are considered to be “at least as likely as not” caused by radiation exposure at work. If the death, however, is caused by a cancer not previously accepted in a Final Decision, the recommended decision recommends acceptance of this new cancer, providing the reasoning behind the acceptance, and recommends approval of the survivor claim. This also applies in cases where DEEOIC accepts a Part B cancer and the death of the employee was caused by the accepted cancer.

(b) Death due to a primary cancer when a metastasis is the only condition accepted. Unless a probability of causation of 50% or greater has been reached, the CE cannot make an assumption that the metastasis contributed to the death without medical support.

For example, under Part B secondary bone cancer was accepted but primary prostate cancer was denied due to a POC less than 50%. If the death certificate shows that the death was due to the prostate cancer alone, and no metastasis is mentioned, causation is not established. The CE reviews the other medical evidence of record or seeks a DMC opinion as to whether the metastatic bone cancer somehow caused or contributed to the death or that the bone cancer metastasized from the prostate cancer. An opinion may also be obtained from the treating physician. The CE simultaneously develops the causal link between the prostate cancer and exposure to a toxic substance.

However, given the same fact scenario, if the death certificate indicates that the cause of death was “metastatic” prostate cancer, and the bone cancer was a metastasis of the prostate cancer, the CE can infer a causal relationship between the accepted metastastic bone cancer and the employee’s death without a DMC referral, since the use of the term “metastatic” incorporates the bone cancer.

(c) DOE physician’s panel. If a DOE physician’s panel finding signed by a DOE official provides the opinion that the covered illness was a significant factor in causing or contributing to the employee’s death, the CE accepts the determination for causation.

(d) Death due to COPD (or another lung condition with test results consistent with CBD) with acceptance of CBD. An acceptance of CBD under Part B does not require a diagnosis of CBD. Rather, the acceptance is based on statutory criteria as described in 42 U.S.C. § 7384l(13). The requirement for pre-1993 cases is that the medical evidence establishes that at least three of the five listed criteria are met. In most cases, one of the criteria used is that an employee has a chronic respiratory disorder consistent with CBD. Such a chronic respiratory disorder by its very nature results in damage to lung tissue, as does CBD. Other pulmonary illnesses such as COPD, emphysema, pulmonary fibrosis, asbestosis, or silicosis also result in damage to lung tissue. Therefore, if the death was caused by any of these pulmonary illnesses, the CE concludes that it is at least as likely as not that CBD, or the chronic respiratory disorder consistent with CBD, aggravated or contributed to the pulmonary illness. The RD/FD must accept the pulmonary illness that caused the death as a compensable illness under the Act. Exhibit 1 serves as medical evidence that can be used in this determination. A copy of this Memorandum from the DEEOIC Medical Director should be placed in the case file. (In this situation it is not necessary that the CE determine whether the other pulmonary illness was directly due to exposure at work). Both CBD and the pulmonary condition resulting in death are coded into ECMS-E with a medical status code of “A.” The RD accepts the condition that caused the death as compensable.

(e) Death certificate lists respiratory failure as the cause of death without specifically mentioning an accepted respiratory illness by name. The CE reviews the medical evidence from the time of death to determine whether it is at least as likely as not that the accepted condition caused, aggravated, or contributed to the respiratory failure. Such evidence may consist of a report from a treating physician discussing the covered condition, the patient’s deterioration, and the circumstances surrounding the death. If the medical evidence of file is sufficient for the CE to make this determination, the CE issues a recommended decision, including a discussion of the medical evidence and the rationale behind the determination.

(1) If there is no contemporaneous medical evidence from the time of death, the CE requests such information from the claimant and/or FWP.

(2) If the medical evidence is insufficient for the CE to determine whether it is “at least as likely as not” that the accepted condition caused, aggravated, or contributed to the respiratory failure, the CE requests an opinion from the treating physician or DMC. Depending on the quality and quantity of the medical evidence of file, the CE may wish to request additional medical evidence from the time of the employee’s death prior to requesting the medical opinion.

14. Non-SEC Cancers. Most primary cancers are considered potentially radiogenic cancers. Chronic lymphocytic leukemia (CLL) is assigned a zero percentage of Probability of Causation (POC) by NIOSH and is not by itself as a the sole claimed condition compensable under Part B, but is potentially compensable under Part E if claimed by itself. NIOSH referral and other processes related to developing and adjudicating cancer claims must conform to the procedures set out under EEOICPA PM 2-600. The CE clearly provides all required information on the NIOSH Referral Summary Document (NRSD) and amends the NRSD immediately if new information comes to light.

a. Cancer Diagnosis. Diagnostic and other medical evidence used to establish a primary cancer diagnosis is the same under Part E as under Part B. The CE may refer to EEOICPA PM 2-600 for guidance.

b. Employment. It must be established that the employee is/was a DOE contractor employee or a RECA section 5 uranium worker who contracted the diagnosed cancer after beginning employment at a DOE facility or a RECA section 5 facility. Certain RECA Section 4 eligible claimants who have not received an award from DOJ for cancer may also be eligible for benefits. Additional guidance is forthcoming regarding these individuals.

c. Causation. Non-SEC cases with verified employment and a confirmed primary cancer diagnosis are developed for causation by evaluating the causal nexus between the covered illness and potential occupational exposure to radiation and/or toxic substances at a covered facility. While both development actions have distinct paths, they are undertaken concurrently to determine whether or not a claimant meets the burden of proof under Part E.

(1) Radiation Exposure Development. When developing a cancer claim for causation the CE must develop for causation due to radiation exposure, unless the claim is for CLL (non-radiogenic cancer developed for toxic exposure only) or is a SEC claim. The CE refers the case file to NIOSH for dose reconstruction so the CE can determine whether or not the cancer is “at least as likely as not” related to the verified covered employment at a DOE or RECA facility. Part E claims based on RECA Section 5 employment that are for cancers other than those accepted by DOJ (i.e. lung cancer) are also referred to NIOSH for dose reconstruction. The “at least as likely as not” standard is a POC of 50% or greater that the exposure to radiation was a significant factor in contributing to or causing the cancer.

The CE determines the POC and accepts or denies the claim based upon the “at least as likely as not” finding. The NIOSH -Interactive Radio Epidemiological Program (NIOSH-IREP) process by which the CE determines the POC and the method by which cases are referred to NIOSH is outlined in EEOICPA PM 2-600. See ECMS Coding below for Part E referrals.

(2) Development for Exposure to a Toxic Substance. In conjunction with the NIOSH dose reconstruction, the CE develops the cancer claim for causation based upon potential exposure to a toxic substance utilizing the development tools set out in this chapter. CLL is developed without a NIOSH referral.

When necessary, the case file is referred to a DMC for an opinion as to whether it is “at least as likely as not” that such exposure was a significant factor in aggravating, contributing to, or causing the diagnosed cancer. Of course, the CE makes certain that all possible development has been exhausted before referring a causation determination to a DMC or IH. The CE reviews all evidence of file (i.e. DAR responses, DOE FWP records, OHQ findings, SEM searches, and any other pertinent exposure records) to reach a causation determination. If no such determination can be reached, the CE may consider referring the case file for DMC or IH review.

(a) DMC or IH Referral. In such cases, a physician or IH specializing in the field of toxic or occupational exposure reviews the entirety of the evidence and provides a rationalized medical opinion as to the “at least as likely as not” causation link. This report may be from a treating physician or from a DMC or IH. If a claimant’s physician is an appropriate specialist and submits a well-rationalized report, this may be accepted. Otherwise, referral to a DMC or IH may be necessary.

(b) Review of the Physician Report. The physician report must be a clearly rationalized medical opinion supported by scientific evidence. The CE reviews the physician report and the evidence of file and makes a factual determination as to causation.

(3) Satisfying Causation Test for Cancer. A cancer claim may prevail and meet the causation test by either means:

(a) POC of 50% or Greater. If the POC is 50% or greater, satisfying the “at least as likely as not” causation requirement, the CE issues a recommended decision to accept the claim under Part B and Part E.

(b) Toxic Substance Causation. If the CE, by weighing the evidence as a whole, acting on guidance set forth in a policy Bulletin related to SEM, and/or acting on information contained in the Matrix Confirming Sufficient Evidence of Covered Illness (Exhibit 2), finds that exposure to a toxic substance “at least as likely as not” was a significant factor in causing, contributing to, or aggravating the cancer, the CE accepts the claim and provides a clear rationale outlined in the recommended decision.

(c) Physician Report. A qualified physician states in a well-rationalized report that occupational exposure to the claimed toxic substance(s) was “at least as likely as not” a significant factor in aggravating, contributing to, or causing the diagnosed cancer. The CE can accept the claim based upon this fully rationalized medical opinion from the physician.

(d) If at any time while the case is pending at NIOSH sufficient medical evidence establishing causation to a toxic substance is received in the DO, the CE renders a factual determination as to acceptance under Part E and issues the recommended decision. If Part B benefits are also claimed, the case file remains at NIOSH until the dose reconstruction is complete and Part B benefits can be adjudicated. If no Part B benefits are claimed, the CE pulls the case file from NIOSH without waiting for the dose reconstruction to be completed and accepts the claim for causation based upon toxic substance exposure.

For example, a claimant is the survivor of a uranium miller covered under Section 5 of the RECA. The claimant is seeking survivorship benefits under Part E of the EEOICPA based upon a claim of esophageal cancer. No Part B benefits are being sought, as the survivor was awarded Part B benefits as a RECA Section 5 beneficiary, and is not eligible for Part B benefits under the esophageal cancer claim. In this case only Part E benefits are sought for the cancer claim, and should the CE establish a causal link between the esophageal cancer and exposure to a toxic substance at a RECA mine, the claim can be immediately accepted and withdrawn from NIOSH without waiting for the dose reconstruction.

(4) Synergistic or Additive Effect. In certain instances a physician might opine that a claimant’s radiation and toxic substance exposure together worked in tandem to produce a synergistic or additive effect that brought about the cancer. DOL has not found scientific evidence to date establishing a synergistic or additive effect between radiation and exposure to a toxic substance, and if the physician presents this finding he or she must provide actual scientific or medical research evidence to support the finding before the CE may consider the assertion.

Such claims are not solicited, but if a physician makes this assertion the CE requests that the physician provide medical evidence of a synergistic or additive effect and a clearly rationalized medical opinion as to whether or not the effect is of a significant nature to establish that the combination of the radiation and the exposure to a toxic substance was “at least as likely as not” a significant factor in aggravating, contributing to, or causing the cancer.

(a) If the physician provides rationalized scientific evidence revealing a synergistic or additive effect, the DO sends the case file to NO for review by a NO Health Physicist (HP) and/or the DEEOIC Medical Director. The HP reviews the physician report and all evidence of file and makes a determination as to causation. See the ECMS section to this Chapter for referral coding.

15. Beryllium Illness. Beryllium sensitivity (BeS) and established chronic beryllium disease (CBD), covered conditions under Part B, are also compensable under Part E, and causation under Part E is established based on a positive Part B determination. BeS may in some rare instances also result in impairment/wage loss, but the CE only develops for these benefits if claimed in writing.

a. Medical Requirements. The CE evaluates all medical evidence of beryllium illness to make a determination of causation. Under Part E CBD is established by a physician’s diagnosis and the medical evidence as a whole.

(1) Beryllium Sensitivity. (BeS) As under Part B, BeS is established by one abnormal beryllium lymphocyte proliferation test (BeLPT) or BeLTT result indicating that an employee’s blood showed an abnormal proliferative response to beryllium sulfate.

(2) Established Chronic Beryllium Disease (CBD). CBD established under Part B is consequently established for a covered Part E employee. However, the statutory requirements that define CBD under Part B do not apply to the evaluation of CBD claims under Part E. Therefore, it is possible for the medical evidence as a whole to establish CBD under Part E, but not under Part B.

(a) Physician Narrative. A report prepared by a treating physician or DOE FWP physician, or a DMC physician that evaluates the employee’s medical condition and finds that it is “at least as likely as not” that exposure to beryllium was a significant factor in aggravating, contributing to, or causing CBD, given the weight of all the medical evidence of file, may establish causation for CBD under Part E. A diagnosis provided by a qualified physician is required to establish CBD under Part E, unless a Part B CBD acceptance exists.

(b) Weight of the Evidence. As always, the CE thoroughly reviews the totality of the medical evidence. DMC referral determinations are made on a case-by-case basis. If the CE determines the weight of the overall evidence does not support the condition claimed or the physician narrative is not present in the case file, a second opinion is considered.

b. Required Employment. The employment evidence must establish that the employee had at least one day of verified DOE contractor/subcontractor employment at a covered DOE site during a covered time period where beryllium dust, particles, or vapor may have been present in order to satisfy the employment requirement.

16. Chronic Silicosis. Chronic silicosis is a non-malignant disease of the lung caused by prolonged exposure to silica dust.

a. Medical Requirements under Part E. The requirements for establishing chronic silicosis under Part E differ from the requirements set out under Part B. Part B requires a written diagnosis of silicosis by a medical doctor accompanied by a chest radiograph interpreted by a certified NIOSH B reader classifying the existence of pneumoconioses of category 1/0 or higher; results from a computer assisted tomograph or other imaging technique consistent with silicosis; or lung biopsy findings consistent with silicosis. These requirements are not necessary to establish chronic silicosis under Part E. The only similarity is that Part E requires the 10 year onset latency period required under Part B. A medical doctor’s written diagnosis of chronic silicosis is required. The diagnosis must also indicate date of initial onset. Where no diagnosis exists, but the required employment element is met and evidence of lung disease presented, the CE requests additional medical evidence from either the claimant or from a DMC. The CE evaluates the DMC opinion and the evidence of file to make a factual determination as to causation.

b. Employment Requirements. Silica exposure in the performance of duty will be assumed if, and only if, the employee was present at a DOE or Section 5 RECA facility where silica is known to have been present. The initial occupational exposure to silica dust must precede the onset of silicosis by at least 10 years, and the CE must review employment evidence accordingly when making causation determinations.

(1) Exceptions – Acute/Accelerated/Complicated Silicosis. The extreme nature, function or duration of exposure can trigger various forms of silicosis. The CE must determine whether the individual’s occupation entailed such exposure that the disease manifested in an acute, accelerated, or complicated form due to such exposure. These forms of silicosis are not covered under Part B, but are potentially covered under Part E based upon the CE’s review of the totality of the evidence.

(2) Employment and Exposure Evidence. The CE obtains evidence of employment and exposure from various sources. The Department of Justice (DOJ) verifies employment for Section 5 RECA claimants. The CE obtains other evidence from DAR records, DOE FWP records, SEM, employment records, and the claimant when developing to establish employment and exposure regarding silicosis.

17. Asbestosis. Asbestosis, a form of pneumoconiosis, is a chronic, progressive pulmonary disease caused by the inhalation of asbestos particles/fibers and the accumulation of those particles/fibers in the lungs. Asbestosis is a Part E covered illness only.

a. Medical and Diagnostic Requirements. Asbestosis is characterized by extensive pulmonary interstitial fibrosis (scarring) and pleural thickening. Progressive thickening and scar formation of the lung tissues occurs with associated loss of respiratory function. These developments are noticeable in the lower parts of the lungs, possibly because they receive the greater part of the inhaled load of particulate matter. Various types of medical evidence can establish an asbestosis diagnosis. It is not required that all elements are present, and the CE must weigh the overall body of evidence to make a fair determination. Each form of medical evidence below will be given greater weight if the test result includes a physician evaluation that suggests asbestosis. The CE must obtain a physician evaluation of all Pulmonary Function Test (PFT) results.

(1) Chest X-rays. Chest x-ray reports that show pulmonary interstitial fibrosis and cardiac enlargement are considered characteristic of asbestosis. The CE must consider such findings as possibly indicative of asbestosis, based upon the totality of the evidence.

(2) Computerized axial tomography (CAT) and magnetic resonance imaging (MRI) that show characteristic lung scarring, pleural thickening and cardiac enlargement may also be used to assist in the diagnosis of asbestosis. A CAT scan uses X-rays and computers to produce an image of a cross-section of the body.

(3) Pulmonary Function Test (PFT) Results. A PFT is a test that evaluates pulmonary function and capacity. Asbestosis typically restricts pulmonary function; therefore, total lung capacity, vital capacity, compliance measurements, and the pulmonary diffusing capacity will be reduced if asbestosis is present.

(4) Lung Biopsy. A lung biopsy is any sampling of lung tissue. Cytological examination of the sputum or bronchial lavage may often show the presence of asbestos bodies. This test is not considered as definitive for asbestosis because it is commonly positive in cases of exposure alone and may be seen in other populations such as hematite (iron ore) miners.

(5) Physician Narrative Report. A report by a medical doctor diagnosing asbestosis and providing a diagnosis date.

(6) DOE FWP. As with other conditions, if there is evidence that the employee was screened for asbestosis through the DOE FWP and found to be positive, such a finding is sufficient to accept the case.

(7) Mesothelioma. Mesothelioma is a rare cancer that is caused almost exclusively by asbestos exposure. Because of this relationship to asbestos, any claims involving a confirmed case of mesothelioma can be accepted, given the requirements for asbestos exposure at a covered facility (i.e., latency period).

(8) DMC Referral. Referral to a DMC to evaluate the medical evidence and render a determination regarding the existence of asbestosis may be necessary when the medical evidence is vague. Sometimes, a DMC review is required in instances of claimed and/or verified high levels of occupational exposure to asbestos to determine whether or not the normal required latency period for onset should be waived. DMC requirements with diagnosed asbestosis are outlined below.

(9) Death Certificate. Asbestosis identified on the death certificate as a cause of or contributing factor to death establishes a diagnosis. In the event the death certificate shows any respiratory illness other than asbestosis, the CE must provide a well rationalized conclusion that asbestosis contributed to the death based on the medical evidence contained in the file. As with other conditions, the death certificate must be signed by a physician.

(a) Pneumoconiosis. If the evidence of file supports a diagnosis of asbestosis and the death certificate lists the cause of death as pneumoconiosis, the CE may presume causation.

b. Employment/Exposure Requirements. Through the usual employment verification development techniques, the CE must verify that the employee was a covered DOE employee at a covered DOE facility during a covered time period for more than one year and was exposed to asbestos while at the DOE facility.

However, if an employee’s occupation was such that the potential for extreme exposure existed and the employee worked less than one year, the CE does not deny based upon length of employment. The CE evaluates the evidence as a whole, considering the amount of occupational exposure and make a factual determination as to causation. A DMC referral is necessary as discussed below.

(1) DOE Employment and Asbestos Exposure. If the CE verifies that the employee was a covered DOE employee employed for more than one year at a covered DOE facility during a covered time period and the presence of asbestos dust is confirmed at that facility by the evidence of record, asbestos exposure will be assumed. If evidence of asbestos exposure is not identified in the file, the CE reviews SEM, contacts a DOE Operations Center, a Corporate Verifier, CPWR, ORISE, and/or the claimant for additional evidence. While not exhaustive, the CE can also verify asbestos presence by these means:

(a) Medical evidence discussing the employee’s work history where asbestos exposure at the covered facility can be safely assumed (i.e. pipe fitter) or is explicitly mentioned.

(b) Personnel records disclosing exposure to asbestos.

(c) Affidavits from other employees attesting to the asbestos exposure and other evidence such as independent studies of the facility, newspaper articles discussing asbestos at the site.

(2) Latency Period. A sufficient latency period must also exist between the covered DOE employment and the onset of the illness. Most asbestos-related diseases and abnormalities usually do not occur for several years (usually at least 10, but in some cases fewer) after onset of exposure. Deaths related to asbestos exposure and resultant diseases are relatively unusual until 20 years after the onset of exposure, yet become increasingly frequent beyond that latency period.

(a) Additional Development. If the latency period is less than 10 years, the CE reviews the evidence of file to determine if sufficient evidence exists to support that the exposure was “at least as likely as not” a significant factor in aggravating, contributing to, or causing asbestosis. Referral to a DMC is required.

(3) Related Medical Supporting Exposure. In addition, the presence of pleural thickening, interstitial fibrosis, neoplasia, or other consistent medical evidence as discussed above helps establish the significance of the relationship between employment and exposure.

(a) Pleural Plaques. Pleural plaques are considered a condition caused by asbestos, but do not constitute an asbestosis diagnosis or finding. Although generally asymptomatic, the CE accepts this condition for medical monitoring and therapeutic drug treatments. Monitoring benefits will likely encompass the following: chest radiology (x-rays or CT scans or MRIs); PFTs; bronchoscopy with or without biopsy; pleural biopsy; and other tests to rule out malignant tumors of the chest. In addition to medical monitoring and therapeutic drugs, it is possible for pleural plaques to cause a ratable impairment. Evaluations for an impairment rating are made on a case-by-case basis and only if the claimant requests an impairment rating (claims impairment) in writing.

(4) Dose-Response Relationship. The CE can safely assume that the longer an employee was exposed to asbestos, or the more intense the exposure, the more likely that asbestosis will develop. Nonetheless, certain medical review criteria must be met based upon the years of potential exposure once the diagnostic criteria are met and potential exposure is verified through reasonable development. Below are the required stages for DMC referral based upon dose-response relationship (i.e. length of potential and/or verified exposure) and instances whereupon a claim can be accepted based upon the exposure period and diagnosis.

(a) The evidence of file shows less than one year of asbestos exposure at a DOE facility and the employment is not indicative of an occupation that typically experiences heavy exposure. In such instances the CE denies the claim because the evidence does not establish a causal link showing that asbestos exposure at the DOE facility was a significant factor in causing, contributing to, or aggravating the condition.

(b) The evidence of file shows less than one year of asbestos exposure at a DOE facility and the employment is indicative of an occupation that typically experiences heavy exposure. The CE forwards the case file to a DMC for a medical determination as to whether or not the asbestos exposure was a significant factor in causing, contributing to, or aggravating the condition.

(c) The evidence of file shows one to ten years of asbestos exposure at a DOE facility. The CE forwards the case file to a DMC for a medical determination as to whether or not the asbestos exposure was a significant factor in causing, contributing to, or aggravating the condition.

(d) The evidence of file shows ten years or more of asbestos exposure at a DOE facility. In this case, if all diagnostic criteria are satisfied the CE can accept this claim for benefits without a DMC review.

18. Chronic Obstructive Pulmonary Disease (COPD) and Other Lung Conditions. COPD refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema, chronic bronchitis, and in some cases asthma. When a claim form is submitted and COPD or some other related lung condition is claimed, the CE develops for all possible conditions before making an evaluation.

Please note that COPD is not a condition found in SEM, because it is not listed as a condition in Haz-Map. The CE should review all medical evidence when a COPD diagnosis is made and try to narrow down the exact condition from which the employee suffered/is suffering.

a. Evaluating Medical Evidence. As with most conditions, the medical evidence must be evaluated in its totality. Any one of the following can be an indication of COPD, but a diagnosis may not be based solely on one of the following criteria. The CE must weigh all the medical evidence before making a finding. Exposure to certain toxic substances that may induce lung ailments are to be taken into consideration when the CE is reviewing the evidence of record. The CE is not qualified to make medical determinations as to the results of the tests described below. All test results must be accompanied by a physician interpretation in order to have probative value. If no physician interpretation is available, the CE must seek such interpretation from either the treating physician or another physician qualified to review the evidence. Finally, when developing for any lung condition, the CE reviews the medical evidence for the employee’s smoking history. No smoking questionnaire is sent. However, if the CE finds a significant smoking history that appears to be related to the condition claimed, a DMC or IH referral or additional treating physician report may be necessary to determine the impact of smoking on the illness. A CE can not make this determination.

(1) Arterial Blood Gas (ABG) Test. Abnormal results of any of the blood gas components may mean that the body is not getting enough oxygen, is not getting rid of enough carbon dioxide, or that there is a problem with kidney function. The test result must include an evaluation by a physician.

(2) Consistent Chest X-rays/CAT scans. Chest x-ray results can vary and show interstitial patterns, scarring, and other abnormalities.

(3) Abnormal Spirometry. The Spirometer measures air flow and air volume. An abnormal reading could be an indication of COPD or some other lung condition.

(4) Bronchoscopy. The bronchoscopy is utilized by physicians to examine the major air passages of the lungs. A finding of an obstruction in the air passages could be indicative of COPD or some other lung condition.

(5) DMC Referral. As always, unless there is sufficient medical evidence that, reviewed cumulatively, establishes a lung condition, the CE refers the case file to a DMC for a determination.

b. Employment Requirements. The CE must develop for covered DOE/RECA Section 5 employment at a covered DOE/RECA Section 5 facility during a covered timeframe, or eligibility as a qualified RECA 4 claimant. Site profiles, SEM, and evidentiary employment evidence are used to determine what toxins were present at the site. The CE makes a decision as to whether it is “at least as likely as not” that the established occupational exposure was a significant factor in aggravating, contributing to, or causing the condition upon review of the evidence as a whole.

19. Other Conditions. Like asbestosis and the lung ailments associated with COPD, there are a host of other conditions potentially covered under Part E that are not covered under Part B. A review of the Part B case file materials for medical evidence will still be helpful in adjudicating these claims, as many non-covered conditions may have been claimed and supported with evidence under Part B. The CE may use Exhibit 2 (“Matrix for Confirming Sufficient Evidence of Covered Illness”) as a resource in determining whether the case file contains sufficient information to accept an illness or whether a physician review is needed. The matrix is organized by specific illness.

a. Causation. The evidence must establish that there is a relationship between exposure to a toxin and an employee’s illness or death. The evidence must further show whether it is “at least as likely as not” that such exposure at a covered DOE facility during a covered time period was a significant factor in aggravating, contributing to, or causing the employee’s illness or death, and that it is “at least as likely as not” that exposure to a toxic substance(s) was related to employment at a DOE facility.

b. Exposure. As noted above, site profiles, SEM, DAR records and other employment exposure data are used by the CE in the causation evaluation process. As the SEM is continually updated with toxic substances and facilities as they are evaluated, the CE searches SEM whenever conducting a causation analysis to determine whether or not evidence exists regarding the illness, exposure and employment claimed. In some instances, with or without sufficient exposure data, it will be necessary to refer the case file to a qualified physician/DMC or IH to evaluate the evidence and render an expert opinion as to causation.

c. Medical Requirements. With the wide variety of conditions claimed under Part E, it is impossible to definitively provide concrete diagnostic requirements of all possible conditions in this chapter. The CE must use his or her best judgment in reviewing the medical evidence and, as always, employ the weight of evidence rule. Physician narrative/DMC/IH and/or toxicologist reports providing a diagnosis, of course, hold the greatest weight. DMC referrals might be necessary for some conditions until a body of program-wide knowledge is available to provide overall guidance.

20. ECMS Coding. Please use the following guidance pertaining to ECMS when coding for causation actions under Part E. All other ECMS coding conforms to the guidance set out under EEOICPA PM 2-1500, the Energy Case Management System (ECMS) Chapter.

a. Coding for DMC or Other Physician Referral. In instances where referral is made for an initial medical determination as to causation as outlined above, the CE uses the following codes:

(1) MS - ‘Sent to Medical Consultant.’ When a CE identifies a case for referral to a DMC, the medical scheduler prepares the file for mailing. Once the package is mailed to the DMC, the medical scheduler notifies the CE so that the CE enters the code ‘MS’ in ECMS. The status effective date for the ‘MS’ code is the date of the letter of referral to the medical consultant. Upon entry in ECMS of the ‘MS’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘MS’ claim status code. Included in the reason cd field are both the full reason for the ‘MS’ code and a two-digit code representing each option. The reason codes available for the ‘MS’ claim status code are as follows:

(a) Impairment (E only)-’IM.’ This is used for referral to a medical consultant in support of impairment.

(b) Causation (E only)-’CA.’ This is used for referral to a medical consultant in support of causation.

(c) Medical Condition Referral (B and E)-’MC.’ This is used for referral to a medical consultant in support of establishing a claimed illness.

(d) Wage Loss (E only) – ‘WL.’ This is used for referral to a medical consultant to determine if wage loss is causally related to a covered illness.

(e) Other/Referral for Multiple Issues (B and E) – ‘OT.’ This is used when a referral is made for multiple purposes (i.e. medical condition, causation for another claimed condition, wage loss and/or impairment).

(2) MR - ‘Received Back from Medical Consultant.’ Upon completion of the review, the district medical consultant (DMC) returns the narrative report and the completed HCFA-1500 to the CE within 21 days. Upon receipt of the narrative report and the bill, the CE enters the code ‘MR’ in ECMS. The status effective date for the ‘MR’ code is the date the report from the DMC is stamped “received” by the DO. Upon entry in ECMS of the ‘MR’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘MR’ claim status code. Included in the reason cd field are both the full reason for the ‘MR’ code and a two-digit code representing each option. The reason codes available for the ‘MR’ claim status code are as follows:

(a) Impairment (E only)-’IM.’ This is used for referral to a medical consultant in support of impairment.

(b) Causation (E only)-’CA.’ This is used for referral to a medical consultant in support of causation.

(c) Medical Condition Referral (B and E)-’MC.’ This is used for referral to a medical consultant in support of establishing a claimed illness.

(d) Wage Loss (E only) – ‘WL.’ This is used for referral to a medical consultant to determine if wage loss is causally related to a covered illness.

b. Coding for Second Opinion Physician Referral. In instances where referral is made for a medical second opinion determination as to causation as outlined above, the CE uses the following codes:

(1) 2S -‘Sent for 2^nd Opinion.’When a CE identifies a case requiring a medical second opinion, the medical scheduler prepares the documentation for mailing. Once the package is mailed to the medical specialist, the medical scheduler notifies the CE so that the CE enters the code ‘2S’ in ECMS. The status effective date for the ‘2S’ code is the date of the referral letter from the DO to the second opinion physician. Upon entry in ECMS of the ‘2S’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘2S’ claim status code. Included in the reason cd field are both the full reason for the ‘2S’ code and a two-digit code representing each option. The reason codes available for the ‘2S’ claim status code are as follows:

(a) Impairment (E only)-’IM.’ This is used for a second opinion in support of impairment.

(b) Causation (E only)-’CA.’ This is used for a second opinion in support of causation.

(c) Medical Condition Referral (B and E)-’MC.’ This is used for a second opinion in support of establishing a claimed illness.

(d) Wage Loss (E only) – ‘WL.’ This is used for referral for a second opinion to determine if wage loss is causally related to a covered illness.

(2) 2R - ‘Received 2^nd Opinion.’ Once the CE receives the medical narrative from the second opinion specialist that adequately addresses the CEs questions, the CE enters the ‘2R’ code in ECMS. The status effective date for the ‘2R’ is the date the medical narrative is date-stamped in the district office. Upon entry in ECMS of the ‘2R’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘2R’ claim status code. Included in the reason cd field are both the full reason for the ‘2R’ code and a two-digit code representing each option. The reason codes available for the ‘2R’ claim status code are as follows:

(a) Impairment (E only)-’IM.’ This is used for a second opinion in support of impairment.

(b) Causation (E only)-’CA.’ This is used for a second opinion in support of causation.

(c) Medical Condition Referral (B and E)-’MC.’ This is used for a second opinion in support of establishing a claimed illness.

(d) Wage Loss (E only) – ‘WL.’ This is used for referral for a second opinion to determine if wage loss is causally related to a covered illness.

c. Coding for Referral to NO for Health Physicist and Industrial Hygienist/Toxicologist referral.

(1) ‘Washington, DC: Sent to WS.’ When the CE or HR identifies an outstanding policy or procedural issue in a case that requires National Office attention, the CE prepares the WS/WR Referral/Response Form. After the Supervisory CE and District Director (DD) or FAB Manager reviews the case file and the referral form and agrees with the determination to send the issue to NO, the DD or FAB Manager (or designate) enters the ‘WS’ code in ECMS. The status effective date is the date the DD or FAB manager signs and dates the WS/WR Referral/Response Form. Use of the ‘WS’ code is restricted to the DD and FAB Manager to ensure he or she agrees with the CE’s rationale for the referral to National Office and also agrees that the CE cannot continue working on the case until the outstanding issue is resolved. Included in the reason cd field are both the full reason for the ‘WS’ code and a two-digit code representing each option.

(a) Health Physicist Review. If a physician provides rationalized scientific evidence revealing a synergistic or additive effect involving radiation and toxic substance exposure together, the DO/FAB sends the case file to NO for review by a NO HP. The CE/HR or DO/FAB staff enters the ‘WS’ code and selects the reason code ‘HP’ (Health Physicist Review) from the corresponding drop down list.

(b) Industrial Hygienist/Toxicologist Review. If a referral is needed to the IH/Toxicologist to determine causation based upon toxic substance exposure, the DO/FAB sends the case file to NO for review. The CE/HR or DO/FAB staff enters the ‘WS’ code and selects the reason code ‘IH’ (Industrial Hygienist Review) from the corresponding drop down list. This code will be used for referrals to the IH and the Toxicologist.

(2) WR - ‘Washington, DC: Received Back From.’ Upon receipt of the HP/IH response, the CE/Hearing Representative enters a ‘WR’ code in ECMS, with an effective date of the date the DO date stamps the case file upon receipt of the response from Washington.

d. The causation determination is entered in ECMS as the ‘cond status’ in relation to the medical condition under review.

(1) Using the A status code: For each medical condition claimed on an EE-1 or EE-2, if the CE determines that the medical evidence meets the criteria necessary to accept the condition for causation, the CE enters an ‘A’ in the ECMS medical cond status list box for “ACCEPTED” in the Medical Condition screen. This does not mean the case is accepted, just that the medical adjudication is complete for each claimed condition and the evidence is acceptable. The case could then either be accepted or denied, but the ‘A’ signifies the medical development is complete and that the medical evidence meets the established criteria for causation for the particular claimed medical condition.

(2) Using the D status code: For each medical condition claimed on an EE-1 or EE-2, if the CE determines that the medical evidence does not meet the criteria necessary to accept the condition for causation, the CE enters a ‘D’ in the ECMS medical cond status list box for “Denied” in the Medical Condition screen.

(3) Using the R status code: If the claimant does not establish a diagnosis of the claimed illness (precluding the need for development of causal relationship), the status code remains ‘R.’

e. Coding NIOSH Referrals for Part E ECMS. When a non-SEC cancer claim is referred to NIOSH or was originally referred to NIOSH as a Part B claim and a new Part E claim is now extant, the CE does not input the ‘NI’ SENT TO NIOSH code into ECMS E to show that the claim is pending dose reconstruction at NIOSH. The ‘NI’ code is input into the Part B only (unless RECA Section 5 case with claim for cancer other than lung cancer). Instead, while the CE is concurrently developing for exposure to a toxic substance, the ‘DO’ code is entered into ECMS E and the CE selects ‘TD’ (Toxic Exposure Development) from the corresponding drop down menu. ECMS codes must reflect a particular development action. If CE takes a development action (i.e. sends a letter to a claimant or a DAR to DOE), then and only then may a ‘DO’ code be entered. The status effective date is the date of the letter.

When toxic exposure development is complete and the CE cannot accept causation, the CE creates a memorandum to file stating that toxic exposure development is complete. The CE then codes ‘NI’ into ECMS E with the status effective date of the date memorandum.

Paragraph and Subject Date Transmittal No.