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Maximum medical improvement (MMI) is not based on ODG or MDA guidelines in Texas workers’ compensation claims.  There are some designated doctors that need to learn this lesson.  They are using these guidelines to end the benefits of injured workers prematurely and illegally.  The ODG, or the Official Disability Guideline, is a treatment guideline.  MDA, or the Medical Disability Advisor, is a disability guideline. Neither is an impairment rating guideline.

What Is Maximum Medical Improvement?

MMI is the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.  It’s basically the point in time when you have healed as much as you can expect to heal.  It is supposed to be based on a review of your medical records and a physical examination.  This means that maximum medical improvement is all about you.  YOUR recovery.  The treatment that YOU need.  That’s why maximum medical improvement is not based on ODG or MDA guidelines.

Maximum Medical Improvement Is Not Based On MDA

The MDA is a book that the Division of Workers’ Compensation uses to get a feel for the average amount of time an average person misses work for a specific type of injury.  So, it may tell you that a person with a low back sprain that works a job classified as “heavy” should be off work between 7 and  84 days, and that most miss about 35 days.  Using this standard to certify MMI means that the doctor is not certifying when YOU have healed, but when an average person should be able to return to work.  These are two different standards.

Maximum Medical Improvement Is Not Based On ODG

The ODG is a book that the Division of Workers’ Compensation uses to determine what kind of treatment a person should have for a specific type of injury.  So, it may tell you that a person with a low back injury might need an MRI, but not before 3 to 4 weeks of conservative therapy without improvement.  Using this standard to certify MMI means that the doctor is not certifying when you have healed, but is certifying a date after which an average person with no complicating factors would exhaust medical treatment.  This doesn’t factor in all the time wasted when insurance companies deny treatment.  This is not a certification about YOU, it’s a certification about other people in “normal” circumstances.

The Effect Of Misusing These Guidelines

The way some designated doctors are using these guidelines is contrary to the vision of the workers’ comp scheme.  These docs will spend 5 minutes with you and declare you reached MMI six months ago.  Your benefits get cut off because temporary income benefits can’t be paid after you reach MMI.  Even worse, since you were paid TIBs for the last 6 months, they now count as your impairment income benefits.  This means you are paid out, you get nothing else, and you don’t get any notice.  The insurance company kicks you to the curb.

The Solution For Injured Workers

There is an appeals panel case addressing this practice.  In Appeals Panel Decision 130191, the panel ruled that using the MDA and the ODG to determine maximum medical improvement violates the rules requiring the certification to be bason on the physical exam and the medical records.  That’s an official ruling that maximum medical improvement is not based on ODG or MDA guidelines. 

If your impairment rating report uses the terms ODG or MDA, you must prepare to dispute that certification. This is very important if you still need medical treatment.  You can refer to our blog on how to dispute an impairment rating for instructions.  You can also find further information on dispute resolution in our free e-book for Texas injured workers.