Defining a Covered Work-Related Injury: Aggravation or Exacerbation?

How do Texas injury benefit plans define a work-related injury? This is important information to understand in making accurate coverage decisions.

Many statutory workers’ compensation systems define compensable aggravations on a subjective basis, meaning employee testimony or documentation of their pain can validate a new, compensable Injury.  

Texas injury benefit plans designed through PartnerSource, however, define compensable aggravations based on objective medical evidence. This means a covered injury should always be supported by tangible evidence of new trauma (for example, bruising, swelling, or other visible findings) and identifiable, diagnostic evidence of new physical damage or harm (also called “acute findings”).  

There is an important distinction here:

An aggravation of a pre-existing condition is identifiable new damage or harm that should be treated and covered by the plan.  
An exacerbation of symptoms, meanwhile, describes a recurrence or remanifestation of an underlying pre-existing, degenerative condition OR a natural progression of a degenerative condition.

By definition, degenerative conditions worsen with the passage of time. Exacerbations are not covered Injuries because their primary cause is an underlying pre-existing or degenerative condition unelated to a work injury.

The experts at PartnerSource understand how important it is that claims and medical teams fully understand the plan definitions, how to apply them, and what evidence is required to properly interpret the definitions. 
To illustrate this point, consider these two different scenarios:

Case #1: A worker reportedly falls to the ground, fracturing her finger. The diagnosis was a closed fracture at the site of an ordinary disease of life, confirmed as a pathological fracture that transected unhealthy bone tissue.  There was no diagnostic evidence of damage or harm to healthy tissue, so the medical director opined that the preexisting condition was a major contributing cause (51%) of the fracture. 

To be thorough, the medical director sent the case to an orthopedic peer review for analysis, and surprisingly, the peer review opinion report was inclusive on causation or extent of injury.  

The medical director and PartnerSource claims team worked together to explain the plan’s definitions to the peer reviewer. They also provided the video of the event; evidence that confirmed the employee did not actually fall to the ground but rather caught herself on a padded surface at waist level. With this information, the peer reviewer provided a very clear addendum excluding the fracture as a personal medical condition. This resulted in the correct coverage decision.

Case #2: A worker reported a lower back injury with constant pain. The plan covered diagnostic testing (MRI of the lumbar), which confirmed multiple levels of disc desiccation, bone spurring, and other findings consistent with degenerative disc disease.  PartnerSource was contacted by an adjuster concerned that the medical director was requesting approval for what the medical director called an exacerbation. This person was ordering treatment under the plan, even though the medical director’s report confirmed “no diagnostically identified structural damage.”

In this case, the medical director was requesting coverage for an expensive procedure for symptoms related to an underlying pre-existing or degenerative condition. PartnerSource was able to quickly intervene and provide guidance to the claim and medical team, resulting in an accurate coverage decision to exclude treatment for symptoms lacking objective clinical evidence of a new Injury.

Just Remember
Work injury plans should only cover aggravations of pre-existing conditions when there is diagnostically identifiable new damage or harm from an accident or NEW Injury.   

These cases illustrate the importance of evidence-based coverage decisions and accurate interpretation of the plan’s injury definitions. PartnerSource claim consultants are here to help guide claims and medical teams to a correct and consistent coverage analysis that includes all available medical and claim investigation evidence.