D.C. Mun. Regs. tit. 7, r. 7-146

Current through Register 71, No. 45, November 7, 2024

Rule 7-146 - WEIGHING MEDICAL EVIDENCE

146.1

When the Program receives medical evidence from more than one source, it should evaluate the relative value, or merit, of each piece of medical evidence.

146.2

In evaluating the merits of medical reports, no preference shall be given to treating physicians. The Program shall evaluate the probative value of the report and assign greater value to:

(a) An opinion based on complete factual and medical information over an opinion based on incomplete, subjective or inaccurate information. Generally, a physician who has physically examined a patient, is knowledgeable of his or her medical history, and has based the opinion on an accurate factual basis, has weight over a physician conducting a file review with no knowledge of the patient's medical history or fails to take into account or omits other relevant medical conditions that relate to or may be related to the condition at issue.

(b) An opinion based on a definitive test(s) and includes the physician's findings. Some medical conditions can be established by objective testing. Medical reports that contain objective findings shall be assigned greater weight than those that fail to account for or include objective findings, where the condition can be established or excluded by such finding.

(c) A well- rationalized opinion over one that is unsupported by affirmative evidence. The term "rationalized" means that the statements of the physician are supported by an explanation of how his or her conclusions are reached, including appropriate citations or studies. An opinion that is well-rationalized provides a convincing argument for a stated conclusion that is supported by the physician's reasonably justified analysis of relevant evidence. For example, an opinion which is supported by the interpretation of diagnostic evidence and relevant medical or scientific literature is well- rationalized. Conversely, an opinion which states a conclusion without explaining the interpretation of evidence and reasoning that led to the conclusion is not well-rationalized.

(d) The opinion of an expert over the opinion of a general practitioner or an expert in an unrelated field. However, conclusive statements of an expert without any underlying justification, other than affirmation of the physician's expertise, are not to be viewed as carrying significant probative value over that of a general practitioner report that is well-rationalized and/or supported by applicable affirmative evidence.

(e) An unequivocal opinion over one that is vague or speculative. A physician offering a clear, unequivocal opinion on a medical matter is to be viewed as more probative compared to an opinion that waivers or hesitates in its presentation or contains vague and speculative language. An opinion which contains verbiage such as "possibly could have" or "may have been" or provides a guess or estimation indicates speculation on the part of the physician.

D.C. Mun. Regs. tit. 7, r. 7-146

Final Rulemaking published at 64 DCR 6325 (7/7/2017)