Alexander Sones, MD, QME
California Qualified Medical Evaluators are frequently asked to evaluate injured workers with impairment involving more than one body part or body system. Once those impairments have been identified, another important question may arise: should they be combined using the Combined Values Chart (CVC), or is there a basis for adding the impairments?
The Workers’ Compensation Appeals Board’s 2024 en banc decision in Vigil v. County of Kern provides important guidance on this issue.
For physicians performing QME and AME evaluations, one of the central lessons from Vigil is that the analysis should focus on how each impairment affects the injured worker’s activities of daily living (ADLs) and whether the CVC accurately reflects the worker’s actual functional impairment.
What Is the Combined Values Chart?
When an injured worker has multiple impairments, the Combined Values Chart is the default method for combining those impairments.
The CVC accounts for the fact that multiple impairments may have overlapping effects on an individual's functioning. Vigil did not create a presumption in favor of adding impairments simply because multiple body parts or body systems are involved. The evaluator should begin with the premise that the impairments will be combined.
However, the CVC may be rebutted in an appropriate case. When substantial medical evidence establishes that the CVC does not accurately reflect the applicant’s actual functional impairment, the impairments may instead be added.
That is where Vigil becomes particularly important.
What Happened in Vigil?
The applicant in Vigil was a maintenance painter who sustained injuries involving his hips and back. His medical history included hip replacement surgeries, and the case ultimately presented questions concerning how his multiple impairments should be evaluated when determining permanent disability.
In its June 10, 2024 en banc decision, the WCAB clarified the evidence necessary to rebut the CVC and support addition of impairments.
Importantly, the analysis is not simply about whether an injured worker has impairment involving different body parts. The focus is on the impact of each impairment on the injured worker’s activities of daily living.
Two Ways the CVC May Be Rebutted
Under Vigil, the CVC may be rebutted and impairments may be added where the applicant establishes the impact of each impairment on the ADLs and demonstrates one of two circumstances.
1. There Is No Overlap in the Effects on ADLs
The first situation occurs when the impairments affect distinct activities of daily living.
Different impairments may produce entirely different functional limitations. When their effects on ADLs do not meaningfully overlap, application of the CVC may understate the applicant’s actual overall impairment.
The analysis therefore should not stop at identifying the diagnoses, anatomical structures, or body parts involved. The functional effects of each impairment should be identified and compared.
2. There Is Overlap, but the Overlap Increases or Amplifies the Impact
The second situation occurs when the effects of the impairments overlap, but their interaction increases or amplifies the impact on the overlapping activities of daily living.
For example, two impairments may independently interfere with the same activity. When present together, however, their interaction may make performance of that activity materially more difficult than would be expected from either impairment independently.
In that circumstance, the CVC may not adequately capture the worker's actual functional loss.
Importantly, overlap alone does not establish a basis for addition. If the functional effects are largely duplicative and the worker's overall functioning is adequately represented by the CVC, the impairments should remain combined.
The Importance of Activities of Daily Living
One of the most important practical lessons from Vigil is that the analysis concerns activities of daily living, not merely anatomy.
When addressing whether the CVC should be rebutted, the physician should specifically discuss the impact of each impairment on the applicant’s activities of daily living, including whether those effects overlap and, if so, whether the overlap increases or amplifies the functional loss.
Depending on the impairments involved, relevant activities may include self-care, communication, physical activity, travel, sleep, household responsibilities, social activities, and other aspects of everyday functioning.
The analysis is therefore individualized. Two applicants with similar diagnoses or impairment ratings may experience substantially different effects on their activities of daily living.
Physicians Need to Explain the “How and Why”
Simply stating that impairments are “synergistic” or that they should be added is not enough.
A persuasive medical opinion should explain how the impairments interact in actual function. The term “synergy,” standing alone, is conclusory.
When addressing rebuttal of the CVC, the analysis should therefore address:
Which activities of daily living are affected by each impairment
How each impairment affects those activities
Whether the functional effects are distinct or overlapping
If there is overlap, whether the impairments merely duplicate one another's effects or instead increase or amplify the functional loss
Whether the CVC adequately reflects the applicant's actual overall impairment
Why combining, adding, or using a combination of the two provides the most accurate assessment of the applicant's impairment
The conclusion should be tied to the particular facts and functional limitations of the individual being evaluated.
How Does Kite Fit Into the Analysis?
Before Vigil, Kite was an important case addressing rebuttal of the CVC.
Kite recognized that the CVC may be rebutted when impairments have a synergistic effect. “Synergy” refers to an interaction between two or more impairments in which their combined effect is greater than the effect expected from considering them independently.
Vigil clarified the analysis further.
Addition may be supported where the applicant establishes the impact of each impairment on activities of daily living and demonstrates either that there is no overlap in those effects or that there is overlap and the interaction increases or amplifies the impact on the overlapping ADLs.
Thus, synergy remains relevant when impairments interact and amplify one another, but simply labeling impairments “synergistic” is insufficient. The physician should explain how the impairments interact and why their combined functional effect is not adequately captured by the CVC.
Vigil also recognizes a separate basis for addition when the impairments affect distinct ADLs without meaningful overlap.
The Analysis Does Not Have to Be All-or-Nothing
In cases involving several impairments, the physician does not necessarily have to choose between combining every impairment or adding every impairment.
Some impairments may warrant addition because they affect distinct functions or because their overlapping effects are amplified. Other impairments may remain appropriately combined because their functional effects are duplicative.
A mixed approach may therefore provide the most accurate impairment assessment.
The evaluator can consider the impairments pair-by-pair or grouping-by-grouping and determine whether the evidence supports rebuttal of the CVC for each particular impairment or group of impairments.
What Does Vigil Mean for Psychiatric QMEs?
Vigil can be particularly relevant for psychiatric QMEs when psychiatric impairment exists alongside impairment involving another body system.
For example, psychiatric and orthopedic impairments may affect some of the same activities of daily living. Alternatively, their functional effects may be distinct.
The existence of both psychiatric and physical impairment does not, by itself, establish that the impairments should be added rather than combined.
Instead, the evaluator should consider how the psychiatric impairment affects the applicant’s ADLs and how the other impairment affects those ADLs. The evaluator can then address whether those effects are distinct or overlapping and, if they overlap, whether the interaction increases or amplifies the impact on the overlapping activities.
For psychiatric evaluators, this makes a careful assessment of functioning especially important. Information concerning daily activities, social functioning, concentration, persistence and pace, adaptation, sleep, travel, household responsibilities, and other relevant activities may help inform the analysis.
Vigil Does Not Eliminate the Combined Values Chart
Vigil should not be understood as establishing a general rule that multiple impairments should be added.
The CVC remains the default. The fact that an applicant has bilateral injuries, multiple injured body parts, or impairments involving different body systems does not itself justify addition.
Instead, the medical evidence must establish why the CVC does not accurately reflect the applicant's actual functional impairment.
If the impairments have largely duplicative effects and the CVC adequately represents the worker's overall functioning, they should be combined. If the impairments affect distinct ADLs or interact in a manner that materially amplifies functional loss beyond what the CVC captures, addition may be appropriate.
Ultimately, the goal is not to maximize the impairment rating. It is to arrive at the most accurate impairment assessment supported by substantial medical evidence.
The Takeaway for Medical Evaluators
For QMEs and AMEs, Vigil reinforces the importance of moving beyond impairment percentages and anatomical labels.
When the potential addition of multiple impairments is at issue, the physician should carefully evaluate and describe the impact of each impairment on the applicant’s activities of daily living.
The central questions are:
How does each impairment affect the applicant’s ADLs?
Are those functional effects distinct, or do they overlap?
If they overlap, are the effects merely duplicative, or does the interaction increase or amplify the functional loss?
Does the CVC accurately reflect the applicant's actual overall impairment?
Would combining, adding, or a mixed approach provide the most accurate impairment assessment?
A reasoned, impairment-specific analysis of those questions provides the foundation for a persuasive Vigil opinion.
