A QME becomes necessary when there is a dispute between the injured worker and the employer or insurance carrier regarding:

The cause of the injury or illness: A QME evaluation aims to determine whether the injury or illness is directly related to the worker’s job duties or workplace conditions. This involves a detailed review of medical records, patient history, and the circumstances surrounding the injury. The QME also considers whether external factors, such as pre-existing conditions or non-work-related incidents, contributed to the condition.

The extent of permanent disability: The evaluation assesses the long-term impact of the injury or illness on the worker’s physical and functional abilities. Using guidelines, the QME calculates the degree of permanent impairment, often expressed as a percentage, which reflects how much the condition limits the worker’s ability to perform activities or job-specific tasks. This helps decide the compensation or benefits the injured worker is entitled to.

The necessity and appropriateness of medical treatment: A QME examines whether the medical treatments already provided or proposed align with the worker’s injury or condition. This includes evaluating whether treatments such as surgeries, therapies, medications, or rehabilitation programs are effective, evidence-based, and necessary for recovery. The evaluation also identifies if additional treatments are required or any current interventions should be adjusted to optimize the worker’s recovery.

Work restrictions: Based on the evaluation, the QME identifies specific physical or functional limitations that may impact the worker’s ability to perform particular tasks or return to their regular job duties. For example, the evaluator might recommend restrictions such as lifting weight limits, avoiding repetitive movements, or prohibiting prolonged standing or sitting. These help create a safe return-to-work plan or consider alternative roles.