|
DISEASE OPTION 1: PAYMENT AMOUNTS
Question:
"If I receive a Disease Option 1 Payment, can I later receive payment
for one (1) of the diseases or conditions in Disease Option 2?"
Answer:
No!
Source: Disease Claimant Information Guide, Dow Corning Breast Implant
Claimants (Class 5) Page 9, Section 3, Question Q-3-2.
|
Any approved disease in Disease Option
1 with a Severity or Disability Level of A, B, C, or D
|
You must have proof that you have or
had one or more Dow Corning
breast
implants
and have not had a Bristol, Baxter or 3M silicone gel breast implant**
|
|
Base Payment
|
+ Premium Payment |
= Total Payment |
|
Severity / Disability Level A |
$50,000 |
+ $10,000 |
= $60,000 |
|
Severity / Disability Level B |
$20,000 |
+ $4000 |
= $24,000 |
|
Severity / Disability Level C |
$10,000 |
+ $2000 |
=$12,000 |
** If you
have acceptable proof that you have or had a Bristol, Baxter, or 3M
silicone gel breast implant, the
Total Payment Amount will be reduced by 50%.
Tab I: Medical Conditions and Characteristics Outline of
Definitions and Classification Criteria
DISEASE PAYMENT OPTION 1:
DEFINITION OF COVERED CONDITIONS
SYSTEMIC SCLEROSIS/SCLERODERMA (SS)
1. A diagnosis of
systemic sclerosis shall be made in accordance with the criteria
established in Kelley, et al.,
Textbook of Rheumatology (4th ed.) at
1113, et seq.
2. Application of these
diagnostic criteria is not intended to exclude from the compensation
program individuals
who present clinical symptoms or laboratory findings atypical
of classical systemic sclerosis but who
nonetheless have a systemic sclero-sis-like
(scleroderma-like) disease, except that an individual will not be
compensated in this category if her symptomology more closely
resembles MCTD, ACTD, or any other
disease or condition defined below.
A "systemic sclerosis-like" or scleroderma-like" disease is
defined as an autoimmune/rheumatic disease that fulfills most
of the accepted standards for the diagnosis of
systemic sclerosis but is in some manner atypical of systemic
sclerosis or scleroderma.
3. Severity/Disability
Compensation Categories
(
) Death or total disability resulting from SS or an SS-like
condition. An individual will be considered totally
disabled if the
individual satisfies the functional capacity test set forth in
Severity/Disability Category A for
ACTD/ARS/NAC or if
the individual suffers from systemic sclerosis with associated
severe renal
involvement
manifested by a decrease in glomerular filtration rates.
(
)
Cardio-pulmonary involvement or diffuse (Type III) scleroderma as
defined l " by Barnett, A Survival
Study of Patients with Scleroderma Diagnosed Over 30 Years 11953
-1983): The Value of a Single
Cutaneous Classification in the Earl~ Stages of theDisease, 15
The Journal of Rheumatology 276 (1988)
and Masi,
Classification of Systemic Sclerosis (Scleroderma): Relationship of
Cutaneous Subgroups in
Early Disease to Outcome and Serologic Reactivity, 15 The
Journal of Rheumatology, 894 (1988).
(
)
Other including CREST, limited, or intermediate scleroderma,
except that any Breast Implant Claimant
who manifests
either severe renal involvement, as defined above, or
cardio-pulmonary involvement, will
be
compensated at either category A or B as appropriate.
(
)
Other not covered above, including localized scleroderma.
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
1. A diagnosis of systemic lupus erythematosus (SLE) shall be made in
accordance with 1982 Revised
Criteria for the Classification of Systemic
Lupus Erythematosus,
25 Arthritis and Rheumatism No. 11
(November 1982) adopted by the American College of
Rheumatology. See Kelley, 4th ed. at 1037,
Table 61-11: A diagnosis of lupus is made if four
(4) of the eleven (11) manifestations listed in the table
were present, either serially or simultaneously,
during any interval of observations.
CRITERION DEFINITION:
( ) Malar Rash: Fixed erythema,
flat or raised, over the malar eminences, tending to spare the
nasolabial folds.
( ) Discoid Rash:
Erythematous raised patches with adherent keratotic scaling and
follicular plugging;
atrophic scarring may occur in older lesions.
( ) Photosensitivity: Skin
rash as a result of unusual reaction to sunlight, by patient history
or physician
observation.
( ) Oral Ulcers: Oral or nasopharyngeal
ulceration, usually painless, observed by a physician.
( ) Arthritis: Nonerosive arthritis
involving two or more peripheral joints, characterized by
tenderness,
swelling or
effusion.
( )
Serositis:
(a) Pleuritis
--convincing history of pleuritic pain or rub heard by a physician
or evidence of pleural
effusion or
(b)
Pericarditis --documented by ECG or rub or evidence of pericardial
effusion.
( ) Renal Disorder:
(a) Persistent proteinuria greater than 0.5
g/day or greater than 3 + if quantitation not performed or
(b) Cellular casts -may be red cell, hemoglobin, granular,
tubular, or mixed.
( ) Neurologic Disorder:
(a) Seizures
-in the absence of offending drugs or known metabolic derangements;
e.g., uremia,
ketoacidosis, or electrolyte imbalance
or
(b) Psychosis -in the absence of offending drugs or known
metabolic derangements; e.g. uremia,
ketoacidosis, or electrolyte imbalance.
( )
Hematologic Disorder:
(a) Hemolytic
anemia -with reticulocytosis or
(b) Leukopenia
-less than 4000/mm total on two (2) or more occasions
or
(c) Lymphopenia -less than 1500/mm on two (2) or more
occasions or
(d) Thrombocytopenia -less than 100,OOO/mm in the absence
of offending drugs.
( )
Immunologic Disorder:
(a) Positive LE
cell preparation or
(b)
Anti-DNA
-antibody to native DNA in abnormal titer or
(c) Anti-Sm -presence of antibody to Sm nuclear antigen or
(d) False
positive serologic test for syphilis known to be positive for at
least six (6) months and
confirmed by Treponema pallidum immobilization or fluorescent
treponemal antibody absorption test.
( )
Antinuclear Antibody: An abnormal titer of antinuclear antibody by
immunofluorescence or an
equivalent assay at any point in time and in the absence of drugs
known to be associated with drug-
induced lupus
syndrome.
2. The application of the
ACR diagnostic criteria is not intended to exclude from the
compensation program
individuals who present clinical symptoms or laboratory
findings atypical of SLE but who nonetheless
have a systemic lupus erythematosus-like disease, except that
an individual will not be compensated in this
category if her symptomology more closely resembles mixed
connective tissue disease (MCTD), ACTO,
or any other disease or condition defined below.
3. Severity/Disability
Compensation Categories:
(
)
Death or total disability resulting from SLE or an SLE-like
condition. An individual will be considered
totally disabled based on either the functional
capacity test set forth in Severity/Disability Category A
for ACTD/ARS/NAC or severe renal involvement.
(
)
SLE with major organ involvement defined as SLE with one (1) or
more of the following:
glomerulonephritis, central nervous system involvement
(i.e. seizures or Lupus Psychosis), myocarditis,
pneumonitis, thrombocytopenic purpura, hemolytic anemia
(marked), severe granulocytopenia,
mesenteric vasculitis.
See Immunological Diseases, Max Samter, Ed. Table 56-6, at
1352.
(
) Non-major organ SLE requiring regular medical attention,
including doctor visits and regular
prescription medications. An individual is not excluded
from this category for whom prescription
medications are recommended but who, because of the
side effects of those medications, chooses
not to take them.
( ) Non-major organ SLE requiring little
or no treatment. An individual will fall into this category if she
is
able to control her symptoms through the following kinds of
conservative measures: over-the-counter
medications, avoiding sun exposure, use of lotions for skin rashes,
and increased rest periods.
ATYPICAL NEUROLOGICAL DISEASE
SYNDROME (ANDS)
1. A diagnosis of
Atypical Neurological Disease Syndrome (ANDS) shall be based upon
the clinical findings
and laboratory tests set forth below. The clinical and
laboratory presentation of these neurological
syndromes have an atypical presentation from the natural
disease and will also have additional
neuromuscular, rheumatological and nonspecific autoimmune
signs and symptoms.
2. Eligibility for
Atypical Neurological Disease Syndrome requires both:
(
) Satisfying the requirements for one (1) of the four (4)
neurological diseases set forth in paragraph 5
below,
and
( ) Any three (3) additional (nonduplicative)
neuromuscular, rheumatic, or nonspecific symptoms or
findings set
forth in the definition for Atypical Connective Tissue Disease
(ACTD).
3. An individual will fit
into this category if her primary symptoms are characteristic of a
neurological disease as
diagnosed by a Board-certified neurologist or by a
physician Board-certified in internal medicine.
4. If the individual's
Qualified Medical Doctor determines that a symptom is clearly and
specifically caused by a
source other than breast implants, that symptom will not be
utilized in the diagnosis of Atypical Neurological
Disease Syndrome unless the Claims Office determines that other
submissions indicate that the symptom
should be utilized. A symptom that may be caused only in part by
a source other than breast implants is not
excluded from such utilization.
5. Neurological disease
types:
Polyneuropathies.
This disease category requires either:
(1) a diagnosis of a polyneuropathy that is confirmed by one or
more of the following or
(2) submission of sufficient evidence of, and the required
findings confirming, such condition:
( )
Objectively-demonstrated loss of sensation to pinprick, vibration,
touch, or position
(
) Proximal or distal muscle weakness
(
)
Tingling and/or burning pain in the extremities
(
)
Signs of dysesthesia
(
)
Loss of tendon reflex
Plus one (1)
or more of the following laboratory findings:
(
) Abnormal levels of anti-mag or anti-sulfatide or anti-GM1
antibodies
(
)
Abnormal sural nerve biopsy
(
) Abnormal electrodiagnostic testing (EMG or nerve conduction
studies, etc.)
Multiple Sclerosis-like
Syndrome. This disease category requires definite evidence of
central nervous system disease, with history and physical findings
compatible with Multiple Sclerosis or Multiple Sclerosis-like
syndrome, involving one (1) or more of the following signs and
symptoms:
(
)
Weakness in the pyramidal distribution
(
) Evidence of optic neuritis documented by ophthalmologist
(
)
Increased Deep Tendon reflexes
(
)
Absent superficial abdominal reflexes
(
)
Ataxia or dysdiadochokinesia as the sign of cerebellar involvement
(
) Neurologically induced tremors
(
)
Internuclear ophthalmoplegia and/or bladder or speech involvement
secondary to central nervous
system disease
Plus one (1)
or more of the following:
(
) Abnormal Brain MRI with foci of increased signal abnormality
suggestive of demyelinating lesions
(
)
Delayed visual evoked responses or abnormal evoked potentials .
(
)
Abnormal CSF with oligoclonal bands.
ALS-Like Syndrome.
This disease
category requires documented evidence of progressive upper and
widespread lower motor neuron disease and/or bulbar involvement, plus
one (1) or more of the following:
(
)
Neurological autoantibodies such as anti-mag, anti-sulfatide,
anti-GM 1
(
)
Abnormal sural nerve biopsy
(
)
Chronic inflammation on muscle or nerve biopsies
(
)
Abnormal EMG
(
)
Documentation on neurological exam of both upper and lower motor
neuron disease and/or bulbar
involvement.
Disease of Neuromuscular Junction
This
disease category requires either:
(1) a
diagnosis of Myasthenia Gravis or Myasthenia Gravis-like syndrome or
disorders of the NMJ,
made by a Board-certified neurologist and
confirmed by abnormal EMG showing typical findings of
decrement on repetitive stimulation testing
and/or elevated acetylcholine receptor antibodies or
(2) submission of sufficient evidence of, and the required findings
confirming, such condition.
6. Severity/Disability Compensation Categories. The compensation
level for ANDS will be based on the
degree to which the individual
is "disabled" by the condition, as the individual's treating
physician
determines in accordance with
the following guidelines. The determination of disability under
these
guidelines will be based on the
cumulative effect of the symptoms on the individual's ability to
perform
her vocational,
avocational, or usual self-care, activities. In evaluating the
effect of the individual's
symptoms, the treating
physicians will take into account the level of pain and fatigue
resulting from the
symptoms. The disability
percentages appearing below are not intended to be applied with
numerical
precision, but are, instead,
intended to serve as a guideline for the physician in the exercise
of his or her
professional judgment.
( )
Death or total disability due to the compensable condition. An
individual shall be considered
totally disabled if she demonstrates a functional capacity adequate
to consistently perform none or
only few of the usual duties or activities of vocation or
self-care.
( )
A Breast Implant Claimant will be eligible for category B
compensation if she is 35% disabled due
to the compensable condition. An individual shall be considered 35%
disabled if she demonstrates
a loss of functional capacity which renders her unable to perform
some of her usual activities of
vocation, avocation, and self-care, or if she can only perform them
with regular or recurring severe
pain.
( )
A Breast Implant Claimant will be eligible for category C
compensation if she is 20% disabled due
to the compensable condition. An individual shall be considered 20%
disabled if she can perform
some of her usual activities of vocation, avocation, and self-care
only with regular or recurring
moderate pain.
MIXED CONNECTIVE TISSUE DISEASE
(MCTD)/OVERLAP SYNDROME
1. A diagnosis of mixed
connective tissue disease (MCTD) shall be based on the presence of
clinical symptoms
characteristic of two (2) or more rheumatic
diseases (systemic sclerosis, SLE, myositis, and Rheumatoid
Arthritis), accompanied by positive RNP Antibodies. See.
e.g., Kelley,
et al. Table 63-1, at 1061.
2. Overlap Syndrome is
defined as anyone (1) of the following three (3):
( ) Diffuse cutaneous scleroderma,
( ) limited cutaneous scleroderma, or
( ) Sine scleroderma, occurring
concomitantly with diagnosis of systemic lupus erythematosus,
inflammatory
muscle disease, or rheumatoid arthritis. See Kelley et
al.,
Table 66-2, at 1114.
3. The application of the
above diagnostic criteria is not intended to exclude from the
compensation program
individuals who present clinical symptoms or laboratory
findings atypical of MCTD but who nonetheless
have an Overlap Syndrome, except that an individual will not
be compensated in this category if her
symptomology more closely resembles an atypical connective
tissue disease condition/atypical rheumatic
syndrome/non-specific autoimmune condition.
4. Severity/Disability
Compensation Categories
(
) Death or total disability resulting from MCTD or Overlap
Syndrome. An individual will be considered
totally
disabled based on the functional capacity test set forth in
Severity/Disability Category A of
Atypical Connective Tissue Disease/Atypical Rheumatic Syndrome.
(
)
MCTD or Overlap Syndrome, plus major organ involvement or major
disease activity including
central
nervous system, cardio-pulmonary, vasculitic, or renal involvement
or hemolytic anemia (marked)
or
thrombocytopenic purpura or severe granulocytopenia.
(
)
C. Other.
POLYMYOSITIS / DERMATOMYOSITIS
1. A diagnosis of polymyositis or dermatomyositis shall be made in
accordance with diagnostic criteria proposed
by Bohan and Peter, i.e.,
(a)
symmetrical proximal muscle weakness;
(b) EMG changes characteristic of myositis including:
(1) short duration, small, low
amplitude polyphasic potential,
(2) fibrillation potentials,
(3) bizarre high- frequency
repetitive discharges;
(c) elevated serum muscle enzymes (CPK, aldolase, SGOT, SGPT,
and LDH);
(d) muscle biopsy showing evidence of necrosis of type I and
II muscle fibers, areas of degeneration and
regeneration of fibers,
phagocytosis, and an interstitial or perivascular inflammatory
response;
(e) dermatologic features including a lilac (heliotrope),
erythematous, scaly involvement of the face, neck,
shawl area and extensor
surfaces of the knees, elbows and medial malleoli, and Gottron's
papules.
A diagnosis of dermatomyositis
requires presence of three (3) of the criteria plus the
rash (fifth
criterion). A diagnosis of polymyositis requires the presence of
four (4) criteria without the rash.
See. Kelley,
et al., at 1163.
2. The application of the
above diagnostic criteria is not intended to exclude from the
compensation program
individuals who present clinical symptoms or laboratory
findings atypical of polymyositis or dermatomyositis
but who nonetheless have a polymyositis or
dermatomyositis-like disease, except that an individual will not
be compensated in this category if her symptomology more
closely resembles an Atypical Connective Tissue
Disease.
3. Severity/Disability
Compensation Categories:
(
)
Death or total disability resulting from polymyositis or
dermatomyositis. An individual will be considered
totally disabled based on the functional capacity test
set forth for Severity/Disability Category A for
Atypical Connective Tissue Disease/Atypical Rheumatic
Syndrome.
(
) Polymyositis or dermatomyositis with associated malignancy
and/or respiratory muscle involvement.
(
)
Other, including polymyositis or dermatomyositis with muscle
strength of Grade III or less.
PRIMARY SJOGREN'S
SYNDROME
1. A clinical diagnosis
of Primary Sjogren's Syndrome shall be made in accordance with
diagnostic criteria
proposed by Fox et al. .s..e..e. Kelley, §.tgJ,., Table
55-1, at 932, or Fox, RI, .e1-.gl, "Primary Sjogren's
Syndrome: Clinical and Immunopathologic Features,"
Seminars Arthritis Rheum., 1984; 4:77-105.
2. Application of the
above diagnostic criteria is not intended to exclude from the
compensation program
individuals who present clinical symptoms or laboratory
findings atypical of Primary Sjogren's Syndrome but
who nonetheless have a Primary Sjogren's-like disease.
3.
Severitv/Disability/ Compensation Categories
(
)
Death or total disability due to the compensable condition. An
individual will be considered totally
disabled
based on the functional capacity test set forth in
Severity/Disability Category A for Atypical
Connective
Tissue Disease/Atypical Rheumatic Syndrome.
(
)
Primary Sjogren's with associated central nervous system or severe
cardio- pulmonary involvement or
primary
Sjogren's with pseudo lymphoma or associated lymphoma.
(
)
Other.
ATYPICAL CONNECTIVE TISSUE DISEASE
(ACTD)
ATYPICAL RHEUMATIC SYNDROME
(ARS)
NON-SPECIFIC AUTOIMMUNE
CONDITION (NAC)
1. This category will provide compensation for Breast Implant
Claimants experiencing symptoms that are
commonly found in autoimmune or rheumatic diseases but which
are not otherwise classified in any of the
other compensable disease categories. This category does not
include individuals who have been diagnosed
with classical rheumatoid arthritis in accordance with ACR
criteria, but will include individuals diagnosed with
undifferentiated connective tissue disease (UCTD). However,
such inclusion is not intended to exclude from
this category persons who do not meet the definition of UCTD,
it being intended that individuals not meeting
the classic definitions of UCTD will be compensated pursuant
to the provisions contained herein relative to
ACTD, ARS, and NAC.
2. As with other
individuals who fit within this disease compensation program, the
fact that a breast implant
recipient has been in the past misdiagnosed with classic
rheumatoid arthritis or the fact that the symptoms of
classic rheumatoid arthritis may coexist with other symptoms
will not exclude the individual from compensation
here- in. Persons who meet the criteria below and may have a
diagnosis of atypical rheumatoid arthritis will
not be excluded from compensation under this category.
3. Eligibility criteria
and compensation levels for eligible Breast Implant Claimants are
set forth below in the
Compensation Categories, which classify individuals in
accordance with the following groups of symptoms.
If the Breast Implant Claimant's Qualified Medical Doctor
determines that a symptom is clearly and specifically
caused by a source other than breast implants, that symptom
will not be utilized in the diagnosis of Atypical
Connective Tissue Disease/Atypical Rheumatic Syndrome unless
the Claims Office determines that other
submissions indicate that the symptom should be utilized. A
symptom that may be caused only in part by a
source other than breast implants is not excluded from such
utilization.
4. A diagnosis of ACTD,
ARS, or NAC must satisfy one of the following sets of criteria:
(
)
any two (2) of the three (3) signs and symptoms listed in 5(a)
(Group I)
(
)
any one (1) of the three (3) signs and symptoms listed in 5(a)
(Group I), plus
any one
(1) of the ten (10) signs and symptoms listed in 5(b) (Group II)
(
)
any three (3) of the ten (10) signs and symptoms listed in 5(b)
(Group II)
(
)
any two (2) of the ten (10) signs and symptoms listed in 5(b)
(Group II), plus anyone (1) additional
(non-duplicative)
sign or symptom from the eighteen (18) listed in 5(c) (Group III)
(
) five (5) non-duplicative signs or symptoms listed in 5(a)
(Group I), 5(b) (Group II), or 5(c) (Group III)
5. Symptom Groupings:
(A) Group I Signs and
Symptoms:
( )
Raynaud's phenomenon evidenced by the patient giving a history of
two (2)
color changes, or visual evidence of vasospasm, or evidence of
digital ulceration
( )
Polyarthritis defined as synovial swelling and tenderness in three
(3) or more joints lasting greater
than six (6) weeks and observed by a physician
( )
Keratoconjunctivitis Sicca: subjective complaints of dry eyes
and/or dry mouth, accompanied by
anyone (1) of the following:
• lacrimal or salivary enlargement
• parotid enlargement
•
abnormal Schirmer's test
•
abnormal Rose-Bengal staining
• filamentous keratitis
•
abnormal parotid scan or ultrasound
• abnormal CT or MRI of parotid
• abnormal labial salivary biopsy
(B) Group II Signs and Symptoms:
(
) Myalgias determined by tenderness on examination .
( )
Immune mediated skin changes or rash as follows:
• changes in texture or rashes that mayor may not be characteristic
of SLE, Systemic Sclerosis
(scleroderma), or dermatomyositis
• diffuse petechiae, telangiectasias, or livedo reticularis
( )
Pulmonary symptoms or abnormalities, which may or may not be
characteristic of SLE, Systemic
Sclerosis
(scleroderma), or Sjogren's Syndrome, as follows:
• pleural and/or interstitial lung disease
• restrictive lung disease
• obstructive lung disease as evidenced by characteristic clinical
findings and either:
(a).
characteristic chest X-ray changes or
(b). characteristic pulmonary function test
abnormalities in a non-smoker (e.g. decreased OLGa
or abnormal arterial blood gases)
( ) Pericarditis defined by consistent
clinical findings and either EKG or echocardiogram
(
) Neuropsychiatric symptoms: cognitive dysfunction (memory loss
and/or difficulty concentrating)
which may be
characteristic of SLE or MGTO as determined by a SPEGT scan or PET
scan or MAl
or EEG or
neuropsychological testing.
(
)
Peripheral neuropathy diagnosed by physical examination showing
one (1) or more of the following:
• loss of sensation to pinprick, vibration, touch, or position
• tingling, paresthesia or burning pain in the extremities
• loss of tendon reflex
• roximal or distal muscle weakness (loss of muscle strength in
extremities or weakness of ankles,
hands, or foot drop)
• Signs of dysesthesia
•
entrapment neuropathies
( ) Myositis or myopathy:
•
diagnosed by weakness on physical examination or by muscle
strength testing
• abnormal GPK or aldolase
•
abnormal cybex testing
• abnormal EMG
• abnormal muscle biopsy
( ) Serologic abnormalities --anyone (1) of
the following: .ANA> or equal to 1 :40
•
positive ANA profile such as Anti-DNA, SSA, SSB, RNP, SM, Scl-70,
centromere, Jo-1,
PM-Scl or dsDNA (preferable to use ELISA with standard cutoffs)
• other autoantibodies, including thyroid antibodies,
anti-microsomal, or anti-cardiolipin, or RF
(by nephelometry with 40 IU cutoff)
• elevation of immunoglobulin (lgG, IgA, IgM)
• serologic evidence of inflammation such as elevated ESR,
CRP
( )
Lymphadenopathy (as defined by at least one (1) lymph node greater
than or equal to 1x1 cm)
documented by a physician
( ) Dysphagia with positive cine-esophagram,
manometry or equivalent imaging
(C) Group III Signs and Symptoms: .
( )
Documented arthralgia.
( )
Documented Myalgias.
( )
Chronic fatigue
( ) Lymphadenopathy
( ) Documented Neurological symptoms including
cognitive dysfunction or paresthesia
( ) Photosensitivity
( ) Sicca symptoms
( ) Dysphagia
( )
Alopecia
( )
Sustained balance disturbances
( )
Documented sleep disturbances
( )
Easy bruisability or bleeding disorder
( ) Chronic cystitis
or bladder irritability
( ) Colitis or bowel
irritability
( ) Persistent low grade fever or night sweats
( ) Mucosal ulcers confirmed by physician
( )
Burning pain in the chest, breast, arms or axilla, or substantial
loss of function in breast due to
disfigurement
or other complications from implants or explantation
( )
Pathological findings: granulomas or siliconomas or chronic
inflammatory response, or breast infections
6.
Severity /Disability Compensation Categories
The compensation level
for ACTD/ARS/NAC will be based on the degree to which the individual
is "disabled" by the condition, as the individual's treating
physician determines in accordance with the following guidelines.
The determination of disability under these guidelines will be based
on the cumulative effect of the symptoms on the individual's ability
to perform her vocational3, avocational4, or usual self-care5
activities. In evaluating the effect of the Breast Implant
Claimant's symptoms, the treating physicians will take into account
the level of pain and fatigue resulting from the symptoms. The
disability percentages appearing below are not intended to be
applied with numerical precision, but are, instead, intended to
serve as a guideline for the physician in the exercise of his
or her professional judgment.
( )
Death or total disability resulting from the compensable
condition. An individual will be considered
totally
disabled if she demonstrates a functional capacity adequate to
consistently perform none or only
few of
the usual duties or activities of vocation or self-care.
( ) A Breast Implant Claimant will be eligible
for category B compensation if she is 35% disabled due to
the
compensable condition. An individual shall be considered 35%
disabled if she demonstrates a loss
of functional
capacity which renders her unable to perform some of her usual
activities of vocation,
avocation,
and self-care, or she can perform them only with regular or
recurring severe pain.
( )
A Breast Implant Claimant will be eligible for category C
compensation if she is 20% disabled due to
the
compensable condition. An individual shall be considered 20%
disabled if she can perform some
of her
usual activities of vocation, avocation, and self-care only with
regular or recurring moderate pain.
* Vocational means activities associated with work, school, and
homemaking.
* A vocational means activities associated with recreation and
leisure.
* Usual
self-care means activities associated with dressing, feeding,
bathing, grooming, and toileting.
DISEASE OPTION 2:
PAYMENT AMOUNTS
|
Locate your approved disease or condition in Disease
Option 2 below and the Severity Level of that disease or
condition.
|
You must have proof that you have or
had a Dow Corning breast implant and have not had a Bristol,
Baxter or 3M silicone gel breast implant.** |
|
Base Payment |
+ Premium Payment |
= Total Payment |
|
Scleroderma (SS) or Lupus (SLE);
Severity Level A |
$250,000 |
+ 50,000 |
= $300,000 |
|
Scleroderma (SS) or Lupus (SLE);
Severity Level B |
$200,000 |
+ $40,000 |
= $240,000 |
|
Scleroderma (SS) or Lupus (SLE);
Severity Level C |
$150,000 |
+ $30,000 |
= $180,000 |
|
Polymyositis (PM) or Dermatomyositis (DM)
(there is only one severity level for PM and DM); General
Connective Tissue Symptoms (GCTS), Severity Level A
|
$110,000 |
+ $22,000 |
= $132,000 |
|
General Connective Tissue Symptoms (GCTS);
Severity Level B
|
$75,000 |
+ $15,000 |
= $90,000 |
**
If you have acceptable proof that you have or had a Bristol, Baxter,
or 3M silicone gel breast implant, the
Total Payment Amount will be reduced by 50%.
PART B. DISEASE AND
DISABILITY/SEVERITY DEFINITIONS:
DISEASE PAYMENT OPTION 2
GENERAL GUIDELINES:
A. A claimant must file
with the Claims Office all medical records establishing the required
findings or laboratory
abnormalities. Qualifying findings must have
occurred within a single 24-month period within the five (5)
years immediately preceding the submission of the claim
except that this period is tolled during the pendency
of the bankruptcy (May 15, 1995 until the Effective
Date). (Findings supplemented in response to a
deficiency letter sent by the Claims Office do not have
to fall within the 24-month period outlined above.)
B. If exclusions are
noted for a required finding, the physician making the finding or
ordering the test must
affirmatively state that those listed exclusions are
not present. The physician recording a GCTS finding or
making a disease diagnosis must also affirmatively
state that the qualifying symptoms did not exist before
the date of first implantation. (This statement can be
based upon patient history so long as consistent with
medical records in the physician's possession.) Failure
to make these affirmative statements will result in a
deficiency letter. All underlying office charts,
radiology/pathology reports, and test results must be supplied
to the Claims Office.
C. QMD statements may be
acceptable proof under Disease Payment Option 2 if the physician is
a Board-
certified rheumatologist -for Lupus, Scleroderma, or
Polymyositis/Dermatomyositis Claims -or is Board-
certified in the appropriate specialty to make the
required GCTS findings, if the statement covered all of
the detailed findings that are required in Disease
Payment Option 2, if the QMD personally examined the
Claimant, and if the doctor included all of the
additional statements required concerning listed exclusions
and pre-existing symptoms. In most cases, additional
physician statements will have to be submitted for
claims under Disease Payment Option 2.
D. Claimants who seek
benefits under Disease Payment Option 2 must file all medical
records establishing the
required findings or laboratory abnormalities.
Claimants must also supply all office charts, radiology/
pathology reports, and test results in the possession
of the physician(s) who make the required findings or
statements, or who order the required tests.
DISEASE PAYMENT OPTION 2:
DEFINITION OF COVERED CONDITIONS
SCLERODERMA (SS)
A claim for scleroderma
must include a diagnosis of systemic sclerosis/scleroderma
made by a Board-certified rheumatologist based upon personal
examination of the patient. [Exclusion: localized scleroderma.]
Supporting medical documentation must affirmatively reveal that the
major or at least two (2) of the minor criteria listed below are
present:
A. Major Criterion:
Proximal scleroderma -symmetric thickening, tightening, and induration
of the skin of the fingers and the skin proximal to the
metacarpophalangeal or metatarsophalangeal joints. The changes may
affect the entire extremity, face, neck, and trunk (thorax and
abdomen). Description of this criterion is adequate if the
Board-certified rheumatologist records that physical examination of
the patient revealed scleroderma skin thickening, and adequately
describes the parts of the body where that thickened skin was found.
B. Minor Criteria:
1. Sclerodactyly:
Above-indicated skin changes limited to the fingers.
2. Digital pitting scars
or loss of substance from the finger pad: Depressed areas at tips of
fingers or loss of
digital pad tissue as a result of ischemia.
3. Bibasilar pulmonary
fibrosis: Bilateral reticular pattern of linear or lineonodular
densities most pronounced
in basilar portions of the lungs on standard chest
roentgenogram; may assume appearance of diffuse
mottling or "honeycomb lung." These changes should not
be attributable I. to primary lung disease.
Compensation Levels:
A. Death resulting from
SS, or severe chronic renal involvement manifested by a glomerular
filtration rate of
less than 50% of the age- and gender-adjusted norm, as
measured by an adequate 24-hour urine
specimen collection.
B. Clinically significant
cardio-pulmonary manifestations of scleroderma or proximal
scleroderma on the
trunk (thorax and abdomen).
C. A diagnosis of
scleroderma in accordance with the above criteria that does not
involve the findings in A
or B above.
LUPUS (SLE)
A claim for SLE must include a diagnosis of SLE (lupus) made by a
Board-certified rheumatologist based upon personal examination of
the patient. [Exclusion: mild lupus (SLE not requiring regular
medical attention including doctor visits and regular prescription
medications).] Supporting medical documentation must affirmatively
reveal that at least four (4) of the following eleven (11) criteria
are present:
Criterion Definition
( ) 1. Malar Rash: Fixed erythema, flat or
raised, over the malar eminences, tending to spare the
nasolabial folds
( )
2. Discoid Rash: Erythematous raised patches with adherent
keratotic scaling and follicular plugging;
atrophic
scarring may occur in older lesions
( )
3. Photosensitivity: Skin rash as a result of unusual reaction to
sunlight, by patient history or physician
observation
( )
4. Oral Ulcers: Oral or nasopharyngeal ulceration, usually painless,
observed by a physician
( )
5. Arthritis: Nonerosive arthritis involving two or more
peripheral joints, characterized by tenderness,
swelling, or
effusion [Exclusion: erosive arthritis]
( )
6. Serositis:
(a) Pleuritis
--convincing history of pleuritic pain or rub heard by a physician
or evidence of
pleural effusion, or
(b)
Pericarditis -documented by ECG or rub or evidence of pericardial
effusion
( ) 7.
Renal Disorder:
(a)
Persistent proteinuria greater than 0.5 grams per day or greater
than three (3)+ if quantitation
not performed, or
(b)
Cellular casts --may be red cell, hemoglobin, granular, tubular, or
mixed
( ) 8.
Neurologic Disorder: Seizures --in the absence of offending drugs or
known metabolic derangements,
e.g.
uremia, ketoacidosis, or electrolyte imbalance
( ) 9.
Hematologic Disorder:
(a) Hemolytic
anemia --with reticulocytosis, or
(b)
Leukopenia -less than 4,OOO/mm total on two (2) or more occasions,
or
(c)
Lymphopenia -less than 1,500/mm on two (2) or more occasions,
or
(d)
Thrombocytopenia -less than 100,OOO/mm in the absence of offending
drugs
( )
1O. Immunologic disorder
( ) Positive LE cell preparation or
(
) Anti- DNA: antibody to native DNA in abnormal titer,
or
( ) Anti-Sm: presence of antibody to Sm nuclear
antigen,
or
( ) False positive serologic test for syphilis known
to be positive for at least 6 months and
confirmed by Treponema pallidum immobilization or fluorescent
treponemal antibody absorption
test.
( )
11. Antinuclear Antibody: An abnormal titer or antinuclear antibody
by immuno-fluorescence or an
equivalent assay at any point in time and in the absence of drugs
known to be associated with
"drug-induced lupus" syndrome.
Compensation Levels:
( )
Death resulting from SLE, or severe chronic renal involvement
manifested by a glomerular filtration rate of
less than 50% of the age- and
gender-adjusted norm, as measured by an adequate 24-hour urine
specimen
collection.
( )
SLE with involvement of one (1) or more of the following:
glomerulonephritis, seizures in the absence of
offending drugs or known metabolic derangements,
Lupus Psychosis, myocarditis, pneumonitis,
thrombocytopenic purpura, hemolytic anemia (with
hemoglobin of 10 grams or less), severe
granulocytopenia (with a total white cell count
less than 2000), or mesenteric vasculitis.
( ) A
diagnosis of lupus in accordance with the above criteria that does
not involve the findings in A or B above.
(Default compensation level.)
POLYMYOSITIS (PM) / DERMATOMYOSITIS
(DM)
A claim for polymyositis
or dermatomyositis must include a diagnosis of the disease made by a
Board-certified rheumatologist based upon personal examination of
the patient. Supporting medical documentation must affirmatively
reveal that the following criteria are present:
-for polymyositis, the
first four (4) criteria without the rash;
-for dermatomyositis,
three (3) of the first four (4) criteria, plus the rash (#5).
Criteria:
( ) symmetrical proximal muscle weakness;
( ) EMG changes characteristic of myositis
including:
(a) short duration, small, low-amplitude
polyphasic potential,
(b) fibrillation potentials,
(c) bizarre high-frequency repetitive discharges;
( ) elevated serum muscle enzymes (CPK, aldolase,
SGOT, SGPT, and LDH);
( ) muscle biopsy showing evidence of necrosis of
type I and II muscle fibers areas of degeneration and
regeneration of fibers, phagocytosis, and
an interstitial or perivascular inflammatory response;
( )
dermatologic features including a lilac (heliotrope), erythematous,
scaly involvement of the face, neck,
shawl area and extensor surfaces
of the knees, elbows and medial malleoli, and Gottron's papules.
Compensation Level:
All confirmed PM/OM
diagnoses will be compensated at the GCTS/PM/OM--A level.
GENERAL CONNECTIVE TISSUE SYMPTOMS
(GCTS)
A claim for GCTS does not have to include a diagnosis for "General
Connective Tissue Symptoms," but the medical documentation must
establish that the combination of findings listed below are present.
[Exclusion: classical rheumatoid arthritis diagnosed in accordance
with the revised 1958 ACR classification criteria.]
( ) For compensation at Level
A:
(1) any two (2) findings
from Group I; or
(2) any three (3)
non-duplicative findings from Group I or Group II.
( ) For compensation at Level
B:
(1) one (1) finding from
Group I plus any four (4) non-duplicative findings from Group II or
Group III; or
(2) two (2) findings from
Group II plus one (1) non-duplicative finding from Group III.
The following duplications exist on the list of findings:
-rashes (#3 and #8)
-sicca (#2 and #12)
-serological abnormalities (#4 and #9)
In addition to the
medical verification of the required findings, a claim for GCTS must
include the affirmative physician statements outlined in General
Guidelines above.
GROUP I FINDINGS
( ) Polyarthritis, defined as synovial swelling and
tenderness in three (3) or more joints in at least two (2)
different joint groups observed on more than one (1) physical
examination by a Board-certified physician
and persisting for more than six (6) weeks.
[Exclusion: osteoarthritis.]
( ) 2.
Keratoconjunctivitis Sicca, defined as subjective complaints of dry
eyes and/or dry mouth, accompanied
(a) in
the case of dry eyes, by either:
(i) a Schirmer's test less than 8 mm wetting per five minutes or
(ii) a positive Rose-Bengal or fluorescein staining of cornea and
conjunctiva; or
(b) in
the case of dry mouth, by an abnormal biopsy of the minor salivary
gland (focus score of greater
than or equal to two (2) based upon average of four (4) evaluable
lobules).
[Exclusions: drugs known to cause dry eyes and/or dry mouth, and
dry eyes caused by
contact lenses.]
( )
Any of the following immune-mediated skin changes or rashes,
observed by a Board-certified
rheumatologist or Board-certified dermatologist:
(a) biopsy-proven discoid
lupus;
(b) biopsy-proven subacute
cutaneous lupus;
(c) malar rash --fixed erythema,
flat or raised, over the malar eminences, tending to spare the
nasolabial
folds. [Exclusion: rosacea or redness caused by sunburn]; or
(d) biopsy-proven vasculitic skin rash.
GROUP II FINDINGS
( ) Positive ANA greater than or equal to 1 :40
(using Hep2), on two (2) separate occasions separated by at
least two (2) months and accompanied
by at least one (1) test showing decreased complement levels of
C3 and C4; or a positive ANA greater
than or equal to 1 :80 (using
Hep2) on two (2) separate occasions
separated by at least two (2) months.
All such findings must be outside of the performing laboratory's
reference ranges.
( )
Abnormal cardiopulmonary symptoms, defined as:
(a). pericarditis
documented by pericardial friction rub and characteristic
echocardiogram findings (as
reported by a Board-certified radiologist or cardiologist);
(b). pleuritic
chest pain documented by pleural friction rub on exam and chest
X-ray diagnostic of pleural
effusion (as report- ed by a Board-certified radiologist); or
(c). interstitial lung disease in a non-smoker diagnosed by a
Board-certified internist or pulmonologist,
confirmed by:
(i)
chest X- ray or CT evidence (as reported by a Board-certified
radiologist) and
(ii)
pulmonary function testing abnormalities defined as decreased OLCa
less than 80% of predicted.
( )
Myositis or myopathy, defined as any two (2) of the following:
(a). EMG changes
characteristic of myositis: short duration, small, low amplitude
polyphasic potential;
fibrillation potentials; and bizarre high-frequency repetitive
discharges;
(b). abnormally elevated
CPK or aldolase from the muscle (outside of the performing
laboratory's
reference ranges) on two (2) separate occasions at least six (6)
weeks apart. (If the level of the initial
test is three (3) times normal or greater, one (1) test would be
sufficient.) [Exclusions: injections,
trauma, hypothyroidism, prolonged exercise, or drugs known to cause
abnormal CPK or aldolase]; or
(c). muscle biopsy (at a site
that has not undergone EMG testing) showing evidence of necrosis of
type 1
and 2
muscle fibers, phagocytosis, and an interstitial or perivascular
inflammatory response interpreted
as
characteristic of myositis or myopathy by a pathologist.
( )
Peripheral neuropathy or polyneurpathy, diagnosed by a
Board-Certified neurologist, confirmed by:
(a). objective loss of sensation to
pinprick, vibration, touch, or position;
(b). symmetrical distal muscle
weakness;
(c). tingling and/or burning pain in
the extremities; or
(d). loss of tendon flex, plus nerve
conduction testing abnormality diagnostic of peripheral neuropathy
or
polyneuropathy recorded from a site that has not undergone neural or
muscular biopsy.
[Exclusions: thyroid disease, antineoplastic treatment,
alcaholism, or other drug dependencies,
diabetes, or infectious disease within the last three (3) montys
preceeding the diagnosis.]
GROUP III FINDINGS
( ) Other immune-mediated skin changes or rashes,
observed by a Board-certified rheumatologist or Board-
certified dermatologist:
(a). livedo
reticularis;
(b). lilac (heliotrope),
erythematous scaly involvement of the face, neck, shawl area and
extensor surfaces
of the
knees, elbows and medial malleoli;
(c). Gottron's sign, pink
to violaceous scaling areas typically found over the knuckles,
elbows, and knees; or
(d). diffuse
petechiae.
( )
Any of the following serologic abnormalities:
(a). ANA greater than or
equal to 1 :40 (using Hep2) on two (2) separate occasions separated
by at least
two (2) months;
(b). one (1) or
more positive ANA profile: Anti-DNA, SSA SSB, RNp, SM, Scl- 70,
centromere, Jo-1
PM-Scl, or double-stranded DNA (using ELISA with standard cutoffs);
(c) anti-microsomal,
anti-cardiolipin, or RF greater than or equal to 1 :80.
( ) Raynaud's phenomenon, evidenced by a
physician-observed two (2) (cold-related) color change
as a progression, or by physician observation of evidence of
cold-related vasospasm, or by physician
observation of digital ulceration resulting from Raynaud's
phenomenon.
( ) Myalgias, defined as tenderness to palpation,
performed by a physician, in at least three (3) muscles,
each persisting for at least six (6)
months.
( ) Dry mouth, subjective complaints of dry mouth
accompanied by decreased parotid flow rate using
Lashley cups with less than 0.5 ml per five minutes.
[Exclusion: drugs known to cause dry mouth.]
|
