When an independent medical examination in a New York workers' compensation case finds permanent partial impairment of a scheduled body part, the examiner records it on the IME-4.3A. For each body part and side it lists three range-of-motion measurements, contralateral range of motion or why it does not apply, guideline special considerations by chapter, and the impairment percentage. It becomes part of the IME report.
The independent medical examiner completes the whole one-page attachment, identifying the claimant by name, Social Security number, WCB case number, injury date and exam date, or attaches a medical narrative containing the same information.
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Attachment for Report of Independent Medical Examination Scheduled Loss of Use
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When the independent examiner concludes there is a schedule loss of use, meaning permanent partial impairment of a scheduled body part. The IME-4 cover sheet instructs examiners to include the IME-4.3A and/or IME-4.3B with the cover sheet and narrative, and the attachment is treated as part of the IME report.
Three measurements of active range of motion for the injured body part, using the greatest, or an explanation if not. It also needs the contralateral body part's range of motion, or why that comparison is inapplicable, plus any special considerations identified by guideline chapter.
The C-4.3's Attachment A is the treating provider's schedule loss of use report and asks for the same elements: three ROM measurements, contralateral ROM, prior schedule losses, special considerations, and loading for digits and toes. The IME-4.3A records the independent examiner's findings on the same points.