IR Medical Requirements

Medical Requirements and Evidence Required to Establish a Silica-Related Disease for Individual Review Claimants

Level I: Silicosis

Medical Criteria

1. Diagnosis of bilateral silicosis by a board-certified doctor of pulmonology, internal medicine or occupational medicine, based upon a physical exam. Note: If the claimant was deceased at the time that the claim was filed, then the diagnosis of silicosis can be based upon (a) pathological evidence of bilateral silicosis by a board-certified pathologist, (b) medical records from a board-certified pulmonologist providing the diagnosis of bilateral silicosis, or (c) either a chest x-ray reading by a certified B-reader or a CT scan read by a board-certified pulmonologist showing bilateral silicosis.
2. X-ray reading by a certified B-reader or a CT scan read by a board-certified pulmonologist.
3. 10 year latency.
4. ILO of 1/0 or greater and rounded opacities of type p, q, or r involving, but not limited to, the upper lobes (read by a certified B-reader).
5. FVC < 80%, or FEV1 < 75% with DLCOsb < 70%.

Exposure Criteria

1. Significant Occupational Exposure.
2. Company Exposure.

Level II: Severe Silicosis

Medical Criteria

1. Diagnosis of bilateral silicosis by a board-certified doctor of pulmonology, internal medicine, or occupational medicine physician based upon a physical exam. Note: If the claimant was deceased at the time the claim was filed, then the diagnosis of silicosis can be based upon (a) pathological evidence of bilateral silicosis by a board-certified pathologist, (b) medical records from a board-certified pulmonologist providing the diagnosis of bilateral silicosis, or (c) either a chest x-ray reading by a certified B-reader or a CT scan read by a board-certified pulmonologist showing bilateral silicosis or severe silicosis.
2. X-ray reading by a certified B-reader or a CT Scan read by a board-certified pulmonologist.
3. 10 year latency.
4. ILO of 2/1 or greater and rounded opacities of type p, q, or r involving, but not limited to, the upper lobes (read by a certified B-reader).
5. FVC < 65%, or FEV1 < 65% or DLCOsb < 60%.

Exposure Criteria

1. Significant Occupational Exposure.
2. Company Exposure.

Level III: Lung Cancer*

Medical Criteria

1. Diagnosis of underlying bilateral silicosis by a board-certified doctor of pulmonology, internal medicine, or occupational medicine based upon a physical exam, physical history (including smoking history), and chest x-ray or, if claimant is deceased, a pathology report (by a board-certified pathologist) indicating that the claimant had underlying bilateral silicosis.
2. Diagnosis of primary lung cancer by a board certified doctor of pulmonology or oncology based upon a physical exam, physical history (including smoking history), and chest x-ray or, if the claimant is deceased, a pathology report by a board-certified pathologist indicating that the claimant had lung cancer.
3. Medical documentation stating that the lung cancer was caused by exposure to silica. If the claimant is deceased, a pathology report by a board-certified pathologist indicating that the lung cancer was caused by silica exposure.
4. 10 year latency.

* Assumes claimants are or were smokers. Non-smokers may receive a higher than scheduled value through value through the Individual Review Process.

Exposure Criteria

1. Significant Occupational Exposure.
2. Company Exposure.

Level IV: Complex Silicosis

Medical Criteria

1. Diagnosis of bilateral silicosis by a board-certified pulmonologist, internist or occupational medicine physician based upon a physical exam, a physical history (including that of smoking), and a chest x-ray. If the claimant is deceased, a pathology report by a board-certified pathologist indicating bilateral silicosis.
2. Diagnosis by a board-certified pulmonologist of (i) tuberculosis, (ii) silicoproteinosis, or (iii) coalescence of silicotic opacities (PMF): or
3. Diagnosis by a board-certified rheumatologist of (i) rheumatoid arthritis (RA), (ii) scleroderma, or (iii) lupus based upon a physical exam, physical history and a chest x-ray or, if the claimant is deceased, a pathology report by a board-certified pathologist stating that the disease was caused by exposure to silica.
4. Medical causation by board-certified pulmonologist (who examined the claimant) for tuberculosis, silico-proteinosis, or PMF, or causal statement from a board-certified rheumatologist (who examined the claimant) for sceleroderma, rheumatoid arthritis, or lupus stating that the disease was caused by silica exposure.  If the claimant is deceased, a pathology report by a board-certified pathologist stating that the disease was caused by exposure to silica.
5. 10 year latency.

Exposure Criteria

1. Significant Occupational Exposure.
2. Company Exposure.

Note: A medical diagnosis of “Consistent with” or “Compatible with” silicosis will not be accepted by the Trust.