Feinberg and Rassp: Vigil and the CVC: A Practical Framework for QMEs

Friday, August 7, 2026 | 0

DISCLAIMER: The article is for the 2027 edition of "Lawyer’s Guide to the AMA Guides and California Workers' Compensation" and is excerpted from the manuscript. The opinions expressed in this document are those of the authors and not of the Department of Industrial Relations, Division of Workers’ Compensation, or the Workers’ Compensation Appeals Board.

Steven D. Feinberg

Introduction

The en banc decision in Vigil v. County of Kern has generated substantial discussion among physicians and attorneys regarding when permanent impairments should be added and when they should be combined under the Combined Values Chart (CVC). In practice, the case is sometimes cited too broadly, as though it established a general preference for adding impairments whenever multiple body parts are involved. That is not a correct interpretation of the decision.

The principal lesson of Vigil is narrower and more useful. The CVC remains the default method under the 2005 Permanent Disability Rating Schedule. Adding is appropriate only when the medical evidence establishes that the CVC does not accurately reflect the injured worker’s activity of daily living (ADLs) deficits because the impairments either affect distinct activities of daily living or overlap in a way that materially amplifies the overall functional loss.

Robert G. Rassp

The default rule

The evaluator should begin with the premise that multiple impairments are combined. That is the standard approach built into the rating schedule. The burden, from a medical-legal standpoint, is to explain why the standard method should or should not be followed in a particular case.

This is an important point because some analyses begin from the opposite direction. They assume that if there are bilateral injuries, similar body parts, or multiple impairments within one extremity, then adding is likely appropriate. Vigil does not always support that assumption. The case does not create a presumption in favor of adding. Rather, it requires a reasoned explanation for rebutting the CVC.

The Appeals Board decision in Vigil uses the term “rebutting the CVC,” which means ALL impairment ratings need to be combined in accordance with the instructions in the 2005 Permanent Disability Rating Schedule and in the AMA Guides 5th Edition. 

The central inquiry: ADLs, not anatomy

The most important clarification in Vigil is that the analysis must focus on the effect of the impairments on activities of daily living. The question is not simply whether the impairments involve the same body system, corresponding limbs, or adjacent joints. The question is whether the functional consequences overlap, and if they do, whether that overlap produces a greater degree of impairment than the CVC is intended to capture.

This is the practical dividing line. If the affected activities of daily living are distinct, adding may be justified. If the activities overlap but the interaction of the impairments materially increases the difficulty of performing those activities, adding may also be justified. But if the effects are largely duplicative and the worker’s overall functioning is adequately represented by the CVC, then the impairments should be combined.

What does and does not qualify as synergy

The term “synergy” can be useful, but only if it is explained. Standing alone, it is conclusory. A persuasive opinion must describe how the impairments interact in actual function.

For example, one impaired hand may interfere with grasping, buttoning, and handling small objects. If both hands are impaired, the loss of effective bimanual function may be substantially greater than would be expected from one-sided impairment alone. In that circumstance, the evaluator may reasonably conclude that the combined effect on daily function is amplified beyond what the CVC predicts. This is the example that the Appeals Board mentioned in the Vigil case.

By contrast, not every bilateral or multi-joint case presents that type of amplification. A shoulder and elbow on the same side may both affect reaching, lifting, carrying, pushing, and pulling. Yet if those limitations substantially overlap and the worker retains meaningful function, then the overall loss of function may still be adequately measured by combining the impairments. In that setting, adding may overstate actual impairment. But, if the overall performance of ADLs may be affected in a greater way than if either the elbow or the shoulder was affected alone, the evaluating physician would have to analyze the effects of a unilateral extremity as to overall ADL functioning in order to arrive at the most accurate rating. 

A careful evaluator should resist the temptation to equate multiple injured body parts with automatic addition. The fact that the impairments can be described as related does not answer the rating question. The proper inquiry is whether adding produces a more accurate estimate of true impairment or merely a higher numerical result.

This distinction is especially important in cases involving numerous body parts. When multiple impairments are added, the resulting whole person impairment can become substantial. That fact alone does not make adding legally improper. The proper question remains whether the medical evidence supports rebuttal of the Combined Values Chart for each added impairment or grouping of impairments through a reasoned analysis of the affected activities of daily living. In complex multi-part cases, the evaluator should therefore proceed carefully, impairment by impairment, and determine whether there is truly no meaningful overlap in ADLs or whether overlapping ADLs are amplified in a manner not adequately captured by the CVC. The analysis should remain bottom-up and function-based, not driven by the mere size of the final rating.

A related issue may arise when defense counsel argues that a high final whole person impairment rating is not consistent with the injured worker’s observed level of function. This issue may be seen more often in cases involving multiple impairments that have been added rather than combined. The proper response is not to disavow adding because the number appears high, but to reexamine whether the rebuttal of the Combined Values Chart is supported for each component by substantial medical evidence. The physician should return to the ADL analysis and explain, for each added impairment or grouping, whether there is no meaningful overlap in ADLs or whether overlapping ADLs are amplified in a manner not adequately accounted for by the CVC. If that reasoning is medically probable and well explained, the resulting rating is not undermined simply because it is numerically large.

The potential effect of surveillance video evidence on impairment ratings

If, after applying the principles in Vigil to a case and adding WPI ratings due to overlapping or synergistic effects of multiple parts of the body that have impairment ratings, the defense provides video surveillance, carefully determine if the video evidence is inconsistent with the actual impairment rating for each injured body part or body system. Remember, the issues here are whether the actual individual WPI ratings are accurate and whether there is an increase in overall loss of function of ADLs due to multiple impairments. In potentially applying Vigil, if there is significant video evidence that is inconsistent with your WPI ratings or inconsistent with adding rather than combining them, you can revisit your conclusions and either apply the CVC or indicate that the video evidence does not affect your conclusions. 

A practical method for the QME

A useful working method is to proceed in five steps.

• First, identify each ratable impairment separately. 
• Second, specify the activities of daily living affected by each impairment, including any relevant instrumental or work-related activities. 
• Third, determine whether the effects are distinct, overlapping, or overlapping with true amplification. 
• Fourth, explain why, in light of that analysis, combining, adding, or a mixed method produces the most accurate estimate of the injured worker’s overall permanent impairment and best reflects the worker’s actual functional limitations.
• Fifth, state your conclusions are based on reasonable medical probability.

This approach keeps the report grounded in functional analysis rather than anatomical labels. It also helps ensure that the final opinion is medically reasoned and suitable for use in the adjudicatory setting.

The role of the mixed approach

In many cases, the most defensible analysis is neither pure adding nor pure combining. Some impairments may warrant addition because they involve distinct functions or clearly amplified overlap, while others should remain subject to the CVC because their effects are duplicative.

This mixed approach is entirely consistent with Vigil. It recognizes that the issue is not methodological purity, but accuracy. The evaluator’s task is to determine, pair by pair or grouping by grouping, whether the evidence supports rebuttal of the CVC. Remember, the goal is for the physician to provide the most accurate ratings if multiple parts of the body or body systems are affected by an industrial injury.

Basis for combining or adding upper extremity impairments

In determining whether the upper extremity impairments should be combined or added, the evaluator must provide substantial medical evidence supporting the selected method and must explain why that method more accurately reflects the patient’s permanent impairment. The analysis should address the clinical findings, functional consequences, and relationship between the involved body parts, and should state the reasoning with sufficient clarity to permit meaningful review. This determination is based on medical judgment and evidentiary support, not on advocacy or semantic preference.

Sample report language favoring combining

“After identifying the activities of daily living affected by each impairment, including reaching, lifting, carrying, pushing/pulling, and certain overhead and forceful tasks, it is my opinion that the functional effects are largely overlapping. Both impairments affect many of the same activities along the same limb, and the applicant retains meaningful ability to compensate through altered mechanics, task pacing, and use of the contralateral upper extremity. Overall functioning in self-care, household, and work-related activities is consistent with the level of limitation predicted by the Combined Values Chart and is not materially worse than that predicted level. Accordingly, the overlap reflects duplication rather than synergistic amplification; the CVC has not been rebutted, and combining rather than adding provides the most accurate estimate of overall permanent impairment.”

Sample report language favoring adding

“After identifying the activities of daily living affected by each impairment, including reaching, lifting, carrying, pushing/pulling, and certain overhead and forceful tasks, it is my opinion that the functional effects are not merely overlapping, but mutually reinforcing. The applicant’s shoulder impairment limits elevation, reaching away from the body, and sustained use of the arm at or above shoulder level, while the elbow impairment further limits effective use of the same extremity for carrying, forceful flexion and extension, and pushing/pulling activities. Because both joints of the same upper extremity are impaired, the applicant cannot effectively compensate within that limb, and the combined effect on reaching, handling, and forceful use is materially greater than would be anticipated from the standard Combined Values Chart. Overall functioning in self-care, household, and work-related activities requiring coordinated use of the right upper extremity is therefore worse than the level predicted by the CVC alone. Accordingly, the overlap between these impairments results in a synergistic amplification of functional loss; the CVC has been rebutted, and adding rather than combining provides the most accurate estimate of overall permanent impairment.”

Conclusion

The enduring value of Vigil is that it directs the evaluator back to first principles. The rating analysis must be driven by actual impairment of ADLs, and by the goal of providing the most accurate impairment rating. The Combined Values Chart remains the default. Adding is reserved for those circumstances in which the medical evidence, based on a careful analysis of activities of daily living, shows that combining understates the injured worker’s actual permanent impairment.

For the evaluating physician, the safest and most persuasive course is straightforward: analyze the activities of daily living carefully, for each separately injured body part or body system, evaluate each impairment or impairment grouping on a reasoned and component-specific basis, describe the interaction of the impairments in ADL functional terms, and select the method that most accurately reflects the injured worker’s real-world loss. In the end, Vigil is not about maximizing the rating. It is about arriving at the most accurate impairment assessment supported by substantial medical evidence.

Steven D. Feinberg, M.D., M.P.H., M.S., is board-certified in physical medicine and rehabilitation and pain medicine. He is an adjunct clinical professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine.

Robert G. Rassp is the presiding judge at the WCAB Los Angeles District Office. He is an adjunct professor of law at Pepperdine Caruso School of Law. The contributions made to this article are academic and are not in the capacity as a judicial officer of the WCAB.