Substantial Medical Evidence
Comprehensive criteria for reports that meet California workers' compensation legal standards
I
Legal Probability
- Opinions stated within reasonable medical probability
- Uses "more likely than not" language
- Avoids speculative terms (could, may, might, possibly)
Critical: Speculative language alone can invalidate the opinion.
II
Adequate & Accurate History
- Complete mechanism of injury
- Accurate symptom onset timeline
- Prior industrial & non-industrial injuries addressed
- Relevant comorbidities discussed
- Records reviewed listed and summarized
Critical: Inaccurate or incomplete history undermines SME.
III
Diagnosis Supported by Objective Evidence
- Diagnosis clearly stated
- Physical exam findings documented
- Imaging reviewed (MRI/X-ray/CT, if applicable)
- Diagnostics addressed (EMG/NCS, labs, etc.)
- Objective findings correlate with complaints
Critical: Diagnosis without objective support is weak SME.
IV
Causation Analysis (AOE/COE)
- Clear industrial causation opinion (yes/no)
- Mechanism of injury logically linked to pathology
- Temporal relationship explained
- Non-industrial causes considered and addressed
- Medical reasoning explained step-by-step
Critical: Conclusory causation opinions are not SME.
V
Apportionment (Labor Code §4663)
- Apportionment addressed when medically appropriate
- Percentages assigned (not vague references)
- Apportionment tied to causation of disability, not injury
- Objective basis cited (imaging, history, pathology)
- Medical explanation provided for each percentage
Critical: "50/50" without explanation fails SME.
VI
Treatment Recommendations (UR / IMR Defense)
- Medical necessity clearly stated
- MTUS/ACOEM guidelines referenced
- Objective findings support treatment
- Functional deficits documented
- Treatment duration and goals explained
Critical: Unsupported treatment opinions are easily denied.
VII
Work Status & Disability
- Temporary disability status addressed
- Specific work restrictions provided
- Restrictions are measurable and time-limited
- MMI status clearly stated (if applicable)
Critical: Vague work status weakens TD/PD claims.
VIII
Internal Consistency
- Opinions consistent throughout report
- No unexplained changes in diagnosis or causation
- Prior reports addressed if opinions differ
- Conflicts in records reconciled
Critical: Unexplained inconsistencies destroy credibility.
IX
Overall SME Determination
- Opinion is factually accurate
- Opinion is well-reasoned
- Opinion is non-speculative
- Opinion can be reasonably relied upon by WCAB