Part One of Four: Almaraz-Guzman – When the AMA Guides Don’t Tell the Whole Story
Why Almaraz–Guzman Matters
California law requires that whole person impairment (WPI) be determined using the AMA Guides, Fifth Edition, as adopted through Labor Code § 4660. In most cases, the Guides’ chapter-specific tables, figures, and diagnosis-based or ROM-based methods provide a complete rating pathway.
But the Guides were never written to address every clinical scenario. Some conditions do not fit neatly into a table. Others present with functional (ADL) losses that the strict rating fails to capture.
This gap is exactly what the WCAB’s en banc decisions in Almaraz/Guzman (2009) and the subsequent Almaraz–Guzman II opinions were intended to address. The decisions reaffirm that the AMA Guides remain the exclusive framework—but allow physicians to apply them more flexibly when the literal rating does not “fairly and accurately” describe the impairment.
What Almaraz–Guzman Actually Allows
The WCAB held that a physician:
- Must begin with the standard, chapter-appropriate AMA Guides rating.
- May depart from that strict impairment rating only if it is not the most accurate and does not reasonably reflect the injured worker’s disability/ADL deficits.
- Must stay entirely within the AMA Guides when selecting an alternative method—meaning:
- Cannot rely on fairness, equity, personal opinion, or external medical literature.
The key requirement is a reasoned medical explanation showing why the standard rating is not the most accurate and why the proposed alternative impairment rating is more accurate and consistent with a disability/ADL deficits.
This is often referred to as an Almaraz–Guzman analysis or A/G rating.
When an Almaraz–Guzman Analysis Is Appropriate
An A/G approach is considered only when the strict application of the Guides is insufficient. Common scenarios include:
1. The Guides Do Not Directly Address the Condition
Examples include conditions that are:
- Not expressly listed (e.g., plantar fasciitis, a hip labral tear, etc.)
- Poorly Defined
2. The Strict Table Undervalues Functional Loss (ADL deficits)
If the worker demonstrates functional ADL restrictions, supported by reasonable subjective complaints, physical examination and diagnostic test findings, that exceed the standard impairment rating, an A/G alternative may be reasonable.
3. Clinical Presentation Falls Between Categories
Examples:
- Spine impairments that straddle two Diagnosis-Related Estimates (DREs)
- Upper extremity disorders with mixed neurologic and soft tissue components
- Conditions with atypical patterns not cleanly addressed by a single method
In each case, the physician must show why the standard rating fails (is not the most accurate) and how another AMA-consistent method more accurately quantifies impairment.
How to Properly Defend an Almaraz–Guzman Rating
A defensible A/G analysis includes the following elements:
1. Start With the Standard Rating
Always present the standard AMA Guides rating first. This establishes compliance with Labor Code § 4660 and shows that the departure was not arbitrary.
2. Explain the Inadequacy
Detail why the strict rating is not the most accurate.
Examples:
- It does not account for persistent functional deficits
- The condition does not fit any defined category
- The clinical presentation lies between two rating classifications
3. Select an AMA-Consistent Analogy
Identify the specific:
- Table
- Chapter
- Method (within the AMA Guides that you believe more accurately reflects the impairment.)
4. Tie the Logic to Table 1-2 (ADLs) as well as other deficits in ADLs (see Table 1)
The AMA Guides require that WPI be proportional to impact on ADLs. This is the strongest foundation for an A/G opinion.
5. Base the Opinion on Clinical Findings, Not Equity
The WCAB is explicit: an A/G analysis cannot rest on fairness, benefit of the doubt, or a general sense of “severity.”
It must arise from medical judgment within AMA methodology.
Example of a Proper Almaraz–Guzman Application
“Plantar fasciitis is not specifically addressed in the AMA Guides. The strict rating under Chapter 17 yields 0% WPI, which does not account for the patient’s persistent limitations in prolonged standing and walking—ADLs referenced in Table 1-2. Using an analogous condition, Achilles tendinopathy (Table 17-33), the patient’s deficits correspond to a 7% WPI, which more accurately reflects the functional impact while remaining within the Guides.”
This example demonstrates:
- Start with strict rating
- Identify inadequacy
- Use analogous AMA content
- Tie to ADLs
Deposition-Ready Explanation
If asked why you departed from the strict rating, a clear and legally grounded response is:
“The AMA Guides acknowledge that clinical judgment is necessary to ensure the impairment rating accurately reflects functional loss. Under Almaraz–Guzman, when the literal table does not fairly describe the impairment, I may use an analogous method within the Guides. My opinion is fully AMA-based and reflects the worker’s demonstrated impact on ADLs.”
This explanation aligns with WCAB expectations and shows familiarity with the legal framework.
Bottom Line
Almaraz–Guzman is not about increasing impairment ratings – it is about accuracy.
When applied correctly:
- It improves the precision of the medical-legal report
- It demonstrates sophisticated use of the AMA Guides
- It withstands scrutiny because the reasoning is clinical, not equitable
Most importantly, it ensures that the impairment rating truly reflects the injured worker’s actual functional loss, as required by California law.
Interested in learning more about how Simplexam can help?