When the AMA Guides Fail: Using Almaraz-Guzman to Win Higher Workers’ Comp Awards

• Mar 22, 2022
• Blog
• Michael Burgis & Associates, P.C

If you’re an applicant attorney or an injured worker, and you want to get an adequate resolution for your workers’ compensation case, there are some tools available that could help you get a much higher award. There are also some recent cases to consider that could give you a lot of insight about what to do and what not to do when you’re seeking that award. The more you understand about the rules and regulations of workers’ comp cases, the more you can work within those rules for a successful outcome.

Understanding Workers’ Compensation Impairment Ratings in California

In the California workers’ compensation system, one of the most critical factors that determines the outcome of a claim is your impairment rating. This rating is meant to reflect how much your injury affects your ability to perform daily tasks and earn a living.

However, how that rating is calculated—particularly in complex or nuanced injury cases—can make or break your claim.

The AMA Guides: The Starting Point for Impairment Assessment

If you’re injured in California, the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment serve as the prima facie (primary) framework for disability assessment. These guides offer a formulaic method of converting clinical findings into a Whole Person Impairment (WPI) percentage.

What Are Whole Person Impairments (WPI)?

WPI is a standardized method for measuring the impact of an injury on a person’s overall body function and functionality. A higher WPI percentage means more significant impairment—and therefore, a potentially higher compensation award.

The AMA Guides look at two main components:

• Objective Medical Evidence such as:
  • MRI scans
  • X-rays
  • Nerve conduction studies
  • Lab results
• Subjective Symptoms and Limitations:
  • Pain levels
  • Range of motion loss
  • Chronic fatigue
  • Depression or anxiety symptoms (in some cases)

Once both elements are reviewed, the physician calculates a rating. This rating is then matched with the Permanent Disability Rating Schedule (PDRS) to determine your financial benefits.

But There’s a Problem: AMA Guides Don’t Always Reflect Reality

The AMA’s strict methodology doesn’t always account for the real-world impact of certain injuries—particularly soft tissue injuries, chronic pain, or psychological trauma.

There are many situations where an injured worker’s functional limitations far exceed what their medical imaging suggests, resulting in an unfairly low impairment rating.

Almaraz-Guzman: A Legal Workaround for Unfair Ratings

That’s where the Almaraz-Guzman doctrine comes in. This legal precedent allows doctors and attorneys to argue for a deviation from the AMA Guides when the standard rating doesn’t adequately represent the true extent of an injury.

What Is the Almaraz-Guzman Decision?

In two landmark cases (collectively known as Almaraz-Guzman), the California Workers’ Compensation Appeals Board held that a medical evaluator is not strictly bound to the AMA Guides if they can explain:

• Why the AMA rating is insufficient
• How does an alternative method better represent the impairment
• What evidence supports this deviation

This deviation is legal—but only if properly justified through:

• Medical documentation
• Functional assessments
• Real-world work limitations
• Clear explanations of “how” and “why”

Maria Estella vs. State of California

The Maria Estella case highlights both the power and pitfalls of the Almaraz-Guzman deviation.

In this case, the injured worker received two separate ratings:

1. One based on the AMA Guides
2. One based on Almaraz-Guzman’s reasoning

However, the court rejected the Almaraz-Guzman-based rating because the doctor failed to explain the basis for the alternative evaluation. There was no detailed rationale or connection between the worker’s limitations and the departure from the AMA Guides.

Key Lessons from the Case:

• A doctor’s opinion must not be conclusory.
• You need to tie impairment to work limitations, using medical logic.
• The “how” and “why” of the deviation must be explicitly stated.

Why Documentation is the Game-Changer

The most common reason injured workers receive lower awards—even with legitimate impairments—is a lack of supporting documentation.

What Should Be Documented?

• Functional limitations (e.g., “cannot lift more than 5 lbs”, “can’t sit for over 30 minutes”)
• Daily life impact (loss of sleep, pain while driving, inability to cook or clean)
• Missed workdays and income disruption
• Emotional distress or psychological symptoms

All of this must be captured by the physician, who then needs to:

• Justify why the AMA Guides are inadequate
• Explain how a different standard better captures your condition
• Use objective evidence where possible (tests, logs, third-party assessments)

The Role of Medical Evaluators: QME vs. AME

A QME (Qualified Medical Evaluator) or AME (Agreed Medical Evaluator) must perform your impairment evaluation. Choose one familiar with:

• Almaraz-Guzman legal precedents
• Functional capacity evaluation tools
• Legal-medical documentation standards

The evaluator must act as both a clinician and a legal narrator, converting subjective suffering into legally actionable data.

Frequently Asked Questions (FAQs)

Can I still win my case if my MRIs and X-rays are normal?

Yes. With proper justification under Almaraz-Guzman, you can argue that your functional limitations are more disabling than what imaging shows.

What types of injuries often require AMA deviation?

• Chronic pain
• Nerve damage not seen in scans
• Psychological injuries
• Complex regional pain syndrome (CRPS)

Do I need a lawyer to apply Almaraz-Guzman?

Yes, it’s highly recommended. The burden of proof lies on the injured worker. A lawyer ensures the correct legal language, medical documentation, and case citations are provided.

What happens if the deviation isn’t explained well?

If the “how” and “why” are not included in your report, the judge may throw out the alternative rating—even if it’s accurate.

Can mental health impairments be rated outside the AMA?

Yes. The AMA Guides include psychological assessments, but in some cases, a broader view of real-world psychological disability may justify a deviation under Almaraz-Guzman.

Take Control of Your Workers’ Compensation Outcome

At Michael Burgis & Associates, we understand how critical it is to have every legal tool and medical detail aligned in your workers’ compensation case.

Don’t let a technicality in the AMA Guides prevent you from receiving the compensation you deserve.

We specialize in handling Almaraz-Guzman deviation cases, and we’ll help you build the strongest claim possible—from proper medical evaluations to compelling legal narratives.

Schedule a Free Consultation today and let our team guide you toward a higher award and a more just outcome.

Final Word

Your impairment is more than a number in a book. With the right knowledge, documentation, and legal strategy, you can break past the limitations of rigid guidelines—and claim what you’re truly owed.

Don’t leave your award to chance. Understand the rules. Use every tool available. And let experienced professionals advocate for your rights.