Written by Robert Clinton, MD, Doctor of Internal Medicine and Brown & Brown Absence Services Group Physician Consultant.
The COVID-19 virus is novel and something with which medicine and humanity had not had experience with until late 2019; thus, we must begin by understanding that there is no science to a pandemic. Science and medicine combine to assess the pandemic and recommendations are driven by data. Governments take the lead as COVID-19 threatens the health and wellbeing of society at large.
After acute COVID-19 infection, individuals reported and physicians observed impairing lingering symptoms. Most common are fatigue, shortness of breath, cough, joint pain, and chest pain. Other symptoms include difficulty with thinking and concentration (“brain fog”), depression, muscle pain, headache, intermittent fever, and fast-beating or pounding heart. Individuals with these finding are called “long-haulers” and are assessed as “post-COVID-19 syndrome” and “long COVID-19.” Currently, early reports from Europe are that 3-5% of individuals who survived acute COVID-19 infection develop these types of lingering symptoms.
Recent history shows two other coronavirus outbreaks that have caused lingering symptoms with functional impairments; Severe Acute Respiratory Syndrome (SARS) which arose in November 2002 and resolved by July 2003 and Middle East Respiratory Syndrome (MERS) which began in June 2012 and still lingers. The most disabling post-infection impairment for these viruses is chronic fatigue syndrome.
Post-COVID-19 syndrome and claims for disability
Other than diagnostic codes for COVID-19 testing (PCR, antibody testing, antigen testing); there is one clinical diagnostic code, U07.1 for a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by a provider, a positive COVID-19 test result or a presumptive positive COVID-19 test result. For chronic lingering signs and symptoms caused by COVID-19, pre-existing codes like post-viral syndrome or viral complications are used. These are non-specific. In time, the scientific method will categorize the chronic syndromes related to COVID-19 to include formulating and proving hypotheses by using postulates that aid in making chronic COVID-19 related diagnoses.
For disability determinations, this is of no consequence because in evaluating individuals for COVID-19 related disability, we objectify subjective reports by correlating the reports with clinical observations and activity. We understand and it is credible that some individuals will develop significant chronic impairment caused by COVID-19. The medical evidence provided will have to be consistent and sufficient to support a significant reduction in functional ability.
We are seeing and will continue to see claims for debilitating fatigue. The COVID-19 type of fatigue is one that is associated with prolonged recovery after mild exertion; individuals show abnormal vital signs including low oxygenation and rapid heart rates with mild activity. Claims will need to be supported by appropriate changes in vital signs with activity and by referrals for specialty care/participation in rehabilitation programs designed for COVID-19 survivors.
The behavioral health side of post-COVID-19 syndrome
We are seeing and will continue to see claims for psychiatric and neurocognitive claims. A recent article entitled “Short-term Neuropsychiatric Outcomes and Quality of Life in COVID-19 Survivors” summarizes research from Spain and Australia. The authors screened post hospitalized COVID-19 survivors and found nearly 59% of individuals had neurocognitive impairment. 39% of the patients had psychiatric morbidity and of the 179 study participants, low quality of life for physical and mental components was detected in 44% and 39% of patients, respectively. Delirium and stress-related symptoms increased approximately 4-fold the odds of developing neurocognitive impairment. Long-term neurocognitive outcomes have not been established however, neurorehabilitation programs may provide benefit to patients sufferings with these symptoms.
In summary, medicine and science learn and understand the effects of COVID-19 infection on human physiology based on what occurs in infected individuals. Science is applied resulting in more discoveries and diagnostic criteria for post-COVID-19 syndrome over time. We understand that chronic lingering symptoms from COVID-19 is a credible cause for sustained reduction in functional ability. Thus, in assessing for disability, we continue to objectify subjective symptom reports by finding correlations to activity levels, psychiatric/behavioral illness, or neurocognitive dysfunction that are consistent with what can occur in COVID-19 individuals after the acute infection. We are responsible in making sure that the medical evidence is sufficient to determine impairment.