Only permanent impairment may be rated according to the Guides, and only after the status of "Maximum Medical Improvement" (MMI) is determined, as explained in Section 2.5e. Impairment should not be considered permanent until a reasonable time has passed for the healing or recovery to occur. This will depend on the nature of underlying pathology, as the optimal duration for recovery may vary considerably from days to months. The clinical findings must indicate that the medical condition is static and well stabilized for the person to have reached MMI.
There may be circumstances in which a patient either declines or fails to comply with surgical, pharmacologic, or therapeutic treatment of impairment. In such cases, an MMI determination may still be required even when logistical barriers or compliance issues preclude optimal disease control and organ functioning. If the patient declines therapy for a permanent impairment, that decision does not decrease or increase the estimated percentage of the individual's impairment, nor does it preclude an impairment evaluation per se. However, the physician should make a written comment in his or her report addressing the suitability of the therapeutic approach and the basis of the individual's refusal. The physician should also indicate that the individual is at MMI without treatment due to declining treatment or treatment noncompliance. Additionally, the physician should estimate the impairment rating that would be likely if the patient had cooperated with the treatment recommendations (if the estimated rating is different from the one determined at the time of the examination).