When faced with a report finding permanent disability per Almaraz/Guzman, remember that, to constitute substantial evidence, the physician must explain HOW and WHY the case qualifies as COMPLEX and EXTRAORDINARY and his/her clinical judgment supports a finding that ACTUAL impairment in this case is not accurately reflected in the chapter, table or measurements provided in a strict interpretation of the Guides. The physician must also provide the strict AMA Guides rating. Failure to do so may result in the report being thrown out as evidence in court.