DECISION AND ORDER

Behavioral Healthcare Associates (Petitioner) appealed the decision of the Texas Workers= Compensation Commission’s (Commission) designee, an independent review organization (IRO), which denied preauthorization for a chronic pain management (CPM) program for a workers= compensation claimant (Claimant). Petitioner’s request for the CPM had been denied by the American Home Assurance Company (Respondent) as not being medically necessary healthcare. This decision finds preauthorization for the CPM is medically necessary and should be granted.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction, notice or venue. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing in this matter convened October 22, 2003, at the State Office of Administrative Hearings, 300 W. 15^th Street, Austin, Texas, with Administrative Law Judge (ALJ) Bill Zukauckas presiding. Petitioner was represented by psychologist Michael Ghormley, Ph.D. Respondent was represented by its claims representative Javier Gonzales. The record closed at the end of the hearing.

II. DISCUSSION

A. Background Facts

Climant is an approximately 45-year-old female who experienced a work-related accident on,_____. Claimant struck her knee when an iron swivel keyboard support (which was bolted to the desk) slid out of position and hit her knee. The injury Atook the skin off her knee and she was in immediate pain. She consulted the company doctor who treated the wound with bandages and instructed her to return to work. The Claimant reported increased burning and pain in her knee following her injury and consulted doctors several times about those symptoms around the time of the injury.

Claimant went through several weeks of modality oriented physical therapy. According to the records, she also received treatment from a chiropractor.

Shortly after the time of the work accident, Claimant developed regional pain syndrome^[1] (RSD), beginning in the area of the knee injury. There has been a spread of symptoms from the leg injury partially to the other leg and to the back, as well as to both upper extremities.

Claimant received injections to treat her pain, including trigger point and stellate ganglion blocks and reports that she received some pain relief from these injections. She has also been through 13 sessions of counseling for the stress and emotional anxiety symptoms associates with the RSD.

Claimant’s medical records indicate she has been off work and depressed since the injury. She has become less active, lost the use off her car, and has had a foreclosure on her home. Claimant notes that prior to her injury, she had an active and generally happy life and demonstrated a stable job history for 25 years, although she reported significant psychological problems dating back to her childhood, including abuse in her home and then a failed marriage. Her records also show that she has an estranged relationship with her mother with whom she has not had any contact in 19 years and reports that she left home when she was 17 to get away from her abusive mother.

B. Legal Standards

Petitioner has the burden of proof in this proceeding. 28 TAC ” 148.21(h) and (i); 1 TAC ‘ 155.41. Pursuant to the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. ‘ 408.021(a). Health care includes all reasonable and necessary medical services, including a medical appliance or supply. TEX. LAB. CODE ANN. ‘401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. ‘ 401.011(31). The decision of an IRO is to be given presumptive weight. 28 TAC ‘133.308(v). Certain types of healthcare, including chronic pain management programs require preauthorization from the carrier. 28 TAC ‘ 134.600(h).

C. The Parties= Arguments

Respondent Carrier’s Position

Respondent relied on the findings of its utilization reviewer and the IRO reviewer that a CPM program was not medically necessary for Claimant. Respondent’s argument, although not disagreeing that the Claimant might benefit from a CPM program, was that Petitioner did show proximate cause connection between Claimant’s relatively minor knee injury and extensive RSD symptoms beyond the site of the injured knee.

Provider’s Position

Provider notes that in January of 2003, a comprehensive behavioral medicine evaluation was conducted for Claimant to assess eligibility for a pain management program. A report from its psychologist, Jonnalee Barta, Ph.D., indicated Claimant’s symptom cluster clearly fit the profile for a patient with chronic pain syndrome. Dr. Barta further noted that Claimant had fully exhausted a broad array of conservative medical and psychological treatments geared toward decreasing her pain. Dr. Barta noted that stellate ganglion blocks, although necessary to decrease the spread of her Complex Regional Pain Syndrome, have not decreased her pain levels enough to return her to her previous employment status. Dr. Barta concluded that Claimant previously exhausted individual pain management psychotherapy sessions, but they did not address the full array of problems Claimant presented. Dr. Barta reported that Claimant clearly needed a more intense, interdisciplinary pain management program.

Provider addressed the connection of the injury to the overall whole body symptoms by noting that these symptoms began appearing immediately after her work injury and that there was no evidence to suggest the symptoms would have otherwise presented themselves, but for the injury.

ALJ’s Analysis

The ALJ starts with the basic presumption that Claimant, regardless of cause, needs the CPM program to address her RSD needs. Both parties agreed she needed the program. The issue at this hearing is whether Provider has shown enough connection between the work-related knee injury and the subsequent progressing whole-body RSD to hold Carrier liable for treatment of the RSD with this CPM program. The ALJ finds the Provider has.

The severity of Claimant’s original work-related knee injury did not seem severe. The records show that it was serious enough for her to see the company doctor, but not so serious that she could not return to work (apparently that same day). Despite the apparent relatively minor knee injury, the ALJ finds that the evidence in the record supports the conclusion that, at the very least, the knee injury triggered the more complicated and confusing RSD symptoms for which Claimant medically needs the CPM program.

The ALJ listened carefully to Carrier’s claims that this was simply an egg-shell employee who had a preexisting condition that was merely precipitated by a very minor knee injury. While there are many situations where the ALJ would agree with this argument based upon some preexisting Claimant condition, the ALJ does not find that Carrier rebutted the original presumption that the work injury caused this situation. Provider presented sufficient evidence to show the RSD problem was part of the compensable knee injury. It did this by showing the origin of the RSD problem at the site of the knee injury and by showing the chronology following of the RSD appearance soon after the knee injury. While the Claimant’s preexisting psychological history might have some bearing on Claimant susceptibility to this syndrome, the Provider makes a valid point that all employees have some preexisting issues. Carrier did not show Claimant had some very obvious preexisting condition that should relieved it from its normal worker’s compensation liability for a work injury.

III. FINDINGS OF FACT

1. In________, Claimant sustained injuries to her right knee compensable under the Texas Workers= Compensation Act (Act).
2. At the time of the compensable injuries, American Home Assurance Company (Carrier) was Claimant’s employer’s workers= compensation insurance coverage carrier.
3. Respondent denied Petitioner’s request to preauthorize Claimant’s participation in the Chronic Pain Management (CPM) program.
4. After Respondent denied preauthorization as medically unnecessary, Petitioner requested medical dispute resolution from the Commission. Pursuant to 28 TEX. ADMIN. CODE (TAC) ‘ 133.308, an IRO selected by the Commission rendered a decision on the medical review dispute.
5. The Independent Review Organization (IRO) upheld Respondent’s denial of preauthorization, stating::

Treatment of the knee injury is not medically necessary in this case. While the patient would not benefit from a pain management program, making it not medically necessary, this patient does need a comprehensive program of treatment. However, there should be much greater emphasis on patient’s self-involvement.

1. Petitioner timely appealed the IRO decision.
2. Pursuant to a notice of hearing sent by Commission staff, Petitioner and Respondent appeared and were represented at the hearing held in this matter on October 22, 2003.
3. Claimant suffers from chronic pain, which has no corresponding pathology that would explain the level of pain she reports.
4. Claimant has undergone various types of injections, physical therapy, and 13 psychological counseling sessions, none of which has provided adequate, long-term pain relief.
5. Claimant is a good candidate for a CPM program.
6. Provider presented sufficient evidence to tie the RSD problem to the knee injury. It did this by showing that the RSD problem originated at the site of the knee injury and by showing the chronological sequencing of the RSD syndrome soon after the knee injury.
7. While the Claimant’s preexisting psychological history might have some bearing on Claimant’s susceptibility to the RSD syndrome exhibited, Carrier did not show that any preexisting condition was so much the cause of Claimant’s RSD symptoms so as to relieve it of normal worker’s compensation liability for an at-work injury.

IV. CONCLUSIONS OF LAW

1. The Texas Workers= Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (Act), TEX. LABOR CODE ANN. ‘ 413.031.
2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to ‘ 413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003.
3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV’T CODE ANN. ch. 2001 and the Commission’s rules, 28 TEX.ADMIN.CODE (TAC) ‘ 133.305(g).
4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV=T CODE ANN. ” 2001.051 and 2001.052.
5. Petitioner had the burden of proof in this proceeding. 28 TAC ” 148.21(h) and (I); 1 TAC ‘ 155.41.
6. Pursuant to the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. ‘ 408.021(a).
7. For a carrier to be liable for reimbursement, it must preauthorize a claimant’s participation in a chronic pain management program. 28 TAC ‘ 134.600(h).
8. Petitioner met its burden of proof to show that a chronic pain management program is reasonable and medically necessary healthcare for Claimant. TEX. LAB. CODE ANN. ‘ 408.021.
9. Petitioner’s request for preauthorization for Claimant to participate in its chronic pain management program should be preauthorized.

ORDER

It is ORDERED that Behavioral Healthcare Associate’s request for preauthorization of a chronic pain management program for Claimant is granted.

Signed November 10, 2003.

BILL ZUKAUCKAS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. An RSD is a reflex sympathetic dystrophy syndrome (RSD). It is a sympathetically-maintained pain stated first recognized during the American Civil war and described with various labels since that time. The role of psychologic factors in the initiation and maintenance of the syndrome was not always recognized, but recent discussions of etiology increasingly include autonomic arousal, anxiety, and conversion tendencies. Psycho Physiologic Aspects Of Reflex Sympathetic Dystrophy Syndrome by William U. Weiss, PhD., American Journal of Pain Management, 1993.↑