DECISION AND ORDER

__ (Claimant) challenged the decision of Continental Casualty Company (Carrier) denying preauthorization for a stellate ganglion block–right side. In this decision, the Administrative Law Judge (ALJ) finds that Claimant did not meet her burden of showing that the requested procedure is reasonable and necessary medical care and should be preauthorized. Therefore, the ALJ does not order Carrier to authorize the requested ganglion block procedure.

The hearing convened and closed on April 25, 2006, before ALJ Steven M. Rivas. Claimant appeared and was assisted by Juan Mireles, Ombudsman. One of Claimant’s treating doctors, Manjit Randhawa, D.O., was scheduled to appear by telephone and provide testimony, but he failed to respond to the ALJ’s phone call at the scheduled time. Carrier appeared and was represented by Doug Pruett, attorney.

I. DISCUSSION

Background Facts

Claimant sustained a compensable injury to her right elbow on___, while turning garment bags inside out. Following her injury, Claimant was treated for her pain complaints by various providers using modalities that included trigger point injections as well as pain medication. At some point in her treatment, Claimant began undergoing stellate ganglion block procedures to treat her pain. Claimant reported temporary relief from the block procedures. On December 27, 2005, one of Claimant’s treating doctors recommended Claimant undergo another ganglion block procedure, which Carrier denied as not medically necessary. The dispute was referred to an Independent Review Organization (IRO), which agreed with Carrier. Provider appealed the IRO decision to the State Office of Administrative Hearings.

Applicable Law

Pursuant to the Texas Workers’ Compensation Act (“the Act”), TEX. Lab. Code Ann. § 408.021et seq., an employee who sustains a compensable injury is entitled to all 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.

Under Tex. Lab. Code Ann§401.011(19), health care includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

Certain categories of health care identified by the Commission require preauthorization, which is dependant upon a prospective showing of medical necessity under § 413.014 of the Act and 28 Tex. Admin. Code (TAC) § 134.600. In this instance under 28 TAC § 134.600(h), preauthorization is required for the ganglion block procedure requested by Claimant.

Evidence and Arguments

Based on the records submitted by Claimant, she began undergoing ganglion block procedures on March 28, 2003, while under the care of Paul Marullo, D.C., and Omar Vidal, M.D. Between March 28, 2003, and June 4, 2004, Claimant underwent a total of seven ganglion blocks. The procedure she requests at this time would be her eighth. Additionally, she testified she has undergone several diagnostic tests and has been diagnosed with Reflex Sympathetic Dystrophy (RSD). Claimant stated she attempted to participate in a physical therapy program, but the pain from her compensable injury prevented her from continuing. She admitted she is not presently undergoing physical therapy. Furthermore, Claimant asserted the prior ganglion block procedures rendered relief for progressively longer periods of time and that during these periods of relief; she did not have to take as many medications, and generally felt better.

Carrier called Neal Blauzvern, M.D., who testified that he treats patients with the same type of injuries as Claimant and performs ganglion block procedures as well. Dr. Blauzvern agreed with the IRO’s determination that the requested treatment was not medically necessary because Claimant’s treating doctors had not established that she suffered from RSD. The IRO report indicated that Claimant had a diagnosis for “possible RSD but has minimal clinical findings to support this.” Dr. Blauzvern contended that ganglion block procedures were not medically necessary without a definite finding of RSD.

Dr. Blauzvern did not dispute the IRO’s finding that Claimant experienced a measure of relief after being treated with the prior seven ganglion block procedures. However, he testified that without a proper diagnosis of RSD or any of the accompanying symptoms, it would not be reasonable to undergo any further ganglion block procedures.

Dr. Blauzvern utilized the guidelines of the American Medical Association (AMA), which holds that a diagnosis of RSD can only be supported by the presence of eight of out eleven symptoms.^[1] Upon examining Claimant’s medical records, which consisted of office visits and the seven prior ganglion block procedure notes, Dr. Blauzvern found no indication that Claimant suffered from any of the symptoms prescribed by the AMA.^[2]

Dr. Blauzvern did note Claimant’s pain complaints and palpation over her right elbow, but he asserted these were not part of the criteria for a diagnosis of RSD based on the AMA guidelines. According to Dr. Blauzvern, some of the symptoms that support a diagnosis of RSD contained in the AMA guidelines include changes in skin temperature and color, edema, soft-tissue atrophy, joint stiffness, and changes in nail and hair growth. Dr. Blauzvern found Claimant not only lacked eight of the eleven symptoms but she lacked all symptoms for the diagnosis of RSD. The record also indicated Claimant did not undergo a bone scan, which Dr. Blauzvern testified might have presented some objective findings of bone damage or osteoporosis.

Another point Dr. Blauzvern made was that stellate ganglion block procedures are designed to be administered in conjunction with a physical therapy program. He testified that while the blocks render pain relief, it is the physical therapy that makes a patient better. Dr. Blauzvern added that while the blocks facilitate therapy, they do not cure RSD.

Dr. Blauzvern also testified that any medical treatment rendered to a patient must be based on scientific evidence and a proper diagnosis rather than subjective report of pain relief. Dr. Blauzvern asserted the risks of stellate ganglion blocks are serious and that Ain the absence of clear medical indication of performing it, the ratio of risk to benefit tilts all the way to risk.

Analysis and Conclusion

The requested stellate ganglion block procedure is not warranted because it will not treat Claimant’s compensable injury. Based on the evidence presented, the requested treatment does not appear to be the proper protocol to treat Claimant’s injury. Claimant had the burden of proof in this proceeding and did not present sufficient evidence that requested procedure was medically necessary.

The ALJ believes Claimant experienced some pain relief with the prior ganglion block procedures, but without a proper diagnosis of RSD, or any other supporting evidence, the ALJ finds the weight of the evidence presented falls in favor of the Carrier. For these reasons, the ALJ finds the requested procedure should not be authorized.

II. FINDINGS OF FACT

1. __ (Claimant) sustained a compensable elbow injury on___.
2. Claimant came under the care of several treating doctors including Omar Vidal, M.D., who recommended Claimant undergo stellate ganglion block procedures.
3. Between March 28, 2003, and June 4, 2004, Claimant underwent a total of seven ganglion block procedures.
4. Claimant sought preauthorization for an eighth ganglion block procedure from Continental Casualty Company (Carrier), which was denied.
5. Claimant sought medical dispute resolution with the Texas Workers’ Compensation Commission’s Medical Review Division, which referred this matter to an Independent Review Organization (IRO). The IRO report concurred with Carrier and denied preauthorization.
6. Provider timely requested a hearing before the State Office of Administrative Hearings (SOAH).
7. Notice of the hearing in this case was mailed to the parties on September 13, 2005. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
8. The hearing convened and closed on April 25, 2006, before Steven M. Rivas, Administrative Law Judge (ALJ). Claimant appeared and was assisted by Juan Mireles, Ombudsman. Carrier appeared and was represented by Doug Pruett, attorney. The hearing was adjourned and the record closed the same day.
9. The requested treatment is used to treat patients who have been diagnosed with Reflex Sympathetic Dystrophy (RSD).
10. Claimant has never received a definite diagnosis of RSD.
11. Ganglion block procedures are not helpful in treating Claimant’s symptoms.
12. Claimant does not have any of the symptoms that would support a diagnosis of RSD based on the guidelines of the American Medical Association.

III. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 401.001et seq. (“the Act”).
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(k) of the Act and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
4. Claimant, as Petitioner, had the burden of proof on appeal by a preponderance of the evidence under §413.031 of the Act, and 28 Tex. Admin. Code §148.21(h).
5. Because Claimant has not been diagnosed with RSD, the requested stellate ganglion block procedure will not treat Claimant’s compensable injury.

ORDER

IT IS, THEREFORE, ORDERED that the stellate ganglion block procedure not be preauthorized.

Signed May 26, 2006

STEVEN M. RIVAS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The AMA Guides to the Evaluation of Permanent Impairment.↑
2. Dr. Vidal performed the ganglion block procedures and saw Claimant on her office visits. Dr. Blauzvern found that Dr. Vidal’s notes had not ruled out any other cause of pain. Additionally, Dr. Blauzvern noted the records of Claimant’s office visits did not contain upper extremity examinations.↑