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At a Glance:
Title:
08035
Date:
March 27, 2008
Status:
Concurrent Medical Necessity

08035

March 27, 2008

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUES

A benefit contested case hearing was held on March 21, 2008, to decide the following disputed issues:

  1. Whether the preponderance of the evidence is contrary to the decision of the Independent Review Organization (IRO) that a lumbar right SI injection is not reasonable and necessary health care services for the compensable injury of ___?

PARTIES PRESENT

Claimant appeared and was assisted by an (Ombudsman). Carrier appeared and was represented by an (Attorney).

BACKGROUND

Claimant and Dr. R testified at the March 21, 2008, CCH. Claimant explained that he was at work for this employer on ___, when he picked up a sheet of plywood and his back went out. Claimant's treating doctor is Dr. R who has diagnosed sacroiliac (ligament) sprain. Dr. S referred Claimant to Dr. F, who initially examined Claimant on December 19, 2007. Dr. F's assessment was 1) Right sacroiliac joint dysfunction; 2) Lumbar disc displacement; 3) Muscular ligamentous strain, right psoas muscle; and 4) Low back pain. Dr. F recommended right sacroiliac joint steroid injection under fluoroscopy. Carrier denied the recommended right sacroiliac joint steroid injection under fluoroscopy, and the reconsideration request was also denied. An IRO was requested, and on January 28, 2008, the IRO reviewer upheld the previous adverse determination regarding the prospective medical necessity of a lumbar right SI injection.

Claimant appealed the adverse IRO determination. In the rationale and analysis section of the IRO, the reviewer discussed the ODG recommended criteria for the use of sacroiliac blocks in conjunction with Claimant's diagnosis. The reviewer concluded that the provider had not supplied enough documentation to support the recommendation of the SI blocks. The reviewer also noted, "Given that the criteria for SI blocks as indicated by the ODG have not been met, the reviewer cannot recommend authorization of this procedure at this time."

In order to prevail Claimant must show that a preponderance of evidence-based medicine is contrary to the IRO determination. In the instant case, Claimant has failed to provide evidence-based medicine that refutes the IRO. Claimant only offered argument and a letter from Dr. F dated March 6, 2008, which did not address the ODG guidelines at all. Dr. F only stated, "I told him again that he will benefit from a right sacroiliac joint injections under fluoroscopy to try to help with his condition. We cannot guarantee the outcome of the block, but I think that should be the next approach."

"Evidence-based medicine," means the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts, and treatment and practice guidelines in making decisions about the care of individual patients. Evidence-based medicine must be provided through a properly qualified medical expert's report or testimony in order to overcome the IRO determination. In the instant case, Claimant failed to offer any expert medical evidence to rebut the IRO determination that a lumbar right SI injection is not reasonable and necessary health care services for the compensable injury of ___.

Claimant also tried to argue that the IRO reviewer did not have all of his medical records, but from the evidence presented, I do not find this argument persuasive.

Even though all the evidence presented was not discussed, it was considered. However, due to the absence of Claimant to provide evidence-based medicine in the form of a report or testimony, the IRO determination is upheld. The Findings of Fact and Conclusions of Law are based on the standard of evidence-based medicine.

FINDINGS OF FACT

  1. The parties stipulated to the following facts:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B.On ___, Claimant was the employee of (Employer), when he sustained a compensable injury.

  • Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • Claimant failed to offer any expert evidence-based medicine to rebut the IRO determination that a lumbar right SI injections is not reasonable and necessary health care services for the compensable injury of ___.
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
    2. Venue is proper in the (City) Field Office.
    3. A lumbar right SI injections is not reasonable and necessary health care services for the compensable injury of ___.

    DECISION

    A lumbar right SI injection is not reasonable and necessary health care services for the compensable injury of ___.

    ORDER

    Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

    The true corporate name of the insurance carrier is TEXAS MUTUAL INSURANCE COMPANY, and the name and address of its registered agent for service of process is

    RUSSELL OLIVER, PRESIDENT

    6210 EAST HWY. 290

    AUSTIN, TEXAS 78723

    Signed this 27th day of March, 2008.

    Cheryl Dean
    Hearing Officer

    End of Document
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