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At a Glance:
Title:
09013
Date:
August 15, 2008
Status:
Concurrent Medical Necessity

09013

August 15, 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 contested case hearing was held on August 12, 2008, to decide the following disputed issue:

  1. Is the requested total right knee replacement reasonably

necessary health care for the compensable injury of ___________?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by JA, ombudsman.

Respondent/Carrier appeared and was represented by MC.

BACKGROUND INFORMATION

Claimant is 5' 6" in height, and weighs 255 pounds (according to Dr. S's medical record of January 30, 2008). Claimant testified that although he was unsure exactly how much he weighed, he believed that he weighed about 232 pounds. His body mass index (BMI) is 42.4. Dr. S, M.D., has recommended that Claimant undergo a total right knee replacement. The request and reconsideration were denied. Claimant requested a review by an Independent Review Organization (IRO). (Independent Review Organization), was selected as the Independent Review Organization (IRO). On March 26, 2008, the IRO concurred with Carrier's denial of the requested procedure. In the "Analysis and Explanation" the IRO reviewer stated the following:

The patient has advanced degenerative changes based on the review of the records.

The medical necessity of a total knee replacement is indicated based upon a review

of records from Dr. S, M.D., and his description of weight-bearing

x-rays of advanced weight-bearing bone-on-bone degenerative varus.

However, ODG guidelines require a BMI of less than 35. The patient's BMI is

recorded at 42.4. The patient is at an increased risk for failure with a BMI of greater

than or equal to 30.

The Division has adopted treatment guidelines under Division Rule 137.100. That rule requires that health care providers provide treatment in accordance with the current edition of the Official Disability Guidelines (ODG), and treatment provided pursuant to those guidelines is presumed to be health care reasonably required as mandated by the above-references sections of the Texas Labor Code. Accordingly, in a medical necessity dispute, the first issue is whether the proposed

care is consistent with ODG.

The ODG addresses "Knee joint replacement," and provides as follows for "ODG Indications for Surgery" for knee arthroplasty:

Criteria for knee joint replacement (If only 1 compartment is affected a unicompartmental

or partial replacement is indicated. If 2 of the 3 compartments are affected a total joint

replacement is indicated).

  1. Conservative Care: Medications OR Visco supplementation injections. OR

Steroid injections. PLUS,

  • Subjective Clinical Findings: Limited range of motion. OR Night-time joint pain.
  • OR No pain relief with conservative care. PLUS

  • Objective Clinical Findings: Over 50 years of age AND Body Mass Index of less
  • than 35. PLUS

  • Imaging Clinical Findings: Osteoarthritis on Standing x-ray. OR Arthroscopy.
  • (Washington, 2003);(ShengSalehCallahan, 1995).

    Claimant presented an article from Obesity Sugery,, (June 15, 2007), that stated as follows:

    Dr. K, M.D., associate director of the (Health care Provider)

    and Knee Replacement Program in (City 1), (State 1), and colleagues compared

    the results of total knee arthroplasty in 39 extremely (or morbidly) obese patients

    (body mass index {BMI} >40 kg) and 39 non-obese patients (BMI < 30 kg). The

    2 groups were matched for age, gender, and date of their procedure.

    Although extremely obese patients had a greater rate of minor wound complications,

    suboptimal alignment, and need for late revision, problems in this group were relatively

    infrequent overall. In addition, a substantial improvement in Knee Society scores and

    a high rate of patient satisfaction were evident in the severely obese cohort. (The Knee

    Society scoring system is a widely accepted functional outcome measure for total knee

    arthroplasty that assesses such parameters as pain, range of motion, and ability to walk

    on level surfaces and ascend and descend stairs.)

    Overall, 8 knees in the severely obese group had minor complications that resolved

    with conservative treatment and without sequelae. There were no wound problems in

    the control group.

    There was also a tendency for the total knee arthroplasty in the severely obese group

    to be sub-optimally aligned, with the knee left in "somewhat excess varus." And indeed

    in this group, 5% of the patients needed revision surgery compared with none of the

    control patients.

    Nevertheless, although the severely obese patients had overall lower knee function

    scores pre as well as postoperatively, the important conclusion from this study is that

    both groups had marked improvements in their Knee Society scores at the latest

    follow-up at a mean of 90 months.

    Carrier presented in its Exhibit G, the following evidence based medical research: 1. The Outcome of Total Knee Arthoroplasty in Obese Patients, Hungerford, et. al., Journal of Bone and Joint Surgery, 2004; 2. Recommendations for the Management of Hip and Knee Osteoarthritis, Part II: OARSI Evidence-based, Expert Consensus Guidelines. (Zang,W., et al, 2008); 3. Total Knee Replacement in Morbidly Obese Patients. Results of a Prospective, Matched Study (Summary), Journal of Bone and Joint Surgery, 2006; 4. The Outcome of Total Knee Arthroplasty in Obese Patients, Journal of Bone and Joint Surgery, 2004; 5.What Effect Does Obesity Have on the Outcome of Total Hip and Knee Arthroplasty? Orthopade, 2005; and 6. Obesity: A Preventable Risk Factor for Large Joint Osteoarthritis Which May Act Through Biomechanical Factors, British Journal of Sports Medicine, 2005.

    The article from Journal of Bone and Joint Surgery, 2004, documents an investigation performed at the the Good Samaritan Hospital, Baltimore, Maryland. The purpose of this study was to compare the clinical and radiographic results of total knee arthroplasties performed in obese patients with those of total knee arthroplasties performed in non-obese patients. Clinical and radiographic data on seventy-eight total knee arthroplasties in sixty-eight obese patients were compared with data on a matched group of non-obese patients. The analysis was also performed after stratification of the obese group for the degree of obesity. All patients had the same prosthesis. The clinical data that were analyzed included the Knee Society objective and functional scores, patellofemoral symptoms, activity level, and complications. The results of the study suggested that any degree of obesity, defined as a body mass index of > 30, has a negative effect on the outcome of total knee replacement.

    In the instant case, the ODG does not recommend a total knee replacement for a patient whose

    BMI is greater than 35. The evidence-based medicine presented by Claimant is not persuasive in that even the article presented by the Claimant acknowledged the post-surgery complications in obese patients. The ODG and the evidence-based medicine presented by the Carrier is the more persuasive evidence.

    Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

    FINDINGS OF FACT

    1. The parties stipulated to the following facts:

    A.Venue is proper in the (City 2) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

    B.On _____________, Claimant was the employee of (Employer), and 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.
  • Dr. S has recommended a total right knee replacement.
  • Claimant is 5'6" and weighs 255 pounds, with a BMI of 42.4.
  • The ODG only recommends a total knee replacement/arthroplasty in patients whose BMI is less than 35.
  • In the instant case, the recommended total knee replacement is not consistent with ODG criteria.
  • The preponderance of the evidence is not contrary to the decision of the IRO that total right knee replacement is not reasonably required medical care 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 2) Field Office.
    3. Total right knee replacement is not reasonably required medical treatment for the

    compensable injury of _____________.

    DECISION

    Total right knee replacement is not reasonably required medical treatment 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 SERVICE LLOYDS INSURANCE

    COMPANY, and the name and address of its registered agent for service of process is

    JOSEPH KELLEY-GRAY, PRESIDENT

    6907 CAPITOL OF TEXAS HIGHWAY NORTH

    AUSTIN, TEXAS 78755

    Signed this 15th day of August, 2008.

    Cheryl Dean
    Hearing Officer

    End of Document
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