Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
09038
Date:
October 20, 2008
Status:
Concurrent Medical Necessity

09038

October 20, 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.

ISSUE

A benefit contested case hearing was opened on September 3, 2008, and closed on October 15, 2008, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that MS Contin 30 mg 1 tab by mouth twice daily #60 no refills, Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill and Toradol 10 mg 1 tablet by mouth 3 times a day with flare-ups of pain #9 with one refill, are not reasonable and necessary health care services for the compensable injury of __________?

By agreement of the parties, the disputed issue was modified as follows:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill, are not reasonable and necessary health care services for the compensable injury of __________?

PARTIES PRESENT

Petitioner appeared and was assisted by PS-G, Ombudsman. Carrier appeared and was represented by CF, Attorney.

BACKGROUND INFORMATION

The claimant received a compensable injury on __________ when he fell off of a piece of equipment, landing on his shoulder and injuring his left arm. Since that time, the claimant has been diagnosed with CRPS of the left upper extremity. He has received numerous medications in an attempt to relieve his pain. The claimant currently has a morphine pump. In addition, the claimant’s physician has requested MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill. A request for preauthorization was denied in March, 2008. A request for a review by an Independent Review Organization (IRO) was submitted in March, 2008. The IRO upheld the previous denial, citing physician progress notes which were confusing with regard to the medications the claimant was taking and the effectiveness of those medications. The IRO went on to quote the Official Disability Guidelines (ODG) on the use of opioid medications, indicating that management should include “ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects.” Because the IRO was unable to glean these facts from the physician notes, the IRO was unable to determine whether or not the medication was medically necessary.

In evidence was a letter from the claimant’s pain medicine physician, Dr. C, documenting that the claimant’s pain is greatly reduced by this medication regimen, there are no side effects, the claimant is able to maintain full-time employment with only occasional trips to the emergency room, and his quality of life is much improved. The physician has follow-up appointments with the claimant every four to six weeks. The claimant testified that in the past six months his pain has been well-managed with the requested combination and he has not missed any work. He reports an improved quality of life and is happy that he can provide for his family with full-time employment.

Texas Labor Code Section 408.021 provides that an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. Health care reasonably required is further defined in Texas Labor Code Section 401.011 (22a) as health care that is clinically appropriate and considered effective for the injured employee's injury and provided in accordance with best practices consistent with evidence based medicine or, if evidence based medicine is not available, then generally accepted standards of medical practice recognized in the medical community. Health care under the Texas Workers' Compensation system must be consistent with evidence based medicine if that evidence is available. Evidence based medicine is further defined in Texas Labor Code Section 401.011 (18a) to be the use of the current best qualified 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 accordance with the above statutory guidance, the Division of Workers' Compensation has adopted treatment guidelines by Division Rule 137.100. This rule directs health care providers to provide treatment in accordance with the current edition of the Official Disability Guidelines (ODG), and such treatment is presumed to be health care reasonably required as defined in the Texas Labor Code. Thus, the focus of any health care dispute starts with the health care set out in the Official Disability Guidelines (ODG).

Because the claimant’s physician addressed the questions raised by the IRO and the ODG allows for the use of opioid medications for ongoing pain management of CRPS, the preponderance of the evidence is contrary to the IRO decision that MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill are not reasonable and necessary health care services for the compensable injury of __________.

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) 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.
    1. Dr. C, the claimant’s pain medicine physician, has prescribed MS Contin 30 mg.1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill to supplement the claimant’s morphine pump for pain management.
    2. The claimant is able to work full-time without absences, has no side effects, and has had an improved quality of life since beginning this regimen of medications for pain management.

      5. Dr. C sees the claimant for follow-up appointments every four to six weeks.

      6.MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill are 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. MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill are reasonable and necessary health care services for the compensable injury of __________.

    DECISION

    The preponderance of the evidence is contrary to the decision of the IRO that MS Contin 30 mg 1 tab by mouth twice daily #60 no refills and Norco 10/325 mg 1 tab by mouth every 8 hours as needed for pain #90 with one refill are not reasonable and necessary health care services for the compensable injury of __________.

    ORDER

    Carrier is 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 TPCIGA FOR RELIANCE INSURANCE CO. and the name and address of its registered agent for service of process is:

    MARVIN KELLY, EXECUTIVE DIRECTOR

    9120 BURNET ROAD

    AUSTIN, TEXAS 78758

    Signed this 20th day of October, 2008.

    Carolyn Cheu
    Hearing Officer

    End of Document
    Top