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At a Glance:
Title:
09045
Date:
November 6, 2008
Status:
Concurrent Medical Necessity

09045

November 6, 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 contested case hearing was held on October 29, 2008, to decide the following disputed issue:

  1. Whether twenty sessions of chronic pain management is reasonably required health care for the compensable injury of __________?

PARTIES PRESENT

Claimant appeared and was assisted by RB, ombudsman. Carrier appeared and was represented by MM, attorney.

BACKGROUND INFORMATION

On __________, Claimant sustained a compensable injury to his lumbar spine. Claimant has had numerous modalities during the course of multiple injuries including five prior back surgeries and participation in Dr. TM’s Pride Program three times including one time since the 1994 injury. Claimant now seeks reversal of the IRO which upheld the adverse determination that Claimant is not entitled to twenty sessions of chronic pain management.

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 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 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 ODG.

The IRO relied upon the ODG in denying the treatment. Claimant was able to provide a letter of medical necessity from his current treating doctor. However, he was unable to offer evidence based medicine contrary to the findings of the IRO. Therefore, Claimant is not entitled to the requested twenty sessions of chronic pain management.

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.
  • Twenty session of chronic pain management is not reasonably required medical treatment 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. The preponderance of the evidence is not contrary to the decision of the IRO that twenty session of chronic pain management is not reasonably required health care for the compensable injury of __________.

    DECISION

    The preponderance of the evidence is not contrary to the decision of the IRO that twenty session of chronic pain management is not reasonably required health care 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 CONTINENTAL CASUALTY COMPANY, and the name and address of its registered agent for service of process is

    CT CORPORATION SYSTEM
    350 NORTH ST. PAUL STREET
    DALLAS, TEXAS 75201

    Signed this 6th day of November, 2008.

    Charles T. Cole
    Hearing Officer

    End of Document
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