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.
A contested case hearing was held on November 13, 2008, to decide the following disputed issue:
- Is the preponderance of the evidence contrary to the decision of the IRO that the Claimant is not entitled to bilateral sacroiliac (SI) joint injection under fluoroscopy for the compensable injury of __________?
Claimant appeared by telephone and was assisted by DJ, ombudsman. Carrier appeared and was represented by DB, attorney, appearing by telephone.
Claimant sustained a compensable low back injury on __________. About two and a half years ago he came under the care of Dr. C for pain management. Dr. C performed SI joint injections on February 3, 2006, September 13, 2006, and May 25, 2007. On January 10, 2008 he requested approval for another SI joint injection.
The request was initially reviewed for the Carrier by Dr. G, an anesthesiologist. In a report dated January 14, 2008 Dr. G concluded that there was insufficient clinical information at that time to warrant procedure approval, noting that Claimant had not been seen by Dr. C for over eight months. A reconsideration review was done by Dr. A, an orthopedic surgeon. In a report dated January 28, 2008 he recommended denial of the request, noting that the request did not meet ODG criteria. Dr. C then requested review by an IRO. In a report dated March 5, 2008, the IRO doctor, a board certified anesthesiologist, concluded that the requested procedure was not medically necessary.
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 Official Disability Guidelines (ODG).
The applicable ODG section for the requested procedure, and the section utilized by Dr. G, Dr. A, and the IRO doctor, is the entry for "sacroiliac joint blocks", which provides as follows:
"Recommended as an option if failed at least 4-6 weeks of aggressive conservative therapy as indicated below. Sacroiliac dysfunction is poorly defined and the diagnosis is often difficult to make due to the presence of other low back pathology (including spinal stenosis and facet arthropathy). The diagnosis is also difficult to make as pain symptoms may depend on the region of the SI joint that is involved (anterior, posterior, and/or extra-articular ligaments). Pain may radiate into the buttock, groin and entire ipsilateral lower limb, although if pain is present above L5, it is not thought to be from the SI joint.
Innervation: The anterior portion is thought to be innervated by the posterior rami of the L1-S2 roots and the posterior portion by the posterior rami of L4-S3.although the actual innervation remains unclear. Anterior innervation may also be supplied by the obturator nerve, superior gluteal nerve and/or lumbosacral trunk. (Vallejo, 2006) Other research supports innervation by the S1 and S2 sacral dorsal rami.
Etiology: includes degenerative joint disease, joint laxity, and trauma (such as a fall to the buttock). The main cause is SI joint disruption from significant pelvic trauma.
Diagnosis: Specific tests for motion palpation and pain provocation have been described for SI joint dysfunction: Cranial Shear Test; Extension Test; Flamingo Test; Fortin Finger Test; Gaenslen’s Test; Gillet’s Test (One Legged-Stork Test); Patrick’s Test (FABER); Pelvic Compression Test; Pelvic Distraction Test; Pelvic Rock Test; Resisted Abduction Test (REAB); Sacroiliac Shear Test; Standing Flexion Test; Seated Flexion Test; Thigh Thrust Test (POSH). Imaging studies are not helpful. It has been questioned as to whether SI joint blocks are the “diagnostic gold standard.” The block is felt to show low sensitivity, and discordance has been noted between two consecutive blocks (questioning validity). (Schwarzer, 1995) There is also concern that pain relief from diagnostic blocks may be confounded by infiltration of extra-articular ligaments, adjacent muscles, or sheaths of the nerve roots themselves. Sacral lateral branch injections have demonstrated a lack of diagnostic power and area not endorsed for this purpose. (Yin, 2003)
Treatment: There is limited research suggesting therapeutic blocks offer long-term effect. There should be evidence of a trial of aggressive conservative treatment (at least six weeks of a comprehensive exercise program, local icing, mobilization/manipulation and anti-inflammatories) as well as evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease prior to a first SI joint block. If helpful, the blocks may be repeated; however, the frequency of these injections should be limited with attention placed on the comprehensive exercise program. (Forst, 2006) (Berthelot, 2006) (van der Wurff, 2006) (Laslett, 2005) (Zelle, 2005) (McKenzie-Brown 2005) (Pekkafahli, 2003) (Manchikanti, 2003) (Slipman, 2001) (Nelemans-Cochrane, 2000) See also Intra-articular steroid hip injection; & Sacroiliac joint radiofrequency neurotomy.
Criteria for the use of sacroiliac blocks:
- The history and physical should suggest the diagnosis (with documentation of at least 3 positive exam findings as listed above).
- Diagnostic evaluation must first address any other possible pain generators.
- The patient has had and failed at least 4-6 weeks of aggressive conservative therapy including PT, home exercise and medication management.
- Blocks are performed under fluoroscopy.
- A positive diagnostic response is recorded as 80% for the duration of the local anesthetic. If the first block is not positive, a second diagnostic block is not performed.
- If steroids are injected during the initial injection, the duration of pain relief should be at least 6 weeks with at least > 70% pain relief recorded for this period.
- In the treatment or therapeutic phase (after the stabilization is completed), the suggested frequency for repeat blocks is 2 months or longer between each injection, provided that at least >70% pain relief is obtained for 6 weeks.
- The block is not to be performed on the same day as a lumbar epidural steroid injection (ESI), transforaminal ESI, facet joint injection or medial branch block.
- In the treatment or therapeutic phase, the interventional procedures should be repeated only as necessary judging by the medical necessity criteria, and these should be limited to a maximum of 4 times for local anesthetic and steroid blocks over a period of 1 year."
The IRO doctor noted the criteria for the use of sacroiliac blocks were not met in the following respects: the requesting physician did not document three positive exam findings from the list in the diagnosis section of the entry; the requesting physician did not document that Claimant had and failed at least 4-6 weeks of aggressive conservative treatment including physical therapy, home exercise, and medication management; and the requesting physician did not document the percentage improvement and duration of benefit of prior bilateral SI joint injections administered to Claimant.
Claimant failed to present an evidence-based medical opinion from a competent source to overcome the IRO’s decision. There was a letter from Dr. C dated April 16, 2008 setting forth his side of the story. Dr. C argues in this letter that Claimant had been under treatment for a long time, with multiple surgeries each followed by physical therapy, and had met the 4-6 weeks of aggressive conservative treatment criterion "on numerous occasions", and that the prior SI injections resulted in "significant improvement", however he does not successfully rebut the specific findings of the IRO doctor regarding failure to meet ODG criteria. Concerning evidence-based medicine, Dr. C states he disagrees with the ODG guidelines but does not point to any other guideline or standard supported by evidence-based medicine.
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
- 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).
C.On __________ Claimant sustained a compensable injury.
D. The Independent Review Organization determined that Claimant should not have bilateral sacroiliac (SI) joint injection under fluoroscopy.
CONCLUSIONS OF LAW
- The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
- Venue is proper in the (City) Field Office.
- The preponderance of the evidence is not contrary to the decision of the IRO that Claimant is not entitled to bilateral sacroiliac (SI) joint injection under fluoroscopy for the compensable injury of __________.
Claimant is not entitled to bilateral sacroiliac (SI) joint injection under fluoroscopy for the compensable injury of __________.
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 of the Act.
The true corporate name of the insurance carrier is TRAVELERS INDEMNITY COMPANY OF ILLINOIS, and the name and address of its registered agent for service of process is
CORPORATION SERVICE COMPANY
701 BRAZOS STREET, SUITE 1050
AUSTIN, TEXAS 78701
Signed this 13th day of November, 2008.