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At a Glance:
Title:
09085
Date:
January 22, 2009
Status:
Concurrent Medical Necessity

09085

January 22, 2009

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 held on January 12, 2008, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that Claimant is not entitled to inpatient total left knee arthroplasty with inpatient length of stay for 3 days for the compensable injury of ______________?

PARTIES PRESENT

Claimant appeared and was represented by DM, attorney. Carrier appeared and was represented by attorney, TW. Present on behalf of Employer was SH.

BACKGROUND INFORMATION

It is undisputed that Claimant sustained a compensable injury to his left knee while working as a policeman for the (Employer). As the result of his compensable injury, Claimant underwent two arthroscopic surgeries, which did not improve his condition. He has returned to work at desk duty as he can no longer perform his pre-injury patrol duties due to the compensable injury.

The records of Claimant’s treating doctor, Dr. M, show that Claimant underwent various conservative procedures including steroid and Hyalgan injections for treatment of his knee injury. Dr. M referred Claimant to an orthopedic surgeon, Dr. DP, who recommended left knee arthroplasty. Dr. M agreed that this procedure would provide Claimant with significant relief and, after rehabilitation, would offer a chance that he would get back to his pre-injury job duties.

Dr. DP saw Claimant in June of 2008, and diagnosed morbid obesity and severe traumatic degenerative joint disease of the left knee. He stated that he would prefer for Claimant to be at least 60 years old before having the surgery, but opined that he did not believe Claimant would make it that long. He did note the fact that carrying more weight on his knee would make Claimant’s condition worse, and recommended the possibility of surgical weight loss procedures as Claimant had difficulty exercising due to his knee injury. Dr. DP requested the total knee arthroplasty on August 26, 2008.

The carrier’s first utilization review doctor cited the ODG indications for knee surgery and denied preauthorization of the requested left knee arthroplasty. The reviewer stated that Claimant was 46 years old with significant arthritis of the knee; stood 67 inches in height; and, weighed 357 pounds, with a body mass index (BMI) of 55.9. The reviewer opined that Claimant did not satisfy the age and body mass index criteria recommended by the ODG for the requested surgery.

The utilization review doctor who reviewed the request on reconsideration also denied the requested surgery. He also cited the ODG and stated that Claimant did not meet the evidence-based criteria for the requested procedure, specifically the third criteria regarding age and body mass index of less than 35.

An IRO reviewer and board certified orthopedic surgeon reviewed the records and upheld the adverse determinations of the utilization review doctors. The IRO reviewer stated that Claimant did not meet the ODG criteria for the requested surgery because he did not have a body mass index of less than 35. The reviewer noted that Claimant met the criteria regarding conservative care, medications and viscosupplementation or steroid injections as well as limited range of motion and pain and no relief after conservative care. The reviewer further noted that imaging studies documented severe changes. The sole reason given for the IRO to uphold the preauthorization denials was that Claimant’s “body mass index is so far from one that would be considered acceptable under the ODG Guidelines that this reviewer is unable to overturn the previous decision….” The reviewer opined that with his hypertension, weight of 357 pounds and a recent rapid weight gain of greater than 100 pounds since the injury, the outcome of the total knee replacement would be jeopardized.

DISCUSSION

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. Section 401.011(22-a) defines health care reasonably required 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: (A) evidence based medicine; or (B) if that evidence is not available, generally accepted standards of medical practice recognized in the medical community.”

“Evidence based medicine” is further defined, by Section 401.011(18-a) as 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.

The Division of Workers’ Compensation 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-referenced sections of the Texas Labor Code.

ODG

The initial inquiry, therefore, in any dispute regarding medical necessity, is whether the proposed care is consistent with the ODG. As the utilization review and IRO doctors in the instant case have stated, the ODG allows for arthroplasty and sets out the circumstances under which such treatment is recommended as reasonable and necessary.

The ODG Treatment Guidelines for arthroplasty for treatment of the knee refer the reader to “knee joint replacement,” which the ODG discuss as follows:

Recommended as indicated below. Total hip and total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function. The most common diagnosis is osteoarthritis. Overall, total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. (EthgenBathisBauwensRestrepoCushnaghanGeorge, 2008)

ODG Indications for Surgery -- Knee arthroplasty:

Criteria for knee joint replacement (If only 1compartment is affected, a unicompartmental or partial replacement is indicated. If 2of the 3 compartments are affected, a total joint replacement is indicated.):

1. Conservative Care: Medications. AND (Visco supplementation injections OR Steroid injection). PLUS

2. Subjective Clinical Findings: Limited range of motion. AND Nighttime joint pain. AND No pain relief with conservative care. PLUS

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

4. Imaging Clinical Findings: Osteoarthritis on: Standing x-ray. OR Arthroscopy.

(ShengSalehCallahan, 1995)

As noted previously herein, “health care reasonably required” means 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 that evidence is not available, generally accepted standards of medical practice recognized in the medical community. Treatment provided pursuant to the ODG is presumed to be health care reasonably required.

Both of the doctors who reviewed the requested arthroplasty and the IRO doctor denied the requested surgery citing the relevant provisions of the ODG, specifically the third criteria regarding age and body mass index. It is clear from the IRO report that Claimant meets all of the other criteria for the requested surgery.

Claimant cited the Cushnaghan study referenced in the ODG in support of his position that there is no justification for withholding total knee arthroplasty from obese patients solely on the grounds of their body mass index. Claimant also cited a study entitled Long-term Outcome of Total Knee Replacement: Does Obesity Matter? published in the Obesity Surgery Journal (Volume 16, Number 1) in January 2006, which concluded that moderate obesity does not affect the clinical and radiologic outcome of total knee arthroplasty; however, total knee arthroplasty results in improved mobility, enhancing the success of subsequent weight loss therapy.

In the instant case, both parties relied on the ODG in support of their position for or against the requested treatment. The IRO cited the ODG as well, and opined essentially that because Claimant’s BMI is so far in excess of that recommended by the ODG the procedure could not be approved.

When both parties cite the ODG in support of their position, that position must be supported by sufficient evidence to justify application of the ODG. Mere citation to the ODG does not carry the day. In the instant case, the IRO report is specific and sets out exactly how Claimant fails to meet the criteria set out in the ODG.

While it is true that there is evidence-based medicine in support of the proposition that BMI alone should not justify withholding total knee arthroplasty from obese patients, Claimant has not provided evidence-based medicine sufficient to overcome the IRO opinion in the instant case. The ODG acknowledges the studies cited by the Claimant herein, however, the ODG criteria did not change based on those studies. The ODG still has a cut-off point for BMI at 35. Claimant’s BMI exceeds the ODG recommended BMI by almost 21. Claimant did not provide an opinion from his surgeon or any other qualified doctor to explain how Claimant’s specific situation justifies a departure from the four criteria set out in the ODG. In fact, Claimant’s own orthopedic surgeon recommended weight-loss surgery in light of his obesity and continued knee problems.

Under the Act, treatment provided pursuant to the ODG is presumed to be health care reasonably required as mandated by the above-referenced sections of the Texas Labor Code. Claimant failed to present an evidence-based medical opinion from a competent source to overcome the IRO’s decision. The preponderance of the evidence is not contrary to the IRO decision and the requested total knee arthroplasty with inpatient length of stay for 3 days does not meet the criteria set out in the ODG.

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.

C.The IRO determined that the requested services were not reasonable and necessary health care services for the compensable injury of ______________.

2.Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and name and street address of Carrier's registered agent which was admitted into evidence as Hearing Officer's Exhibit Number 2.

3.Claimant’s orthopedic surgeon recommended total knee arthroplasty with inpatient length of stay for 3 days as needed for treatment of Claimant’s compensable left knee injury.

4.For treatment of the knee, the ODG sets out the circumstances under which total knee arthroplasty is recommended.

5.Claimant meets three of the four ODG criteria for total knee arthroscopy; but, does not meet the third criteria regarding age and body mass and index.

6.The IRO decision upheld the Carrier’s denial of the requested total knee arthroplasty for treatment of the left knee injury because the requested surgery did not meet the criteria set out in the ODG.

7.The requested service is not consistent with the ODG criteria for total knee arthroplasty of the left knee.

8.The requested total knee arthroplasty with inpatient length of stay for 3 days is not health care reasonably required 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 was proper in the (City) Field Office.

3.The preponderance of the evidence is not contrary to the decision of IRO that total knee arthroplasty with inpatient length of stay for 3 days is not health care reasonably required for the compensable injury of ______________.

DECISION

Claimant is not entitled to total knee arthroplasty with inpatient length of stay for 3 days 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 Section 408.021.

The true corporate name of the insurance carrier is
TEXAS POLITICAL SUBDIVISIONS JOINT SELF-INSURANCE FUNDS and the name and address of its registered agent for service of process is

TIM OFFENBERGER

12720 HILLCREST DRIVE, SUITE 100

DALLAS, TEXAS 75230

Signed this 22nd day of January, 2009.

Erika Copeland
Hearing Officer

End of Document
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