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At a Glance:
Title:
09088-m6r
Date:
January 15, 2009

09088-m6r

January 15, 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 contested case hearing was held on 12/16/08 to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of the

Independent Review Organization (IRO) that repeat lumbar epidural

steroid injections are not reasonable and necessary health care services

for the compensable injury of _______?

PARTIES PRESENT

Claimant /Petitioner appeared and was assisted by CL, ombudsman. Carrier /Respondent appeared and was represented by DP, attorney. WH was present for the Employer.

BACKGROUND INFORMATION

On _______, Claimant sustained a compensable injury when he fell from an oilrig and injured his back. After the injury, Claimant was treated conservatively by Dr. W and given three epidural steroid injections in 2004. Claimant said these injections did not help. Claimant changed doctors and came under the treatment of Dr. DB, neurologist. Dr. DB treated Claimant with an epidural steroid injection on 07/31/07 and a second epidural steroid injection on 09/28/07. Dr. DB recommended the third in a series-of- three epidural steroid injections. Carrier denied the treatment and was successful in the Utilization Review and Independent Review Organization process in its denial of the treatment.

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. In this case, the Independent Review Organization physician, board certified in physical medicine and rehabilitation, denied the additional epidural steroid injection because there was no documentation of significant improvement after the first and second injections.

The initial inquiry in any dispute regarding medical necessity is whether the proposed care is consistent with the ODG. The ODGnotes the purpose of epidural steroid injections is to reduce pain and states this treatment alone offers no significant long-term functional benefit. The ODGstates current research does not support a routine use of "series-of-three" injections in either the diagnostic or the therapeutic phase. If the decision is made to use "series-of-three" epidural steroid injections, the ODG criteria requires, among other things, a baseline documentation of a 50% to 70% relief of pain after each injection. This means the treating physician must first establish a baseline threshold of pain before the injections begin. After the first injection, there must be at least a 50% decrease in pain from this baseline, and this must be documented timely in the records.

By report dated 08/13/08, Dr. DB reports Claimant's pain was cut in half by the prior epidural steroid injections. However, there is no record of an established baseline pain threshold and no contemporaneous documentation of 50%--70% pain reduction after the injections. Claimant continued to work at his regular job, and his Employer, WH, testified the Claimant seemed better after the first two epidural steroid injections.

Dr. NT testified that series-of-three epidural steroid injections are no longer considered proper treatment and are not recommended.

Claimant failed to present evidence-based medical evidence to overcome the Independent Review Organization's decision. The conclusory statements of Dr. DB, without sufficient reference to the ODG, or other evidence-based medicine justifying departure from the ODG, do not meet the evidentiary standard required to overcome the presumption afforded the decision of the Independent Review Organization. The preponderance of the evidence is not contrary to the decision of the Independent Review Organization that the requested repeat lumbar epidural steroid injection does not meet the criteria set out in the ODG, and is not recommended.

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).

C.Claimant sustained a compensable injury on _______

D.The Independent Review Organization determined the requested services were

not reasonable and necessary health care services for the compensable injury of

____________.

  • 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.
  • The requested repeat lumbar epidural steroid injection is not consistent with the criteria as set out in the ODG because there was no documentation of a 50% pain reduction from an established base-line pain threshold after the prior epidural steroid injections.
  • The preponderance of the evidence is not contrary to the decision of the Independent Review Organization that repeat lumbar epidural steroid injections are not 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. The requested repeat lumbar epidural steroid injections are not reasonable and necessary health care services for the compensable injury of _______.

    DECISION

    The preponderance of the evidence is not contrary to the decision of the Independent Review Organization that Claimant is not entitled to a repeat lumbar epidural steroid injection 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 MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is:

    MR. RUSSELL OLIVER, PRESIDENT

    6210 EAST HWY. 290

    AUSTIN, TX 78723

    Signed this 15th day of January, 2009.

    G. W. Quick
    Hearing Officer

    End of Document
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