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 July 27, 2009, 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 a left sacroiliac joint injection for the compensable injury of _____________?

PARTIES PRESENT

Claimant appeared, and was assisted by Ombudsman PB, and Petitioner appeared by telephone; Respondent/Carrier appeared, and was represented by Adjustor RM.

BACKGROUND INFORMATION

Claimant twisted his low back when he fell between a truck and a loading dock on _____________. After Claimant was treated with medication and physical therapy, he was referred to Dr. B for an orthopedic consultation. Dr. B has recommended that Claimant undergo the proposed left sacroiliac joint injection of anti-inflammatory medication, so as to allow the body’s natural healing process to occur.

The Independent Review Organization denied the requested treatment as being not reasonable or necessary under the circumstances presented by this case. Specifically, the IRO observed that the medical documentation provided does not support a conclusion that Claimant has undergone the four to six weeks of aggressive conservative therapy that the Official Disability Guidelines (ODG) considers a prerequisite to sacroiliac joint blocks; moreover, the IRO stated that the positive Faber’s test that Dr. B noted is not indicative of sacroiliac joint dysfunction.

DISCUSSION

Section 408.021 of the Texas Labor Code 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.

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.

With regard to sacroiliac joint injections, the ODG sets forth the following:

Recommended as an option if failed at least 4-6 weeks of aggressive conservative therapy. See the Hip & Pelvis Chapter for more information, references, and ODG Criteria for the use of sacroiliac blocks.

The Hip and Pelvis Chapter, cited above, provides the following additional information regarding sacroiliac joint blocks:

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:

1. The history and physical should suggest the diagnosis (with documentation of at least 3 positive exam findings as listed above).
2. Diagnostic evaluation must first address any other possible pain generators.
3. The patient has had and failed at least 4-6 weeks of aggressive conservative therapy including PT, home exercise and medication management.
4. Blocks are performed under fluoroscopy. (Hansen, 2003)
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.

Comparing the content of the ODG with the specifics of the case at bar, the Hearing Officer notes that, as Dr. B testified, the ODG does, indeed, state that a positive Faber’s test describes sacroiliac joint dysfunction. However, the indefinite evidence of the frequency and duration of Claimant’s physical therapy^[1] is not sufficient to establish compliance with the ODG’s third criterion for the use of a sacroiliac block, set forth above.

As the evidence contained in the record of the Contested Case Hearing does not show compliance with the ODG, and as Claimant has presented no evidence-based medical opinion to justify a departure from the ODG and the IRO opinion based thereon, a decision in Carrier’s favor is appropriate with respect to the sole issue presented for resolution herein.

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 fact:

On _____________, Claimant’s residence was located within seventy-five miles of the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation

On _____________, Claimant was employed by (Employer).

On _____________, Employer subscribed to a policy of workers’ compensation insurance issued by the Hartford Fire insurance Company, Carrier.

On _____________, Claimant sustained an injury arising out of the course and scope of his employment with Employer.

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.

Claimant’s treating doctor, Dr. B, M.D., recommended that Claimant undergo a left sacroiliac joint injection as treatment for Claimant’s compensable injury of _____________.

The Independent Review Organization (IRO) determined that a left sacroiliac joint injection was not reasonable and necessary health care for Claimant’s compensable injury of _____________.

A left sacroiliac joint injection is not health care reasonably required for Claimant’s 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 IRO’s decision that a left sacroiliac joint injection is not health care reasonably required for the compensable injury of _____________.

DECISION

Claimant is not entitled to a left sacroiliac joint injection for his 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 HARTFORD FIRE INSURANCE COMPANY, and the name and address of its registered agent for service of process is

CORPORATION SERVICES COMPANY

701 BRAZOS STREET, SUITE 1050

AUSTIN, TEXAS 78701

Signed this 28^th day of July, 2009.

Ellen Vannah
Hearing Officer

1. Dr. B testified that he thought Claimant had attended sixteen sessions of therapy.

2. ↑