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April 29, 2010


April 29, 2010


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 April 23, 2010, having been rescheduled from April 20, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization that Claimant is not entitled to injection of platelet rich plasma into the left Achilles tendon lesion for the compensable injury of _______________?


Petitioner/Claimant appeared and was assisted by JT, ombudsman.

Respondent/Carrier was represented by SS, attorney.


Dr. S has recommended that Claimant have an injection of platelet rich plasma into her left Achilles tendon lesion. The reviewer for the IRO agreed with two utilization reviewers that the treatment was not medically necessary for Claimant’s compensable injury. All three reviewers relied on the Official Disability Guidelines (ODG), which does not recommend the treatment. The IRO reviewer, a medical doctor who is board certified in orthopaedics, also relied on peer reviewed national accepted literature, listing the articles.

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. The Commissioner of the Division of Workers' compensation is required to adopt treatment guidelines that are evidence-based, scientifically valid, outcome-focused and designed to reduce excessive or inappropriate medical care while safeguarding necessary medical care. Texas Labor Code Section 413.011(e). Medical services consistent with the medical policies and fee guidelines adopted by the commissioner are presumed reasonable in accordance with Texas Labor Code Section 413.017(1).

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 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. Also, in accordance with Division Rule 133.308 (t), "A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division are considered parties to an appeal. In a Contested Case Hearing (CCH), the party appealing the IRO decision has the burden of overcoming the decision issued by an IRO by a preponderance of evidence-based medical evidence."

The ODG provides the following for treating Achilles tendons with injections

Under study. There is no evidence for the effectiveness of injected corticosteroid therapy for reducing plantar heel pain. (Crawford, 2000) Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. (Crawford, 2003) There is little information available from trials to support the use of peritendonous steroid injection in the treatment of acute or chronic Achilles tendinitis. (McLauchlan, 2000) While evidence is limited, therapeutic injections are generally used procedures in the treatment of patients with ankle or foot pain or pathology. Ideally, a therapeutic injection will: reduce inflammation; relieve secondary muscle spasm; relieve pain; and support therapy directed at functional recovery. If overused, injections may be of significantly less value. (Colorado, 2001) Corticosteroid injection is more efficacious and multiple times more cost-effective than ESWT in the treatment of plantar fasciopathy. (Porter, 2005) Alcohol injection of Morton's neuroma has a high success rate and is well tolerated. The results are at least comparable to surgery, but alcohol injection is associated with less morbidity and surgical management may be reserved for nonresponders. (Hughes, 2007) Most evidence for the efficacy of intra-articular corticosteroids is confined to the knee, with few studies considering the joints of the foot and ankle. No independent clinical factors were identified that could predict a better postinjection response. (Ward, 2008) See also Hyaluronic acid injections; & Platelet-rich plasma (PRP).

The ODG provides the following for treating Achilles tendon with platelet-rich plasma:

Not recommended, with recent higher quality evidence showing this treatment to be no better than placebo. The first high quality study (an RCT in JAMA) concluded that injections of platelet-rich plasma (PRP) for chronic Achilles tendon disorder, or tendinopathy (also known as tendinitis), does not appear to reduce pain or increase activity more than placebo. Making a prediction based on previous studies, the authors hypothesized that the VISA-A (Victorian Institute of Sports Assessment-Achilles) score of the PRP group would be higher than that of the placebo group, but their findings proved otherwise. Results after 24 weeks showed that for the PRP group, the mean VISA-A score improved by 21.7 points, and the placebo group's score increased by 20.5 points, with no significant distinction between the 2 groups during any measurement period. Plus, no differences were seen in secondary outcome measures, including subjective patient satisfaction and the number of patients returning to activity. Both treatment groups showed clinical progression in this study and also in other studies on PRP, maybe due to the fact that exercises were performed in each group, and exercises have been shown to be effective, but conservative treatment is disappointing and 25% to 45% of patients eventually require surgery. (de Vos, 2010) PRP looks promising, but it is not yet ready for prime time. PRP has become popular among professional athletes because it promises to enhance performance, but there is no science behind it yet. In a prospective cohort study 30 patients with chronic refractory Achilles tendonosis were treated with PRP, and the authors concluded that PRP should be reserved for the worst of the worst patients with refractory Achilles tendonosis. (AAOS, 2010) For more discussion and references, see the Elbow Chapter

Claimant relied on some of the articles cited by the IRO reviewer and on an article cited by Dr. S. The articles cited by the IRO reviewer corroborated the reviewer’s comments that the proposed treatment has not yet received sufficient successful results to be recommended as a treatment. The article cited by Dr. S also corroborated the reviewer’s comments that the proposed treatment has not yet been proven to be effective in treating patients such as Claimant. While the treatment may some day be accepted, that day has not arrived.

Claimant’s evidence based medical evidence was not persuasive in overcoming the opinion of the IRO.

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.


  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, who was the employee of (Employer), sustained a compensable injury.

C.The Independent Review Organization determined that the requested service was not a reasonable and necessary health care service 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.
  • Injection of platelet rich plasma into the left Achilles tendon lesion is not health care reasonably required for the compensable injury of _______________.

    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 injection of platelet rich plasma into the left Achilles tendon lesion is not health care reasonably required for the compensable injury of _______________.


    Claimant is not entitled to injection of platelet rich plasma into the left Achilles tendon lesion 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.

    The true corporate name of the insurance carrier is ACE PROPERTY & CASUALTY INSURANCECOMPANY and the name and address of its registered agent for service of process is



    DALLAS, TEXAS 75201

    Signed this 29th day of April, 2010.

    Hearing Officer

    End of Document