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At a Glance:
Title:
11044-m6r
Date:
October 18, 2010

11044-m6r

October 18, 2010

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.

ISSUES

A contested case hearing was held on October 18, 2010, to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that a right total knee arthroplasty is not reasonably required health care for the compensable injury of ____________?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by PA, ombudsman. Respondent/Carrier appeared and was represented by JF, attorney. The employer representative was BJ.

BACKGROUND INFORMATION

Claimant injured her right knee as she stepped off a curb while leaving work on ____________. She was seen at the emergency room where x-rays were taken. No fracture was noted and Claimant was given a knee immobilizer, crutches, and anti-inflammatory medications. She then saw the company doctor who recommended an MRI. Since he was unable to have an MRI scheduled through the company dispensary, he referred her to (Healthcare Provider) where she saw SS. Ms. SS ordered the MRI and, upon reviewing the results, referred Claimant to Dr. J, MD. Dr. J had previously been Claimant’s surgeon for a right knee ACL reconstruction using a graft in 2002. Dr. J’s 2002 surgery followed a prior ACL reconstruction in the early 80s and a later arthroscopic surgery to repair a bucket-handle tear of the medial meniscus.

Claimant testified that when she went to Dr. J, the only treatment option suggested was a total knee arthroplasty. Dr. J requested pre-authorization for the total knee arthroplasty and Carrier denied the request. After Carrier’s second denial of pre-authorization, Claimant requested that the matter be submitted to an Independent Review Organization (IRO). The Department appointed (Independent Review Organization) as the IRO. The IRO assigned the case to a board certified orthopedic surgeon for review. The physician reviewer agreed with Carrier’s Utilization Review doctors that the Official Disability Guidelines (ODG) did not support a total knee replacement under the circumstances and that it was not reasonably required health care for the compensable injury. The physician reviewer noted that he had reviewed a letter from Dr. J, dated July 13, 2010, in considering the pre-authorization request.

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 making decisions about the care of individual patients. 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 (sic) 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."

With regard to a total knee arthroplasty, also referred to as a total knee joint replacement, the ODG says:

Knee joint replacement

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. (Ayers, 2010)

Unicompartmental knee replacement: Recommended as an option. Unicompartmental knee replacement is effective among patients with knee OA restricted to a single compartment. (Dalury, 2009)

Obesity: After total knee arthroplasty (TKA) for osteoarthritis of the knee, obese patients fare nearly as well as their normal-weight peers. A British research team reports that higher BMI (up to 35) should not be a contraindication to TKA, provided that the patient is sufficiently fit to undergo the short-term rigors of surgery. TKA also halts the decline and maintains physical function in even the oldest age groups (> 75 years). (Stets, 2010)

Minimally invasive total knee arthroplasty: No significant benefit was seen in using a minimally invasive surgical technique over a standard traditional technique for total knee arthroplasty, but the study did not focus on quality-of-life outcomes (eg, length of hospital stay, reliance on pain medications, and the need for inpatient rehabilitation after discharge), in which the minimally invasive approach is purported to show an advantage. (Wülker, 2010)

ODG Indications for Surgery -- Knee arthroplasty:

Criteria for knee joint replacement (If only 1compartment is affected, a unicompartmental or partial replacement may be considered. 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, where increased BMI poses elevated risks for post-op complications. PLUS
  4. Imaging Clinical Findings: Osteoarthritis on: Standing x-ray. OR Arthroscopy.

(Callahan, 1995)

Claimant testified that Dr. J did not suggest viscosupplementation, steroid injections, or any other conservative care. He feels the only viable option for her treatment is the total right knee arthroplasty. In a letter dated September 23, 2010, Dr. J wrote that “the only way to cure” Claimant’s right knee problems is with the recommended total knee arthroplasty and that steroid injections and viscosupplementation “really do not correct the underlying problem” and would afford only short term relief. At the time of the IRO review, Claimant was less than 50 years old. There is no documentation of nighttime joint pain in Claimant’s medical records, although she testified during the hearing that she experiences nighttime pain. Since Dr. J has not attempted any conservative care, the preponderance of the evidence is not contrary to the IRO decision that evidence based medicine does not support the requested total knee arthroplasty.

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 sustained a compensable injury while employed by (Employer).

C.The Texas Department of Insurance appointed (Independent Review Organization) as the Independent Review Organization in this matter.

  • 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 has not received viscosupplementation or steroid injections to the right knee as part of a course of conservative treatment for the compensable injury to the right knee.
  • A right total knee arthroplasty is not reasonably required medical treatment 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 preponderance of the evidence is not contrary to the decision of IRO that a total right knee arthroplasty is not reasonably required medical care for the compensable injury of ____________.

    DECISION

    Claimant is not entitled to a total right knee arthroplasty 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 §408.021.

    The true corporate name of the insurance carrier is ACE AMERICAN INSURANCE COMPANY and the name and address of its registered agent for service of process is

    CT CORPORATION SYSTEM

    350 NORTH ST. PAUL STREET

    DALLAS, TX 75201

    Signed this 18th day of October, 2010.

    KENNETH A. HUCHTON
    Hearing Officer

    End of Document
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