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At a Glance:
Title:
11132
Date:
May 4, 2011
Status:
Concurrent Medical Necessity

11132

May 4, 2011

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 continued from March 11, 2011, until April 28, 2011, 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 stellate ganglion block with anesthesia for the compensable injury of ________________?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by BT, ombudsman. Respondent/Carrier appeared and represented by LM, attorney.

BACKGROUND INFORMATION

Claimant, a welder, sustained a compensable left hand crush injury on ________________. Claimant testified that he came under the care of Dr. F, M.D. and underwent a regimen of physical therapy, medication, and one steroid injection. Claimant has not undergone surgery. Claimant continued to experience ongoing left hand pain and Dr. F recommended that Claimant undergo a stellate ganglion block with anesthesia. Carrier denied Claimant’s request and Claimant requested an IRO review of Carrier's denial.

The IRO reviewer was identified as a medical doctor who was board certified in physical medicine and rehabilitation. The IRO reviewer upheld Carrier’s denial and determined that the stellate ganglion block with anesthesia was not health care reasonably required for Claimant’s compensable injury. The IRO reviewer noted that the medical records that were reviewed indicated Claimant had ongoing complaints of pain, swelling, and discoloration in the left upper extremity, and a December 11, 2009, left hand X-ray indicated that Claimant had a small foreign body near the left thumb. The IRO reviewer further noted that the Official Disability Guidelines (ODG) states that there is limited evidence to support the stellate ganglion block with anesthesia, and that it should be used where there has been a diagnosis of complex regional pain syndrome (CRPS) and for the diagnosis and treatment of sympathetic pain. The IRO reviewer further stated that the foreign body near Claimant’s left thumb based on the X-ray may be contributing to Claimant’s symptoms, and should be further examined to rule out all other possible diagnoses prior to undergoing the stellate ganglion block with anesthesia.

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. 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 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."

Under the ODG, the section on stellate ganglion blocks provides as follows:

“Recommendations are generally limited to diagnosis and therapy for CRPS. See CRPS, sympathetic and epidural blocks for specific recommendations for treatment. Detailed information about stellate ganglion blocks, thoracic sympathetic blocks, and lumbar sympathetic blocks is found in Regional sympathetic blocks.”

The pertinent section of the ODG on CRPS that addresses sympathetic and epidural blocks provides as follows:

“Recommended only as indicated below, for a limited role, primarily for diagnosis of sympathetically mediated pain and as an adjunct to facilitate physical therapy. Detailed information about stellate ganglion blocks, thoracic sympathetic blocks, and lumbar sympathetic blocks is found in Regional sympathetic blocks.”

The pertinent section of the ODG concerning stellate ganglion blocks is found under Regional sympathetic blocks and provides as follows:

“Recommendations are generally limited to diagnosis and therapy for CRPS. See CRPS, sympathetic and epidural blocks for specific recommendations for treatment. Also see CRPS, diagnostic criteria; CRPS, medications; & CRPS.

Stellate ganglion block (SGB) (Cervicothoracic sympathetic block): There is limited evidence to support this procedure, with most studies reported being case studies. The one prospective double-blind study (of CRPS) was limited to 4 subjects. Anatomy: Sympathetic flow to the head, neck and most of the upper extremities is derived from the upper five to seven thoracic spinal segments. The stellate ganglion is formed by a fusion of the inferior and first thoracic sympathetic ganglia in 80% of patients. In the other 20%, the first thoracic ganglion is labeled the stellate ganglion. The upper extremity may also be innervated by branches for Kuntz’s nerves, which may explain inadequate relief of sympathetic related pain. Proposed Indications: This block is proposed for the diagnosis and treatment of sympathetic pain involving the face, head, neck, and upper extremities. Pain: CRPS; Herpes Zoster and post-herpetic neuralgia; Frostbite. Circulatory insufficiency: Traumatic/embolic occlusion; Post-reimplantation; Post-embolic vasospasm; Raynaud’s disease; Vasculitis; Scleroderma. Testing for an adequate block: Adequacy of a sympathetic block should be recorded. A Horner’s sign (ipsilateral ptosis, miosis, anhydrosis conjunctival engorgement, and warmth of the face) indicates a sympathetic block of the head and face. It does not indicate a sympathetic block of the upper extremity. The latter can be measured by surface temperature difference (an increase in temperature on the side of the block). Somatic block of the arm should also be ruled out (the incidence of brachial plexus nerve block is ~ 10%). Complete sympathetic blockade can be measured with the addition of tests of abolition of sweating and of the sympathogalvanic response. Documentation of motor and/or sensory block should occur. Complications: Incidental recurrent laryngeal nerve block or superior laryngeal nerve block, resulting in hoarseness and subjective shortness of breath; Brachial plexus block; Intravascular injection; Intrathecal, subdural or epidural injection; Puncture of the pleura with pneumothorax; Bleeding and hematoma. There appears to be a positive correlation between efficacy and how soon therapy is initiated (as studied in patients with CRPS of the hand). Duration of symptoms greater than 16 weeks before the initial SGB and/or a decrease in skin perfusion of 22% between the normal and affected hands adversely affected the efficacy of SGB therapy. (Ackerman, 2006) (Sayson, 2004) (Grabow, 2005) (Colorado, 2006) (Price, 1998) (Day, 2008) (Nader, 2005) See also Stellate ganglion block.”

Claimant appealed the IRO decision. In accordance with Division Rule 133.308(t), Claimant, the appealing party of the IRO decision, had the burden of overcoming the IRO decision by a preponderance of evidence-based medical evidence. Claimant was the sole witness on his behalf. Claimant testified about the events surrounding his compensable injury, the course of treatment that he had received, and that he supported Dr. F’s recommendation that he undergo the stellate ganglion block with anesthesia. After a careful review and consideration given to the evidence, Claimant did not meet his burden of proof of overcoming the IRO decision by a preponderance of evidence-based medical evidence. The preponderance of the evidence-based medical evidence is not contrary to the decision of the IRO that Claimant is not entitled to a stellate ganglion block with anesthesia for the compensable injury of ________________.

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.On ________________, Employer provided workers’ compensation insurance with Arch Insurance Company.

D.Claimant sustained a compensable left hand crush injury on ________________.

E.The Independent Review Organization (IRO) determined that Claimant is not entitled to a stellate ganglion block with anesthesia 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 stellate ganglion block with anesthesia 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 is proper in the (City) Field Office.
    3. The preponderance of the evidence is not contrary to the decision of the IRO that the stellate ganglion block with anesthesia is not health care reasonably required for the compensable injury of ________________.

    DECISION

    Claimant is not entitled to the stellate ganglion block with anesthesia 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 of ________________, in accordance with Texas Labor Code Ann. §408.021.

    The true corporate name of the insurance carrier is ARCH 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, TEXAS 75201

    Signed this 4th day of May, 2011.

    Wes Peyton
    Hearing Officer

    End of Document
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