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At a Glance:
Title:
12010
Date:
July 27, 2011
Status:
Concurrent Medical Necessity

12010

July 27, 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 held on July 26, 2011 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to a cervical epidural steroid injection (ESI) at C4-5 and C5-6 for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared and was represented by TP, attorney.

Respondent/Carrier appeared and was represented by SC, attorney. Dr. B appeared telephonically and represented himself.

BACKGROUND INFORMATION

Claimant sustained a compensable injury to her lumbar spine on (Date of Injury) when she was pulling a patient. Claimant stated that she immediately felt pain in her neck. Claimant underwent an MRI of the cervical spine on 4/25/10 which revealed multilevel spondylosis most pronounced at C4-5 and C5-6. The Claimant’s treating doctor, Dr. B, requested a Cervical ESI at C4-5 and C5-6. An EMG on 6/29/10 was grossly unremarkable. The claimant underwent physical therapy. The request by Dr. B was for two interlaminar levels to be injected. This request was denied by the Carrier and referred to an IRO who determined that the recommended treatment was not medically necessary.

The IRO reviewer, board certified in physical medicine and rehabilitation and in pain management, upheld the previous adverse determination stating that, based on the clinical documentation, the requested procedure did not meet the Official Disability Guidelines (ODG) and would not be considered medically necessary. The IRO reviewer noted that the Claimant had undergone prior physical therapy and taken pain medications with no significant benefits; however, the request still did not meet the ODG criteria. The IRO reviewer cited the ODG noting that to consider an ESI injection there must be unequivocal evidence of radiculopathy. The ODG provides that no more than one interlaminar level should be injected in one session. During the hearing the doctor stated that two injections were requested in error by his office. The IRO reviewer indicated in his report that additional studies, such as an EMG, did not support radiculopathy for this Claimant.

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 for 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 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. 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."

ODG Criteria for the use of epidural steroid injections:

Recommended as an option for treatment of radicular pain (defined as pain in dermatomal distribution with corroborative findings of radiculopathy). See specific criteria for use below. In a recent Cochrane review, there was one study that reported improvement in pain and function at four weeks and also one year in individuals with chronic neck pain with radiation. (Peloso-Cochrane, 2006) (Peloso, 2005) Other reviews have reported moderate short-term and long-term evidence of success in managing cervical radiculopathy with interlaminar ESIs. (Stav, 1993) (Castagnera, 1994) Some have also reported moderate evidence of management of cervical nerve root pain using a transforaminal approach. (Bush, 1996) (Cyteval, 2004) A recent retrospective review of interlaminar cervical ESIs found that approximately two-thirds of patients with symptomatic cervical radiculopathy from disc herniation were able to avoid surgery for up to 1 year with treatment. Success rate was improved with earlier injection (< 100 days from diagnosis). (Lin, 2006) There have been recent case reports of cerebellar infarct and brainstem herniation as well as spinal cord infarction after cervical transforaminal injection. (Beckman, 2006) (Ludwig, 2005) Quadriparesis with a cervical ESI at C6-7 has also been noted (Bose, 2005) and the American Society of Anesthesiologists Closed Claims Project database revealed 9 deaths or cases of brain injury after cervical ESI (1970-1999). (Fitzgibbon, 2004) These reports were in contrast to a retrospective review of 1,036 injections that showed that there were no catastrophic complications with the procedure. (Ma, 2005) The American Academy of Neurology recently concluded that epidural steroid injections may lead to an improvement in radicular lumbosacral pain between 2 and 6 weeks following the injection, but they do not affect impairment of function or the need for surgery and do not provide long-term pain relief beyond 3 months, and there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain. (Armon, 2007) There is evidence for short-term symptomatic improvement of radicular symptoms with epidural or selective root injections with corticosteroids, but these treatments did not appear to decrease the rate of open surgery. (Haldeman, 2008) (Benyamin, 2009) See the Low Back Chapter for more information and references.

Criteria for the use of Epidural steroid injections, therapeutic:

Note: The purpose of ESI is to reduce pain and inflammation, thereby facilitating progress in more active treatment programs, and avoiding surgery, but this treatment alone offers no significant long-term functional benefit.

  1. Radiculopathy must be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing.
  2. Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle relaxants).
  3. Injections should be performed using fluoroscopy (live x-ray) for guidance
  4. If used for diagnostic purposes, a maximum of two injections should be performed. A second block is not recommended if there is inadequate response to the first block. Diagnostic blocks should be at an interval of at least one to two weeks between injections.
  5. No more than two nerve root levels should be injected using transforaminal blocks.
  6. No more than one interlaminar level should be injected at one session.
  7. In the therapeutic phase, repeat blocks should only be offered if there is at least 50% pain relief for six to eight weeks, with a general recommendation of no more than 4 blocks per region per year.
  8. Repeat injections should be based on continued objective documented pain and function response.
  9. Current research does not support a “series-of-three” injections in either the diagnostic or therapeutic phase. We recommend no more than 2 ESI injections.
  10. It is currently not recommended to perform epidural blocks on the same day of treatment as facet blocks or stellate ganglion blocks or sympathetic blocks or trigger point injections as this may lead to improper diagnosis or unnecessary treatment.
  11. Cervical and lumbar epidural steroid injection should not be performed on the same day.

Criteria for the use of Epidural steroid injections, diagnostic:

To determine the level of radicular pain, in cases where diagnostic imaging is ambiguous, including the examples below:

  1. To help to evaluate a pain generator when physical signs and symptoms differ from that found on imaging studies;
  2. To help to determine pain generators when there is evidence of multi-level nerve root compression;
  3. To help to determine pain generators when clinical findings are suggestive of radiculopathy (e.g. dermatomal distribution), and imaging studies have suggestive cause for symptoms but are inconclusive;
  4. To help to identify the origin of pain in patients who have had previous spinal surgery.

Pursuant to the ODG recommendations for ESI's, radiculopathy must be documented and objective findings on examination need to be present. Without documented, objective evidence of radiculopathy, the criteria for ESI’s, as set forth in the ODG, has not been met. Additionally, the request for two interlaminar levels to be injected at one session does not conform with the guidelines. The IRO reviewer found that the medical records fail to establish the presence of active cervical radiculopathy and the cervical MRI does not support the diagnoses. The Petitioner has the burden of proof to overcome the IRO determination and the Petitioner failed to present sufficient evidence based medical opinion contrary to the determination of the IRO that the Claimant is not entitled to a cervical ESI at C4-5 and C5-6 for the compensable injury of (Date of Injury). In fact, the petitioner admitted that his office made a mistake in requesting two interlaminar levels to be injected in one session.

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:
    1. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    2. On (Date of Injury), Claimant was the employee of (Employer).
    3. Claimant sustained a compensable injury to her cervical spine on (Date of Injury).
  2. 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.
  3. The Claimant does not meet the requirements of the ODG for a cervical ESI at C4-5 and C5-6, and neither petitioner nor claimant presented other evidence based medicine sufficient to overcome the determination of the IRO.
  4. The cervical ESI at C4-5 and C5-6 is not health care reasonably required for the compensable injury of (Date of Injury).

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 Claimant is not entitled to cervical ESI injections at C4-5 and C5-6 for the compensable injury of (Date of Injury).

DECISION

Claimant is not entitled to cervical ESI injections at C4-5 and C5-6 for the compensable injury of (Date of Injury)

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 TRAVELERS INDEMNITY COMPANY and the name and address of its registered agent for service of process is:

CORPORATION SERVICE COMPANY

211 EAST 7TH ST, STE. 620

AUSTIN, TEXAS 78701

Signed this 27th day of July, 2011.

Susan Meek
Hearing Officer

End of Document
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