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.
A contested case hearing was held on February 21, 2013 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 right knee arthroscopy with debridement and synovectomy for the compensable injury of (Date of Injury)?
Petitioner/Claimant appeared and was assisted by SL, ombudsman.
Respondent/Carrier was represented by PM, attorney.
On (Date of Injury), Claimant sustained a compensable injury to her right knee while performing her duties as a cook. As a result of the compensable injury, Claimant had arthroscopic surgery to her right knee in 2001. On December 1, 2003, she underwent a total knee replacement and in 2009 had a revision of the total knee replacement. Claimant has continued to receive treatment to her right knee and her treating physician requested a right arthroscopy with debridement and synovectomy. The requested procedure was denied by the Carrier and referred to an IRO who upheld the Carrier's denial.
The IRO reviewer, a physician Board Certified in Orthopedic Surgery, noted the multiple medical records he reviewed, including the diagnostic tests and operative reports. The reviewer stated that the “ODG does not address debridement or synovectomy following total knee arthroplasty. Further, as there are no current imaging studies available for review, there is no present clinical indication for further intervention at this time. All told, the request right knee arthroscopy with debridement and synovectomy is not supported as medically necessary for treatment of this patient’s medical condition.”
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 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."
With regard to the arthroscopy, the ODG states as follows:
Recommended as indicated below. Second look arthroscopy is only recommended in case of complications from OATS or ACI procedures, to assess how the repair is healing, or in individual cases that are ethically defendable for scientific reasons, only after a thorough and full informed consent procedure. (Vanlauwe, 2007) In patients with osteoarthritis, the value of MRI for a precise grading of the cartilage is limited, compared to diagnostic arthroplasty. When the assessment of the cartilage is crucial for a definitive decision regarding therapeutic options in patients with osteoarthritis, arthroscopy should not be generally replaced by MRI. The diagnostic values of MRI grading, using arthroscopy as reference standard, were calculated for each grade of cartilage damage. For grade 1, 2 and 3 lesions, sensitivities were relatively poor, whereas relatively better values were noted for grade 4 disorders. (von Engelhardt, 2010)
ODG Indications for Surgery -- Diagnostic arthroscopy:
Criteria for diagnostic arthroscopy:
- Conservative Care: Medications. OR Physical therapy. PLUS
- Subjective Clinical Findings: Pain and functional limitations continue despit conservative care. PLUS
- Imaging Clinical Findings: Imaging is inconclusive.
(Washington, 2003) (Lee, 2004)
For average hospital LOS if criteria are met, see Hospital length of stay (LOS).
Claimant testified that her treating physician has recommended the procedure because of the pain, swelling and fluid that is in her knee. Claimant stated that when her physician removes fluid from her knee, he also removes blood, which is why he wants to perform the requested the procedure. The treating physician provided a letter stating “this patient presents repetitively to my office with recurrent hemorrhagic effusions within the knee. In an effort to treat this condition, I have offered to her an arthroscopic evaluation of the knee for synovectomy and oblation of this hemorrhagic synovitis that she has present within her knee. There is no ODG Guideline that this lady fits into, but she continues to suffer from her work-related injury and continues to suffer unnecessarily because her condition does not fit a Guideline.” However, this statement is insufficient and merely provided a conclusion. Based on the evidence presented, Claimant did not overcome the IRO determination by a preponderance of evidence-based medical evidence.
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
- The parties stipulated to the following facts:
- Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
- On (Date of Injury), Claimant was the employee of (Employer), Employer.
- On (Date of Injury), Employer provided workers’ compensation insurance with American Home Assurance Company, Carrier.
- On (Date of Injury), Claimant sustained a compensable injury.
- 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 IRO determined that the requested service was not reasonable and necessary health care for the compensable injury of (Date of Injury).
- Claimant failed to present evidence-based medical evidence contrary to the IRO decision.
- Right knee arthroscopy with debridement and synovectomy is health care reasonably not required for the compensable injury of (Date of Injury).
CONCLUSIONS OF LAW
- The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
- Venue is proper in the (City) Field Office.
- The preponderance of the evidence is not contrary to the decision of the IRO that right knee arthroscopy with debridement and synovectomy is health care reasonably not required for the compensable injury of (Date of Injury).
Claimant is not entitled to a right knee arthroscopy with debridement and synovectomy for the compensable injury of (Date of Injury).
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 AMERICAN HOME ASSURANCE COMPANY, and the name and address of its registered agent for service of process is
CORPORATION SERVICE COMPANY
211 EAST 7TH STREET, SUITE 620
AUSTIN, TEXAS 78701-3218
Signed this 1st day of March, 2013.
Teresa G. Hartley