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At a Glance:
Title:
14070-nnr
Date:
June 24, 2014

14070-nnr

June 24, 2014

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and the Rules of the Texas Department of Insurance, Division of Workers’ Compensation. For the reasons discussed herein, the Hearing Officer determines that: (1) the preponderance of the evidence is not contrary to the decision of the IRO that Claimant is not entitled to 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, for the compensable injury of (Date of Injury).

ISSUES

A contested case hearing was held on June 5, 2014, to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant failed to appear for the contested case hearing. Carrier/Respondent appeared and was represented by PM, attorney.

BACKGROUND INFORMATION

Although properly notified, Claimant failed to appear for the contested case hearing scheduled for 8:30 a.m. on June 5, 2014. A letter advising that the hearing had convened and that the record would be held open for ten days to afford Claimant the opportunity to respond and request that the hearing be rescheduled to permit him to present evidence on the disputed issues and to show “good cause” for his failure to attend the hearing was mailed to Claimant on June 5, 2014. Claimant failed to respond to the Division’s 10-day letter. The record was closed effective June 20, 2014. Having failed to appear and offer evidence in support of his claim, Claimant failed to show that he is entitled to the relief he seeks.

Evidence presented in the hearing revealed that Petitioner/Claimant sustained a compensable injury on (Date of Injury), when he fell while he was trying to sit in a chair and missed. Petitioner/Claimant was evaluated on November 16, 2012, for low back pain, neck pain and left knee pain. Petitioner/Claimant was diagnosed with lumbar radiculopathy, herniated/bulging disc at L5-S1, sciatica bilaterally, degenerative joint disease of the bilateral knees, myospasm and chronic pain syndrome.

The utilization review dated September 26, 2013, resulted in a denial for 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013.

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 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(s), "A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division is 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 pertinent provisions of the ODG applicable to this case are as follows, to wit:

Carisoprodol (Soma®)

Not recommended. This medication is FDA-approved for symptomatic relief of discomfort associated with acute pain in musculoskeletal conditions as an adjunct to rest and physical therapy. (AHFS, 2008) This medication is not indicated for long-term use. Carisoprodol is a commonly prescribed, centrally acting skeletal muscle relaxant whose primary active metabolite is meprobamate (a schedule-IV controlled substance). Carisoprodol is now scheduled in several states but not on a federal level. It has been suggested that the main effect is due to generalized sedation and treatment of anxiety. Abuse has been noted for sedative and relaxant effects. In regular abusers the main concern is the accumulation of meprobamate. Carisoprodol abuse has also been noted in order to augment or alter effects of other drugs. This includes the following:

  1. increasing sedation of benzodiazepines or alcohol;
  2. use to prevent side effects of cocaine;
  3. use with tramadol to produce relaxation and euphoria;
  4. as a combination with hydrocodone, an effect that some abusers claim is similar to heroin (referred to as a “Las Vegas Cocktail”); &
  5. as a combination with codeine (referred to as “Soma Coma”).
  6. (Reeves, 1999) (Reeves, 2001) (Reeves, 2008) (Schears, 2004) (Owens, 2007)
  7. There was a 300% increase in numbers of emergency room episodes related to carisoprodol from 1994 to 2005. (DHSS, 2005) Intoxication appears to include subdued consciousness, decreased cognitive function, and abnormalities of the eyes, vestibular function, appearance, gait and motor function. Intoxication includes the effects of both carisoprodol and meprobamate, both of which act on different neurotransmitters. (Bramness, 2007) (Bramness, 2004) A withdrawal syndrome has been documented that consists of insomnia, vomiting, tremors, muscle twitching, anxiety, and ataxia when abrupt discontinuation of large doses occurs. This is similar to withdrawal from meprobamate. (Reeves, 2010) (Reeves, 2007) (Reeves, 2004) There is little research in terms of weaning of high dose carisoprodol and there is no standard treatment regimen for patients with known dependence. Most treatment includes treatment for symptomatic complaints of withdrawal. Another option is to switch to phenobarbital to prevent withdrawal with subsequent tapering. A maximum dose of phenobarbital is 500 mg/day and the taper is 30 mg/day with a slower taper in an outpatient setting. Tapering should be individualized for each patient. (Boothby, 2003) For more information and references, see Muscle relaxants. See also Weaning of medications.

The case was reviewed by a physical medicine and rehabilitation specialist who upheld the denial of the 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013. The basis of the denial was that Petitioner/Claimant lacked clinical documentation. The only available documentation at the time was pharmacy billing dated September 20, 2013. Evidence-based treatment guidelines indicate that carisoprodol is not recommended. This medication is FDA-approved for symptomatic relief of discomfort associated with acute pain in musculoskeletal conditions as an adjunct to rest and physical therapy. This medication is not indicated for long-term use. This medication should only be used for short periods [up to two or three weeks]. There was no clinical documentation revealing subjective or objective findings or other treatment provided to the Petitioner/Claimant. Also there was no documentation revealing the provider’s clinical rationale for the requested medications.

Petitioner/Claimant did not present any evidence in support of his position.

Medical documentation and testimony were insufficient to establish that the treatment requested was medically necessary. Therefore, the Petitioner has failed to meet his burden to overturn the decision of the IRO that Claimant is not entitled to a 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013.

The Hearing Officer considered all of the evidence admitted. The Findings of Fact and Conclusions of Law are based on an assessment of all of the evidence whether or not the evidence is specifically discussed in this Decision and Order.

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), Employer.
    3. On (Date of Injury), Claimant sustained a low back compensable injury.
    4. On (Date of Injury), Employer provided workers’ compensation insurance with American Home Assurance Company, Carrier.
  2. Carrier delivered to Claimant and Provider 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 IRO determined that THE Claimant was not entitled to 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, for treatment of for the compensable injury of (Date of Injury).
  4. 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, 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 o 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 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, is not health care reasonably required for the compensable injury of (Date of Injury).

DECISION

Claimant is not entitled to 90 Carisoprodol 350 mg between September 23, 2013, and November 22, 2013, 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 AMERICAN HOME ASSURANCE COMPANY and the name and address of its registered agent for service of process is:

CORPORATION SERVICES COMPANY

701 BRAZOS STREET, STE. 1050

AUSTIN, TEXAS 78701

Signed this 24th day of June, 2014.

Jacqueline Harrison
Hearing Officer

End of Document
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