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 Claimant is not entitled to 10 sessions of work hardening (80 hours) for the compensable injury of (Date of Injury).
STATEMENT OF THE CASE
A contested case hearing was held on September 23, 2014 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 10 sessions of work hardening (80 hours) for the compensable injury of (Date of Injury)?
Petitioner, JT, D.C., appeared without representation. Respondent/Carrier appeared and was represented by DP, attorney. Claimant waived her appearance.
The following witnesses testified:
For Claimant: JT, D. C.
For Carrier: Dr. JH.
The following exhibits were admitted into evidence:
Hearing Officer’s Exhibit HO-1 and HO-2.
Claimant’s Exhibits C-A through C-D.
Carrier’s Exhibits CR-A through CR-N.
The Claimant’s healthcare provider, JT, D.C., recommended that the Claimant undergo 10 sessions of an initial work hardening program, which would equate to 80 hours, for the compensable injury. A contested case hearing was undertaken regarding the extent of the compensable injury and the Division determined that the compensable injury extended to include a lumbar sprain/strain and an abdominal/umbilical hernia. Petitioner noted that his request was not for the repaired hernia, but was requested for the lumbar spine, and that he understood that that the compensable injury had been determined to be a lumbar sprain/strain. Petitioner’s request was denied by the Carrier and he filed a request for review, which was undertaken by a utilization review agent (URA). The URA denied the request. Petitioner requested a reconsideration of the URA’s denial and a second URA reviewed the request. This URA denied the request. Petitioner appealed this denial and the request was review by an Independent Review Organization (IRO), which denied the request. In its denial, the IRO reviewer, utilizing the Official Disability Guidelines (ODG), cited its reasoning that noted four different reasons for rejecting the request. The reviewer noted that Claimant’s job duties as a schoolteacher were sedentary in nature and a work hardening program requires at least a moderate level job duty, that Claimant suffers from co-morbid conditions, such as obesity and degenerative disc disease, that there was no evidence of a specific and defined return-to-work goal or job plan that was established, communicated or documented and that Claimant is over two-years post-injury.
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 (s), "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.”
The ODG provides the following criteria for assessing the medical necessity of the health care at issue:
Criteria for admission to a Work Hardening (WH) Program:
- Prescription: The program has been recommended by a physician or nurse case manager, and a prescription has been provided.
- Screening Documentation: Approval of the program should include evidence of a screening evaluation. This multidisciplinary examination should include the following components:
- History including demographic information, date and description of injury, history of previous injury, diagnosis/diagnoses, work status before the injury, work status after the injury, history of treatment for the injury (including medications), history of previous injury, current employability, future employability, and time off work;
- Review of systems including other non work-related medical conditions;
- Documentation of musculoskeletal, cardiovascular, vocational, motivational, behavioral, and cognitive status by a physician, chiropractor, or physical and/or occupational therapist (and/or assistants);
- Diagnostic interview with a mental health provider;
- Determination of safety issues and accommodation at the place of work injury.
- Screening should include adequate testing to determine if the patient has attitudinal and/or behavioral issues that are appropriately addressed in a multidisciplinary work hardening program. The testing should also be intensive enough to provide evidence that there are no psychosocial or significant pain behaviors that should be addressed in other types of programs, or will likely prevent successful participation and return-to-employment after completion of a work hardening program. Development of the patient’s program should reflect this assessment.
- Job demands: A work-related musculoskeletal deficit has been identified with the addition of evidence of physical, functional, behavioral, and/or vocational deficits that preclude ability to safely achieve current job demands. These job demands are generally reported in the medium or higher demand level (i.e., not clerical/sedentary work). There should generally be evidence of a valid mismatch between documented, specific essential job tasks and the patient’s ability to perform these required tasks (as limited by the work injury and associated deficits).
- Functional capacity evaluations (FCEs): A valid FCE should be performed, administered and interpreted by a licensed medical professional. The results should indicate consistency with maximal effort, and demonstrate capacities below an employer verified physical demands analysis (PDA). Inconsistencies and/or indication that the patient has performed below maximal effort should be addressed prior to treatment in these programs.
- Previous PT: There is evidence of treatment with an adequate trial of active physical rehabilitation with improvement followed by plateau, with evidence of no likely benefit from continuation of this previous treatment. Passive physical medicine modalities are not indicated for use in any of these approaches.
- Rule out surgery: The patient is not a candidate for whom surgery, injections, or other treatments would clearly be warranted to improve function (including further diagnostic evaluation in anticipation of surgery).
- Healing: Physical and medical recovery sufficient to allow for progressive reactivation and participation for a minimum of 4 hours a day for three to five days a week.
- Other contraindications: There is no evidence of other medical, behavioral, or other comorbid conditions (including those that are non work-related) that prohibits participation in the program or contradicts successful return-to-work upon program completion.
- RTW plan: A specific defined return-to-work goal or job plan has been established, communicated and documented. The ideal situation is that there is a plan agreed to by the employer and employee. The work goal to which the employee should return must have demands that exceed the claimant’s current validated abilities.
- Drug problems: There should be documentation that the claimant’s medication regimen will not prohibit them from returning to work (either at their previous job or new employment). If this is the case, other treatment options may be required, for example a program focused on detoxification.
- Program documentation: The assessment and resultant treatment should be documented and be available to the employer, insurer, and other providers. There should (sic) documentation of the proposed benefit from the program (including functional, vocational, and psychological improvements) and the plans to undertake this improvement. The assessment should indicate that the program providers are familiar with the expectations of the planned job, including skills necessary. Evidence of this may include site visitation, videotapes or functional job descriptions.
- Further mental health evaluation: Based on the initial screening, further evaluation by a mental health professional may be recommended. The results of this evaluation may suggest that treatment options other than these approaches may be required, and all screening evaluation information should be documented prior to further treatment planning.
- Supervision: Supervision is recommended under a physician, chiropractor, occupational therapist, or physical therapist with the appropriate education, training and experience. This clinician should provide on-site supervision of daily activities, and participate in the initial and final evaluations. They should design the treatment plan and be in charge of changes required. They are also in charge of direction of the staff.
- Trial: Treatment is not supported for longer than 1-2 weeks without evidence of patient compliance and demonstrated significant gains as documented by subjective and objective improvement in functional abilities. Outcomes should be presented that reflect the goals proposed upon entry, including those specifically addressing deficits identified in the screening procedure. A summary of the patient’s physical and functional activities performed in the program should be included as an assessment of progress.
- Concurrently working: The patient who has been released to work with specific restrictions may participate in the program while concurrently working in a restricted capacity, but the total number of daily hours should not exceed 8 per day while in treatment.
- Conferences: There should be evidence of routine staff conferencing regarding progress and plans for discharge. Daily treatment activity and response should be documented.
- Voc rehab: Vocational consultation should be available if this is indicated as a significant barrier. This would be required if the patient has no job to return to.
- Post-injury cap: The worker must be no more than 2 years past date of injury. Workers that have not returned to work by two-years post injury generally do not improve from intensive work hardening programs. If the worker is greater than one-year post injury a comprehensive multidisciplinary program may be warranted if there is clinical suggestion of psychological barrier to recovery (but these more complex programs may also be justified as early as 8-12 weeks, see Chronic pain programs). Exceptions to the 2-year post-injury cap may be made for patients with injuries that have required long-term medical care; i.e., extensive burns, diagnoses requiring multiple surgical procedures, or recent (within 6 months) completion of the last surgery, for patients who do not have the psychological barriers to return to work that would qualify them for a CPM program. (L&I, 2013)
- Program timelines: These approaches are highly variable in intensity, frequency and duration. APTA, AOTA and utilization guidelines for individual jurisdictions may be inconsistent. In general, the recommendations for use of such programs will fall within the following ranges: These approaches are necessarily intensive with highly variable treatment days ranging from 4-8 hours with treatment ranging from 3-5 visits per week. The entirety of this treatment should not exceed 20 full-day visits over 4 weeks, or no more than 160 hours (allowing for part-day sessions if required by part-time work, etc., over a longer number of weeks). A reassessment after 1-2 weeks should be made to determine whether completion of the chosen approach is appropriate, or whether treatment of greater intensity is required.
- Discharge documentation: At the time of discharge the referral source and other predetermined entities should be notified. This may include the employer and the insurer. There should be evidence documented of the clinical and functional status, recommendations for return to work, and recommendations for follow-up services. Patient attendance and progress should be documented including the reason(s) for termination including successful program completion or failure. This would include noncompliance, declining further services, or limited potential to benefit. There should also be documentation if the patient is unable to participate due to underlying medical conditions including substance dependence.
- Repetition: Upon completion of a rehabilitation program (e.g., work conditioning, work hardening, outpatient medical rehabilitation, or chronic pain/functional restoration program) neither re-enrollment in nor repetition of the same or similar rehabilitation program is medically warranted for the same condition or injury.
Petitioner provided evidence to show that Claimant’s job functions as a special needs school teacher involved more than sedentary work level. In fact, a description of her job duties reflects that those duties were more in the moderate work level. Petitioner argued that although Claimant is obese and does have some degenerative disc disease, the co-morbid conditions contemplated in the ODG more likely would be conditions such as heart conditions, terminal illnesses and drug addiction. In addition, Petitioner testified that it is at the discretion and subject to the interpretation of the requestor as to which co-morbid conditions would exclude an individual from participating in a work hardening program. Finally, Petitioner pointed to his request for the work hardening program and noted that he had outlined the return to work goals in that request and that his request had occurred slightly over two years after the date of the injury because Carrier had disputed Claimant’s injury for quite some time. However, it is undisputed that Claimant’s compensable injury regarding the spine was a lumbar sprain/strain and that Petitioner had requested the work hardening program for that condition. Carrier presented the testimony of orthopedist, Dr. JH. Dr. H noted that Claimant is entitled to medical treatment for her compensable injury; however, a lumbar sprain/strain resolves on its own within three to four months. As such, Dr. H noted that a request for a work hardening program after two years from the date of injury for a condition such as a resolved lumbar sprain/strain would not be reasonable medical care for the compensable injury. Claimant suffers from other lumbar spine conditions and perhaps a request for work hardening program could be requested for those conditions, but those conditions are not part of the compensable injury. As such, Petitioner has failed to present evidence-based medical evidence to show that 10 sessions of work hardening (80 hours) is health care reasonably required for the compensable lumbar sprain/strain injury of (Date of Injury).
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
- 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 and sustained a compensable injury.
- On (Date of Injury), Employer provided workers’ compensation insurance via self-insurance.
- Carrier delivered to 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.
- Claimant sustained a compensable injury in the form of a lumbar sprain/strain and abdominal/umbilical hernia.
- Petitioner did not present sufficient evidence-based medical evidence to overcome the IRO’s decision that Claimant is not entitled to 10 sessions of work hardening (80 hours) for the compensable injury of (Date of Injury).
- 10 sessions of work hardening (80 hours) is not health care reasonably 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 10 sessions of work hardening (80 hours) is not health care reasonably required for the compensable injury of (Date of Injury).
Claimant is not entitled to 10 sessions of work hardening (80 hours) for the compensable injury of (Date of Injury).
Carrier is not liable for the benefits at issue in this hearing, and it is so ordered. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.
The true corporate name of the insurance carrier is (Self-Insured), and the name and address of its registered agent for service of process is
(CITY), TEXAS (ZIPCODE)
Signed this 25th day of September, 2014.