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At a Glance:
Title:
16012-nnr
Date:
December 1, 2015

16012-nnr

December 1, 2015

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 entitled to a lumbar sympathetic block for the compensable injury of (Date of Injury).

ISSUE

A contested case hearing was held on November 24, 2015, 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 a lumbar sympathetic block for the compensable injury of (Date of Injury)?

PARTIES PRESENT

The Petitioner/Claimant appeared and was represented by AW, attorney.

The Respondent/Carrier appeared and was represented by PM, attorney.

EVIDENCE PRESENTED

Witnesses for Claimant/Petitioner: Claimant.

Witnesses for Carrier/Respondent: None.

The following exhibits were admitted into evidence:

Hearing Officer’s Exhibits HO-1 through HO-3.

Evidence for Claimant/Petitioner: Exhibits CL-1 through CL-12.

Evidence for Carrier/Respondent: Exhibits CR-A through CR-G.

BACKGROUND INFORMATION

Claimant sustained a compensable injury on (Date of Injury) when she fell inside a shipping container at work. Carrier had accepted as compensable a nondisplaced fracture of the left lateral malleolus, left peroneal tendonitis, status post repair of distal fibula and proximal tibial bone graft nonunion, and left ankle and hindfoot sprain/strain. In a Decision and Order dated April 20, 2015, it was determined that Claimant’s compensable injury extends to and includes left ankle Achilles tendon contracture, left hindfoot varus deformity, and complex regional pain syndrome II. Claimant’s doctor, AA, M.D., recommended the lumbar sympathetic block currently in dispute. The procedure was denied by the Carrier and an Independent Review Organization (IRO) assessment was requested.

True Decisions, Inc., was appointed to act as IRO by the Texas Department of Insurance. An anesthesiologist was the reviewer through True Decisions, Inc. The reviewer upheld the Carrier’s denial of the requested lumbar sympathetic block. The reviewer assessed Claimant’s condition according to the Harden criteria and it was determined that she did not meet a standard for Complex Regional pain syndrome. Without further discussion, the reviewer upheld the prior denial.

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. 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."

On the date of this medical contested case hearing, the ODG provides the following with regard to the requested procedures:

Recommendations (based on consensus guidelines) for use of sympathetic blocks (diagnostic block recommendations are included here, as well as in CRPS, diagnostic tests):

  1. There should be evidence that all other diagnoses have been ruled out before consideration of use.
  2. There should be evidence that the Budapest (Harden) criteria have been evaluated for and fulfilled.
  3. If a sympathetic block is utilized for diagnosis, there should be evidence that this block fulfills criteria for success including that skin temperature after the block shows sustained increase (≥ 1.5° C and/or an increase in temperature to > 34° C) without evidence of thermal or tactile sensory block. Documentation of motor and/or sensory block should occur. This is particularly important in the diagnostic phase to avoid overestimation of the sympathetic component of pain. A Horner’s sign should be documented for upper extremity blocks. [Successful stellate block would be noted by Horner's syndrome, characterized by miosis (a constricted pupil), ptosis (a weak, droopy eyelid), or anhidrosis (decreased sweating).] The use of sedation with the block can influence results, and this should be documented if utilized.
  4. Therapeutic use of sympathetic blocks is only recommended in cases that have positive response to diagnostic blocks and diagnostic criteria are fulfilled (See #1-3). These blocks are only recommended if there is evidence of lack of response to conservative treatment including pharmacologic therapy and physical rehabilitation.
  5. In the initial therapeutic phase, maximum sustained relief is generally obtained after 3 to 6 blocks. These blocks are generally given in fairly quick succession in the first two weeks of treatment with tapering to once a week. Continuing treatment longer than 2 to 3 weeks is unusual.
  6. In the therapeutic phase repeat blocks should only be undertaken if there is evidence of increased range of motion, pain and medication use reduction, and increased tolerance of activity and touch (decreased allodynia) is documented to permit participation in physical therapy/ occupational therapy. Sympathetic blocks are not a stand-alone treatment.
  7. There should be evidence that physical or occupational therapy is incorporated with the duration of symptom relief of the block during the therapeutic phase.
  8. In acute exacerbations of patients who have documented evidence of sympathetically medicated pain (see #1-3), 1 to 3 blocks may be required for treatment.
  9. A formal test of the therapeutic blocks should be documented (preferably using skin temperature).

At the Contested Case Hearing, Claimant provided evidence that the diagnosis of CRPS was made a part of the compensable injury as of April 20, 2015. The diagnosis having been made and deemed compensable, the threshold question – whether the Claimant has CRPS - has been answered. The follow-on question is the need for a lumbar sympathetic block for therapeutic purposes. The ODG notes that the treatment should only be undertaken “if there is evidence of increased range of motion, pain and medication use reduction, and increased tolerance of activity and touch.” Claimant testified that the previous lumbar sympathetic block relieved her symptoms and was helpful, allowing her to increase her activities of daily living. There is documentation of this in the medical record. A spinal cord stimulator has apparently been approved and is a long-term solution. The preponderance of the evidence is contrary to the IRO decision; Claimant is entitled to a lumbar sympathetic block for the compensable 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

  1. The parties stipulated to the following facts:
    1. Venue is proper in the (City) Field Office of the Workers’ Compensation Division of the Texas Department of Insurance.
    2. On (Date of Injury), Claimant was the employee of (Employer), Employer.
    3. On (Date of Injury), Claimant sustained a compensable injury.
    4. On (Date of Injury), Employer was self-insured for the purpose of workers’ compensation.
  2. The Carrier delivered to the Claimant a single document stating the true corporate name of the Carrier, and the name and street address of the Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  3. True Decisions, Inc. was appointed to act as Independent Review Organization by the Texas Department of Insurance.
  4. The IRO determined that the Claimant was not entitled to lumbar sympathetic block for the compensable injury of (Date of Injury).
  5. Complex regional pain syndrome was administratively determined to be part of the compensable injury.
  6. The ODG recognizes a lumbar sympathetic block as treatment for complex regional pain syndrome.
  7. A lumbar sympathetic block for the compensable injury of (Date of Injury) is health care reasonably required for the compensable injury of (Date of Injury).

CONCLUSIONS OF LAW

  1. The Workers’ Compensation Division of the Texas Department of Insurance has jurisdiction to hear this case.
  2. Venue is proper in the (City) Field Office.
  3. The preponderance of the evidence is contrary to the decision of the Independent Review Organization (IRO) and the Claimant is entitled to lumbar sympathetic block for the compensable injury of (Date of Injury).

DECISION

The preponderance of the evidence is contrary to the decision of the Independent Review Organization (IRO) and the Claimant is entitled to lumbar sympathetic block for the compensable injury of (Date of Injury).

ORDER

Carrier is ordered to pay benefits in accordance with this decision, the Texas Workers’ Compensation Act, and the Commissioner’s Rules. Accrued but unpaid income benefits, if any, shall be paid in a lump sum together with interest as provided by law.

The true corporate name of the insurance carrier is (Employer), SELF-INSURED and the name and address of its registered agent for service of process is:

CT CORPORATION SYSTEM

1999 BRYAN STREET, SUITE 900

DALLAS, TEXAS 75201-3136

Signed this 1st day of December, 2015.

Carolyn Cheu Mobley
Hearing Officer

End of Document
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