DECISION AND ORDER
This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Texas Department of Insurance, Division of Workers’ Compensation. For the reasons discussed herein, the Hearing Officer determines that the preponderance of the evidence-based medical evidence is contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to an L5-S1 anterior/posterior discectomy and fusion for the Claimant’s compensable injury of (Date of Injury).
STATEMENT OF THE CASE
A contested case hearing was opened on February 3, 2016, with the record closing on April 26, 2016, to decide the following disputed issue:
Is the preponderance of the evidence-based medical evidence contrary to the decision of the IRO that the claimant is not entitled to an L5-S1 anterior/posterior discectomy and fusion for the compensable injury of (Date of Injury)?
After the record closed on February 3, 2016, the undersigned reopened the record to hold a second session of the hearing to ask additional questions of the Claimant’s surgeon, Dr. K. B. The second session of the hearing was held on April 26, 2016, and the record closed on that date.
On both February 3, 2016 and April 26, 2016, the Petitioner/Claimant appeared and was represented by P.C., attorney, and the Respondent/Carrier appeared and was represented by K.M., adjuster.
The following witnesses testified:
- (Claimant), Petitioner/Claimant
- Dr. K. B. (by telephone)
The following exhibits were admitted into evidence:
Hearing Officer’s Exhibit HO-1 and HO-2
Petitioner/Claimant’s Exhibits C-1 through C-5
Respondent/Carrier’s Exhibits CR-A through CR-D
It was undisputed that the Claimant sustained a compensable injury at level L5-S1 of his spine on (Date of Injury) while working for (Employer). The Claimant was diagnosed by Dr. K. B., who is a board-certified orthopedic surgeon, with a disc herniation at L5-S1, and after conservative treatment, Dr. B. performed a revision laminectomy surgery at level L5-S1 of the Claimant’s spine on July 21, 2014. The Claimant had undergone his first laminectomy at that level in 2000 due to a prior injury. According to Dr. B.’s testimony, which was persuasive, the July 21, 2014 surgery helped the Claimant’s radiculopathy symptoms, but the Claimant still had low back pain and neurogenic claudication symptoms that radiated to the left hip, buttock and thigh. Dr. B. testified that the Claimant’s neurogenic claudication symptoms are worse with standing and walking, and they are relieved by sitting and bending forward. After the July 21, 2014 surgery, the Claimant underwent post-operative physical therapy from July 2014 through approximately April 2015, but still continued to have the neurogenic claudication symptoms. Dr. B. thereafter recommended the surgery in dispute, which was denied by two of the Carrier’s utilization review agents (URAs). The denials were upheld by an IRO. The IRO physician reviewer who, like Dr. B., is a board-certified orthopedic surgeon, bases the decision on medical judgment, the Official Disability Guidelines (ODG), and other peer-reviewed literature, including the North American Spine Society Treatment Guidelines. The IRO physician reviewer suggests that radiculopathy should be present for the requested procedure, or if it is based on spinal stenosis, there should be a showing that the pain is typically exacerbated by walking/standing and improved with sitting or bending forward. It appears that the IRO physician reviewer is of the opinion that neither scenario is presented by the facts of this case. The IRO physician reviewer also stated that applicable guidelines do not recommend fusion surgery unless instability is present at the level in question.
Texas Labor Code §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 §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 §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 §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 §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 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 addresses the medical necessity of laminectomy/laminotomy surgery as follows:
Recommended for lumbar spinal stenosis. For patients with lumbar spinal stenosis, surgery (standard posterior decompressive laminectomy alone, without discectomy) offered a significant advantage over nonsurgical treatment in terms of pain relief and functional improvement that was maintained at 2 years of follow-up, according to a new SPORT study. Discectomy should be reserved for those conditions of disc herniation causing radiculopahy. Laminectomy may be used for spinal stenosis secondary to degenerative processes exhibiting ligamental hypertrophy, facet hypertrophy, and disc protrusion, in addition to anatomical derangements of the spinal column such as tumor, trauma, etc. (Weinstein, 2008) (Katz, 2008) This study showed that surgery for spinal stenosis and for disc herniation were not as successful as total hip replacement but were comparable to total knee replacement in their success. Pain was reduced to within 60% of normal levels, function improved to 65% normal, and quality of life was improved by about 50%. The study compared the gains in quality of life achieved by total hip replacement, total knee replacement, surgery for spinal stenosis, disc excision for lumbar disc herniation, and arthrodesis for chronic low back pain. (Hansson, 2008) A comparison of surgical and nonoperative outcomes between degenerative spondylolisthesis and spinal stenosis patients from the SPORT trial found that fusion was most appropriate for spondylolisthesis, with or without listhesis, and decompressive laminectomy alone most appropriate for spinal stenosis. (Pearson, 2010) In patients with spinal stenosis, those treated surgically with standard posterior decompressive laminectomy showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated nonoperatively, and the results in both groups were stable between 2 and 4 years. (Weinstein, 2010) Comparative effectiveness evidence from SPORT shows good value for standard posterior laminectomy after an imaging-confirmed diagnosis of spinal stenosis [as recommended in ODG], compared with nonoperative care over 4 years. (Tosteson, 2011) Decompressive surgery (laminectomy) is more effective for lumbar spinal stenosis than land based exercise, but given the risks of surgery, a self-management program with exercise prior to consideration of surgery is also supported. (Jarrett, 2012) This study indicates that in patients with a primary diagnosis of lumbar spinal stenosis (LSS), the rate of fusions and the use of implants has increased, and the decompression rate has decreased. Trends in the surgical management of stenosis have become increasingly important to study because more invasive procedures, including the addition of fusion and the use of implants, have been associated with greater use of resources and increased complications. (Bae, 2013) Over time surgery (laminectomy for spinal stenosis) results in better outcomes out to at least 5 years, but the benefits of surgery likely erode beyond that time as patients age. (Lurie, 2015) Laminectomy is a surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves. See also Discectomy/laminectomy for surgical indications, with the exception of confirming the presence of radiculopathy. For average hospital LOS after criteria are met, see Hospital length of stay (LOS).
The ODG addresses the medical necessity of discectomy/laminectomy surgery as follows:
Recommended for indications below. Surgical discectomy for carefully selected patients with radiculopathy due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Unequivocal objective findings are required based on neurological examination and testing. (Gibson-Cochrane, 2000) (Malter, 1996) (Stevens, 1997) (Stevenson, 1995) (Buttermann, 2004) (Chou, 2008) For unequivocal evidence of radiculopathy, see AMA Guides. (Andersson, 2000) Standard discectomy and microdiscectomy are of similar efficacy in treatment of herniated disc. (Bigos, 1999) While there is evidence in favor of discectomy for prolonged symptoms of lumbar disc herniation, in patients with a shorter period of symptoms but no absolute indication for surgery, there are only modest short-term benefits. (Osterman, 2006) The SPORT studies concluded that both lumbar discectomy and nonoperative treatment resulted in substantial improvement after 2 years, but those who chose discectomy reported somewhat greater improvements than patients who elected nonoperative care. (Weinstein, 2006) (Weinstein2, 2006) In the treatment of patients with lumbar spinal stenosis, patients improved over the 2-year follow-up regardless of initial treatment, and those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability, but the relative benefit of initial surgical treatment diminished over time while still remaining somewhat favorable at 2 years. (Malmivaara, 2007) Patients undergoing lumbar discectomy are generally satisfied with the surgery, but only half are satisfied with preoperative patient information. (Ronnberg, 2007) If patients are pain free, there appears to be no contraindication to their returning to any type of work after lumbar discectomy. A regimen of stretching and strengthening the abdominal and back muscles is a crucial aspect of the recovery process. (Burnett, 2006) Although both surgery and nonsurgery have similar outcomes after 1 year, early surgery remains a valid treatment option for well-informed patients. (Peul-NEJM, 2007) (Deyo-NEJM, 2007) There is no obvious additional benefit was noted by combining decompression with instrumented fusion. (Hallett, 2007) A British study found that lumbar discectomy improved patients’ self-reported overall physical health more than other elective surgeries. (Guilfoyle, 2007) Microscopic sequestrectomy may be an alternative to standard microdiscectomy. In this RCT, both groups showed dramatic improvement. (Barth, 2008) Discectomy is moderately cost-effective compared with nonsurgical treatment, according to a SPORT study shows. The costs per quality-adjusted life-year gained with surgery compared with nonoperative treatment, including work-related productivity costs, ranges from $34,355 to $69,403, depending on the cost of surgery. It is wise and proper to wait before initiating surgery, but if the patient continues to experience pain and is missing work, then the higher-cost option such as surgery may be worthwhile. (Tosteson, 2008) Four-year results for the Dartmouth Spine Patient Outcomes Research Trial indicated that patients who underwent standard open discectomy for a lumbar disc herniation achieved significantly greater improvement than nonoperatively treated patients (using recommended treatments - active physical therapy, home exercise instruction, and NSAIDs) in all primary and secondary outcomes except work status (78.4% for the surgery group compared with 84.4%). Although patients receiving surgery did better generally, all patients in the study improved. (Weinstein2, 2008) In most patients with low back pain, symptoms resolve without surgical intervention. (Madigan, 2009) This study showed that surgery for disc herniation was not as successful as total hip replacement but was comparable to total knee replacement in success. (Hansson, 2008) Both standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months, but patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up. (Chou, 2009) Use of appropriateness criteria to guide treatment decisions for each clinical situation involving patients with low back pain and/or sciatica, with criteria based upon literature evidence, along with shared decision-making, was observed in one prospective study to improve outcomes in low back surgery. (Danon-Hersch, 2010) An updated SPORT trial analysis confirmed that outcomes of lumbar discectomy were better for patients who have symptoms of a herniated lumbar disc for six months or less prior to treatment. Increased symptom duration was related to worse outcomes following both operative and nonoperative treatment, but the relative increased benefit of surgery compared with nonoperative treatment was not dependent on the duration. (Rihn, 2011) Comparative effectiveness evidence from SPORT shows good value for standard open discectomy after an imaging-confirmed diagnosis of intervertebral disc herniation [as recommended in ODG], compared with nonoperative care over 4 years. (Tosteson, 2011) Carefully selected patients who underwent surgery for a lumbar disc herniation (standard open discectomy) achieved greater improvement than nonoperatively treated patients (active physical therapy, education/counseling with home exercise instruction, and NSAIDS), and there was little to no degradation of outcomes in either group (operative and nonoperative) from 4 to 8 years. (Lurie, 2014) Note: Surgical decompression of a lumbar nerve root or roots may include the following procedures: discectomy or microdiscectomy (partial removal of the disc) and laminectomy, hemilaminectomy, laminotomy, or foraminotomy (providing access by partial or total removal of various parts of vertebral bone). Discectomy is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. A laminectomy is often involved to permit access to the intervertebral disc in a traditional discectomy.
Patient Selection: Microdiscectomy for symptomatic lumbar disc herniations in patients with a preponderance of leg pain who have failed nonoperative treatment demonstrated a high success rate based on validated outcome measures (80% decrease in VAS leg pain score of greater than 2 points), patient satisfaction (85%), and return to work (84%). Patients should be encouraged to return to their preinjury activities as soon as possible with no restrictions at 6 weeks. Overall, patients with sequestered lumbar disc herniations fared better than those with extruded herniations, although both groups consistently had better outcomes than patients with contained herniations. Patients with herniations at the L5-S1 level had significantly better outcomes than did those at the L4-L5 level. (Dewing, 2008) Workers' comp back surgery patients are at greater risk for poor lumbar discectomy outcomes than noncompensation patients. (DeBerard, 2008) (DeBerard, 2011) Overweight and obese patients demonstrated an increased risk of postoperative complications after lumbar spine surgery, but these are not associated with a greater risk of mortality. (Marquez-Lara, 2014)
Spinal Stenosis: For patients with lumbar spinal stenosis, standard posterior decompressive laminectomy alone (without discectomy) offers a significant advantage over nonsurgical treatment. Discectomy should be reserved for those conditions of disc herniation causing radiculopahy. (See Indications below.) Laminectomy may be used for spinal stenosis secondary to degenerative processes exhibiting ligamental hypertrophy, facet hypertrophy, and disc protrusion, in addition to anatomical derrangements of the spinal column such as tumor, trauma, etc. (Weinstein, 2008) (Katz, 2008) A comparison of surgical and nonoperative outcomes between degenerative spondylolisthesis and spinal stenosis patients from the SPORT trial found that fusion was most appropriate for spondylolisthesis, with or without listhesis, and decompressive laminectomy alone most appropriate for spinal stenosis. (Pearson, 2010) See also Laminectomy.
Risk versus benefit: The primary tradeoff is whether to undergo the risks of surgery, which are fairly small in this case, to achieve good short-run improvement of symptoms (success rate > 80%) faster than could also be achieved from conservative treatment alone. Minor pain and discomfort may not be worth the risks of surgery and the recovery time from surgery, depending on the patient's tolerance for risk, and there is no downside in delaying surgery. Patients whose pain is controlled in a manner that is acceptable to them may decide to postpone surgery in the hope that it will not be needed, without reducing their chances for complete recovery at 12 months. There is good evidence that discectomy is moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 6 months, but patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up. (Chou, 2009) (Chou, 2008) Similar evidence supports the use of surgery for spinal stenosis, but the outcomes look better with surgery out to about 2 years. (Malmivaara, 2007) In this trial, early surgery is associated with better short-term outcomes, but at 1 year, disability outcomes of early surgery vs conservative treatment (with eventual surgery if needed) are similar. The median time to recovery was 4.0 weeks for early surgery and 12.1 weeks for prolonged conservative treatment. (Peul, 2007) (Deyo, 2007) Consequently, for patients who don't want surgery no matter how bad their pain is, they will likely improve and they will not have complications from nonoperative treatment, but those patients whose leg pain is severe and is limiting their function, who meet the ODG criteria for discectomy, can do better in the short-term with surgery, and the risks are extremely low. (Weinstein2, 2008) In general, the risk of surgical complications is fairly small, about 3% for readmission and reoperation (Pugely, 2014), and 0.10% for death. (HCUP, 2012) For those receiving workers’ compensation, surgery may not be better than non-surgical treatment for most patients, even in the short-run. (Atlas, 2010) (DeBerard, 2008) In workers’ comp it is recommended to screen for presurgical biopsychosocial variables because they are important predictors of discectomy outcomes. (DeBerard, 2011) Obese patients have an increased risk of postoperative complications after lumbar spine surgery, but these are not associated with a greater risk of mortality. (Marquez-Lara, 2014) Smokers have much worse outcomes from lumbar decompression than nonsmokers, with an odds ratio for reoperation over 11. (Bydon, 2015) (Dewing, 2008)
NNH/NNT: Without taking into account specific risk factors, like smoking, obesity, or workers’ comp, the NNH (number needed to harm) is about 33, and the NNT (number needed to treat) for short-term improvement is about 1.2, but the NNT for long-term improvement is well over 10, compared to conservative treatment.
ODG Indications for Surgery -- Discectomy/laminectomy --
Required symptoms/findings; imaging studies; & conservative treatments below:
- I.Symptoms/Findings which confirm presence of radiculopathy. Objective findings on examination need to be present. Straight leg raising test, crossed straight leg raising and reflex exams should correlate with symptoms and imaging.
Findings require ONE of the following:
- L3 nerve root compression, requiring ONE of the following:
- Severe unilateral quadriceps weakness/mild atrophy
- Mild-to-moderate unilateral quadriceps weakness
- Unilateral hip/thigh/knee pain
- L4 nerve root compression, requiring ONE of the following:
- Severe unilateral quadriceps/anterior tibialis weakness/mild atrophy
- Mild-to-moderate unilateral quadriceps/anterior tibialis weakness
- Unilateral hip/thigh/knee/medial pain
- L5 nerve root compression, requiring ONE of the following:
- Severe unilateral foot/toe/dorsiflexor weakness/mild atrophy
- Mild-to-moderate foot/toe/dorsiflexor weakness
- Unilateral hip/lateral thigh/knee pain
- S1 nerve root compression, requiring ONE of the following:
- Severe unilateral foot/toe/plantar flexor/hamstring weakness/atrophy
- Moderate unilateral foot/toe/plantar flexor/hamstring weakness
- Unilateral buttock/posterior thigh/calf pain
(EMGs are optional to obtain unequivocal evidence of radiculopathy but not necessary if radiculopathy is already clinically obvious.)
- I.Imaging Studies, requiring ONE of the following, for concordance between radicular findings on radiologic evaluation and physical exam findings:
- Nerve root compression (L3, L4, L5, or S1)
- Lateral disc rupture
- Lateral recess stenosis
Diagnostic imaging modalities, requiring ONE of the following:
- MR imaging
- CT scanning
- CT myelography & X-Ray
- Conservative Treatments, requiring ALL of the following:
- Activity modification (not bed rest) after patient education (>= 2 months)
- Drug therapy, requiring at least ONE of the following:
- NSAID drug therapy
- Other analgesic therapy
- Muscle relaxants
- Epidural Steroid Injection (ESI)
- L.Support provider referral, requiring at least ONE of the following (in order of priority):
- Physical therapy (teach home exercise/stretching)
- Manual therapy (chiropractor or massage therapist)
- Psychological screening that could affect surgical outcome
- Back school (Fisher, 2004)
For average hospital LOS after criteria are met, see Hospital length of stay (LOS).
See Functional anesthetic discography (FAD).
Finally, the ODG addresses the medical necessity of a lumbar fusion surgery as follows:
Recommended as an option for spondylolisthesis, unstable fracture, dislocation, acute spinal cord injury with post-traumatic instability, spinal infections with resultant instability, scoliosis, Scheuermann's kyphosis, or tumors, as indicated in the Blue Patient Selection Criteria below. Not recommended in workers’ compensation patients for degenerative disc disease (DDD), disc herniation, spinal stenosis without degenerative spondylolisthesis or instability, or nonspecific low back pain, due to lack of evidence or risk exceeding benefit. See rationale below including Surgical decision making, Return to Work, Lumbar fusion in workers' comp, and Risk versus benefit.
Lumbar spinal fusion surgeries use bone grafts, interbody spacers, and are often combined with metal implants designed to facilitate a process similar to the healing of a fracture between two or more adjacent vertebrae. The therapeutic objective of spinal fusion surgery is to unite two or more vertebrae to prevent any movement of the motion segment thereby reducing instability and stabilizing any neurological deficit caused by excess motion. For complete references, see separate document with all studies focusing on Fusion (spinal).
There is limited scientific evidence about the long-term effectiveness of fusion for degenerative disc disease compared with natural history, placebo, or conservative treatment. (Gibson-Cochrane, 2000) (Savolainen, 1998) (Wetzel, 2001) (Molinari, 2001) (Bigos, 1999) (Washington, 1995) (DeBarard-Spine, 2001) (Fritzell-Spine, 2001) (Fritzell-Spine, 2002) (Deyo-NEJM, 2004) (Gibson-Cochrane/Spine, 2005) (Soegaard, 2005) (Glassman, 2006) (Atlas, 2006) (Resnick, 2005) (Fritzell, 2004) (Airaksinen, 2006)For chronic LBP in the absence of instability, prospective randomized controlled trials have concluded that therapeutic exercise combined with cognitive behavioral intervention appears to result in pain and functional outcomes at 1-2 years equivalent to lumbar fusion without the potentially high surgical complication rates including revision surgery. (Brox-Spine, 2003) (Keller-Spine, 2004) (Fairbank-BMJ, 2005) (Brox, 2006) (Brox, 2010) (Mannion, 2013) (Mannion, 2014) One prospective randomized controlled trial concluded a small benefit for lumbar fusion at 2 years over usual care regarding pain and function; however, the control group in this trial involved unstructured care, including physical therapy (content and visits depending upon clinicians), and thus was not comparable. (Fritzell-Spine, 2001) In addition, benefits decreased at year 2 and functional improvement in the fusion group may not have met Minimum Clinically Important Difference. (Fritzell-Spine, 2001) (Fritzell-Spine, 2002) (Fritzell, 2004) The four-year follow-up evaluating the results of two combined RCTs of fusion versus cognitive intervention and exercises for disc degeneration with chronic low back pain concluded that this invasive and high-cost surgical procedure does not afford better outcomes compared with conservative care. (Brox, 2010) Long term follow-up (8-15 years, average 11 years) of three multicenter randomized controlled trials of fusion vs. cognitive behavioral and exercise rehabilitation found no significant clinical difference in patient self-reported outcomes. Outcomes considered included a primary outcome of function, and secondary outcomes of pain, medication use, work status, health-related quality of life, satisfaction with care and global treatment outcome. (Mannion, 2013) (Mannion, 2014)
There have been several systematic reviews regarding fusion for chronic low back pain. There are differences in focus of these reviews (e.g. diagnoses, surgery vs. non-operative care, comparison of alternative surgical techniques) and the types of studies included (e.g. controlled or uncontrolled, prospective or retrospective, levels of bias). A systematic review of randomized controlled trials of surgical vs. non-surgical treatments of chronic low back pain (CLBP) noted that lumbar fusion is not more efficacious than structured cognitive-behavioral interventions combined with exercise therapy, though surgery may be more efficacious than unstructured nonsurgical care. (Mirza, 2007) Three additional systematic reviews of surgery for degenerative lumbar spondylosis, chronic non-specific low back pain and low back disorders had similar conclusions regarding equivalent clinical outcomes for fusion vs. cognitive behavioral interventions combined with therapeutic exercise. (Gibson, 2005) (Andrade, 2013) (Jacobs, 2013) One systematic review suggested improvements in pain and function associated with fusion to treat CLBP; however, the analysis included multiple types of studies (fusion vs. non-operative treatment, comparisons of surgical treatments) and variable study designs (prospective and retrospective, randomized and non-randomized, and some studies with substantial risk of bias). (Phillips, 2013) An evidence review by the American Pain Society recommended that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function. This review found that less than half of patients experience optimal outcomes following fusion. (Chou, 2009)
A prospective observational cohort study observed that lumbar fusion is the least successful common elective orthopedic surgery (including procedures involving hip and knee replacement, decompression for lumbar spinal stenosis and disc herniation, surgery for knee meniscal tears and fusion for ankle and subtalar osteoarthritis). The data show that patients with back pain are rendered worse off by surgery with respect to self-reported outcomes including pain and participation in usual activities. (Hansson, 2008)
In contrast to these results, recent studies document a 220% increase in lumbar spinal fusion surgery rates, and without demonstrated improvements in patient outcomes or disability rates. (Deyo, 2009) Among Medicare recipients, the frequency of complex spinal fusion procedures increased 15-fold in just six years. Several factors may contribute to these observations including geographic trends, the lack of evidence and variability of surgical decision making and financial incentives. (Weinstein, 2006) (Willems, 2011) (Willems, 2013) (Deyo, 2015) A recent 13 state analysis found that workers were more likely to undergo low back surgery in locations with higher concentrations of orthopedic surgeons and neurosurgeons and in areas where doctors receive higher surgical reimbursements. (Yee, 2015) The introduction and marketing of new surgical devices and financial incentives may stimulate more invasive surgery. (Deyo-JAMA, 2010)
See also Adjacent segment disease/degeneration (fusion) & Iliac crest donor-site pain treatment.
SPECIFIC RECOMMENDED CONDITIONS:
Spondylolisthesis: Recommended as an option for symptomatic isthmic or degenerative spondylolisthesis with instability; and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis, with corroborating physical findings and imaging, and after failure of non-operative treatment subject to criteria below. (Washington, 2009) (Weinstein-SPORT, 2007) (Deyo-NEJM, 2007) (Jacobs, 2013) (Resnick, 2014)
Posterolateral fusion in adult lumbar isthmic spondylolisthesis results in a modestly improved long-term outcome compared with a 1-year exercise program. At long-term follow-up, pain and functional disability were significantly better than before treatment in instrumented and non-instrumented patients and no significant differences were observed between instrumented and non-instrumented patients. (Ekman, 2005) One study found 27% of patients met the “highly effective” success criteria after spinal fusion for low back pain and “discogenic pain” based on a positive discogram, versus a 72% success rate in patients who underwent fusion for unstable spondylolisthesis. (Carragee, 2006) A systematic review of observational studies failed to find a clear association of isthmic spondylolisthesis with low back pain, raising questions regarding use of lumbar fusion to treat low back pain with isthmic spondylolisthesis in the absence of documented instability or radiculopathy. (Andrade, 2015)
Patients with degenerative spondylolisthesis who undergo laminectomy and fusion showed substantially greater improvement in pain and function during a period of 2 years than patients treated non-surgically. (Weinstein-SPORT, 2007) (Deyo-NEJM, 2007) For degenerative lumbar spondylolisthesis, spinal fusion may lead to a better clinical outcome than decompression alone. (Martin, 2007) Unilateral instrumentation for the treatment of degenerative lumbar spondylolisthesis is as effective as bilateral instrumentation. (Fernandez-Fairen, 2007) Fusion is most appropriate for spondylolisthesis, and decompressive laminectomy alone most appropriate for spinal stenosis. (Pearson, 2010) The latest SPORT study concluded that leg pain is associated with better surgical fusion outcomes in degenerative spondylolisthesis than low back pain. (Pearson, 2011) Comparative effectiveness evidence from SPORT shows good value for laminectomy and/or bilateral single-level fusion for degenerative spondylolisthesis, compared with non-operative care over 4 years. (Tosteson, 2011) There is a lack of evidence to support lumbar fusion to treat symptomatic spinal stenosis in the absence of spondylolisthesis or instability. (Resnick, 2014)
Spinal cord injury (SCI): In acute spinal cord injury (SCI), if the spine is unstable following injury, surgical fusion and bracing may be necessary. (Bagnall-Cochrane, 2004) (Siebenga, 2006)
Scheuermann's kyphosis: Recommended as an option for adult patients with severe deformities (e.g. more than 70 degrees for thoracic kyphosis), neurological symptoms, and pain not adequately resolved non-operatively (e.g. physical therapy, back exercises). Good outcomes have been found in a relatively large series of patients undergoing either combined anterior-posterior or posterior only fusion for Scheuermann's kyphosis. (Lonner, 2007) See also Fusion for adult idiopathic scoliosis.
OTHER GUIDELINES: A study on improving quality through identifying inappropriate care found that use of guideline-based Utilization Review (UR) protocols resulted in a denial rate for lumbar fusion 59 times the denial rates using non-guideline based UR. (Wickizer, 2004) Data on geographic variations in medical procedure rates suggest that there is significant variability in spine fusion rates, which may be interpreted to suggest a poor professional consensus on the appropriate indications for performing spinal fusion. (Deyo-Spine, 2005) (Weinstein, 2006). According to the Medicare Coverage Advisory Committee Technology Assessment, the evidence for lumbar spinal fusion does not conclusively demonstrate short-term or long-term benefits compared with nonsurgical treatment. (CMS, 2006) According to the AANS/NASS Guidelines, lumbar fusion is recommended as a treatment for carefully selected patients with disabling low back pain due to one- or two-level degenerative disc disease after failure of an appropriate period of conservative care. This recommendation was, in part, based on one study that contained numerous flaws, including a lack of standardization of conservative care in the control group. At the time of the 2-year follow up in that study, it appeared that pain had significantly increased in the surgical group from year 1 to 2. In addition, there remains no direction regarding how to define the “carefully selected patient.” (Resnick, 2005) (Fritzell, 2004)
The European Guidelines concluded that fusion surgery for nonspecific chronic LBP cannot be recommended unless 2 years of all other recommended conservative treatments, including multidisciplinary approaches with combined programs of cognitive intervention and exercises, have failed, or such combined programs are not available. (Airaksinen, 2006) The ECRI health technology assessment concluded that the evidence is insufficient to support lumbar fusion being more effective (to a clinically meaningful degree) than nonsurgical treatments (intensive exercise and rehabilitation plus cognitive behavioral therapy) in patients with and without prior surgery. (ECRI, 2007) In response to a denial of coverage by BlueCross, the presidents of AAOS, NASS, AANS, CNS, and SAS issued a joint statement to BlueCross recommending patient selection criteria for lumbar fusion in degenerative disc disease. The criteria included at least one year of physical and cognitive therapy, inflammatory endplate changes (i.e., Modic changes), moderate to severe disc space collapse, absence of significant psychological comorbidities (e.g. depression, somatization disorder), and absence of litigation or compensation issues. The criteria of denying fusion if there are compensation issues might apply to workers' compensation patients. (Rutka, 2011) The Washington State Department of Labor & Industries 2009 guidelines recommend lumbar fusion in workers’ compensation only for radiographically documented instability and for grade 2 or greater spondylolisthesis. (Washington, 2009) The draft AHRQ Comparative Effectiveness Research concluded that limited data suggests that fusion leads to greater improvement in back pain relief and function than physical therapy at 2-year follow-up, but whether the difference is clinically significant is unclear, and serious adverse events occurred in the fusion group but not the noninvasive-intervention group. (Clancy, 2012)
Surgical decision making: There is a lack of consensus regarding the utility of tests to assist decision making for lumbar fusion in chronic back pain patients. There is variability in clinician recommendations regarding the need for surgery, as well as the type of surgical procedure advised. A survey of surgeons in the Dutch Spine Society found a lack of consensus regarding the utility of lumbar MRI, discography and immobilization to assist in decision making for fusion. (Willems, 2011) Another study involving surgeons involved in clinical outcomes research found variability in recommendations for surgery vs. non-operative treatment, and the type of fusion surgery when presented with two clinical vignettes of patients with back pain due to lumbar spondylosis and lumbar spondylolysis. (Lee, 2011)
Surgeons were also asked about their recommendations in specific settings compared to related research. Over 30% would consider fusion of three or more levels, 53% would fuse obese and 24% morbidly obese chronic back patients, and 41% would fuse heavy smokers despite evidence of poor outcomes in these surgical groups. A systematic review of the accuracy of tests for patient selection concluded that “no subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment.” (Willems, 2013) Psychological distress and poor coping skills are factors associated with less optimal outcomes from low back pain care including surgery. However, spine surgeons may have limited ability to detect these conditions. A prospective study of patients presenting for spine evaluation looked at physician clinical impressions of patient psychological distress compared with the results based upon the use of a standardized questionnaire (Distress and Risk Assessment Method [DRAM]). Overall, 64% of patients had some level of psychological distress and 22% were identified as having high levels of distress using the DRAM. However, only 28.7% of patients with high levels of distress were identified by clinical evaluation, with non-operative spine specialists having higher rates of clinical detection (41.7%) of high distress patients than surgeons (19.6%) (Daubs, 2010)
Techniques/implants: Outcomes from complicated surgical fusion techniques (with internal fixation) may be no better than the traditional posterolateral fusion. (van Tulder, 2006) (Maghout-Juratli, 2006) Despite the new technologies, reoperation rates after lumbar fusion have become higher. (Martin, 2007) No obvious additional benefit was noted by combining decompression with an instrumented fusion in patients with single-level degenerative disc disease and foraminal stenosis. (Hallett, 2007) Postmenopausal female patients who underwent lumbar spinal instrumentation fusion were susceptible to subsequent vertebral fractures within 2 years after surgery (in 24% of patients). (Toyone, 2010) See also Bone-morphogenetic protein (BMP). Posterolateral bone-grafting fusion is not necessary when a Denis type-B thoracolumbar burst fracture associated with a load-sharing score of <or=6 is treated with short-segment pedicle screw fixation. (Dai, 2009)
Return to Sports and Work: Literature regarding return to work or return to athletics primarily consists of narrative reviews, observational studies and expert opinion surveys. According to one publication based upon published research and the author’s clinical practice decision making, when lumbar fusion surgery is performed, either with lateral fusion alone or with interbody fusion, unlike cervical fusion, there is no absolute contraindication to patients returning even to contact sports after complete recovery from surgery. Like patients with a thoracic injury, those with a lumbar injury should have no disabling neurological deficit, and exhibit evidence of bone fusion on x-ray films before returning. (Burnett, 2006) A systematic review of literature regarding return to play post lumbar fusion noted the absence of prospective randomized controlled trials. Conclusions based upon low level evidence concluded that a positive return to play decision can be made 6 months after surgery when there is complete anatomical and functional healing, safety issues are addressed during training and competition, sport-specific skills are regained, and the athlete is psychosocially ready. (Niederer, 2014) The authors noted that some patients never manage to return to full contact sports or sports with collisions. An uncontrolled observational study of post-lumbar fusion patients who participated in a 4-week sports conditioning program focusing on strength and endurance noted significant gains in physical demand levels, with 13% in medium, 35.2% medium/heavy, 9.3% heavy and 37% very heavy PDLs. (Cole, 2009)
Return to work in Workers’ Comp (WC) patients: See detailed discussion below
Studies assessing return to work after lumbar fusion in workers’ compensation have demonstrated limited benefits. A Washington State cohort of workers who underwent lumbar fusion between 1986 and 1987 for a variety of diagnoses observed that 68% were disabled at 2 year follow-up (Franklin, 1994) A subsequent Washington State study of workers who underwent lumbar fusion between 1994 and 2001 reported 63.9% work disability at 2 year follow-up. (Maghout-Juratli, 2006) A retrospective cohort study of workers with lumbar fusion between 1999 and 2006 reported early and later assessments. At the time of the initial report, only 6% of lumbar fusion subjects were able to go back to work a year later (Nguyen, 2007) At two year follow-up, only 26% of workers treated with fusion were able to return to work compared with 67% of subjects evaluated as non-surgical controls. (Nguyen, 2011)
Lumbar fusion in workers' comp (WC) patients: In cases of workers' compensation, patient outcomes related to fusion may have other confounding variables that may affect overall success of the procedure, and which should be considered. It appears that workers’ compensation populations require particular scrutiny when being considered for fusion for chronic low back pain, as there is evidence of poorer outcomes in subgroups of patients who were receiving compensation or involved in litigation. (Fritzell-Spine, 2001) (Harris-JAMA, 2005) (Maghout-Juratli, 2006) (Atlas, 2006) (Gum,2013) (Anderson, 2015) Despite poorer outcomes in workers’ compensation patients, utilization is much higher in this population than in group health. (Texas, 2001) (NCCI, 2006) In the Washington state system, the most frequent cause of death in those who had had a lumbar fusion was reported as opioid analgesic overdose, suggesting the fusion was not successful. (Juratli , 2009)
Pre-surgical biopsychosocial variables predict patient outcomes from lumbar fusion, which may help improve patient selection. Workers' compensation status, smoking, depression, and litigation were the most consistent pre-surgical predictors of poorer patient outcomes. (DeBerard-Spine, 2001) (DeBerard, 2003) (Deyo, 2005) (LaCaille, 2005) (Maghout-Juratli, 2006) (Trief-Spine, 2006) Clinical depression is a strong predictor of poor lumbar fusion outcomes among workers' compensation subjects. (Anderson, 2015b) Obesity and litigation in workers' compensation cases predict high costs associated with interbody cage lumbar fusion. (LaCaille, 2007) A systematic review found some evidence that catastrophizing is associated with worse outcomes including pain and disability in patients with acute, subacute, and chronic low back pain, and thus could impact post-fusion outcomes as well. (Wertli, 2014)
The series of retrospective cohort studies in Washington State and Ohio noted in the return to work section have shed additional light on lumbar fusion outcomes in worker’s compensation patients. (Franklin, 1994) (Maghout-Juratli, 2006) (Nguyen, 2007) (Nguyen, 2011) The outcomes of lumbar fusion in worker’s compensation in Washington State included 67.7% reporting increased pain and 55.8% no improvement in quality of life. Further surgery was performed in 23%. (Franklin, 1994) Repeat surgery was performed in 22.1% of workers' compensation fusion patients in the second Washington State study. (Maghout-Juratli, 2006) The authors also assessed post-operative and three year mortality, observing that 21% of all deaths were associated with analgesic use, with increased risks associated with instrumented fusions and patients diagnosed with degenerative disc disease. (Juratli, 2009) The Ohio study of workers' compensation patients who had lumbar fusion found that a year later, 27% needed another operation, and over 90% were in enough pain that they were still taking narcotics at follow-up. (Nguyen, 2007) At two years follow-up, 76% continued opioid use with an estimated 41% increase in mean daily opioid dose (MED). This large historical cohort study suggests that lumbar fusion may not be an effective operation in workers’ compensation patients with disc degeneration, disc herniation, and/or radiculopathy, and it is associated with significant increase in disability, opioid use, prolonged work loss, and poor RTW status. (Nguyen, 2011)
A comparative study evaluated pain, function and general health status outcomes after lumbar fusion in worker’s compensation patients vs. a matched group. The authors concluded that only 9% of patients receiving worker’s compensation achieved substantial clinical benefit in function compared to 33% of those not receiving worker’s compensation. (Carreon, 2009) After controlling for covariates known to affect lumbar fusion outcomes, patients receiving workers' comp have significantly less improvement, including only 19% with minimum clinically significant improvement in disability and 16% in physical health status. (Carreon, 2010) Another study demonstrated a significant difference in outcomes after lumbar spinal fusion between workers' comp populations and those on long-term disability or government supported insurance. Both populations only achieved marginal improvement after lumbar fusion, but workers' compensation had a clear, negative influence on outcome even when compared to other disability compensation patients. (Gum, 2012) Another cohort study comparing single level lumbar fusion outcomes for workers' compensation (WC) subjects with degenerative disc disease (DDD) vs. spondylolisthesis concluded that DDD is a questionable indication for spinal fusion. (Anderson, 2015)
Risk versus benefit: For non-recommended conditions, there are equivalent outcomes of pain, function, and quality of life in RCTs comparing conservative care with cognitive behavioral and rehabilitation exercise vs. lumbar fusion. However, fusion is associated with significant risks in these RCTs. Early complications were identified in 18% with a fusion rate of 84% according to one RCT (Brox-Spine, 2003), with 9% early complications in their subsequent RCT. (Brox, 2006) Another large RCT observed surgical complications in 14% with repeat surgery performed in 8% within 2 years. (Fairbank-BMJ, 2005) Lumbar fusion outcomes studies have also noted significant surgical risks including complications and repeat surgery. Surgical complications were reported from 11.8% (Maghout-Juratli, 2006) up to 36%. (Nguyen, 2011) Observations regarding the rate of repeat surgery were reported as 23% (Franklin, 1994), 24% (DeBerard-Spine, 2001), 22.1% (Maghout-Juratli, 2006), and 27% (Nguyen, 2011). Risks are even greater in obese patients undergoing lumbar spine fusion surgery. The incidence of postoperative complications was significant in 45% of morbidly obese and 44% of obese patients. The authors proposed that morbidly obese patients should undergo bariatric surgery before spine fusion surgery. (Vaidya, 2009) There is a high rate of complications (56.4%) in spinal fusion procedures, especially related to instrumentation. (Campbell, 2011) The type of fusion procedure may also affect perioperative morbidity and mortality, with procedure related complications in 15.7% for Posterior Spinal Fusion, 18.7% for Anterior Spinal Fusion and 23.8% for Anterior/Posterior Spinal Fusion patients. (Memtsoudis, 2011) Another long term complication to consider is described in Adjacent segment disease/degeneration.
A systematic review by the International Society for the Study of the Lumbar Spine estimated the odds of common complications associated with spinal surgery with a goal of helping surgeons provide evidence based information to patients. (Ng, 2011)
Additional risk considerations include potential continued and increased opioid use post-fusion. At two years follow-up, 76% of post-fusion Ohio cohorts were still taking opioids. Estimated increase in mean opioid MED was 41% post fusion in the Ohio study. (Nguyen, 2011) (Anderson, 2015c) The 3-year cumulative mortality rate in the Washington State study post-fusion was 1.93% and analgesic-related deaths were responsible for 21% of all deaths and 31.4% of all potential life lost. (Juratli, 2009)
NNH/NNT: Without taking into account specific risk factors, like smoking, obesity, or workers’ comp, the NNH (number needed to harm) is about 2, and the NNT (number needed to treat) about 10, compared to conservative treatment.
Patient Selection Criteria for Lumbar Spinal Fusion:
- A.Recommended as an option for the following conditions with ongoing symptoms, corroborating physical findings and imaging, and after failure of non-operative treatment (unless contraindicated e.g. acute traumatic unstable fracture, dislocation, spinal cord injury) subject to criteria below:
- Spondylolisthesis (isthmic or degenerative) with at least one of these:
- a.instability, and/or
- symptomatic radiculopathy, and/or
- c.symptomatic spinal stenosis;
- Disc herniation with symptomatic radiculopathy undergoing a third decompression at the same level;
- Revision of pseudoarthrosis (single revision attempt);
- Unstable fracture;
- Acute spinal cord injury (SCI) with post-traumatic instability;
- Spinal infections with resultant instability;
- Scoliosis with progressive pain, cardiopulmonary or neurologic symptoms, and structural deformity;
- Scheuermann's kyphosis;
- Not recommended in workers’ compensation patients for the following conditions:
- Degenerative disc disease (DDD);
- Disc herniation;
- Spinal stenosis without degenerative spondylolisthesis or instability;
- Nonspecific low back pain.
- Instability criteria: Segmental Instability (objectively demonstrable) - Excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy, with relative angular motion greater than 15 degrees L1-2 through L3-4, 20 degrees L4-5, 25 degrees L5-S1. Spinal instability criteria includes lumbar inter-segmental translational movement of more than 4.5 mm. (Andersson, 2000) (Luers, 2007) (Rondinelli, 2008)
- After failure of two discectomies on the same disc [(A)(2) above], fusion may be an option at the time of the third discectomy, which should also meet the ODG criteria. (See ODG Indications for Surgery -- Discectomy.)
- Revision Surgery for failed previous fusion at the same disc level [(A)(3) above] if there are ongoing symptoms and functional limitations that have not responded to non-operative care; there is imaging confirmation of pseudoarthrosis and/or hardware breakage/malposition; and significant functional gains are reasonably expected. Revision surgery for purposes of pain relief must be approached with extreme caution due to the less than 50% success rate reported in medical literature. Workers compensation and opioid use may be associated with failure to achieve minimum clinically important difference after revision for pseudoarthrosis (Djurasovic, 2011) There is low probability of significant clinical improvement from a second revision at the same fusion level(s), and therefore multiple revision surgeries at the same level(s) are not supported.
- Pre-operative clinical surgical indications for spinal fusion should include all of the following:
- All physical medicine and manual therapy interventions are completed with documentation of reasonable patient participation with rehabilitation efforts including skilled therapy visits, and performance of home exercise program during and after formal therapy. Physical medicine and manual therapy interventions should include cognitive behavioral advice (e.g. ordinary activities are not harmful to the back, patients should remain active, etc.);
- X-rays demonstrating spinal instability and/or myelogram, CT-myelogram, or MRI demonstrating nerve root impingement correlated with symptoms and exam findings;
- Spine fusion to be performed at one or two levels;
- Psychosocial screen with confounding issues addressed; the evaluating mental health professional should document the presence and/or absence of identified psychological barriers that are known to preclude post-operative recovery;
- For any potential fusion surgery, it is recommended that the injured worker refrain from smoking for at least six weeks prior to surgery and during the period of fusion healing; (Colorado, 2001) (BlueCross BlueShield, 2002)
- There should be documentation that the surgeon has discussed potential alternatives, benefits and risks of fusion with the patient;
- For average hospital LOS after criteria are met, see Hospital length of stay (LOS).
Dr. B.’s testimony at this hearing was very helpful and persuasive and it, along with other evidence, shows that the criteria listed in the ODG for the disputed surgery is met in this case. The issue is relatively complex because, when looking at just a discectomy surgery, the ODG requires that radiculopathy be present. For a laminotomy or laminectomy, which is not listed as one of the disputed services but is relevant to the analysis herein, the ODG does not require the presence of radiculopathy. The evidence in this case shows that the Claimant does not have radiculopathy, but he does have neurogenic claudication symptoms. Dr. B., who testified that he has performed the procedure in question approximately 200 times, explained that in order to do a fusion surgery, the surgeon usually must do a laminectomy or laminotomy to remove all or part of a lamina to get to the disc. Then, once the surgeon gets to the disc, the disc must be removed (a discectomy) to perform the fusion, which includes putting bone in the space that the disc once occupied. He clarified that even if the request for surgery only listed a fusion, these other procedures (laminectomy/laminotomy and discectomy) usually must be performed to accomplish the fusion. Therefore, the salient question, according to Dr. B., is whether the ODG criteria are met for the performance of a fusion in this case. Looking at the ODG criteria for a fusion, Dr. B. explained that the pertinent fact in this case is that this surgery would be the Claimant’s third decompression surgery 0at the L5-S1 level for stenosis. Therefore, he testified that Section (A)(2) of the Patient Selection Criteria for Lumbar Spinal Fusion is met. He further testified that, in looking at Section (F), which lists the pre-operative clinical surgical indications for spinal fusion, subsections (1) through (7) are met. He testified that the Claimant has undergone an extensive period of rehabilitation; the MRI performed on September 23, 2014 demonstrates the narrowing of the left neural foramen and encasement of the left nerve root at L5-S1; the fusion is only to be performed at L5-S1; a psychosocial screen performed on the Claimant on June 12, 2015 found no psychological barriers to him undergoing a lumbar fusion; the Claimant is a non-smoker; and Dr. B. and the Claimant discussed potential alternatives and the risks/benefits of a lumbar fusion, and the Claimant wants to proceed with the surgery. After a careful review of the entire record, it is determined that the evidence establishes that the preponderance of the evidence-based medical evidence is contrary to the IRO decision. For the reasons stated, it is, therefore, determined that the record establishes that the requested discectomy and fusion surgery is health care reasonably required for the compensable (Date of Injury) 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.
- On (Date of Injury), Employer had workers' compensation insurance coverage with National Casualty Co., Carrier.
- On (Date of Injury), the Claimant sustained a compensable L5-S1 injury while in the course and scope of his employment with (Employer).
- The L5-S1 anterior/posterior discectomy and fusion has been shown to be health care reasonably required for the Claimant's compensable (Date of Injury) injury.
- The Carrier delivered to 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 was admitted into evidence as Hearing Officer’s Exhibit Number 1.
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-based medical evidence is contrary to the decision of the IRO that the Claimant is not entitled to an L5-S1 anterior/posterior discectomy and fusion for the compensable injury of (Date of Injury), since the L5-S1 anterior/posterior discectomy and fusion have been shown to be health care reasonably required for the Claimant's compensable (Date of Injury) injury.
The Claimant is entitled to an L5-S1 anterior/posterior discectomy and fusion for the compensable injury of (Date of Injury).
The Carrier is ORDERED to pay medical benefits in accordance with this decision, the Act and the implementing Rules.
The true corporate name of the Carrier is NATIONAL CASUALTY COMPANY, and the name and address of its registered agent for service of process is
NATIONAL CASUALTY COMPANY
CORPORATION SERVICE COMPANY
211 E. 7TH STREET, STE. 620
AUSTIN, TX 78701-3218
Signed this 16th day of May, 2016.
- a.instability, and/or