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At a Glance:
Title:
16022-nnr
Date:
June 1, 2016

16022-nnr

June 1, 2016

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder. For the reasons discussed herein, the Hearing Officer determines that the preponderance of the evidence-based medical evidence is not contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to hardware removal left knee, left total knee arthroplasty, 3 days inpatient stay for the compensable injury of (Date of Injury).

ISSUES

A contested case hearing was held on May 16, 2016 to decide the following disputed issue:

  1. Is the preponderance of the evidence contrary to the decision of the IRO that the claimant is not entitled to hardware removal left knee, left total knee arthroplasty, 3 days inpatient stay for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared by telephone and was assisted by JH, ombudsman. Respondent/Carrier appeared by telephone and was represented by RJ, attorney.

BACKGROUND INFORMATION

It was undisputed that the Claimant sustained a compensable left knee injury on (Date of Injury) while working for (Employer). On April 8, 1998, he underwent left knee surgery performed by Dr. TS, which included an anterior cruciate ligament (ACL) reconstruction and partial medial and lateral meniscectomies.

On October 30, 2015, Dr. TS requested pre-authorization to perform the left knee surgery that is at issue herein, and this request was denied by two Carrier utilization review agents (URAs). The Carrier denials were upheld by an IRO. The IRO physician reviewer, who is a board-certified orthopedic surgeon, reasoned that the Claimant does not meet the Official Disability Guidelines (ODG) for the surgery since no documentation was provided showing any recent therapeutic interventions to include therapy or injections, as well as the fact that the Claimant’s body mass index (BMI) exceeds the recommendation for the proposed procedure. The IRO physician reviewer based the decision on medical judgment and the recommendations set forth in the ODG.

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.

The ODG addresses the medical necessity of a knee joint replacement, and a hospital length of stay for such surgery, as follows:

Knee joint replacement

Recommended as indicated below. Total hip and total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function. The most common diagnosis is osteoarthritis. Overall, total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. (Ethgen, 2004) Total knee arthroplasty was found to be associated with substantial functional improvement. (Kane, 2005) Navigated knee replacement provides few advantages over conventional surgery on the basis of radiographic end points. (Bathis, 2006) (Bauwens, 2007) The majority of patients who undergo total joint replacement are able to maintain a moderate level of physical activity, and some maintain very high activity levels. (Bauman, 2007) Functional exercises after hospital discharge for total knee arthroplasty result in a small to moderate short-term, but not long-term, benefit. In the short term physical therapy interventions with exercises based on functional activities may be more effective after total knee arthroplasty than traditional exercise programs, which concentrate on isometric muscle exercises and exercises to increase range of motion in the joint. (Lowe, 2007) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense physical therapy and exercise) reduced mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008) In this RCT, perioperative celecoxib (Celebrex) significantly improved postoperative resting pain scores at 48 and 72 hrs, opioid consumption, and active ROM in the first three days after total knee arthroplasty, without increasing the risks of bleeding. The study group received a single 400 mg dose of celecoxib, one hour before surgery, and 200 mg of celecoxib every 12 hours for five days. (Huang, 2008) Total knee arthroplasty (TKA) not only improves knee mobility in older patients with severe osteoarthritis of the knee, it actually improves the overall level of physical functioning. Levels of physical impairment were assessed with three tools: the Nagi Disability Scale, the Instrumental Activities of Daily Living Scale (IADL) and the Activities of Daily Living (ADL) Scale. Tasks on the Nagi Disability Scale involve the highest level of physical functioning, the IADL an intermediate level, and the ADL Scale involves the most basic levels. Statistically significant average treatment effects for TKA were observed for one or more tasks for each measure of physical functioning. The improvements after TKA were "sizeable" on all three scales, while the no-treatment group showed declining levels of physical functioning. (George, 2008) This study showed that total knee replacement is the second the most successful orthopaedic procedure for relieving chronic pain, after total hip. 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. Hip replacement reduced pain to levels normal for age, reduced physical functioning to within 75% normal levels, and restored quality of life to virtually normal levels. Total knee replacement was the next most successful procedure, and it all but eliminated pain, improved physical functioning to 60% normal, and restored quality of life to within 65% of normal. (Hansson, 2008) A 6-week program of progressive strength training targeting the quadriceps femoris muscle group substantially improves strength and function following total knee arthroplasty for treatment of osteoarthritis, compared to patients who received standard of care therapy; however, addition of neuromuscular electrical stimulation (NMES) to the strength training exercise did not improve outcomes. (Petterson, 2009) Knee replacement surgery is expensive but worth the cost, especially if performed by experienced surgeons, according to a recent study. Some $11 billion is spent on 500,000 total knee replacements each year in the United States, and the number is projected to multiply seven times by 2030 because of the aging, overweight population. Over 90% knee replacements are successful, knee pain goes away and patients become more mobile. In the study, knee replacement surgery and subsequent costs added up to $57,900 per patient, which was $20,800 more than was spent on those who did not get the surgery. Those who got artificial knees lived more than a year longer in good health than those who did not, and the researchers calculated the added cost per year of good-quality life at $18,300. (Losina, 2009) In a 7-year prospective study, patients with severe osteoarthritis who had total knee replacement had significant improvements in health-related quality of life, but health outcomes were negatively influenced by obesity and postdischarge complications, and women typically did not get as much benefit from surgery as do men. Overall, 76.8% were satisfied or very satisfied with their total knee replacement, and 79.5% said they would have the surgery again in similar circumstances. (Núñez, 2009) More than 95% of patients report that they are satisfied with the outcome of their total knee replacement 1 year after surgery. Factors that increased risk for dissatisfaction were younger age, being female, valgus alignment of the knee, and posttraumatic arthritis. (Ayers, 2010) Patients undergoing total knee arthroplasty (TKA) should receive ongoing COX-2 Inhibitor therapy for 6 weeks after their procedure, according to this unpublished RCT. (Schroer, 2011) The prevalence of knee pain and knee replacement surgeries has risen substantially during the last 20 years, but the reasons for the increase remain obscure. The rise in knee surgeries may be linked more to an increased awareness of knee pain, as opposed to aging, increased obesity, or radiographic knee osteoarthritis. The authors recommend treating physicians carefully consider, from the signs and symptoms of the patient presenting with knee pain, a broad differential diagnosis, since not all knee pain in middle-aged and older adults is the result of osteoarthritis. (Nguyen, 2011) Knee replacement surgery is a success story of modern medicine, yet consensus is lacking about the precise indications for the procedure. The number of total knee replacements (TKRs) in the United States increased from 31.2 per 100,000 person-years in the period from 1971 to 1976 to 220.9 per 100,000 person-years in 2008, for a total that year of more than 650,000 procedures. Demand for knee replacement will continue to grow in light of aging populations and rising obesity rates, which both portend higher rates of osteoarthritis. Outcomes data break down into those for TKRs vs those for partial-knee replacements (PKRs). Surgeons and their patients sometimes will choose a PKR for the sake of a more normal-feeling knee, less extensive surgery, and a lower risk for infection, knowing that they have the option of converting to a TKR if need be. However, partial replacement has a higher risk for revision surgery than total replacement, and a conversion TKR is more likely to require more follow-up than a primary TKR, according to registry data. In addition to recommending better patient selection and better reporting of outcomes, particularly as it relates to individual implant devices, the authors also call for new strategies to treat early-stage osteoarthritis in younger patients that will avoid the need for major surgery altogether. (Carr, 2012) Since there is platinum level evidence that therapeutic exercise results in improved physical function for people with knee OA, this should be part of conservative care prior to knee arthroplasty. (Fransen, 2008) This systematic review concluded that PT interventions that empower patients to actively self-manage knee OA (such as aerobic, strength, and proprioception exercise) improved outcomes the best. (Wang, 2012) The latest AAOS Guidelines for Treatment of Osteoarthritis of The Knee, include a strong recommendation that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. (AAOS, 2013) One third of total knee replacement surgeries in the U.S. may be inappropriate. Using a modified version of the Escobar classification system, this study found that 44% were appropriate, 22% were inconclusive, and 34% were inappropriate. Most patients in the appropriate category had intense or severe symptoms, were at least 55 years old, and had limited mobility. Most patients in the inconclusive category were similar but with normal mobility. Most patients in the inappropriate category had slight or moderate symptoms and had pain and functional loss less than half that of the average patient undergoing TKA. In addition, it was common in this group for patients to be younger than 55 years. TKA might not be appropriate for patients with milder symptoms. (Riddle, 2014) There is no evidence to recommend high-flexion implants and sex-specific implants in total knee replacement over established devices. (Nieuwenhuijse, 2014)

Unicompartmental knee replacement: Recommended as an option. Unicompartmental knee replacement is effective among patients with knee OA restricted to a single compartment. (Zhang, 2008) In this RCT, the early results demonstrated that the unicompartmental knee replacement (UKR) group had less complications and more rapid rehabilitation than the total knee replacement (TKR) group. At five years there were an equal number of failures in the two groups but the UKR group had more excellent results and a greater range of movement. The 15 years survivorship rate based on revision or failure for any reason was 89.8% for UKR and 78.7% for TKR. The better early results with UKR are maintained at 15 years with no greater failure rate. (Newman, 2009) Long-term studies are needed to appropriately define the role of less invasive unicompartmental surgical approaches. (Borus, 2008) Unicondylar knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both recommended for the treatment of medial compartment osteoarthritis in the varus knee. Citing the arduous rehabilitation and bone loss associated with traditional knee arthroplasty, some opt for UKA, especially in young, high-demand patients. (McAllister, 2008) With appropriate patient selection, UKAs are a successful option for patients with osteoarthritis. (Dalury, 2009) See also Osteotomy.

Bicompartmental knee replacement: Not recommended. See separate entry for Bicompartmental knee replacement.

Obesity: In balancing risks versus rewards, a BMI threshold of 40 is recommended. Consideration should be given to delaying total joint arthroplasty in a patient with a BMI > 40, especially when associated with other comorbid conditions, such as poorly controlled diabetes or malnutrition. Obese patients (BMI > 30) have similar satisfaction rates as the nonobese population following total joint arthroplasty, however, as BMI increases over 40, the functional improvement becomes less and/or occurs more gradually and must be tempered with the associated increased complication profile. (AAHKS, 2013) (Jämsen, 2012) (Baker2, 2012) But morbid obesity (BMI > 40) is a significant risk factor. (Watts, 2014) A British research team reports that higher BMI (up to 35) should not be a contraindication to TKA, provided that the patient is sufficiently fit to undergo the short-term rigors of surgery. TKA also halts the decline and maintains physical function in even the oldest age groups (> 75 years). (Cushnaghan, 2008) In this study, the rate of failure of total knee implants, at least up to 5 years after surgery, and the time to failure, were not influenced by patients' BMI, except for subjects affected by morbid obesity. (Bordini, 2009) Obese patients presented for and underwent joint replacement surgery at a younger age as compared to nonobese patients. (Gandhi, 2010) Adverse events (eg, perioperative complications, post-op wound infections) occurred in 14.2% of the non-obese, 22.6% of the obese and 35.1% of the morbidly obese patients after total knee replacement. (Dowsey, 2010) A 2-year review showed that hospital stays were longer in those who were obese than in those who were not. (Parks, 2010) Obese patients may have clinically significant weight loss after total joint arthroplasty, since their osteoarthritis had limited their mobility and ability to exercise. (Stets, 2010) Obese patients are nearly twice as likely to incur infection after a total knee replacement, but even with an elevated complication rate, total knee replacements provide an important improvement for patients with a high BMI. (Kerkhoffs, 2012)

Minimally invasive total knee arthroplasty: No significant benefit was seen in using a minimally invasive surgical technique over a standard traditional technique for total knee arthroplasty, but the study did not focus on quality-of-life outcomes (eg, length of hospital stay, reliance on pain medications, and the need for inpatient rehabilitation after discharge), in which the minimally invasive approach is purported to show an advantage. (Wülker, 2010) While cosmetically pleasing, minimally invasive incisions for knee arthroplasty have been shown to be limited by equivocal functional outcomes and some increases in complications. (Harkess, 2014)

Bilateral knee replacement: The safety of simultaneous bilateral total knee replacement remains controversial. Compared with staged bilateral or unilateral total knee replacement, simultaneous bilateral total knee replacement carries a higher risk of serious cardiac complications, pulmonary complications, and mortality. (Restrepo, 2007) Recommend that congestive heart failure and pulmonary hypertension be contraindications for bilateral total knee arthroplasty (BTKA), but not age per se. BTKA is seen as offering advantages over staged unilateral knee replacement surgery, including reduced time in the hospital, decreased costs, and a faster return to active life. The procedure also has been shown, however, to carry an increased risk for morbidity and mortality compared with unilateral knee replacement, with overall incidence of major in-hospital complications and mortality of 9.5%. Patients with the highest risk for adverse outcomes were those with congestive heart failure (odds ratio [OR], 5.5) compared with those without comorbidities, and those with pulmonary hypertension (OR, 4.1). Other risk factors included older age, with patients who were 65 to 74 years old or older than 75 years having about twice the likelihood of complications compared with patients 45 to 65 years old. Men also showed a 50% greater risk for complications than women. Older age, however, should not necessarily rule out patients who can otherwise benefit from bilateral knee replacement, and age by itself will be a risk factor in any kind of surgery. Factors that can increase the risk with congestive heart failure include bone particles and marrow entering the bloodstream to embolize in the pulmonary vasculature and other organs. (Memtsoudis, 2011)

Revision total knee arthroplasty is an effective procedure for failed knee arthroplasties based on global knee rating scales. (Saleh, 2002) It would be recommended for failure of the originally approved arthroplasty.

Risk versus benefit: The risk/benefit tradeoff for total knee arthroplasty (TKA) is best for patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility, and a BMI < 40. It is less favorable for patients who have slight or moderate symptoms and have pain and functional loss less than that of the average patient undergoing TKA. TKA might not be appropriate for patients with milder symptoms. (Riddle, 2014) Patients should be prepared to lose a few months to pain after surgery, limited mobility, and vigorous rehabilitation. Patients who do not commit to rehab will not regain the maximum range of motion. The primary reason for joint replacement is pain relief. Of secondary importance is improvement of joint function, but the results of that are less predictable. Knee replacement has the same dangers as other major surgeries, including infections or blood clots. Patients with comorbidities, such as heart conditions, diabetes, or weak immune systems, are the most at risk. Other risks include implants that become loose or dislocate. And the artificial knee might wear out after about 20 years, requiring another joint replacement down the road. Factors that increase risk for dissatisfaction are younger age, being female, valgus alignment of the knee, and posttraumatic arthritis. (Ayers, 2010) In deciding who should have knee joint replacement surgery for osteoarthritis, we need to balance potential benefits against potential risks, using the concept of capacity to benefit, that the benefits of overcoming functional limitations should considerably outweigh any likely risks or unintended consequences in an individual by a considerable margin for it to be indicated for that person. (Dieppe, 2011) Surgeons and their patients sometimes will choose a partial replacement (PKR) for the sake of a more normal-feeling knee, less extensive surgery, and a lower risk for infection, knowing that they have the option of converting to a TKR if need be. However, partial replacement has a higher risk for revision surgery than total replacement, and a conversion TKR is more likely to require more follow-up than a primary TKR. (Carr, 2012) Citing the arduous rehabilitation and bone loss associated with traditional knee arthroplasty, some opt for unicondylar knee arthroplasty, especially in young, high-demand patients. (McAllister, 2008) Consideration should be given to delaying total joint arthroplasty in a patient with a BMI > 40, especially when associated with other comorbid conditions. Obese patients (BMI > 30) have similar satisfaction rates as the nonobese population following total joint arthroplasty, however, as BMI increases over 40, the functional improvement becomes less and/or occurs more gradually and must be tempered with the associated increased complication profile. (AAHKS, 2013) (Jämsen, 2012) (Baker2, 2012) More than 90% of patients who have knee replacement surgery experience less pain and greater mobility in their knee after the procedure. (Losina, 2009) Fewer than 2% of total knee replacement surgeries result in serious complications, and the 30-day mortality rate for total knee replacement is about 0.25%. (HCUP, 2015)

NNH/NNT: On average, the NNH (number needed to harm) is about 50, and the NNT (number needed to treat) is about 1.1.

ODG Indications for Surgeryä -- Knee arthroplasty:

Criteria for knee joint replacement (If only 1 compartment is affected, a unicompartmental or partial replacement may be considered. If 2 of the 3 compartments are affected, a total joint replacement is indicated.):

  1. Conservative Care: Exercise therapy (supervised PT and/or home rehab exercises). AND Medications. (unless contraindicated: NSAIDs OR Visco supplementation injections OR Steroid injection). PLUS
  2. Subjective Clinical Findings: Limited range of motion (<90° for TKR). AND Nighttime joint pain. AND No pain relief with conservative care (as above) AND Documentation of current functional limitations demonstrating necessity of intervention. PLUS
  3. Objective Clinical Findings: Over 50 years of age AND Body Mass Index of less than 40, where increased BMI poses elevated risks for post-op complications. PLUS
  4. Imaging Clinical Findings: Osteoarthritis on: Standing x-ray (documenting significant loss of chondral clear space in at least one of the three compartments, with varus or valgus deformity an indication with additional strength). OR Previous arthroscopy (documenting advanced chondral erosion or exposed bone, especially if bipolar chondral defects are noted). (Washington, 2003) (Sheng, 2004) (Saleh, 2002) (Callahan, 1995)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS). See also Skilled nursing facility LOS (SNF)

For hospital length of stay for this surgery, the ODG states as follows:

Recommend the median length of stay (LOS) based on type of surgery, or best practice target LOS for cases with no complications. For prospective management of cases, median is a better choice that mean (or average) because it represents the mid-point, at which half of the cases are less, and half are more. For retrospective benchmarking of a series of cases, mean may be a better choice because of the effect of outliers on the average length of stay. Length of stay is the number of nights the patient remained in the hospital for that stay, and a patient admitted and discharged on the same day would have a length of stay of zero. The total number of days is typically measured in multiples of a 24-hour day that a patient occupies a hospital bed, so a 23-hour admission would have a length of stay of zero. (HCUP, 2011) Efforts to reduce costs by discharging patients who have total knee replacements (TKRs) sooner have largely succeeded, but shorter length of stay (LOS) is associated with a rise in readmissions, according to a large study based on Medicare data. The average hospital LOS for primary TKR declined from 7.9 days between 1991 and 1994 to 3.5 days between 2007 and 2010, for a relative decline of 55.7%. Meanwhile, all-cause 30-day readmission rates increased from 4.2% between 1991 and 1994 to 5.0% between 2007 and 2010. (Cram, 2012) See also Skilled nursing facility LOS (SNF).

ODG hospital length of stay (LOS) guidelines:

Knee Replacement (81.54 - Total knee replacement)

Actual data -- median 3 days; mean 3.4 days (± 0.0); discharges 615,716; charges (mean) $44,621

Best practice target (no complications) -- 3 days

Revise Knee Replacement (81.55 - Revision of knee replacement, not otherwise specified)

Actual data -- median 4 days; mean 4.8 days (±0.2); discharges 4,327; charges (mean) $60,129

Best practice target (no complications) -- 4 days

Meniscectomy (81.43 - Knee repair)

Actual data -- insufficient overnight stays

Best practice target (no complications) -- Outpatient

Osteochondral Autografts and Allografts (81.47 - Other repair of knee)

Actual data -- median 2 days; mean 3.1 days (±0.1); discharges 6,941; charges (mean) $37,063

Best practice target (no complications) -- 2 days

ACL Repair (81.45 - Repair of the cruciate ligaments)

Actual data -- median 1 day; mean 2.1 days (±0.2); discharges 3,617; charges (mean) $35,808

Best practice target (no complications) -- 1 day or Outpatient

Collateral Ligaments Repair (81.46 - Repair of the collateral ligaments)

Actual data -- median 3 days; mean 3.8 days (±0.4); discharges 636; charges (mean) $41,920

Best practice target (no complications) -- 3 days

Patella Dislocation Repair (81.44 - Patellar stabilization)

Actual data -- median 2 days; mean 2.2 days (±0.1); discharges 1,265; charges (mean) $21,340

Best practice target (no complications) -- 2 days

Knee Fusion (81.22 - Arthrodesis of knee)

Actual data -- median 5 days; mean 6.0 days (±0.3); discharges 843; charges (mean) $64,547

Best practice target (no complications) -- 5 days

Arthroscopy (80.26 - Knee arthroscopy)

Actual data -- insufficient overnight stays

Best practice target (no complications) – Outpatient

Broken tibia/fibula (79.36 - Open reduction of fracture with internal fixation tibia and fibula)

Actual data -- median 3 days; mean 4.0 days (± 0.1); discharges 131,583; charges (mean) $36,963

Best practice target (no complications) -- 3 days

Amputation (84.15 - Amputation below knee, of leg through tibia and fibula)

Actual data -- median 10 days; mean 12.8 days (± 0.2); discharges 27,424; charges (mean) $77,577

Best practice target (no complications) -- 10 days

Arthrotomy (80.16 - Arthrotomy, knee)

Actual data -- median 5 days; mean 6.7 days (± 0.2); discharges 11,228; charges (mean) $41,099

Best practice target (no complications) -- 5 days

Synovectomy (80.76 - Synovectomy, knee)

Actual data -- median 5 days; mean 6.7 days (± 0.2); discharges 5,996; charges (mean) $46,829

Best practice target (no complications) -- 5 days

Quadriceps Tendon Repair (83.73 - Reattachment of tendon)

Actual data -- median 2 day; mean 2.4 days (±0.3); discharges 92 - insufficient overnight stays

Best practice target (no complications) -- 1 day or Outpatient

The evidence in the record does not establish that the Claimant had any physical therapy for years prior to Dr. TS’s request for the procedure in dispute, although he has been taking NSAID medications over the years. Dr. TS did recommend that the Claimant begin physical therapy in February 2016, but this recommendation came after the request for surgery. In addition, Dr. TS noted that the Claimant, who is 54, has a BMI of 47.3, which exceeds the ODG recommendation that the surgical candidate have a BMI of less than 40. Finally, Dr. TS did order x-rays of the Claimant’s left knee on October 23, 2015 which showed severe tri-compartmental degenerative changes, but it is not clear from his records that a standing x-ray showing significant loss of chondral clear space in at least one of the three compartments, with varus or valgus deformity, was done, as is recommended by the ODG. For these reasons, and after a careful review of the entire record, it is determined that the evidence does not establish that the preponderance of the evidence-based medical evidence is contrary to the IRO decision. It is, therefore, determined that the record does not establish that the requested surgery is health care reasonably required for the Claimant’s 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

  1. The parties stipulated to the following facts:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B.On (Date of Injury), Claimant was the employee of (Employer), Employer.

C.On (Date of Injury), Employer had workers' compensation insurance coverage with (Carrier), Carrier.

D.On (Date of Injury), the Claimant sustained a compensable left knee injury while in the course and scope of his employment with (Employer).

  • The requested procedure (hardware removal left knee, left total knee arthroplasty, 3 days inpatient stay) is not shown to be health care reasonably required for the Claimant's compensable (Date of Injury) injury.
  • The preponderance of the medical evidence does not establish that the requested procedure is consistent with best practices consistent with evidence-based medicine or generally accepted standards of medical practice recognized in the medical community.
  • 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

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to 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 the Claimant is not entitled to hardware removal left knee, left total knee arthroplasty, 3 days inpatient stay for the compensable injury of (Date of Injury).

    DECISION

    The Claimant is not entitled to hardware removal left knee, left total knee arthroplasty, 3 days inpatient stay for the compensable injury of (Date of Injury).

    ORDER

    The Carrier is not liable for the benefits at issue in this hearing. The Claimant remains entitled to medical benefits for the compensable injury in accordance with Section 408.021 of the Act.

    The true corporate name of the insurance carrier is (Carrier), and the name and address of its registered agent for service of process is

    CORPORATION SERVICES COMPANY

    211 EAST 7TH STREET, STE. 620

    AUSTIN, TX 78701

    Signed this 1st day of June, 2016.

    Patrice Fleming-Squirewell
    Hearing Officer

    End of Document
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