Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
16023-nnr
Date:
June 7, 2015

16023-nnr

June 7, 2015

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and the Rules of the Texas Department of Insurance, Division of Workers’ Compensation. For the reasons discussed herein, the Hearing Officer determines that:

Claimant is not entitled to caudal ESI for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

Thomas Hight, a Division hearing officer, held a contested case hearing on May 3, 2016, which continued and was concluded on June 7, 2016, with the record closing on June 7, 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 caudal ESI for the compensable injury of (Date of Injury)?

PARTIES PRESENT

On May 3, 2016 Petitioner/Claimant did not appear. MV, ombudsman, appeared to assist Claimant had she appeared. Respondent/Carrier appeared and was represented by JF, attorney.

On June 7, 2016 Petitioner/Claimant appeared and was assisted by MV, ombudsman. Respondent/Carrier appeared and was represented by JF, attorney.

DISCUSSION

Claimant failed to appear at the contested case hearing scheduled for May 3, 2016, however she timely responded to a Division 10 day letter, and the hearing was reset to June 7, 2016. Claimant had good cause for her failure to appear at the May 3, 2016 hearing in that she was confused about the setting date.

Dr. BB requested pre-authorization for an epidural caudal injection. The IRO doctor upheld the previous denials, and Claimant appealed the IRO decision.

Texas Labor Code Section 408.021 provides that an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. Health care reasonably required is further defined in Texas Labor Code Section 401.011 (22a) as health care that is clinically appropriate and considered effective for the injured employee's injury and provided in accordance with best practices consistent with evidence based medicine or, if evidence based medicine is not available, then generally accepted standards of medical practice recognized in the medical community. Health care under the Texas Workers' Compensation system must be consistent with evidence based medicine if that evidence is available. Evidence based medicine is further defined in Texas Labor Code Section 401.011 (18a) to be the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines. The Commissioner of the Division of Workers' Compensation is required to adopt treatment guidelines that are evidence-based, scientifically valid, outcome-focused and designed to reduce excessive or inappropriate medical care while safeguarding necessary medical care. Texas Labor Code Section 413.011(e). Medical services consistent with the medical policies and fee guidelines adopted by the commissioner are presumed reasonable in accordance with Texas Labor Code Section 413.017(1).

In accordance with the above statutory guidance, the Division of Workers' Compensation has adopted treatment guidelines by Division Rule 137.100. This rule directs health care providers to provide treatment in accordance with the current edition of the Official Disability Guidelines (ODG), and such treatment is presumed to be health care reasonably required as defined in the Texas Labor Code. Thus, the focus of any health care dispute starts with the health care set out in the ODG. Also, in accordance with Division Rule 133.308(s), "A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division 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 provides the following criteria for the use of epidural steroid injections (ESIs):

Criteria for the use of Epidural steroid injections:

Note: The purpose of ESI is to reduce pain and inflammation, thereby facilitating progress in more active treatment programs, reduction of medication use and avoiding surgery, but this treatment alone offers no significant long-term functional benefit.

(1) Radiculopathy (due to herniated nucleus pulposus, but not spinal stenosis) must be documented. Objective findings on examination need to be present. Radiculopathy must be corroborated by imaging studies and/or electrodiagnostic testing.

(2) Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs, muscle relaxants & neuropathic drugs).

(3) Injections should be performed using fluoroscopy (live x-ray) and injection of contrast for guidance.

(4) Diagnostic Phase: At the time of initial use of an ESI (formally referred to as the “diagnostic phase” as initial injections indicate whether success will be obtained with this treatment intervention), a maximum of one to two injections should be performed. A repeat block is not recommended if there is inadequate response to the first block (< 30% is a standard placebo response). A second block is also not indicated if the first block is accurately placed unless: (a) there is a question of the pain generator; (b) there was possibility of inaccurate placement; or (c) there is evidence of multilevel pathology. In these cases a different level or approach might be proposed. There should be an interval of at least one to two weeks between injections.

(5) No more than two nerve root levels should be injected using transforaminal blocks.

(6) No more than one interlaminar level should be injected at one session.

(7) Therapeutic phase: If after the initial block/blocks are given (see “Diagnostic Phase” above) and found to produce pain relief of at least 50-70% pain relief for at least 6-8 weeks, additional blocks may be supported. This is generally referred to as the “therapeutic phase.” Indications for repeat blocks include acute exacerbation of pain, or new onset of radicular symptoms. The general consensus recommendation is for no more than 4 blocks per region per year. (CMS, 2004) (Boswell, 2007)

(8) Repeat injections should be based on continued objective documented pain relief, decreased need for pain medications, and functional response.

(9) Current research does not support a routine use of a “series-of-three” injections in either the diagnostic or therapeutic phase. We recommend no more than 2 ESI injections for the initial phase and rarely more than 2 for therapeutic treatment.

(10) It is currently not recommended to perform epidural blocks on the same day of treatment as facet blocks or sacroiliac blocks or lumbar sympathetic blocks or trigger point injections as this may lead to improper diagnosis or unnecessary treatment.

(11) Cervical and lumbar epidural steroid injection should not be performed on the same day. (Doing both injections on the same day could result in an excessive dose of steroids, which can be dangerous, and not worth the risk for a treatment that has no long-term benefit.)

The IRO doctor, a pain management physician, decided the requested procedure was not medically necessary because:

The pain diagram (in the records reviewed) does not depict any radicular symptoms per patient history. Also, an MRI report is not available for review which demonstrates pathology to support treatable causes of radiculopathy. Per ODG guidelines the medical necessity due to above is not met.

Claimant testified concerning her injuries and what Dr. BB had told her. Claimant put into evidence a lumbar MRI done on November 9, 2015 (prior to the IRO review on February 29, 2016) along with medical records and an April 26, 2016 letter from Dr. BB. In the letter Dr. BB stated the MRI showed central canal stenosis at L5-S1 secondary to spondylolisthesis and right lateral recess stenosis at L4-5 secondary to a disc bulge. He concluded:

Given the bilateral and multi-level origin of (Claimant’s) pain, we opted for the caudal ESI to provide relief to all affected nerve roots rather than perform several separate injections.

The ODG entry for therapeutic ESIs provides that ESIs are “not recommended for spinal stenosis” (CR-C, page 1). Dr. BB did not testify, and there was no showing that an exception should be made in this case for treatment not recommended by the ODG treatment guidelines. Claimant failed to overcome the IRO by the preponderance of evidence based medical evidence.

There was no objection to the testimony, reports, or qualifications of any doctor.

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 provided workers’ compensation insurance with (Carrier), Carrier.

D.On (Date of Injury) Claimant sustained a compensable injury.

E.The Independent Review Organization determined Claimant should not have the requested treatment.

  • Carrier delivered to Claimant a single document stating the true corporate name of Carrier and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • Caudal ESI is not health care reasonably required for the compensable injury of (Date of Injury).
  • CONCLUSIONS OF LAW

    1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction 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 caudal ESI is not health care reasonably required for the compensable injury of (Date of Injury).

    DECISION

    Claimant is not entitled to caudal ESI for the compensable injury of (Date of Injury).

    ORDER

    Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with 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 SERVICE COMPANY

    211 EAST 7th STREET, SUITE 620

    AUSTIN, TEXAS 78701

    Signed this 7th day of June, 2015.

    Thomas Hight
    Hearing Officer

    End of Document
    Top