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At a Glance:
Title:
16032-nr
Date:
July 4, 2016
Type:

16032-nr

July 4, 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 Petitioner / Claimant timely appealed the IRO decision and that Petitioner / Claimant is entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

A medical contested case hearing was held on June 23, 2016, to decide the following disputed issues:

  1. Did the Claimant / Petitioner timely appeal the IRO decision?
  2. Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that Petitioner / Claimant is not entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner / Claimant appeared and was assisted by S B, ombudsman. Respondent / Carrier appeared and was represented by DG, attorney.

EVIDENCE PRESENTED

The following witnesses testified:

For Petitioner / Claimant: R H, M.D.

For Carrier / Respondent: None.

The following exhibits were admitted into evidence:

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

Petitioner / Claimant’s Exhibits C-1 through C-6.

Carrier / Respondent’s Exhibits CR-A through CR-K.

DISCUSSION

On (Date of Injury), Petitioner / Claimant worked for the employer, (Employer), and sustained an injury to his left shoulder in the form of at least a rotator cuff tear. He received medical treatment for his injury and was seen by RM, M.D, on several occasions, including for two surgeries that were performed on November 1, 2013 and August 6, 2014. It was noted by Dr. RM, after the second surgery, that Petitioner / Claimant’s rotator cuff tear was irreparable and that Petitioner / Claimant needed a reverse total shoulder arthroplasty.

Petitioner / Claimant then visited with RH, M.D, on August 25, 2015, who ordered a repeat MRI of the left shoulder and a repeat EMG. On September 22, 2015, after receiving the results of the MRI and the EMG, Dr. RH spoke with Petitioner / Claimant about the surgical options available between a reverse total shoulder arthroplasty and a left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair. Petitioner / Claimant chose the latter. Thereafter, a request for the left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair was proposed. Such request underwent utilization review and was denied on October 5, 2015 by WM, M.D, an orthopedic surgeon.

Reconsideration was requested and such reconsideration was denied on October 7, 2015 by RH, M.D, another orthopedic surgeon. Petitioner / Claimant then appealed the denials to an IRO and the IRO reviewer, also an orthopedic surgeon, upheld the previous adverse determinations. Consequently, Petitioner / Claimant appealed the IRO decision and this is the reason for the present discussion and decision.

Timeliness

Title 28 of the Texas Administrative Code §133.308(s)(1)(A) [hereinafter “Rule”] states, to wit:

The written appeal must be filed with the [D]ivision's Chief Clerk of Proceedings no later than the later of the 20th day after the effective date of this section or 20 days after the date the IRO decision is sent to the appealing party and must be filed in the form and manner required by the [D]ivision.

Id (emphasis added). Essentially, the Rule actually provides for two separate deadlines for the filing of an appeal of the IRO decision with the later in time applying.

In this particular case, the IRO decision was sent to the parties on December 12, 2015. Therefore, the applicable deadline for the filing of the appeal of the IRO decision in this case was 20 days from December 12, 2015, which was January 1, 2016. January 1, 2016 fell on a Friday and was a holiday. Consequently, the deadline is extended until January 4, 2016.

Petitioner / Claimant filed his appeal of the IRO decision with the Chief Clerk of Proceedings on January 14, 2016. However, it was noted that the IRO decision was sent to Petitioner / Claimant addressed to (Address) and that Petitioner / Claimant’s address is (Address). There are no other applicable provisions and/or Division Rules providing for extensions of and/or good cause exceptions to the 20-day deadline for appealing the IRO decisions. But, basic principles of appellate procedure and case law would require that, at a bare minimum, the IRO decision be sent to the appealing party’s correct address in order to begin the appellate deadline.

Since the IRO decision was sent to the wrong address, Claimant / Petitioner complied with the 20-day deadline contained in the applicable Division Rules and the appeal of the IRO decision is timely. As such, a decision on the merits of this case will be reached.

Medical Necessity

An injured employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. TEX. LAB. CODE §408.021(a). "Health care reasonably required" is defined 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. TEX. LAB. CODE §401.011(22a). Health care under the Texas Workers' Compensation system must be consistent with evidence-based medicine if that evidence is available. "Evidence-based medicine" means 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. TEX. LAB. CODE §401.011(18a). 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. TEX. LAB. CODE §413.011(e). Medical services consistent with the medical policies and fee guidelines adopted by the commissioner are presumed reasonable in accordance with the Texas Labor Code. TEX. LAB. CODE §413.017(1).

In accordance with the above statutory guidance, the Division has adopted treatment guidelines by rule. See Rule 137.100. This Rule directs health care providers to provide treatment in accordance with the current edition of the Official Disability Guidelines (hereinafter "ODG") and that 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.

Some of the pertinent provisions of the ODG applicable to this case are as follows, to wit:

Graft, rotator cuff:

Under study. Over the past few years, many biologic patches have been developed to augment repairs of large or complex rotator cuff tendon tears. These patches include both allograft and xenografts. Regardless of their origins, these products are primarily composed of purified type I collagen. There is a lack of studies demonstrating which ones are effective. (Coons, 2006). For short-term periods, restoring a massive rotator cuff tendon defect with synthetic grafts can give significant pain relief, but there is still some risk of new tears. (Audenaert, 2006). See also Amniotic membrane allograft (AmnioFix) for shoulder surgery; Bioengineered tissue grafts (for shoulder surgery); Extracellular matrix (for shoulder surgery); Graftjacket tissue matrix (for shoulder surgery).

Reverse shoulder arthroplasty:

Recommended as indicated below. Reverse shoulder arthroplasty is often used for people who have shoulder arthritis coupled with an irreparable rotator cuff tear, and it is also performed for patients with very complex shoulder problems, including those with failed previous surgical treatments. It is a newer type of shoulder replacement developed in Europe in the 1980s and approved by the FDA in 2004. It involves the insertion of a hemispherical implant in place of the glenoid instead of the humerus and the cup section being added to the humerus, allowing the arm to be moved primarily by the deltoid instead of the rotator cuff. Early results are encouraging, but not all shoulder surgeons have experience in reverse shoulder replacement. The reverse shoulder arthroplasty prosthesis was originally designed for rotator cuff arthropathy, and provided good results. Over time, the indications have expanded to include, among others, irreparable rotator cuff tears and rheumatoid arthritis, and the results have become more variable. There are also fundamental differences in the designs of the original Delta III prostheses and the later developed reverse shoulder prosthesis, and many studies that provide the results in reverse shoulder arthroplasties do not consider these 2 prostheses separately. (Khan, 2011). Reverse shoulder arthroplasty indications are steadily increasing in acute displaced proximal humeral fracture. Pain and articular movement results appear better than those with hemiarthroplasty. Healing rate was 37% in hemiarthroplasty group compared to 84% in the reverse arthroplasty group, and the highest rate of complications was recorded in the hemiarthroplasty group. (Baudi, 2014). Displaced proximal humeral fractures have traditionally been treated with hemiarthroplasty in older adults, but sometimes hemiarthroplasty results in poor functional outcomes due to rotator cuff deficiency. Reverse shoulder arthroplasty (RSA) can offer potentially improved outcomes in these situations. RSA results in improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Complications following fracture do not appear to be appreciably higher in the RSA group. The results of this review suggest that RSA is a reasonable alternative for treating older adults with proximal humeral fractures, but more research and longer follow-up are needed. (Mata-Fink, 2013). See also Arthroplasty (shoulder); Arthroscopic debridement (for shoulder arthritis). For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Risk versus benefit: Overall complication rates were 25% (5% major) after primary RSA and 69% after revision RSA. (Saltzman, 2014). RSA compared with TSA patients, had significantly longer length of stay, higher hospital charges that are not completely attributable to increased implant costs alone, and increased rates of perioperative complications. (Jiang, 2014). Early RSA revision has been associated with age less than 65, smoking and obesity, with dislocation being the most common reason. (Werner, 2015). Young age, high pre-operative function, and neurologic dysfunction were associated with poor functional improvement after RSA for massive rotator cuff tears without arthritis. (Hartzler, 2015). Due to higher surgical risks for these more complex conditions, RSA should be carefully considered for strict indications only. Compared to other total joint arthroplasties there is reported to be a steep surgical learning curve as well as relatively poor revision options.

ODG Indications for Surgery -- Reverse Shoulder Arthroplasty:

Non-functioning irreparable rotator cuff and gleno-humeral arthropathy; or

Failed hemiarthroplasty or failed total shoulder arthroplasty with irreparable rotator deficiency; or

Comminuted fractures (3 or 4 part) of the proximal humerus in an older population (65 years of age or older).

And meet all of the following criteria:

- Limited functional demands; &

- Intractable pain that has not responded to conservative therapy (including NSAIDs, intra-articular steroid injections, and physical therapy for at least 6 months and failed); &

- Adequate deltoid function; &

- Adequate passive range of motion to obtain functional benefit from the prosthesis; &

- Residual bone permits firm fixation of the implant; &

- No evidence of shoulder infection; &

- No severe neurologic deficiency.

Superior capsule reconstruction (Mihata procedure):

Not recommended until there are quality studies, still investigational. See also Graft, rotator cuff.

Superior capsule reconstruction has been described in two publications by Mihata. The procedure was developed in 2007 for salvage of irreparable rotator cuff tears. A cadaveric study showed that a superior capsule patch graft completely restored superior stability while patch grafting of the supraspinatus only partially restored it. The described graft was attached medially to the superior glenoid and laterally to the greater tuberosity. (Mihata, 2012). A level 4 case-series investigated arthroscopic superior capsule reconstruction (ASCR) in 24 consecutive patients (mean age 65.1) with irreparable rotator cuff tears from 2007-2009. Although ASCR reportedly had good results in restoring glenohumeral stability and function, a 17% graft failure rate occurred (34 month mean follow-up). (Mihata, 2013). No other studies have yet been published to substantiate this single clinical application. Also, there appear to be several different biologic grafts used and commercially available (Arthrex) with no comparative studies yet.

Surgery for rotator cuff repair:

Recommended as indicated below. Repair of the rotator cuff is indicated for significant tears that impair activities by causing weakness of arm elevation or rotation, particularly acutely in younger workers. However, rotator cuff tears are frequently partial-thickness or smaller full-thickness tears. For partial-thickness rotator cuff tears and small full-thickness tears presenting primarily as impingement, surgery is reserved for cases failing conservative therapy for three months. The preferred procedure is usually arthroscopic decompression, but the outcomes from open repair are as good or better. Surgery is not indicated for patients with mild symptoms or those who have no limitations of activities. Ejnisman-Cochrane, 2004)(Grant, 2004). Lesions of the rotator cuff are best thought of as a continuum, from mild inflammation and degeneration to full avulsions. Studies of normal subjects document the universal presence of degenerative changes and conditions, including full avulsions without symptoms. Conservative treatment has results similar to surgical treatment but without surgical risks. Studies evaluating results of conservative treatment of full-thickness rotator cuff tears have shown an 82-86% success rate for patients presenting within three months of injury. The efficacy of arthroscopic decompression for full-thickness tears depends on the size of the tear; one study reported satisfactory results in 90% of patients with small tears. A prior study by the same group reported satisfactory results in 86% of patients who underwent open repair for larger tears. Surgical outcomes are much better in younger patients with a rotator cuff tear, than in older patients, who may be suffering from degenerative changes in the rotator cuff. Referral for surgical consultation may be indicated for patients who have: Activity limitation for more than three months, plus existence of a surgical lesion; Failure of exercise programs to increase range of motion and strength of the musculature around the shoulder, plus existence of a surgical lesion; Clear clinical and imaging evidence of a lesion that has been shown to benefit, in both the short and long term, from surgical repair; Red flag conditions (e.g., acute rotator cuff tear in a young worker, glenohumeral joint dislocation, etc.). Suspected acute tears of the rotator cuff in young workers may be surgically repaired acutely to restore function; in older workers, these tears are typically treated conservatively at first. Partial-thickness tears are treated the same as impingement syndrome regardless of MRI findings. Outpatient rotator cuff repair is a well-accepted and cost-effective procedure. (Cordasco, 2000). Difference between surgery & exercise was not significant. (Brox, 1999). There is significant variation in surgical decision-making and a lack of clinical agreement among orthopaedic surgeons about rotator cuff surgery. (Dunn, 2005) For rotator cuff pain with an intact tendon, a trial of 3 to 6 months of conservative therapy is reasonable before orthopaedic referral. Patients with small tears of the rotator cuff may be referred to an orthopaedist after 6 to 12 weeks of conservative treatment. (Burbank2, 2008). Patients with workers' compensation claims have worse outcomes after rotator cuff repair. (Henn, 2008).

Revision rotator cuff repair: The results of revision rotator cuff repair are inferior to those of primary repair. While pain relief may be achieved in most patients, selection criteria should include patients with an intact deltoid origin, good-quality rotator cuff tissue, preoperative elevation above the horizontal, and only one prior procedure. (Diurasovic, 2001).

Recent research: Evidence on the pros and cons of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive, an AHRQ comparative effectiveness review concluded. While the data are sparse, patients improved substantially with all interventions; there were few clinically important differences between approaches, and complications were rare. Most patients try to resolve their pain and disability with a course of physical therapy before attempting surgery, but the study found very little good quality research to guide the choice of nonoperative treatment, the timing of treatment, and who would most benefit from various forms of treatment. Four out of five studies comparing surgical and nonsurgical management favored operative repair, but the evidence was too limited to make conclusions regarding comparative effectiveness. 113 studies comparing various operations found no differences in functional outcomes between open vs mini-open repair, mini-open vs arthroscopic repair, arthroscopic repairs with vs without acromioplasty, and single-row vs double-row fixation. Patients who had mini-open repair returned to work about a month earlier than patients who had open repair. On the other hand, functional improvement was better after open repair compared with arthroscopic debridement. With regard to adding continuous passive motion to postoperative physical therapy, 11 trials yielded moderate evidence for no difference in function or pain. One study found no difference in range of motion or strength, while another suggested that adding continuous passive motion shortened the time until return to work and the time to 90 degrees abduction. For other postoperative rehabilitation strategies, one study showed that progressive loading reduced pain compared to traditional loading. In general, though, most studies found no difference in health-related quality of life, function, pain, range of motion, and strength with one approach versus another (e.g., with or without aquatics, individualized vs at home alone, videotape vs therapist-based, etc.). In the 72 studies that assessed prognostic factors, older age, increasing tear size, and greater preoperative symptoms were consistently associated with recurrent tears, whereas gender, workers’ compensation status, and duration of symptoms usually did not predict poorer outcomes. (Seida, 2010). "Rotator cuff surgery is a viable option for many patients, but, as with any surgery, it is not for everybody," said AHRQ Director C M. C, M.D. "This report has good news: most interventions work, and each patient should talk to his or her doctor about which to option to pursue." Most older patients who suffer a rotator cuff tear are first treated with up to 3 months of nonsurgical treatment such as pain and anti-inflammatory medications, exercise, and rest. If treatments other than surgery do not work, the rotator cuff may be repaired surgically, using a variety of methods ranging from minimally invasive techniques to an open operation. Patients can then undergo rehabilitation to restore their range of motion, muscle strength, and function following surgery. Rotator cuff tears also can occur in younger adults, usually as a result of traumatic injury. In such cases they are almost always treated with surgery. Some doctors have maintained that earlier surgery results in less pain and better use of the shoulder, leading to an earlier return to work and decreased costs; so, patients often face the difficult decision of opting for surgery rather than waiting for nonoperative treatments to work. However, researchers found little evidence that earlier surgery benefits patients. Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears is the newest comparative effectiveness report from the AHRQ's Effective Health Care Program. The Effective Health Care Program represents the leading federal effort to compare alternative treatments for health conditions and make the findings public, to help doctors, nurses, pharmacists and others work together with patients to choose the most effective treatments. (Clancy, 2010). This prospective cohort study concluded that PT is effective for most patients with atraumatic full-thickness rotator cuff tears and shoulder pain, without the need for surgery. At six weeks fewer than 10% of patients had decided to undergo surgery, and after 2 years, only 2% of the rest had opted for surgery. Patients did most of their physical therapy at home and usually made only 1 weekly visit to the physical therapist. (Kuhn, 2011). One-third of rotator cuff repairs fail, and 74% of the failures occur within three months of surgery. Healed tendons, or recurrent tears, at six months can predict outcomes at seven years. (Kluger, 2011). Not surprisingly, larger tears are harder to repair, and the retear rate based on rotator cuff tear size is: 10% for ≤2 cm2; 16% for 2–4 cm2; 31% for 4–6 cm2; 50% for 6–8 cm2; & 57% for >8 cm2. (Murrell, 2012). There is insufficient evidence to suggest efficacy in operative or nonoperative treatment of rotator cuff tears in in patients aged older than 60 years. (Downie, 2012). In this RCT, full-thickness rotator cuff repair outcomes were the same, with or without acromioplasty. Acromioplasty is commonly performed during arthroscopic rotator cuff repair, but it does not improve outcomes by 2-year follow-up. (Abrams, 2014). Non-contrast MRI is sufficient for rotator cuff tears, and contrast enhancement is recommended for SLAP tears. (Spencer, 2013) (Farshad-Amacker, 2013)(Arnold, 2012)(Major, 2011). See also Stem cell autologous transplantation (shoulder).

ODG Indications for Surgery -- Rotator cuff repair:

Criteria for rotator cuff repair with diagnosis of full thickness rotator cuff tear AND Cervical pathology and frozen shoulder syndrome have been ruled out:

  1. Subjective Clinical Findings: Shoulder pain and inability to elevate the arm; tenderness over the greater tuberosity is common in acute cases. PLUS
  2. Objective Clinical Findings: Patient may have weakness with abduction testing. May also demonstrate atrophy of shoulder musculature. Usually has full passive range of motion. PLUS
  3. Imaging Clinical Findings: Conventional x-rays, AP, and true lateral or axillary views. AND MRI, ultrasound, or arthrogram shows positive evidence of deficit in rotator cuff.

Criteria for rotator cuff repair OR anterior acromioplasty with diagnosis of partial thickness rotator cuff repair OR acromial impingement syndrome (80% of these patients will get better without surgery.)

  1. Conservative Care: Recommend 3 to 6 months: Three months is adequate if treatment has been continuous, six months if treatment has been intermittent. Treatment must be directed toward gaining full ROM, which requires both stretching and strengthening to balance the musculature. PLUS
  2. Subjective Clinical Findings: Pain with active arc motion 90 to 130 degrees. AND Pain at night (Tenderness over the greater tuberosity is common in acute cases.) PLUS
  3. Objective Clinical Findings: Weak or absent abduction; may also demonstrate atrophy. AND Tenderness over rotator cuff or anterior acromial area. AND Positive impingement sign and temporary relief of pain with anesthetic injection (diagnostic injection test). PLUS
  4. Imaging Clinical Findings: Conventional x-rays, AP, and true lateral or axillary view. AND MRI, ultrasound, or arthrogram shows positive evidence of deficit in rotator cuff.

(Washington, 2002)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

In the instant case, the utilization review doctors (i.e., Dr. M and Dr. H) denied the requested treatment and the IRO reviewer upheld the denial of the requested treatment. The IRO reviewer, who is an orthopedic surgeon, reviewed Petitioner / Claimant’s records and opined that the proposed treatment was not indicated as medically necessary based on the ODG in that the requested treatment was not recommended and investigational. Thereafter, the IRO reviewer cited medical judgment, clinical experience and expertise in accordance with accepted medical standards, as well as the ODG, in upholding the denials of the requested treatment.

When weighing expert testimony, the hearing officer must first determine whether the doctor rendering an expert opinion is qualified to offer such. In addition, the hearing officer must determine whether the opinion is relevant to the issues at bar and whether it is based upon a reliable foundation. An expert’s bald assurance of validity is not enough. See Black v. Food Lion, Inc., 171 F.3d 308 (5th Cir. 1999); E.I. Du Pont De Nemours and Company, Inc. v. Robinson, 923 S.W.2d 549 (Tex. 1995). A medical doctor is not automatically qualified as an expert on every medical question and an unsupported opinion has little, if any, weight. See Black, 171 F.3d 308. In determining reliability of the evidence, the hearing officer must consider the evidence in terms of (1) general acceptance of the theory and technique by the relevant scientific community; (2) the expert’s qualifications; (3) the existence of literature supporting or rejecting the theory; (4) the technique’s potential rate of error; (5) the availability of other experts to test and evaluate the technique; (6) the clarity with which the theory or technique can be explained to the trial court; and (7) the experience and skill of the person who applied the technique on the occasion in question. Kelly v. State, 792 S.W.2d 579 (Tex. App.-Fort Worth 1990) aff'd, 824 S.W.2d 568 (Tex. Crim. App. 1992).

Additionally, "[a] decision issued by an IRO is not considered an agency decision and neither the [D]epartment nor the [D]ivision” are considered parties to an appeal. See Division Rule 133.308 (s). "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." Id. Evidence-based medical evidence entails the opinion of a qualified expert that is supported by evidence-based medicine, if evidence-based medicine exists.

Accordingly, Petitioner / Claimant, as the party appealing the IRO decision, had the burden of overcoming the IRO decision by a preponderance of evidence-based medical evidence. In this case, Petitioner / Claimant presented documentary evidence, including his medical records, and the testimony of Dr. RH. Dr. RH explained during his testimony how and why the requested procedure was medically reasonable and necessary for Petitioner / Claimant. He described the differences between the requested procedure and the reverse total shoulder arthroplasty, which he considered to be more risky in terms of complications. Dr. RH did admit that the ODG does not recommend the requested procedure due to its newness and the unavailability of studies. However, he added that he and his partners are currently conducting a study and that there is sufficient evidence-based literature and medical evidence to support the requested procedure. Dr. RH’s testimony and opinion was found to be credible, persuasive, and convincing. He provided explanations through the use of evidence-based medical evidence as to how Petitioner / Claimant met the requirements for the requested treatment.

Petitioner / Claimant established the necessity of the requested treatment at issue through other evidence-based medical evidence outside of the ODG. As such, evidence-based medical evidence explaining that the requested treatment was medically reasonable and necessary existed in this case. Therefore, the preponderance of the evidence is contrary to the decision of the IRO that Petitioner / Claimant is not entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury).

The Hearing Officer considered all of the evidence admitted. The Findings of Fact and Conclusions of Law are based on an assessment of all of the evidence whether or not the evidence is specifically discussed in this Decision and Order.

FINDINGS OF FACT

  1. The parties stipulated to the following facts:

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

B. On (Date of Injury), Petitioner / Claimant was an employee of (Employer), the employer.

C.On (Date of Injury), employer provided workers’ compensation insurance with (Carrier), the Respondent / Carrier.

D.On (Date of Injury), Petitioner / Claimant sustained a compensable injury in the form of at least a left shoulder rotator cuff tear.

E.The IRO determined that Petitioner / Claimant is not entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury).

  • Respondent / Carrier delivered to Petitioner / Claimant a single document stating the true corporate name of Respondent / Carrier, and the name and street address of Respondent / Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • The IRO decision was sent to the parties on December 12, 2015.
  • The IRO decision was sent to Petitioner / Claimant addressed to (Address)
  • Petitioner / Claimant’s address is (Address).
  • Petitioner / Claimant filed his appeal of the IRO decision on January 14, 2016.
  • Left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair is 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. Petitioner / Claimant timely appealed the IRO decision.
    4. The preponderance of the evidence is contrary to the decision of the IRO that Petitioner / Claimant is not entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury).

    DECISION

    Petitioner / Claimant timely appealed the IRO decision. Petitioner / Claimant is entitled to left arthroscopic rotator cuff repair, superior capsular reconstruction, lysis adhesions, extensive debridement, allograft reinforced repair for the compensable injury of (Date of Injury).

    ORDER

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

    The true corporate name of the Respondent / 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, TX 78701-3218

    Signed this 4th day of July 2016.

    Julio Gomez, Jr.
    Hearing Officer

    End of Document
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