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At a Glance:
Title:
16034-nnr
Date:
July 13, 2016

16034-nnr

July 13, 2016

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 revision of left total knee arthroplasty for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

On July 13, 2016, Carol A. Fougerat, a Division Hearing Officer, held a contested case hearing to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to revision of left total knee arthroplasty for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by M H, ombudsman.

Respondent/Carrier appeared and was represented by J L, attorney.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: Claimant

For Carrier: WN, M.D.

The following exhibits were admitted into evidence:

Hearing Officer’s Exhibits: HO-1 and HO-2

Claimant’s Exhibits: C-1 through C-6

Carrier’s Exhibits: CR-1 through CR-E

DISCUSSION

Claimant sustained a compensable injury on (Date of Injury), when he struck his left knee on a trailer hitch while moving equipment. Claimant had undergone prior left knee surgeries, including a total knee replacement, which was performed approximately 10 years prior to this injury. In a Decision and Order dated December 16, 2015, the Hearing Officer determined that the loosening of components of the left total knee arthroplasty and fibula collateral ligament bursitis of the left knee were related to the (Date of Injury) injury, but that the advanced degenerative joint disease of the left knee and enthesopathy of the left knee were not caused or aggravated by the compensable injury of (Date of Injury). Claimant’s treating doctor, R S, M.D., has recommended a revision of the left knee arthroplasty. This procedure was denied by Carrier and appealed to an IRO.

The IRO reviewer, identified as a pediatrics orthopedic doctor and orthopedic surgeon, upheld Carrier’s denial and determined that the requested surgery was not medically necessary. The IRO reviewer noted, per medical literature (which was cited), a subject failure of a total knee replacement may occur through several mechanisms and diagnosis is made by evidence of progressive radial lucency on serial radiographs and bone scans may also play a role in the diagnosis. Most critical is ruling out the possibility of infection. Once infection is ruled out, the patient with symptomatic aseptic prosthetic failure may be a candidate for revision of total knee arthroplasty. The IRO reviewer stated that the documentation submitted for review indicated that Claimant has an irregular lucent zone along the medial and lateral tibial plateaus of the tibial component, and that the possibility of infection was not ruled out. The IRO reviewer concluded that the requested total left knee arthroplasty revision was not medically necessary at this time.

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 (22-a) 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 (18-a) 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."

ODG Indications for Surgery -- Knee arthroplasty:

Criteria for knee joint replacement (If only 1compartment is affected, a unicompartmental or partial replacement may be considered. If 2of 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). {Surgery should be delayed at least 6 months following any intra-articular corticosteroid injection due to risk of infections.} 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)

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

The two utilization review (URA) doctors, both board certified orthopedic surgeons, determined that further diagnostic testing was necessary before revision total knee replacement would be warranted, in addition to ruling out infection. Claimant was recommended to undergo a three-phase bone scan and video fluoroscopy. Claimant did undergo the bone scan on March 18, 2016; however, he has not undergone the recommended stress views under fluoroscopy to identify if there is loosening in the joints, and if so, where. W N, M.D., board certified in orthopedic surgery, testified at the contested case hearing. Dr. WN agreed with the URA doctors, as well as the IRO reviewer. Dr. WN testified that further investigation into what is causing Claimant’s left knee pain was necessary before undergoing additional surgery. Dr. WN noted that specific loosening of the prior knee replacement had not been identified, nor had Dr. S ruled out possible infection, which is a requirement pursuant to the recommendations in the ODG.

Claimant submitted a letter dated July 8, 2016, from Dr. RS. Dr. RS notes that Claimant has failed conservative treatment options, and that Claimant is having recurrent disabling pain and stiffness with functional limitation due to the failed total knee replacement. Dr. RS opines that the surgery is needed; however, he does not address the concerns raised by the IRO reviewer and the other board certified orthopedic surgeons. Dr. RS also failed to explain how Claimant meets the requirements in the ODG for the requested surgery or identify any other evidence-based medicine on which he relied on in making this recommendation for the left knee procedure.

Based on the evidence presented, Claimant does not meet the requirements in the ODG for the requested total left knee arthroplasty revision, and Claimant failed to present evidence sufficient to contradict the determination of the IRO. The preponderance of the evidence is not contrary to the IRO decision that Claimant is not entitled to revision of left total knee arthroplasty 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), Claimant was the employee of (Employer), Employer.

C.On (Date of Injury), Employer provided workers’ compensation coverage with (Carrier), Carrier.

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

E.The IRO determined that the proposed revision of left total knee arthroplasty is not medically necessary for the compensable injury of (Date of Injury).

  • 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.
  • Claimant does not meet the recommendations of the ODG for a left total knee arthroplasty revision, and Claimant failed to present evidence-based medical evidence sufficient to overcome the determination of the IRO.
  • Revision of left total knee arthroplasty 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 revision of left total knee arthroplasty is not health care reasonably required for the compensable injury of (Date of Injury).

    DECISION

    Claimant is not entitled to revision of left total knee arthroplasty for the compensable injury of (Date of injury).

    ORDER

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

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

    JAMES B. CROW

    7703 N. LAMAR

    AUSTIN, TX 78752

    Signed this 13th day of July, 2016.

    Carol A. Fougerat
    Hearing Officer

    End of Document
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