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 left side fluoroscopy guided genicular NB (nerve block) - left knee for the compensable injury of (Date of Injury).
STATEMENT OF THE CASE
On January 30, 2017, 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 left side fluoroscopy guided genicular NB - left knee for the compensable injury of (Date of Injury)?
Petitioner/Claimant appeared and was assisted by JR, ombudsman.
Respondent/Carrier appeared and was represented by CF, attorney.
No witnesses testified at the contested case hearing.
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: None
Claimant sustained a compensable injury to her left knee on (Date of Injury), as a result of a slip and fall. Claimant has been recommended to undergo left knee surgery. Claimant’s treating doctor has recommended a genicular nerve block to the left knee, which was denied by Carrier and appealed to an IRO.
The IRO reviewer, identified as an anesthesiologist and pain management physician, upheld Carrier’s denial and determined that the requested procedure was not medically necessary. The IRO reviewer noted that, according to the Official Disability Guidelines (ODG), genicular nerve blocks are not recommended. The IRO reviewer went on to state that nerve blocks may be recommended for evaluation and treatment of neuromas, but not for genicular nerves, to include arthritis and post-total knee arthroplasty. The IRO reviewer noted that there was a lack of clinical documentation to support the request outside the guidelines.
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 Criteria for Nerve Blocks:
Recommended only for evaluation and treatment of neuromas, but not for genicular nerves (arthritis, post-TKA). The purpose of performing a diagnostic injection or block of any nerve around the knee would be to assess whether marked pain relief occurs. It could be accompanied with cortisone which could potentially be therapeutic. In the case of the genicular nerves, such blocks have been requested primarily to argue for unproven treatments like neurotomy, ablation, or neurectomy, and these are not recommended due to lack of sufficient evidence. See Nerve excision (following TKA); Neurotomy; Radiofrequency neurotomy (of genicular nerves in knee).
Based on the evidence presented, Claimant does not meet the requirements in the ODG for the requested psychotherapies, and she 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 left side fluoroscopy guided genicular NB - left knee 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
- 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 provided workers’ compensation coverage with Hartford Underwriters Insurance Company, Carrier.
- Claimant sustained a compensable injury on (Date of Injury).
- The IRO determined that the proposed left side fluoroscopy guided genicular NB - left knee 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 genicular nerve blocks, and Claimant failed to present evidence-based medical evidence sufficient to overcome the determination of the IRO.
- Left side fluoroscopy guided genicular NB - left knee is not health care reasonably required for the compensable injury of (Date of Injury).
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 is not contrary to the decision of the IRO that left side fluoroscopy guided genicular NB - left knee is not health care reasonably required for the compensable injury of (Date of Injury).
Claimant is not entitled to left side fluoroscopy guided genicular NB - left knee for the compensable injury of (Date of Injury).
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 HARTFORD UNDERWRITERS INSURANCE COMPANY, and the name and address of its registered agent for service of process is:
CT CORPORATION SYSTEM
1999 BRYAN STREET, SUITE 900
DALLAS, TX 75201
Signed this 30th day of January, 2017.
Carol A. Fougerat