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At a Glance:
Title:
16060-nr
Date:
February 27, 2017
Type:

16060-nr

February 27, 2017

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 Tizanidine cap 4 mg 30 day supply quantity 30 with one refill or Hydrocodone APAP tab 10-325 30 day supply quantity 90 for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

On February 23, 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 Tizanidine cap 4 mg 30 day supply quantity 30 with one refill and Hydrocodone APAP tab 10-325 30 day supply quantity 90 for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by MH, ombudsman. Respondent/Carrier appeared and was represented by MA, attorney. In attendance on behalf of the employer was TV.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: None

For Carrier: None

The following exhibits were admitted into evidence:

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

Claimant’s Exhibits: C-1 and C-2

Carrier’s Exhibits: CR-A through CR-C

DISCUSSION

Claimant sustained a compensable injury on (Date of Injury). As a result of this injury, Claimant has undergone multiple surgeries, physical therapy and pain management. Claimant’s treating doctor has recommended continued use of the prescriptions Tizanidine and Hydrocodone, which was denied by the Carrier and appealed to an IRO.

The IRO reviewer, identified as a medical doctor board certified in physical medicine and rehabilitation, upheld Carrier’s denial and determined that the requested prescriptions were not medically necessary. The IRO reviewer noted that the ongoing use of Tizanidine at 4 mg, muscle relaxants, are not recommended for routine or long-term use to address musculoskeletal pain. The IRO reviewer stated that the records did not demonstrate any recent injuries or any indication of recent flare-ups of musculoskeletal spasms or pain.

Regarding the use of Hydrocodone, the IRO reviewer referred to the recommendations in the Official Disability Guidelines (ODG), noting that the ODG does not recommend long-term use of narcotic medications for chronic musculoskeletal or neuropathic pain, as there is limited evidence in the literature demonstrating long-term function improvement with this class of medications. The IRO reviewer also noted that ODG recommends that records document the efficacy of short-acting narcotics to include pain relief and functional improvement, as well as demonstrate compliance through risk assessments and urine drug screens. The IRO concluded that, based on the records available for review, medical necessity for the prescriptions has not been established.

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."

ODG Criteria for Tizanidine and Hydrocodone:

Tizanidine (Zanaflex®, generic available) is a centrally acting alpha2-adrenergic agonist that is FDA approved for management of spasticity; unlabeled use for low back pain. (Malanga, 2008) Eight studies have demonstrated efficacy for low back pain. (Chou, 2007) One study (conducted only in females) demonstrated a significant decrease in pain associated with subacute and chronic myofascial pain syndrome and the authors recommended its use as a first-line option to treat myofascial pain. (Malanga, 2002) May also provide benefit as an adjunct treatment for fibromyalgia. (ICSI, 2007)

Side effects: somnolence, dizziness, dry mouth, hypotension, weakness, hepatotoxicity (LFTs should be monitored baseline, 1, 3, and 6 months). (See, 2008)

Dosing: 4 mg initial dose; titrate gradually by 2 – 4 mg every 6 – 8 hours until therapeutic effect with tolerable side-effects; maximum 36 mg per day. (See, 2008) Use with caution in renal impairment; should be avoided in hepatic impairment. Tizanidine use has been associated with hepatic aminotransaminase elevations that are usually asymptomatic and reversible with discontinuation. This medication is related to clonidine and should not be discontinued abruptly. Weaning should occur gradually, particularly in patients that have had prolonged use. (Zanaflex-FDA, 2008)

Benzodiazepines: Not recommended due to rapid development of tolerance and dependence. There appears to be little benefit for the use of this class of drugs over nonbenzodiazepines for the treatment of spasm. (See, 2008) See Benzodiazepines.

Claimant failed to offer evidence-based medical evidence contrary to the determination of the IRO or to support the necessity of the prescriptions. Based on the evidence presented, Claimant has not met the requirements in the ODG for the requested prescriptions and he failed to present evidence-based medical 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 Tizanidine cap 4 mg 30 day supply quantity 30 with one refill or Hydrocodone APAP tab 10-325 30 day supply quantity 90 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:
    1. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    2. On (Date of Injury), Claimant was the employee of (Employer), Employer.
    3. On (Date of Injury), Employer provided workers’ compensation coverage as a self-insurer.
    4. Claimant sustained a compensable injury on (Date of Injury).
    5. The IRO determined that the proposed Tizanidine cap 4 mg 30 day supply quantity 30 with one refill and Hydrocodone APAP tab 10-325 30 day supply quantity 90 were not medically necessary for the compensable injury of (Date of Injury).
  2. 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.
  3. Claimant does not meet the recommendations of the ODG for the prescriptions Tizanidine and Hydrocodone.
  4. Tizanidine cap 4 mg 30 day supply quantity 30 with one refill and Hydrocodone APAP tab 10-325 30 day supply quantity 90 are 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 Tizanidine cap 4 mg 30 day supply quantity 30 with one refill and Hydrocodone APAP tab 10-325 30 day supply quantity 90 are not health care reasonably required for the compensable injury of (Date of Injury).

DECISION

Claimant is not entitled to Tizanidine cap 4 mg 30 day supply quantity 30 with one refill or Hydrocodone APAP tab 10-325 30 day supply quantity 90 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 §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:

(NAME)

(STREET ADDRESS)

(CITY), TX (ZIPCODE)

Signed this 27th day of February, 2017.

Carol A. Fougerat
Hearing Officer

End of Document
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