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 lumbar epidural steroid injection, L4-5 on the right X1 is not health care reasonably required for the compensable injury of (Date of Injury).
STATEMENT OF THE CASE
A contested case hearing was held on August 8, 2017 to decide the following disputed issue:
Is the preponderance of the evidence contrary to the decision of the IRO that Claimant is not entitled to lumbar epidural steroid injection, L4-5 on the right X1 for the compensable injury of (Date of Injury)?
Claimant appeared and was assisted by BO, ombudsman. Carrier appeared and was represented by RJ, attorney.
The following witnesses testified:
For the Claimant: TN.
For Carrier None.
The following exhibits were admitted into evidence:
Hearing officer’s Exhibits HO-1 and Ho-2.
Claimant’s Exhibits C-1 through C-3.
Carrier’s Exhibits CR-A through CR-H.
Claimant sustained a compensable injury to her lumbar and thoracic spine when she slipped and fell at work, landing on her buttocks. When conservative treatment failed to relieve her pain, she underwent surgery for T-12 fracture which consisted of a T11-T12 fusion. Claimant’s request for lumbar epidural steroid injection (ESI), through her treating doctor, AT, MD was denied in June 2014. Claimant testified that she has never had the injection, however the medical records in evidence show that she has been treated with epidural injections and trigger point injections in the past.
Claimant testified that the pain has gone on for many years and has not improved with any of the treatment options. Claimant’s current treatment plan includes medications and the appeal for the lumbar epidural steroid injection. Claimant’s request has been denied multiple times, most recently on March 15, 2017 due to no correlation of symptoms, physical exam findings, and diagnostic studies to support radiculopathy. Claimant disagrees with the IRO decision that upheld Carrier's denial of the lumbar epidural steroid injection, L4-5 on the right X1. The IRO reviewer, who is board certified in physical medicine and rehabilitation as well as in pain management and in electrodiagnostic medicine, relied on the Official Disability Guidelines (ODG), the AMA Guides, and on the reviewer's medical judgment, clinical experience and expertise in accordance with accepted medical standards. The reviewer wrote that medical records on Claimant did not document radiculopathy or radicular pain in dermatomal distribution with corroborative findings of radiculopathy.
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.”
With regard to lumbar epidural steroid injection, the ODG lists the following criteria:
Recommended as an option for treatment of radicular pain (defined as pain in dermatomal distribution with corroborative findings of radiculopathy). See specific criteria for use below. In a recent Cochrane review, there was one study that reported improvement in pain and function at four weeks and also one year in individuals with chronic neck pain with radiation. (Peloso-Cochrane, 2006) (Peloso, 2005) Other reviews have reported moderate short-term and long-term evidence of success in managing cervical radiculopathy with interlaminar ESIs. (Stav, 1993) (Castagnera, 1994) Some have also reported moderate evidence of management of cervical nerve root pain using a transforaminal approach. (Bush, 1996) (Cyteval, 2004) A recent retrospective review of interlaminar cervical ESIs found that approximately two-thirds of patients with symptomatic cervical radiculopathy from disc herniation were able to avoid surgery for up to 1 year with treatment. Success rate was improved with earlier injection (< 100 days from diagnosis). (Lin, 2006) There have been recent case reports of cerebellar infarct and brainstem herniation as well as spinal cord infarction after cervical transforaminal injection. (Beckman, 2006) (Ludwig, 2005) Quadriparesis with a cervical ESI at C6-7 has also been noted (Bose, 2005) and the American Society of Anesthesiologists Closed Claims Project database revealed 9 deaths or cases of brain injury after cervical ESI (1970-1999). (Fitzgibbon, 2004) These reports were in contrast to a retrospective review of 1,036 injections that showed that there were no catastrophic complications with the procedure. (Ma, 2005) The American Academy of Neurology recently concluded that epidural steroid injections may lead to an improvement in radicular lumbosacral pain between 2 and 6 weeks following the injection, but they do not affect impairment of function or the need for surgery and do not provide long-term pain relief beyond 3 months, and there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain. (Armon, 2007) There is evidence for short-term symptomatic improvement of radicular symptoms with epidural or selective root injections with corticosteroids, but these treatments did not appear to decrease the rate of open surgery. (Haldeman, 2008) (Benyamin, 2009) See the Low Back Chapter for more information and references.
Criteria for the use of Epidural steroid injections, therapeutic: The purpose of ESI is to reduce pain and inflammation, thereby facilitating progress in more active treatment programs, and avoiding surgery, but this treatment alone offers no significant long-term functional benefit. (1) Radiculopathy must be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing. (2) Initially unresponsive to conservative treatment (exercises, physical methods, NSAIDs and muscle relaxants). (3) Injections should be performed using fluoroscopy (live x-ray) for guidance (4) If used for diagnostic purposes, a maximum of two injections should be performed. A second block is not recommended if there is inadequate response to the first block. Diagnostic blocks should be at 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) In the therapeutic phase, repeat blocks should only be offered if there is at least 50% pain relief for six to eight weeks, with a general recommendation of no more than 4 blocks per region per year. (8) Repeat injections should be based on continued objective documented pain and function response. (9) Current research does not support a “series-of-three” injections in either the diagnostic or therapeutic phase. We recommend no more than 2 ESI injections. (10) It is currently not recommended to perform epidural blocks on the same day of treatment as facet blocks or stellate ganglion blocks or 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.
Criteria for the use of Epidural steroid injections, diagnostic: To determine the level of radicular pain, in cases where diagnostic imaging is ambiguous, including the examples below:
(1) To help to evaluate a pain generator when physical signs and symptoms differ from that found on imaging studies; (2) To help to determine pain generators when there is evidence of multi-level nerve root compression; (3) To help to determine pain generators when clinical findings are suggestive of radiculopathy (e.g. dermatomal distribution) but imaging studies are inconclusive; (4) To help to identify the origin of pain in patients who have had previous spinal surgery.
Board certified anesthesiologist, NM, MD, performed a peer review dated February 15, 2017. He reviewed a lumbar spine MRI report dated January 9, 2017, Appeal Review report dated January 10, 2017, a Pre-Authorization Review report dated December 20, 2016, and pre-authorization and office visit notes. Dr. M opined that the request for lumbar ESI at L4-5 on the right X1 is not medically necessary because there is no documentation of radiculopathy on physical examination as evidenced by sensory loss, strength, weakness corroborating with the level of the requested injection. He further opined that the ODG criteria for ESI was not satisfied, therefore, the request is not medically necessary.
RK, MD, also prepared a peer review report dated March 10, 2017, in which he opined that the request for lumbar ESI at L4-5 is not substantiated as medically necessary. Dr. K further opined that the ODG recommends that for a patient to be a candidate for such treatment, there should be correlation of symptoms, physical exam findings and diagnostic studies, which correlation does not exist at this time. Dr. K noted that “the same guidelines recommend epidural injections early in the course of an injury in order to facilitate initial functional restoration. It is not clear that there is any meaningful benefit from ESI in a chronic phase, such as currently.”
After a careful review of all of the evidence presented, Claimant has failed to prove that the preponderance of the evidence based medical evidence is contrary to the IRO decision.
Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.
FINDINGS OF FACT
- The parties stipulated to the following facts:
- The Texas Department of Insurance, Division of Workers’ Compensation has jurisdiction in this matter.
- 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.
- Claimant sustained a compensable injury on (Date of Injury).
- The Independent Review Organization determined that claimant should not have lumbar epidural steroid injection, L4-5 on the right X1.
- 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.
- Lumbar epidural steroid injection, L4-5 on the right X1 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 lumbar epidural steroid injection, L4-5 on the right X1 is not health care reasonably required for the compensable injury of (Date of Injury).
Lumbar epidural steroid injection, L4-5 on the right X1 is not health care reasonably required for the compensable injury of (Date of Injury).
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 WAUSAU UNDERWRITERS INSURANCE COMPANY 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 18th day of August, 2017.