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 Administrative Law Judge determines that Claimant is not entitled to physical therapy, 3 time a week for 4 weeks, for the compensable injury of (Date of Injury).
STATEMENT OF THE CASE
A contested case hearing was held on October 3, 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 physical therapy, three times a week for four weeks, for the compensable injury of (Date of Injury)?
Petitioner/Claimant appeared and was assisted by DS, ombudsman.
Respondent/Carrier appeared and was represented by GS, attorney.
Claimant sustained a compensable injury on (Date of Injury), when she fell as she was leaving work. Carrier accepted a right knee lateral meniscus tear. Claimant underwent surgery for the accepted meniscus tear on March 8, 2017, and received 12 sessions of post-operative physical therapy. Claimant requested preauthorization for an additional 12 sessions, but it was denied. It was again denied after reconsideration and Claimant requested that the request be reviewed by an independent review organization in accordance with Division Rule 133.308. The physician reviewer agreed with Carrier’s denial of the additional physical therapy and Claimant requested a medical contested case hearing. On October 3, 2017, Kenneth A. Huchton, a Division administrative law judge, held a medical contested case hearing to decide the disputed issue.
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 defined by Texas Labor Code Section 401.011 (18a) as 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, in making decisions for the treatment of a particular patient. 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. A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division is considered a party to an appeal. In a contested case hearing, 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. (Division Rule 133.308 (s).)
With regard to physical therapy after a meniscectomy, the Knee and Leg chapter of the ODG provides:
Physical medicine treatment
Recommended as indicated below. As with any treatment, if there is no improvement after 2-3 weeks, the protocol may be modified or re-evaluated. See also specific modalities linked below. (Philadelphia, 2001)
ODG Physical Medicine Guidelines –
Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home PT. Also see other general guidelines that apply to all conditions under Physical Therapy in the ODG Preface.
Post-surgical (Meniscectomy): 12 visits over 12 weeks
Controversy exists about the effectiveness of physical therapy after arthroscopic partial meniscectomy. (Goodwin, 2003) Supervised therapeutic exercise improves outcomes in patients who have osteoarthritis or claudication of the knee. Compared with home exercise, supervised therapeutic exercise has been shown to improve walking speed and distance. (Rand, 2007)
Many patients do not require PT after partial meniscectomy. (Morrissey, 2006)
Active Treatment versus Passive Modalities: See the Low Back Chapter for more information. The use of active treatment modalities instead of passive treatments is associated with substantially better clinical outcomes. The most commonly used active treatment modality is Therapeutic exercises (97110), but other active therapies may be recommended as well, including Neuromuscular reeducation (97112), Manual therapy (97140), and Therapeutic activities/exercises (97530). This systematic review concluded that PT interventions that empower patients to actively self-manage knee OA (such as aerobic, strength, and proprioception exercise) improved outcomes the best. (Wang, 2012)
After reviewing the medical evidence, the physician reviewer concluded that the clinical notes “failed to include evidence of acute exacerbation or extenuating circumstances that would necessitate additional physical therapy sessions above guidelines” and failed to “include any circumstance that would prevent the patient from being compliant with a home exercise program.” The physician reviewer based his opinion on the ODG and his medical judgment, clinical experience and expertise in accordance with accepted medical standards.
In contesting the IRO physician reviewer’s opinion, Claimant offered a written statement from JO, MPT, the physical therapist that conducted the 12 post-operative physical therapy sessions she had attended. In his statement, Mr. O opined that Claimant had been unable to progress sufficiently during the physical therapy sessions as a result of a long pre-surgical period of conservative treatment that caused deconditioning and right leg weakness. He opined that Claimant needed "further strength, balance, proprioception, and conditioning to regain her pre-injury level of function.” Mr. O did not cite any medical literature in expressing his opinion and did not show that Claimant is an outlier whose care is not adequately addressed by the ODG. It is noted that the ODG states in part that studies had not determined that proprioception and strength training were of benefit for patients with ACL issues; but did not address what, if any, benefit that type of physical therapy would be for patients after lateral meniscus arthroscopic surgery.
After considering the evidence presented, the Administrative Law Judge does not find that the preponderance of the evidence-based medical evidence is contrary to the IRO determination upholding Carrier’s denial of the request for an additional 12 sessions of post-operative physical therapy.
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:
- 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 compensable injury is a lateral meniscus tear of the right knee.
- Claimant requested preauthorization for physical therapy, three times a week for four weeks, for the compensable injury of (Date of Injury).
- Carrier denied preauthorization for the requested physical therapy.
- Independent Resolutions, Inc. was appointed as the independent review organization to address the requested physical therapy.
- The IRO upheld Carrier’s denial of the request for physical therapy, 3 times a week for 4 weeks, 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 underwent 12 sessions of physical therapy after her partial lateral meniscectomy of the right knee.
- The preponderance of the medical evidence failed to show that additional physical therapy would be more effective than a home based exercise program.
- An additional 12 sessions of post-operative physical therapy is not health care reasonably required for the compensable 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-based medical evidence is not contrary to the IRO determination that physical therapy, 3 time a week for 4 weeks, is not health care reasonably required for the compensable injury of (Date of Injury).
Claimant is not entitled to physical therapy, 3 time a week for 4 weeks, 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 HARTFORD ACCIDENT & INDEMNITY 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, TX 78701-3218
Signed this 6th day of October, 2017.
KENNETH A. HUCHTON
Administrative Law Judge