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At a Glance:
Title:
17016-nnr
Date:
November 30, 2017

17016-nnr

November 30, 2017

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 Administrative Law Judge determines that Claimant is entitled to left total knee arthroplasty for the compensable injury of (Date of Injury).

ISSUES

A contested case hearing was held on November 29, 2017 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the IRO that the Claimant is entitled to left total knee arthroplasty for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Petitioner/Claimant appeared and was assisted by BC, ombudsman. Respondent/Carrier appeared and was represented by JM, attorney.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: Claimant.

For Carrier: None.

The following exhibits were admitted into evidence:

Administrative Law Judge’s Exhibits ALJ-1 and ALJ-2.

Claimant’s Exhibits C-1 through C-4.

Carrier’s Exhibits CR-A through CR-E.

BACKGROUND INFORMATION

Carrier contested the determination of the IRO doctor who determined that Claimant is entitled to left total knee arthroplasty for the compensable injury of (Date of Injury). Carrier relied on medical records and the opinion of the two utilization review doctors and Dr. RH, peer reviewer. Claimant argued that Carrier offered insufficient evidence-based medicine to overcome the IRO decision, which is based on the Official Disability Guidelines (ODG).

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." The ODG addresses the necessity for total knee arthroplasty as follows:

Recommended as indicated below. Both total hip and total knee arthroplasty (TKA) are well accepted as reliable and suitable surgical procedures to return highly symptomatic patients to better function. The most common indicated diagnoses are advanced osteoarthritis (OA) followed by rheumatoid arthritis. Recent population-based studies have raised serious questions regarding the efficacy of TKA for individuals with only mild-to-moderate disease.

See also Computer-assisted navigation surgery; Customized knee joint replacement; Outpatient joint replacement; Robotic-assisted knee surgery; and Surgery for arthrofibrosis.

ODG Indications for Surgery™ -- Knee arthroplasty:

(If only 1 compartment is affected, a unicompartmental or partial replacement may be considered. If 2 of the 3 compartments are affected, a total joint replacement is indicated.)

Criteria for knee joint replacement:

  1. Conservative Care:
  2. (b)Exercise therapy (supervised PT and/or home rehab exercises) AND
  3. (c)Medications (unless contraindicated: NSAIDs OR Viscosupplementation injections OR Steroid injections) {Surgery should be delayed at least 6 months following any intra-articular corticosteroid injection due to the risk of infection}. PLUS
  4. Subjective Clinical Findings:
  5. (e)Stiffness AND
  6. (f)Nighttime joint pain AND
  7. (g)Marked daily pain despite conservative care AND
  8. (d) Documentation of current significant functional limitations including limited mobility. PLUS
  9. Objective Clinical Findings:
  10. (i)Over 50 years of age AND
  11. (j)Body mass index (BMI) < 40, as increased BMI poses elevated risks for post-op complications. PLUS
  12. Imaging Clinical Findings: Osteoarthritis on either
  13. (l)Standing X-ray (documenting significant loss of chondral clear space in at least one of the three compartments; varus or valgus deformity with medial or lateral loss of joint space) OR
  14. (m)Previous arthroscopy (documenting advanced chondral erosion or exposed bone, especially if bipolar chondral defects are noted). (Washington, 2003b) (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).

Risk versus benefit: The risk/benefit tradeoff for total knee arthroplasty (TKA) favors patients who have intense or severe symptoms of knee osteoarthritis, are at least 55 years old, have limited mobility, and have a BMI < 40. It is much less favorable for patients who have slight or moderate symptoms and have pain and functional loss less than that of the average patient undergoing TKA. TKA is probably not appropriate for patients with milder symptoms. (Riddle, 2014) After surgery, patients should be prepared to lose a few months to pain, limited mobility, and vigorous rehabilitation. Patients who do not commit to rehab will not regain the maximum range of motion. The primary reason for joint replacement is pain relief. Of secondary importance is improvement of joint function, but those results are less predictable. Knee replacement carries the same dangers as other major surgeries, including infections and blood clots. Patients with comorbidities, such as heart conditions, diabetes, or weak immune systems, are the most at risk. Other risks include implants that become loose or dislocate. Furthermore, the artificial knee might wear out after about 20 years, requiring another joint replacement down the road. Factors that increase the risk of dissatisfaction are younger age, being female, valgus alignment of the knee, and post-traumatic arthritis. (Ayers, 2010) In deciding who should have knee joint replacement surgery for osteoarthritis, there is a need to balance potential benefits against potential risks using the concept of capacity to benefit, and the benefits of overcoming functional limitations should considerably outweigh any likely risks or unintended consequences in an individual by a considerable margin for it to be indicated. (Dieppe, 2011) Surgeons and their patients sometimes will choose a partial replacement (PKR) for the sake of a more normal-feeling knee, less extensive surgery, and a lower risk for infection, knowing that they have the option of converting to a TKR if need be. However, partial replacement has a higher risk for revision surgery than total replacement, and a conversion TKR is more likely to require more follow-up than a primary TKR. (Carr, 2012) Citing the arduous rehabilitation and bone loss associated with traditional knee arthroplasty, some still opt for unicondylar knee arthroplasty, especially in young, high-demand patients. (McAllister, 2008) Consideration should be given to delaying total joint arthroplasty in a patient with a BMI > 40, especially when associated with other comorbid conditions. Obese patients (BMI > 30) have similar satisfaction rates as the non-obese population following total joint arthroplasty; however, as BMI increases over 40, the functional improvement lessens and/or occurs more gradually and must be tempered with the associated increased complication profile. (AAHKS, 2013) (Jämsen, 2012) (Baker2, 2012) More than 90% of patients who have knee replacement surgery experience less pain and greater mobility in their knee after the procedure. (Losina, 2009) Fewer than 2% of total knee replacement surgeries result in serious complications, and the 30-day mortality rate for total knee replacement is about 0.25%. (HCUP, 2015)

NNH/NNT: On average, the NNH (number needed to harm) is about 50, and the NNT (number needed to treat) is about 1.1.

Overall, total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. (Ethgen, 2004) Total knee arthroplasty was found to be associated with substantial functional improvement. (Kane, 2005) Navigated knee replacement provides few advantages over conventional surgery based on radiographic end points. (Bathis, 2006) (Bauwens, 2007) The majority of patients who undergo total joint replacement are able to maintain a moderate level of physical activity, and some maintain very high activity levels. (Bauman, 2007) Functional exercises after hospital discharge for total knee arthroplasty result in a small to moderate short-term, but not long-term, benefit. In the short term, physical therapy interventions with exercises based on functional activities may be more effective after total knee arthroplasty than traditional exercise programs, which concentrate on isometric muscle exercises and exercises to increase range of motion in the joint. (Lowe, 2007) Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty (including intense physical therapy and exercise) reduced the mean hospital length of stay (LOS) from 8.8 days before implementation to 4.3 days after implementation. (Larsen, 2008) In this RCT, perioperative celecoxib (Celebrex) significantly improved postoperative resting pain scores at 48 and 72 hrs, opioid consumption, and active ROM in the first three days after total knee arthroplasty, without increasing the risks of bleeding. The study group received a single 400 mg dose of celecoxib, one hour before surgery, and 200 mg of celecoxib every 12 hours for five days. (Huang, 2008)

Total knee arthroplasty (TKA) not only improves knee mobility in older patients with severe osteoarthritis of the knee, it actually improves the overall level of physical functioning. Levels of physical impairment were assessed with three tools: the Nagi Disability Scale, the Instrumental Activities of Daily Living Scale (IADL) and the Activities of Daily Living (ADL) Scale. Tasks on the Nagi Disability Scale involve the highest level of physical functioning, the IADL involves an intermediate level, and the ADL Scale involves the most basic levels. Significant average treatment effects for TKA were observed for one or more tasks for each measure of physical functioning. The improvements after TKA were "sizeable" on all three scales, while the no-treatment group showed declining levels of physical functioning. (George, 2008) An observational cohort study showed that total knee replacement is the second most successful orthopedic procedure for relieving chronic pain, after total hip. Comparisons were made of the gains in quality of life achieved by total hip replacement, total knee replacement, surgery for spinal stenosis, disc excision for lumbar disc herniation, and arthrodesis for chronic low back pain. Hip replacement reduced pain to levels normal for age, reduced physical functioning to within 75% normal levels, and restored quality of life to virtually normal levels. Total knee replacement was the next most successful procedure, and it all but eliminated pain, improved physical functioning to 60% normal, and restored quality of life to within 65% of normal. (Hansson, 2008) A 6-week program of progressive strength training targeting the quadriceps femoris muscle group substantially improved strength and function following total knee arthroplasty for the treatment of osteoarthritis, compared to patients who received standard of care therapy; however, the addition of neuromuscular electrical stimulation (NMES) to the strength training exercise did not further improve outcomes. (Petterson, 2009)

Knee replacement surgery is expensive but worth the cost, especially if performed by experienced surgeons, according to a recent study. Approximately $11 billion is spent on 500,000 total knee replacements each year in the United States, and the number is projected to multiply seven times by 2030 because of the aging, overweight population. Over 90% of knee replacements are successful; knee pain goes away, and patients become more mobile. In the study, knee replacement surgery and subsequent costs added up to $57,900 per patient, which was $20,800 more than was spent on those who did not get the surgery. Patients who got artificial knees lived more than a year longer in good health than those who did not, and the researchers calculated the added cost per year of good-quality life at $18,300. (Losina, 2009) In a 7-year prospective study, patients with severe osteoarthritis who had total knee replacement had significant improvements in health-related quality of life, but health outcomes were negatively influenced by obesity and post-discharge complications, and women typically did not get as much benefit from surgery as did men. Overall, 76.8% were satisfied or very satisfied with their total knee replacement, and 79.5% said they would have the surgery again under similar circumstances. (Núñez, 2009) More than 95% of patients report that they are satisfied with the outcome of their total knee replacement 1 year after surgery. Factors that increased the risk for dissatisfaction were younger age, being female, valgus alignment of the knee, and post-traumatic arthritis. (Ayers, 2010) Patients undergoing total knee arthroplasty (TKA) should receive ongoing COX-2 Inhibitor therapy for 6 weeks after their procedure, according to a double-blind RCT. (Schroer, 2011) The prevalence of knee pain and knee replacement surgeries has risen substantially during the last 20 years, but the reasons for the increase remain obscure. The rise in knee surgeries may be linked more to an increased awareness of knee pain, as opposed to aging, increased obesity, or radiographic knee osteoarthritis. The authors recommend treating physicians carefully consider, from the signs and symptoms of the patient presenting with knee pain, a broad differential diagnosis, since not all knee pain in middle-aged and older adults is the result of osteoarthritis. (Nguyen, 2011)

Knee replacement surgery is a success story of modern medicine, yet consensus is lacking about the precise indications for the procedure. The number of total knee replacements (TKRs) in the United States increased from 31.2 per 100,000 person-years in the period from 1971 to 1976 to 220.9 per 100,000 person-years in 2008, for a total that year of more than 650,000 procedures. Demand for knee replacement will continue to grow due to aging populations and rising obesity rates, both of which portend higher rates of osteoarthritis. Outcome data break down into those for TKRs vs those for partial-knee replacements (PKRs). Surgeons and their patients will sometimes choose a PKR for the sake of a more normal-feeling knee, less extensive surgery, and a lower risk for infection, knowing that they have the option of converting to a TKR if need be. However, partial replacement has a higher risk for revision surgery than total replacement, and a conversion TKR is more likely to require more follow-up than a primary TKR, according to registry data. In addition to recommending better patient selection and better reporting of outcomes, particularly as it relates to individual implant devices, the authors also call for new strategies to treat early-stage osteoarthritis in younger patients that will avoid the need for major surgery altogether. (Carr, 2012) Since there is platinum-level evidence that therapeutic exercise results in improved physical function for people with knee OA, this treatment should be part of conservative care prior to knee arthroplasty. (Fransen, 2008) A systematic review concluded that PT interventions that empower patients to actively self-manage knee OA (such as aerobic, strength, and proprioception exercise) resulted in the best outcomes. (Wang, 2012) The AAOS Guidelines for Treatment of Osteoarthritis of The Knee include a strong recommendation that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education and that they engage in physical activity consistent with national guidelines. (AAOS, 2013) One-third of total knee replacement surgeries in the U.S. may be inappropriate. Using a modified version of the Escobar classification system, this study found that 44% were appropriate, 22% were inconclusive, and 34% were inappropriate. Most patients in the appropriate category had intense or severe symptoms, were at least 55 years old, and had limited mobility. Most patients in the inconclusive category were similar but with normal mobility. Most patients in the inappropriate category had slight or moderate symptoms and had pain and functional loss less than half that of the average patient undergoing TKA. In addition, it was common in this group for patients to be younger than 55 years. TKA is probably not appropriate for patients with milder symptoms. (Riddle, 2014) A population-based cohort analysis of 4498 TKAs followed for 9 years noted lower quality adjusted life years (QALYs) than had been previously reported by others. Specifically, in the absence of poor functional status at baseline, minimal effects on quality of life were measured, strongly suggesting that TKA should be restricted to severely affected patients. (Ferket, 2017)

There is no evidence to recommend high-flexion implants and sex-specific implants in total knee replacement over established devices. (Nieuwenhuijse, 2014)

Unicompartmental knee replacement: Recommended as an option. Unicompartmental knee replacement is effective among patients with knee OA restricted to a single compartment. (Zhang, 2008) In this RCT, the early results demonstrated that the unicompartmental knee replacement (UKR) group had less complications and more rapid rehabilitation than the total knee replacement (TKR) group. At five years, there were an equal number of failures in the two groups, but the UKR group had more excellent results and a greater range of movement. The 15-year survivorship rate based on revision or failure for any reason was 89.8% for UKR and 78.7% for TKR. The better early results with UKR are maintained at 15 years with no greater failure rate. (Newman, 2009) Long-term studies are needed to appropriately define the role of less invasive unicompartmental surgical approaches. (Borus, 2008) Unicondylar knee arthroplasty (UKA) and total knee arthroplasty (TKA) are both recommended for the treatment of medial compartment osteoarthritis in the varus knee. Citing the arduous rehabilitation and bone loss associated with traditional knee arthroplasty, some opt for UKA, especially in young, high-demand patients. (McAllister, 2008) With appropriate patient selection, UKAs are a successful option for patients with osteoarthritis. (Dalury, 2009) See also Osteotomy.

Bicompartmental knee replacement: Not recommended. See separate entry for Bicompartmental knee replacement.

Obesity: In balancing risks versus rewards, a BMI threshold of 40 is recommended. Consideration should be given to delaying total joint arthroplasty in a patient with a BMI > 40, especially when associated with other comorbid conditions, such as poorly controlled diabetes or malnutrition. Obese patients (BMI > 30) have similar satisfaction rates as the non-obese population following total joint arthroplasty; however, as BMI increases over 40, the functional improvement is reduced and/or occurs more gradually and must be tempered with the associated increased complication profile. (AAHKS, 2013) (Jämsen, 2012) (Baker2, 2012) But morbid obesity (BMI > 40) is a significant risk factor. (Watts, 2014) A British research team reports that higher BMI (up to 35) should not be a contraindication to TKA, provided that the patient is sufficiently fit to undergo the short-term rigors of surgery. TKA also halts the decline and maintains physical function in even the oldest age groups (> 75 years). (Cushnaghan, 2008) In this study, the rates of failure of total knee implants, at least up to 5 years after surgery, and the time to failure, were not influenced by patients' BMI, except for subjects affected by morbid obesity. (Bordini, 2009) Obese patients presented for and underwent joint replacement surgery at a younger age as compared to non-obese patients. (Gandhi, 2010) Adverse events (e.g., perioperative complications, post-op wound infections) occurred in 14.2% of the non-obese, 22.6% of the obese and 35.1% of the morbidly obese patients after total knee replacement. (Dowsey, 2010) A 2-year review showed that hospital stays were longer in those who were obese than in those who were not. (Parks, 2010) Obese patients may have clinically significant weight loss after total joint arthroplasty, since their osteoarthritis had limited their mobility and ability to exercise. (Stets, 2010) Obese patients are nearly twice as likely to incur infection after a total knee replacement, but even with an elevated complication rate, total knee replacements provide an important improvement for patients with a high BMI. (Kerkhoffs, 2012) An institutional registry analysis of over 22 thousand total knee surgeries showed strong association of reoperation, implant removal or exchange, wound infection, and deep infection per unit of BMI over 35 kg/m. (Wagner, 2016)

Prior intra-articular corticosteroid injections: Previous research regarding the possibility of increased risk of infection following TKA associated with pre-operative knee injections had shown conflicting results, being limited by small cohort sizes. Two systematic reviews indicated that surgeons may be unaware of such a potential risk but that available studies were underpowered, and further research was needed. (Marsland, 2014) (Charalambous, 2014) Another meta-analysis evaluating both knee and hip arthroplasties reported higher deep but not superficial infection rates in those receiving pre-operative injections, but the evidence quality was very low. (Xing, 2014) A very large cohort involving 83,684 TKAs, comparing the 35% who received injections with 65% that did not, found a higher (4.4 vs. 3.6%) post-operative infection rate out to 6 months between injection and surgery. It was concluded that injection prior to TKA is associated with a higher risk of post-operative infection, which is time-dependent with closer proximity to surgery. (Bedard, 2016) This evidence supports delay of TKA to at least 6 months following any intra-articular corticosteroid knee injection. See also Bone & joint infections: prosthetic joints in the Infectious Diseases Chapter.

Minimally invasive total knee arthroplasty: No significant benefit was seen in using a minimally invasive surgical technique over a standard traditional technique for total knee arthroplasty, but the study did not focus on quality-of-life outcomes (e.g., length of hospital stay, reliance on pain medications, and the need for inpatient rehabilitation after discharge), for which the minimally invasive approach is purported to show an advantage. (Wülker, 2010) While cosmetically pleasing, minimally invasive incisions for knee arthroplasty have been shown to be limited by equivocal functional outcomes and some increases in complications. (Harkess, 2014)

Bilateral knee replacement: The safety of simultaneous bilateral total knee replacement remains controversial. Compared with staged bilateral or unilateral total knee replacement, simultaneous bilateral total knee replacement carries a higher risk of serious cardiac complications, pulmonary complications, and mortality. (Restrepo, 2007) It is recommended that congestive heart failure and pulmonary hypertension, but not age per se, should be contraindications for bilateral total knee arthroplasty (BTKA). BTKA is seen as offering advantages over staged unilateral knee replacement surgery, including reduced time in the hospital, decreased costs, and a faster return to active life. The procedure has also been shown, however, to carry an increased risk for morbidity and mortality compared with unilateral knee replacement, with an overall incidence of major in-hospital complications and mortality of 9.5%. Patients with the highest risk for adverse outcomes were those with congestive heart failure (odds ratio [OR], 5.5) compared with those without comorbidities, and those with pulmonary hypertension (OR, 4.1). Another risk factor was older age, with patients who were 65 to 74 years old and those older than 75 years having about twice the likelihood of complications compared with patients 45 to 65 years old. Men also showed a 50% greater risk for complications than women. Older age, however, should not necessarily rule out patients who can otherwise benefit from bilateral knee replacement, and age by itself will be a risk factor in any kind of surgery. Factors that can increase the risk with congestive heart failure include bone particles and marrow entering the bloodstream to embolize in the pulmonary vasculature and other organs. (Memtsoudis, 2011)

Revision total knee arthroplasty: This surgery is a reasonably effective procedure for failed unicompartmental or total knee replacement based on global knee rating scales. (Saleh, 2002) It would be recommended for failure of the primary arthroplasties.

The IRO reviewer opined that the requested treatment did meet ODG criteria. Specifically, the IRO reviewer noted that Claimant had “…met the criteria for conservative care to include previous physical therapy sessions and steroid injections.” IRO reviewer further noted that “[t]he records indicate [Claimant] has stiffness, night time joint pain, and limited mobility evidence by feeling he has to use his arms to pick his leg up to walk sometimes.”

Carrier provided a peer review from Dr. RH who opined that Claimant did not have conservative treatment and the treatment notes lacked objective documentation beyond subjective complaints. The first utilization review doctor also opined that “[t]he records do not document failure of lesser measures, and there is need for clarity regarding to the degree of osteoarthritis about the knee.” The second utilization doctor opined that “[t]he severity of [Claimant’s] osteoarthritis is unclear” and “[f]urther clarification as to the pathology present on imaging would be needed prior to determining the medical necessity of this request.”

Dr. H’s and the two utilization review doctors’ opinions did not establish that the preponderance of the evidence is contrary to the IRO decision as they were a difference of opinion from that of the IRO. The mere fact that these doctors interpretation of the Claimant’s medical records lacked conservative treatment based on the ODG guidelines is insufficient to overcome the IRO decision nor do the medical records in evidence rebut the explanation of the IRO reviewer.

Carrier has the burden of proof in this case to show by the preponderance of evidence-based medical evidence that the disputed procedure is health care that is not clinically appropriate and considered effective for his injury. Evidence-based medical evidence entails the opinion of a qualified expert that is supported by evidence-based medicine. The evidence presented at the hearing is found to be insufficient to constitute evidence-based medical evidence to overcome the decision of the IRO reviewer. As Carrier did not overcome the IRO decision by a preponderance of the evidence-based medical evidence, they have accordingly failed to meet their burden of proof.

The Administrative Law Judge 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 insurance through Insurance Company of the State of Pennsylvania.
    4. On (Date of Injury), Claimant sustained a compensable injury.
    5. The Independent Review Organization determined Claimant should have left total knee arthroplasty 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 Administrative Law Judge’s Exhibit Number 2.
  3. The Claimant’s left total knee arthroplasty is 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 Claimant’s left total knee arthroplasty is health care reasonably required for the compensable injury of (Date of Injury).

DECISION

Claimant is entitled to left total knee arthroplasty for the compensable injury of (Date of Injury).

ORDER

Carrier is ordered to pay benefits in accordance with this decision, the Texas Workers’ Compensation Act, and the Commissioner’s Rules. Accrued but unpaid income benefits, if any, shall be paid in a lump sum together with interest as provided by law.

The true corporate name of the insurance carrier is INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA, 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 78701-3232

Signed this 30th day of November, 2017.

Travis Dupree
Administrative Law Judge

End of Document
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