DECISION AND ORDER
Southwest Independent School District (Southwest or Petitioner), appealed the decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) preauthorizing a chronic pain management program (CPM) requested by Brad Burdin, D.C. (Provider), for _____(Claimant). Dr. Burdin claimed the CPM program was necessary to treat Claimant’s debilitating pain, related depression, and difficulties coping with the activities of daily living. Southwest asserted that the objective indications demonstrated Claimant’s fractured scaphoid had healed and, therefore, additional treatment of alleged continuing pain was not reasonable or necessary. This decision finds that, according to the relevant guidelines, Dr. Burdin’s request for the CPM program for Claimant is appropriate and the order authorizes the requested CPM program.
I. JURISDICTION, NOTICE, AND VENUE
There were no contested issues of jurisdiction, notice, or venue. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.
II. PROCEDURAL HISTORY
The hearing in this matter was held February 25, 2002, at the Hearings Facility of the State Office of Administrative Hearings, Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas, with Administrative Law Judge (ALJ) Nancy N. Lynch presiding. Southwest appeared through its attorney, Dean G. Pappas. Dr. Burdin, Respondent, appeared telephonically and through his attorney, Hector Q. Martinez, who appeared in person. The record closed the same day.
Claimant, _____, sustained a compensable injury to her wrists and hands on_____, while she was working as a janitor. She was cleaning up a spill in a cafeteria when she was tripped by a student. She fell, landing first on her hands and then falling flat to the ground.
She was first seen by the company doctor, who examined her twice and returned her to work both times. He referred her to another doctor who could not communicate with her effectively. She was then referred to Miguel J. Saldana, M.D., who treated her from September 1998 until February 2000.
She sustained a scaphoid fracture of the left wrist and treatment initially focused on that wrist. The fracture appeared to heal; however, she continued to have problems with both wrists. During that time Claimant saw Dr. Saldana approximately once a month underwent two surgeries, had injections, wore splints, and did physical andor occupational therapy. On virtually every visit to Dr. Saldana, she complained about pain in her wrists. Her initial complaints emphasized the fractured left wrist.
Dr. Brad Burdin, D.C., a Chiropractic Neurologist (licensed as a chiropractor and is certified as a Diplomate by the American Board of Chiropractic Neurology), became Claimant’s treating physician in April 2000. After assessing the Claimant and having her evaluated by other health care providers, Dr. Burdin requested preauthorization for CPM. In fact, he requested CPM for Claimant on at least five occasions. All requests were denied by Southwest. This case is Dr. Burdin’s appeal of the most recent denial. The MRD did not consider Southwest’s response to the appeal because it was not timely filed. The MRD found for Dr. Burdin and ordered that Claimant receive the requested 30-day CPM program.
Southwest called Dr. Gary C. Freeman, M.D., Diplomate, American Board of Orthopaedic Surgery, as a witness. Dr. Freeman testified that because there was no longer any objective evidence of an injury, there could be no basis for pain in this situation. In his opinion, Claimant was indulging in symptom magnification, aided and abetted by Dr. Burdin’s excessive attentions. Dr. Freemen characterized CPM as “bogus”; in fact, he equated CPM with chiropractic.
The Workers’ Compensation Commission, however, must not share Dr. Freeman’s opinion since it provides for CPM under appropriate conditions. Dr. Burdin testified that pain is a private perceptual experience that may continue even in the absence of objectively perceived injuries. Though it had been several years since the original injury, Claimant continued to have pain even through several other treatments had been used. Dr. Burdin admitted it was unusual for a patient to have this degree of pain so many years after an injury but when a patient, like Ms. Garza, has had such continuing pain, it was reasonable to treat it. CPM is appropriate treatment for this Claimant because it is designed to treat the whole person through a multi-disciplinary approach. Dr. Burdin’s opinion was that CPM would help Claimant manage her perceived pain, learn ways to change her focus away from her perception of pain, and learn techniques that would allow her to engage in the activities of daily living without the pain she has experienced since her injury.
The Southwest, as Petitioner, bears the burden of proof that the CPM program is not reasonable and necessary in this case. The ALJ finds Southwest failed to prove by a preponderance of the evidence that the requested treatment was unreasonable and unnecessary.
The record indicates that Claimant’s complaints of pain have been present throughout the course of her treatment. She also had a limited range of motion, weak grip strength, depression, and functional limitations engaging in the activities of daily living. She is entitled to all health care reasonably required by the injury as and when needed. Specifically, she is entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment.
Pain clinics require preauthorization, which will be given upon a showing of medical necessity. As indicated in the Findings of Fact and Conclusions of Law below, Claimant’s chronic condition is suitable for the Tertiary Level of Care, which provides interdisciplinary, individualized, coordinated, and intensive care. She meets the criteria set out in The Mental Health Treatment Guidelines (MHTG) for a chronic pain management program. For all the reasons stated above, and in the Findings and Conclusions which follow, the requested 30-day program is preauthorized by this decision and order.
IV. FINDINGS OF FACT
- On______, Claimant, a Hispanic Spanish-speaking female in her mid-50s, suffered a compensable injury while employed as a ___.
- Claimant was cleaning a cafeteria when a student tripped her, causing her to fall to the floor. She was holding a mop in her right hand when she fell and did not let go of it until just before she hit the ground. She landed with both hands in front of her, injuring her hands and wrists. She collapsed onto the floor bending her wrists backwards since her arms could not sustain her weight.
- She reported the injury and after about a week was seen by the company doctor, Edmundo Garcia. He took some radiographs and said he did not think anything was wrong with her. He released her back to work. She returned to work in pain and, about a month later, went back to the company doctor. He took radiographs again. This time he said something was there, but told her she would be O.K. and returned her back to work. She worked for about another five months in pain.
- After he referred her to a doctor that could not communicate with her, Dr. Garcia referred her to Dr. Miguel J. Saldana, M.D., F.A.C.S., a member of Hand and Microsurgery Associates, who treated her from September 1998, until February 2000.
- In September 1998, Dr. Miguel J. Saldana, M.D. examined Claimant and described her injury as a healed scaphoid fracture of the left wrist. He removed her cast, noted stiffness of the left wrist, instructed her to use the wrist in daily activities, and to return for another examination in three weeks to see if she could return to work.
- By the end of September, Dr. Saldana’s records revealed she was not working.
- When he saw her on October 2, 1998, he discovered that in addition to the healed scaphoid, Claimant had an “ulnar abutment syndrome, left wrist, as a result of the scaphoid fracture,” and a “possible scapholunate ligament tear.”
- Dr. Saldana’s x-rays, taken during that visit, revealed the healed scaphoid on the left side and “a cyst on the lunate as it is abutting against the ulna, and that is the area of tenderness . . . there is a scapholunate gap of 6 mm.”
- An x-ray of the right wrist also revealed ulnar abatement, cystic degeneration, and a scapholunate gap of 5 mm. on that wrist.
- Claimant had pain in her wrists when working, especially when mopping, and reported pain when Dr. Saldana manipulated her wrist during his October 2, 1998, examination.
- During her October 27, 1998, visit to Dr. Saldana, she was in pain and he found “point tenderness right distal to the tubercle and there is ballottement of the lunotriquetral area when I gently palpate it. When I do the Watson maneuver there is a clunk that is painful.”
- On November 17, 1998, Dr. Saldana referred Claimant to physical therapy. The physical therapy included exercises designed to enable her to regain full functional status, massage to desensitize areas of tenderness, and home exercises to increase grip strength. This did not relieve Claimant’s symptoms.
- On December 1, 1998, Dr. Saldana referred Claimant for an arthrogram of the left wrist. After receiving the arthrogram report, Dr. Saldana performed surgery on her left wrist.
- Dr. Saldana’s operative report noted: “This lady broke her scaphoid, healed and then started having an ulnar abutment syndrome that is quite painful. Conservative measures have failed.”
- Dr. Saldana found Claimant’s left arm to be progressing satisfactorily on January 7, 1999, after the surgery and began to address the pain in her right wrist, which also had signs and symptoms of ulnar abutment syndrome.
- On February 9, 1999 (the record erroneously indicated 1998), Dr. Saldana applied a “Cor-Flex splint” to the left wrist which had been operated on a month and a half before that date. He noted she had limited rotation and pronation/supination on the left wrist, and ulnar abutment syndrome in the right wrist. He told her to return in a month and they would discuss surgery on the right wrist at that time.
- At her March 9, 1999, appointment with Dr. Saldana, Claimant reported pain in her left arm if she put it down on a recliner or on a sharp edge. She continued to have symptoms of an ulnar abutment in her right arm, causing a lot of discomfort and pain in that arm.
- On April 8, 1999, Dr. Saldana interpreted his x-rays to reveal a healed left wrist bone with a normal range of motion. Claimant still had minor discomfort and continued to wear a splint. Dr. Saldana placed no duty restrictions on her left hand. The right wrist still had the ulnar abutment syndrome. He instructed Claimant to return in three months.
- Dr. Mark Sanders performed an impairment evaluation between April 8, 1999, and April 22, 1999, and determined the left ulna had not healed, contrary to Dr. Saldana’s opinion.
- On April 22, 1999, when Dr. Saldana examined Claimant, her right wrist was still tender to palpation on the ulnar side, especially with ulnar deviation and grasping.
- On May 6, 1999, Claimant still had a lot of pain and discomfort in her right wrist and some pain in her left wrist as well. Dr. Saldana’s physical examination revealed tenderness to palpation to the right ulna, especially with ulnar deviation and gripping. Dr. Saldana told Claimant to quit wearing the splint on her left wrist but to use a splint on her right wrist.
- On June 3, 1999, Claimant returned to Dr. Saldana and he prescribed Celebrex 200 mg. once a day for Claimant and told her to return in six weeks. He found that Claimant had bilateral ulnar abutment syndromes. The left wrist was healed post-surgery; he wanted to proceed to surgery on the right wrist.
- On July 15, 1999, when she was examined by Dr. Saldana, Claimant was experiencing a lot of pain and discomfort, especially in the right arm at nighttime.
- On September 30, 1999, Dr. Saldana scheduled surgery on her right wrist. His physical examination of Claimant revealed continued tenderness to palpation on the left ulnar side.
- Dr. Saldana performed surgery on October 16, 1999, and reported the patient left the operating room in satisfactory condition.
- On October 17, 1999, the day after the surgery, Claimant experienced chest pain approximately 5:00 a.m. and was admitted for observation and consultation. She described symptoms as “heavy left-sided type pressure,” along with the left extremities falling asleep and some numbness on the left side of her face.
- Excitement, anxiety, walking, and doing other activities had caused similar episodes over the last two years. These episodes had been more frequent over the last couple of weeks, and tended to last up to about 20 minutes. Various follow up recommendations were made by the consulting doctor, Ha T. Nguyen, D.O.
- On October 16, 1999, a week after surgery on the right wrist, Dr. Saldana x-rayed her wrist, found everything to be in proper order, and put her in a short arm cast.
- On November 30, 1999, about six weeks after surgery on the right wrist, Claimant returned per Dr. Saldana’s instructions. She was experiencing a lot of pain in both the left and right hand.
- An x-ray showed a fine line across the fracture that still needed to heal. Dr. Saldana found point tenderness to palpation over the wound.
- He replaced the short-arm cast for another four weeks and told her to return at the end of the four weeks.
- On January 11, 2000, Dr. Saldana examined Claimant. X-rays “seemed” to show the fracture healing. Physical examination revealed a stiff wrist and a well-healed scar. He gave Claimant a “Core-Flex” splint to use only when driving or doing heavy housework.
- On February 10, 2000, Dr. Saldana took an x-ray of the right forearm which looked normal although she was experiencing some discomfort. He found a normal range of motion, and a lack of strength. He recommended therapy once a week and suggested she start thinking about going back to work in one or two months.
- On April 7, 2000, Dr. Brad Burdin, D.C., a Board Certified Chiropractic Neurologist associated with the Neuromuscular Institute of Texas, became Claimant’s treating physician. When he examined her, she complained of pain in her wrists, along with the dorsal aspect of the forearms, and then also in the neck and trapezius musculature.
- She described her wrist pain as a throbbing pain, but indicated her neck pain had a burning component to the sensation. She rated her pain as 10 on a scale of 10 with 10 being the worst pain possible.
- The pain interfered with Claimant’s ability to work, her sleep patterns, and her daily routine. She was depressed because of the pain. It interfered with her ability to work, her sleep patterns, and her daily routine. She was unable to work or enjoy life as had before her injury. Before her injury, she felt fine. She was taking Paxil, Synthroid, and Ambien.
- During his examination on April 7, 2000, Dr. Burdin learned Claimant had received four weeks of therapy to the left upper extremity. She was not given therapy for the right upper extremity.
- Dr. Burdin ordered an occupational therapy evaluation and ordered wrist cock-up splints to decrease pain. He indicated he would send her to occupational for approximately four weeks, then re-evaluate, and consider a rehabilitation program at that time.
- On April 13, 2000, Dr. Burdin gave Claimant a series of diagnostic tests. She showed deficits in range of motion wrist flexion left, radial deviation right, and ulnar deviation bilaterally. She demonstrated mild to moderate deficits in strength in both wrists, in grip strength, and pinch tests. While performing NOSH lifts, she complained of increased pain, was unable to validate arm lift, and was unable to perform high far lift due to severe weakness.
- On May 22, 2000, she returned to Dr. Burdin for reevaluation follow-up. She still was having pain in her wrists, forearms, and neck. She had also reported she had started having seizures approximately a month after the injury and was being seen by Dr. Torres for the seizures. She has continued pain in her hands, bilateral significant grade 3 to 4 weakness in her hands, and a limited range of motion. The braces did provide some relief and the pain decreased in intensity at times. She was significantly depressed.
- On June 9, 2000, she returned to Dr. Burdin after being seen by Dr. Fisher, who was considering removing some of the pins from her wrists. She continued to be in a great deal of pain in her hands and especially in her wrists. She also had some depression and anxiety related to her work-related injury and her inability to perform activities she used to enjoy.
- On May 26, 2000, Claimant was examined by Anjali Jain, M.D., of the Injury Pain and Rehabilitation Center in San Antonio. His physical examination of the patient noted “significant tenderness to deep palpation with slightly decreased grip strength in the bilateral hands as well as numbness.” The Claimant had continued pain in both shoulders and both hands. She stated she also had decreased strength and dropped things.
- Claimant received trigger point injections from Dr. Jain on July 14, 2000; July 28, 2000; and on August 25, 2000. Initially Claimant experienced “excellent pain relief” from the August injections. However, the relief was not long-term.
- On September 15, 2000, Dr. Jain administered six trigger point injections, but also recommended a chronic pain program.
- On June 2, 2000, Claimant was examined by Peter Fisher, M.D., of San Antonio’s Plastic Surgery Center, P.A.. His conclusion was that she suffered from bilateral carpal tunnel syndrome.
- On June 25, 2000, Lin Sutton, Ph.D., L.P.C., assessed Claimant’s current psychological status to determine whether she was an appropriate candidate for a chronic behavioral pain management program. She concluded Claimant was a good candidate for a chronic pain management program for the following reasons:
- Claimant was a non-smoker and non-drinker who reported only minor health problems other than the pain resulting from her injury.
- Claimant’s pain ratings, on a scale where 0 ‘no pain and 10 ‘excruciating pain were as follows: at its worst B 9, at its least B 6, on average B 7.5.
- Claimant’s pain interfered with her participation in daily household tasks, socialization, exercise, sleep and leisure activities.
- Claimant demonstrated moderate depression scoring 29 out of a possible 63 on the Beck Depression Inventory (2nd Edition). Claimant struggled with feelings of sadness, pessimism, failure, worthlessness, lack of concentration, loss of pleasure in previously enjoyable activities, self-dislike, and crying due to her constant pain.
- Claimant, a Hispanic female in her 50s, has had conflicts with her normally supportive family because of the anxiety, depression, and irritability associated with the constant pain. Her family includes five children, 14 grandchildren, and one great-grandchild.
- Claimant’s pain had interfered with her ability to do both inside and outside work, general activity level, sleeping ability, and enjoyment of life within the preceding 24 hours, as indicated by the Brief Pain Inventory. Her mood, walking ability, and social relationships were severely affected by her pain during that time.
- Claimant demonstrated the determination to learn to function in her everyday life while being careful to avoid participating in any activity that might make the pain worse, as demonstrated by the Pain and Impairment Relationship Scale. She often thought about her pain and she had trouble concentrating on anything else. She wanted to do whatever was necessary to return to the level of activity and enjoyment in life she had before the chronic pain and was willing to learn the necessary techniques to make that happen.
- Claimant’s Global Assessment of Functioning (GAF) was 53 and she had stressors of chronic pain and finances.
- Claimant’s high level of pain had persisted longer than the typical time of healing and had felt minimal brief relief from pain with customary treatments.
- Dr. Sutton recommended a chronic pain management program consisting of 30 sessions of six hours each in a behavioral pain management program, including individual and group psychotherapy, physical and occupational rehabilitation, hypnosis, biofeedback, music therapy, and psycho-educational groups.
- Dr. Burdin assessed Claimant again on July 10, 2000, for an impairment rating. She displayed deficits in range of motion, had severe deficits grip tests and pinch tests bilaterally. She reported increased pain in both wrists with increased activity.
- Dr. Burdin assessed Claimant again on August 25, 2000. She continued to have a great deal of pain in her neck, wrists and forearms. He sought approval for a CPM program, concluding a multi-disciplinary approach would be the most effective treatment.
- On October 3, 2000, Claimant was again examined by Dr. Burdin. She was wearing bilateral wrist splints; had significant limits in her range of motion, especially in her ability to extend her left wrist. She was getting angry very easily which was unusual. She had a very weak grip bilaterally and a loss of sensation as well. She described specific pain in the left ulnar side of the wrist. Dr. Burdin talked to her about different treatment options but again concluded she needed a behavioral pain management program.
- Dr. Burdin referred Claimant to Dr. Donna Bain, an orthopedic hand specialist, to see if any other treatment might help her. On November 13, 2000, Dr. Bain did some injections to the carpal region which gave her some relief from the pain for about two days. Then, the pain returned. Dr. Bain suggested a carpal tunnel release might be necessary.
- On December 18, 2000, Claimant was examined by Dr. Burdin. She had a weak grip, significant depression, increased pain in both wrists (especially the left one), anxiety, and a limited range of motion in both wrists. Dr. Burdin decided to request CPM preauthorization again.
- Dr. Burdin examined Claimant again on January 19, 2001. Her primary complaints were of pain in her hand, but now she also had almost as much pain in her neck. She continued to have trouble grasping objects, difficulty sleeping, and being depressed.
- Dr. Boehme (also spelled “Bain”in Dr. Burdin’s records) requested preauthorization for surgery on the left wrist, but the request was denied by Southwest.
- On February 3, 2001, Claimant was examined by Dr. Burdin. She had a seizure on the previous Saturday. Dr. Burdin discussed referring her to Dr. Lampert for an evaluation, probably including an EEG.
- On March 1, 2001, Claimant was evaluated by Morris H. Lampert, M.D., P.A., Diplomate of the American Board of Psychiatry and Neurology. He diagnosed her with carpal tunnel syndrome related to her work injury. He found no evidence that her other complaints (seizure disorder and cervical disorder) were related to the work injury.
- On March 8, 2001, a TWCC hearings officer determined that her compensable injury to both her wrists and hands as a result of her fall on______, did not extend to, nor include an injury to her neck. This decision was upheld by a TWCC Appeals Panel.
- On June 6, 2001, Dr. Sutton assessed Claimant’s psychological status to determine whether it would still be appropriate for her to participate in a CPM program.
- Claimant’s pain levels were higher overall. Her pain, at its worst, was rated 10; at its least was 8.5; and on average was 9.1. The scale used was 0 ‘no pain; 10 = excruciating pain.
- Claimant experienced chronic pain nearly constantly (60% to 95% of the time) in her bilateral upper extremities, shoulders, cervical spine, and head.
- Her stress level is high because of her injury, consequential chronic pain, familial relationships, and her sister’s cancer diagnosis.
- Her pain interfered with her ability to perform indoor and outdoor activities, participate in recreational activities, socialize with her friends, engage in physical exercise, sleep, and sometimes eating. It caused conflicts with her family. In the past month, it caused feelings of anxiety and tension and frequent feelings of depression, discouragement, irritation and upset.
- In the 24 hours prior to Dr. Sutton’s assessment, Claimant’s pain level averaged a 9 out of 10. She experienced no relief from pain medication. The pain has severely interfered with her general activity, ability to perform indoor and outdoor activities, sleep and general enjoyment of life at the level of a 9 on a scale of 10, with 10 being complete interference.
- Her pain frequently caused conflicts and disharmony with her family. In the past month her pain had constantly caused feelings of anxiety and tension, as well as frequent feelings of depression, discouragement, irritation, and upset.
- She described her pain as at 95% of the time with it averaging a constant 9. She feared not being able to return to work and realized her life has changed since the injury. She disliked feeling angry all the time and was frustrated with her future.
- Claimant’s Global Assessment of Functioning (GAF) was 56 and she had stressors including major depression, chronic pain, finances, and a sister with cancer.
- Claimant’s high complaint of pain had persisted longer than the typical time of healing and she had felt brief relief from pain with customary treatment.
- Dr. Sutton concluded Claimant could benefit greatly from a CPM program with assistance from Spanish-speaking staff.
- Dr. Sutton recommended the CPM include stress management techniques, biofeedback, proper ergonomics and prevention techniques, individual and group therapy, occupational therapy specifically designed to increase her functional level and decrease her pain, physical rehabilitation, and psycho-educational groups.
- Dr. Sutton’s recommended treatment goals for Claimant’ CPM were: modifications of anxiety and stress response, modification of pain associated behaviors, modification of depression, modification of emotional level associated with anger and hostility, modification of general activity levels, modification of activity types, modification of body use, education and implementation of general relaxation methods, modification of compliance with relaxation components and modification of family dynamics.
- On June 22, 2001, Dr. Burdin examined Claimant again. She rated her pain as 9 out of 10. Claimant was very frustrated and depressed. She did not feel like going out, talking to anyone or even getting dressed due to high level of pain. She was not interested in having sexual relations with her husband.
- Dr. Burdin examined Claimant on August 6, 2001. She continued to have complaints of pain in both wrists and forearms but especially in her left wrist which disabled her quite a bit. Claimant continued to wear splints periodically on both wrists and had a limited range of motion in her ability to flex. Her grip strength was markedly weaker on the left compared to the right.
- Dr. Brad Burdin again sought preauthorization to treat claimant in a 30 day chronic pain management program.
- Southwest denied preauthorization for a chronic pain management program on at least five occasions: 9-19-00, 10-2-00, 1-26-01, 3-19-01, and most recently on 8-16-01.
- Southwest’s denial was timely appealed to the MRD of TWCC by Dr. Brad Burdin.
- TWCC’s MRD authorized the CPM program for Claimant.
- Southwest timely appealed that ruling to SOAH.
- TWCC Medical Fee Guidelines, Chronic Pain Management, requires the presence of the following symptoms to be eligible for such a program:
- The complaint of enduring pain that has not responded to previous appropriate medical, surgical and/or injection treatment, and
- that interferes with the injured worker’s physical, psychological, social, andor vocational functioning.
- Three years after the injury, the Claimant experienced continuing pain that had not responded to previous appropriate medical, surgical and/or injection treatment except for brief minimal relief. Her chronic pain interfered with her ability to function both at home and at work, including the activities of daily living such as getting dressed or socializing. Claimant had major depression related to her chronic pain.
- Claimant was appropriate for the tertiary level of care because she was an injured worker who demonstrated physical and psychological changes consistent with chronic pain. She failed to respond to a series of nonoperative and operative treatments surpassing the usual healing period for her injury. Further, she lost the ability to engage in many activities of daily living and other physical functions because of her chronic pain.
- Interdisciplinary programs are among the interventions recommended by the guideline for patients at the tertiary level. A chronic pain management program is an interdisciplinary treatment program that is individualized, coordinated, and intensive.
- A chronic pain management program is appropriate for this Claimant.
V. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (Act), Tex. Labor Code Ann. §413.031.
- The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and Tex. Gov’t Code Ann. ch. 2003.
- The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann §§ 2001.051 and 2001.052.
- An employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. Code Ann. § 408.021(a).
- Health care includes all reasonable and necessary medical services. Tex. Lab. Code Ann. § 401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. Tex. Lab. Code Ann. § 401.011(31).
- Pursuant to Tex. Lab. Code § 413.014 and the Commission rule at 28 Tex. Admin. Code (TAC) §134.600, for a carrier to be liable for certain services and supplies, it must preauthorize them, have documented evidence that the service was provided in response to a life-threatening emergency, or have an order from the Commission.
- Among the services which must be preauthorized are pain clinics. 28 TAC § 134.600(h).
- 28 TAC §134.1002(d)(3), the Upper Extremities Guideline, provides that the Medical Review Division will use the guideline in its review of prospective treatment. Section (f) of that Guideline describes the components of primary, secondary, and tertiary levels of care. Interdisciplinary programs are among the interventions recommended for patients in the tertiary level of care.
- The Commission’s Upper Extremities Treatment Guideline, 28 TAC §134.1002(e)(2)(A), mandates that treatment be adequately documented, provided in the least intensive setting, and cost effective.
- The Commission’s Mental Health Treatment Guideline, 28 TAC §134.1000(1)(B), requires the patient meet the following criteria for participation in a CPM program:
- a GAF of 40-90 with any psycho social stressor rating;
- failure to respond to primary or secondary stages of outpatient physical therapy or mental health treatment;
- disruption of daily living activities due to the impact of pain on the patient's physical, mental, or emotional state and two or more of the following:
- significant, permanent loss of functioning requiring major physical, vocational, and psychological readjustment;
- insufficient diagnostic findings to explain the pain or further invasive medical treatment not an option;
- pain has persisted beyond the expected tissue healing time;
- chronic pain is linked to adverse interpersonal relationships which interfere with rehabilitation;
- greater than expected mental or physical impairment based on the diagnosed condition and treatment or differential diagnosis requiring treatment in a more structured or supervised setting;
- documented history of inappropriate and excessive use of healthcare services or of excessive use of painkillers, including narcotics and alcohol;
- unrealistic expectations regarding the outcome of medical or psychiatric intervention to relief symptomatology; or
- if the patient is at risk for developing an excessively disabled lifestyle, referral earlier in treatment is appropriate.
Based on the Findings of Fact and Conclusions of Law above, Claimant meets the criteria for participation in a chronic pain management program.
Based on the foregoing, Dr. Burdin’s request for preauthorization of a CPM program for Claimant should be granted.
IT IS ORDERED that Dr.Brad Burdin’s request for preauthorization is granted and ________ is preauthorized to participate in a 30-day chronic pain management program as requested by Dr. Burdin.
Signed this 27th day of March, 2002.
NANCY N. LYNCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS