DECISION AND ORDER
Great American Assurance Company (Carrier) appealed the findings of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) which approved The Suchowiecky Center’s (Provider) request for preauthorization for thirty sessions of chronic pain management. This decision agrees with the MRD and authorizes ___ (Claimant) to receive thirty sessions of chronic pain management as medically reasonable and necessary.
I. PROCEDURAL HISTORY, NOTICE AND JURISDICTION
A hearing in this matter was convened on March 12, 2002, at the William C. Clements Building, 300 W. 15th Street, 4th Floor, Austin, Texas. The Carrier was represented by its attorney, Mr. Scott Bouton. The Provider was represented by Dr. Mary Ann Spires. The Texas Workers’ Compensation Commission (Commission) submitted a written waiver of appearance. Suzanne Formby Marshall, an Administrative Law Judge (ALJ) with the State Office of Administrative Hearings (SOAH), presided. The Provider’s representative, Dr. Mary Ann Spires, and one witness on behalf of Carrier, Dr. Hooman Sedighi, appeared via telephone. The record closed at the conclusion of the hearing.
There are no contested issues of notice or jurisdiction in this proceeding. Therefore, these matters are addressed in the findings of fact and conclusions of law without further discussion here.
II. FACTUAL BACKGROUND
The Claimant,___, injured his right wrist on _____, as he was lifting a pallet to place it on an assembly line. The Claimant reported the injury and was referred to Dr. Bill Gray, who x-rayed his wrist, and treated him with a wrist splint and Ibuprofen. The Claimant returned to work at light duty in the office. Due to continued pain and inability to perform light duty, Claimant saw Dr. Sam Liscum on January 29, 2001. Dr. Liscum diagnosed Claimant with right hand sprain/strain, grade II, right De Quervain’s tenosynovitis, and muscle spasm. Dr. Liscum removed Claimant from work and prescribed physical therapy and stellate injections to the wrist. Dr. Liscum referred Claimant to George Richardson, M.D., for an orthopedic evaluation and to the Suchowiecky Center for pain medication evaluation. Dr. Richardson noted tenderness in Claimant’s forearm, along with swelling and a small nodule which was consistent with intersection syndrome. He gave Claimant an injection and recommended a right hand brace. At a later exam, Dr. Richardson noted tenderness and the need for further strengthening.
Claimant was evaluated by Dr. Suchowiecky on February 2, 2001. He was diagnosed with right wrist pain and adjustment disorder. Claimant moved to the Houston area and received treatment through the Suchowiecky Center. He was assessed by Dr. Liza Leal on June 18, 2001. She recommended that Claimant participate in thirty sessions of pain management, including medication management, individual therapy, group therapy, biofeedback therapy, physical conditioning, massage therapy, and vocational counseling. Her recommendation was based upon Claimant’s persistent pain, psychosocial impairment and functional limitations, as well as the potential for symptom progression without appropriate intervention.
On May 18, 2001, the Provider requested preauthorization to provide the Claimant with the recommended thirty sessions of pain management. The request was denied by Carrier on June 27, 2001, based on inadequate clinical information. Another request was resubmitted to Carrier on May 24, 2001; this was denied on July 9, 2001. The Carrier disputed the necessity of the treatment. On July 16, 2001, after a physician-to-physician discussion between Dr. Leal and Dr. Sedighi, the Carrier’s physician, the Carrier again denied the request. Provider requested review through the MRD process. The MRD found that the documentation submitted by Provider was sufficient to substantiate the medical necessity of the proposed treatment, consistent with the Mental Health Treatment Guidelines. The Claimant appealed the decision. This appeal concerns the denial to preauthorize thirty sessions of chronic pain management.
III. LEGAL STANDARDS
A. Entitlement to Medical Benefits.
Section 408.021 of the Texas Workers’ Compensation Act (Act) provides:
(1)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. The employee is specifically entitled to health care
(1) cures or relieves the effects naturally resulting from the
- (1)promotes recovery; or
- (1)enhances the ability of the employee to return to or retain
Section 401.011(19) of the Act defines “health care” to include “all reasonable and necessary medical . . . services.”
The Commission has identified certain categories of health care which require preauthorization, dependent upon a prospective showing of medical necessity. Tex. Labor Code Ann. § 413.014; 28 Tex. Admin. Code (TAC) § 134.600. In this instance, under 28TAC §134.600(h)(10)(B), preauthorization is required for chronic pain management treatment.
B. Mental Health Treatment Guidelines
The Mental Health Treatment Guidelines (MHTG), 28 TAC § 134.1000 sets forth the criteria to be met for referral to chronic pain management programs. Critera for referral to a chronic pain management outpatient treatment program are:
- a Global Assessment of Functioning (GAF) rating of 40-90 with any psychosocial stressor (PSS) rating;
- the patient has not responded to primary or secondary stages of outpatient physical therapy and/or mental health treatment in a reasonable period of time (e.g., within four to six months); and/or
- the patient exhibits pain behavior, functional limitations, and/or mental/emotional dysfunction, which are disruptive to their activities of daily living, and two or more of the following:
- (1)the patient is facing significant, permanent loss of functioning that requires major physical, vocation, and psychological readjustment;
- (1)diagnostic findings are insufficient to explain the pain or further invasive medical treatment is not an option;
- (1)pain has persisted beyond the expected tissue healing time;
- (1)the patient has chronic pain linked to adverse interpersonal relationships which interfere with rehabilitation;
- (1)the patient has physical/mental impairment greater than expected on the basis of the diagnosed medical condition and treatment or differential diagnosis and treatment required in a more structured/supervised setting;
- (1)documented history of inappropriate and excessive use of narcotic sedative/hypnotic medications, or alochol;
- (1)the patient continues to express unrealistic expectations regarding outcome or medical/psychiatric intervention in relief of their own symptomatology; or
- (1)referral to such programs is also appropriate earlier in treatment in order to prevent later development of an excessively disabled lifestyle role if the patient is judged to be at risk for developing such problems.
Id. at 134.1001(i)(3)(B).
The Carrier maintains that the requested treatment is not medically necessary. The Carrier raises two points in support of its contention: (1) that Claimant’s diagnosis is questionable and the underlying condition of Claimant is unknown, and (2) the facts do not support referral to a chronic pain management program at this time. In support of its contentions, the Carrier called Dr. Hooman Sedighi as its witness. Dr. Sedighi is Board-certified in Physical Medicine and Rehabilitation and has practiced in this area for nine and one-half years. He reviewed the medical records of Claimant and concluded that a chronic pain management program was not medically necessary nor appropriate at this time. In support of his conclusion, Dr. Sedighi notes that Claimant’s symptoms do not support the diagnosis of DeQuervain’s tenosynovitis (DeQuervain’s), given originally by Dr. Sam Liscum, a chiropractor.
Dr. Sedighi testified that if Claimant had DeQuervain’s, he should have received total, although transitory, relief from steroid injections, instead of only the minimal relief he reported. Further, Dr. Sedighi testified that DeQuervain’s should go away in four to six weeks with appropriate treatment, and should not have continued this long.
Dr. Sedighi testified that Claimant should have had a positive response on the Finkelstein diagnostic test and should have displayed inflammation, a hallmark of DeQuervain’s tenosynisitis, when he was examined by Dr. Barry Veazey, an orthopedic surgeon to whom Claimant was referred
for an independent medical examination on April 16, 2001. Dr. Sedighi stated that Dr. Veazy did not diagnose Claimant with De Quervain’s but instead, noted that it had been the working diagnosis. Although Dr. Veazy’s report recommended a bone scan and referral to an occupational therapist, Dr. Sedighi notes that this was not followed through.Dr. Sedighi noted that it would have been particularly valuable to have had Claimant seen by an occupational therapist who was a hand specialist since Claimant’s treating physician, Dr. Liscum, was a chiropractor who has no specialty in treatment of the hand.
Dr. Sedighi was critical of Dr. Liscum’s diagnosis and treatmentof Claimant. He testified that the treatments, specifically conditioning treatments, prescribed by Dr. Liscum for Claimant were not appropriate for the DeQuervain’s diagnosis. He also testified that DeQuervain’s can be treated and should not require more than thirteen days away from employment. Dr. Sedighi testified that if the underlying diagnosis of DeQuervain’s is called into question, then the need for chronic pain management is also called into question since it will not be successful until the true diagnosis is known.
The Provider was represented by Dr. Mary Ann Spires, who testified as a witness. Dr. Spires is a physician in the Suchowiecky Center and is a member of Claimant’s treatment team. She testified that she had seen Claimant as part of his referral to the Center. Dr. Spires testified that Claimant was referred to the Suchowiecky Center by Dr. Liscum for medication management initially. On his initial assessment at the Center in February, 2001, Claimant exhibited a pain level of 8 out of 10, which was significant. He also exhibited a positive response on the Finkelstein test. Dr. Spires testified that Claimant was originally diagnosed by Dr. Suchowiecky as having right wrist pain and adjustment disorder. After Claimant relocated to Houston, he was regularly treated by the Center. Dr. Spires testified that Claimant was referred to a hand specialist, Dr. Bruce Varone, who
wanted to perform a DeQuervain release on Claimant’s wrist but due to a dispute over compensability, the procedure was not performed.
Dr. Spires testified that in June of 2001, Claimant showed significant deterioration. He reported his pain was a constant 8 out of 10, he was visibly depressed with a flat affect, reported disrupted sleep with multiple awakenings, limitations in his daily and recreational life, and was not back at work. He scored a 52 on the GAF (global assessment of functioning) scale compared to the original score of 55 in February, with a PSS (psychosocial stressor) of moderate. He was diagnosed with right wrist pain and referred to the chronic pain management program. Dr. Spires testified that Claimant’s current diagnosis is chronic pain syndrome, which is characterized by Claimant’s enduring pain lasting more than six months which differs significantly from his pre-morbid state (of no wrist injury), no history of mental depression or illness, lack of response to previous treatment, and interference with his physical, social, and psychological functioning. Dr. Spires noted that Claimant has decompensated physically and emotionally. Treatment with antidepressants was not successful and his pain behavior and functional limitations persisted past the expected healing time for his injury. Dr. Spires testified that DeQuervain’s should have healed within sixteen days and a wrist strain should have healed within six to eight weeks. Dr. Spires testified that the diagnostic findings were insufficient to explain Claimant’s pain and that invasive medical treatment is not an option. Dr. Spires testified that a GAF score of 51 to 60 indicates moderate difficulty in functioning and that Claimant met the criteria for referral to a chronic pain management program.
Dr. Spires testified that the Benefits Review Conference and Contested Case Hearing at the Commission had resulted in findings that de Quervain’s was compensable as related to the worker’s compensation injury.
V. ANALYSIS AND CONCLUSION
The issue in this case is whether the requested thirty sessions of chronic pain management should be preauthorized as medically necessary and reasonably required to treat Claimant’s ______, injury. Pursuant to § 413.014 of the Act and 28 TAC § 134.600(h), preauthorization is required. The Commission’s Upper Extremities Treatment Guideline, (UETG), 28 TAC§ 134.1002(f)(2), describes the primary, secondary and tertiary levels of nonoperative care. Claimant is in the third stage, or tertiary, level of care. The requested treatment is among the recommended interventions at this level. As the party challenging the MRD decision, the Carrier has the burden of proof. 18 TAC §148.21(h) (2000). The ALJ has concluded that a review of the testimony and medical records demonstrates that the chronic pain management therapy is medically necessary and should be preauthorized for the treatment of the injury.
In reaching this conclusion, the ALJ finds that Carrier failed to prove that a chronic pain management program is not medically necessary for Claimant. To the contrary, the evidence, which is supported by Dr. Sedighi’s testimony, is that Claimant’s diagnostic findings are insufficient to explain his pain; further invasive medical treatment is not an option; the pain has persisted beyond the expected tissue healing time; and the Claimant has physical and mental impairment greater than expected on the basis of the diagnosed medical condition and treatment or differential diagnosis and treatment required in a more structured/supervised setting. Further, Claimant’s GAF score was 52; he has not responded to primary or secondary stages of outpatient physical therapy and/or mental health treatment in a reasonable period of time; and he exhibits pain behavior, functional limitations and/or mental/emotional dysfunction which are disruptive to his activities of daily living. This evidence puts Claimant squarely within the criteria for referral to a chronic pain management program.
Although Carrier claims that there is a need for determining Claimant’s true diagnosis, there is no evidence that Carrier ever attempted to do so. Dr. Spires testified that despite their attempts to secure approval for a bone scan or MRI, the Carrier would not approve other diagnostic exams to confirm Claimant’s condition. Although Carrier attempts to discredit the DeQuervain’s diagnosis, it was the diagnosis cited by Drs. Liscum and Veazey, both of whom examined Claimant. Dr. Veazey is an orthopedic surgeon. In Dr. Veazey’s report, the section titled “13. Diagnosis,” states the diagnosis is DeQuervains tenosynovitis, which is presumably Dr. Veazey’s diagnosis. Although his report later refers to DeQuervains as a working diagnosis, he does not dispute it, but recommends referral for a bone scan and an occupational therapist for further information. Carrier does not offer any evidence of any other diagnosis to explain Claimant’s injury, nor does Carrier dispute that Claimant suffered a wrist sprain or strain.
It is undisputed that Claimant suffered an injury to his right wrist. There is no evidence that he suffered from any other injury or medical condition in his wrist. Whether Claimant’s pain and other symptoms are a result of a wrist sprain or strain or DeQuervain’s tenosynovitis, the fact remains that Claimant has not recovered from his wrist injury and, indeed, seems to be deteriorating based upon the testimony of Dr. Spires. Dr. Spires testified that the diagnosis of chronic pain syndrome is appropriate for Claimant, given his lack of response to treatment for the original injury. This diagnosis, as well as the original diagnoses of wrist sprain/strain and DeQuervain’s, support the referral for the chronic pain management program.Because the evidence is clear that Claimant is an appropriate candidate for a chronic pain management program, it should be preauthorized.
VI. FINDINGS OF FACT
- The Commission sent a notice of the hearing in this matter to all parties on February 5, 2001.
- The notice of hearing contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
- The hearing was convened on March 12, 2002, and all parties appeared and participated in the hearing.
- The Claimant,___, sustained a compensable work-related injury on ______, while he was lifting a pallet to place it on an assembly line.
- He was treated by Dr. Bill Gray, who x-rayed his wrist, treated him with a wrist splint and Ibuprofen and recommended he return to work in a light duty capacity.
- On January 29, 2001, Claimant was examined by Dr. Sam Liscum, D.C., who diagnosed Claimant with a wrist sprain, DeQuervains tenosynovitis, and muscle spasm. Dr. Liscum removed Claimant from work and prescribed physical therapy.
- In addition to the physical therapy, Claimant also received stellate injections which alleviated the pain, but only minimally.
- Dr. Liscum referred Claimant to the Suchowiecky Clinic for medication pain management in February, 2001.
- Dr. Suchowiecky diagnosed Claimant with right wrist pain and adjustment disorder. He noted a score of 55 on the GAF (global assessment of functioning).
- Claimant’s current diagnosis from the Suchowiecky Center is chronic pain syndrome.
- Dr. Liza Leal performed an assessment of Claimant on June 18, 2001. She recommended that Claimant participate in thirty sessions of pain management, including medication management, individual therapy, group therapy, biofeedback therapy, physical condition, massage therapy, and vocational counseling. Her recommendation was based upon Claimant’s persistent pain, psychosocial impairment and functional limitations. Provider requested preauthorization for the pain management sessions.
- Dr. Leal’s recommendation for chronic pain management contained documented, expected outcomes for Claimant which would result in reduced pain by 30 to 40%, better management of pain, education about pain coping patterns, decreased sleep latency and increased number of uninterrupted sleep, and increased strength and endurance.
- On June 27, 2001, Carrier denied preauthorization approval for the requested pain management sessions and requested additional information.
- On July 3, 2001, Provider submitted additional information as requested to Carrier. Carrier again denied preauthorization for the treatment. After a physician-to-physician discussion between Dr. Leal and Dr. Sedighi, Carrier’s physician, Carrier again denied preauthorization on July 16, 2001.
- Carrier requested medical dispute resolution through the Commission’s MRD process.
- On November 12, 2001, the MRD preauthorized thirty sessions of chronic pain management treatment for Claimant.
- On December 3, 2001, Carrier appealed a Decision issued by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
VII. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented in this case, pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. § 413.031 (Vernon 2001).
- SOAH has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2001).
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. ch. 2001.052 (Vernon 2001).
- As the party appealing the MRD decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code (TAC) § 148.21(h).
- Under Tex. Labor Code §408.021 (a), 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. 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. Labor Code Ann. § 413.014 (Vernon 1996) and 28 TAC § 134.600 (2000) require that chronic pain management programs receive preauthorization, dependent upon a showing of medical necessity
- Carrier failed to establish that the chronic pain management sessions would not cure or relieve the effects naturally resulting from Claimant’s injury, promote his recovery, or enhance his ability to return to or retain employment.
- Carrier did not establish that the thirty sessions of chronic pain management were not medically necessary to treat Claimant’s injury.
- Based on the foregoing Findings of Fact, the thirty sessions of chronic pain management requested by Provider, Dr. David Suchowiecky, for the claimant’s treatment represents an element of health care medically necessary under § 408.021 of the Act.
- Based on the foregoing Findings of Fact and Conclusions of Law, the Findings and Decision of the Medical Review Division, issued in this matter on November 12, 2001, are affirmed; preauthorization for the requested thirty sessions of chronic pain management should be approved, pursuant to §413.014 of the Act and 28 TAC §134.600.
IT IS ORDERED THAT the Claimant is entitled to preauthorization of thirty sessions of chronic pain management by Provider.
Signed this 16th day of April, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
SUZANNE FORMBY MARSHALL
Administrative Law Judge
- The extent of Claimant’s injury has been contested by Carrier. An initial Benefits Review Conference at the Commission on this matter resulted in a decision in Claimant’s favor; a contested hearing was held on July 12, 2001, which also found in Claimant’s favor. Carrier has appealed that decision to the Commission’s Appeals Panel. At the current hearing, the Carrier reported that there has been no final decision on this matter.↑
- Dr. Liscum’s report, dated January 29, 2001, refers to this doctor as Dr. Roquet. The rest of the record refers to the original doctor as Dr. Gray. This difference is not significant for purpose of this decision.↑
- Dr. Spires testified that the Carrier would not authorize the requested bone scan or an MRI; however, there is nothing in the record besides this testimony to reflect that authorization was requested by Provider or denied by the Carrier.↑
- Carrier’s counsel was also critical of Dr. Liscum’s report wherein he stated that there was a 50-80% chance of continued residual pain, which will interfere with or limit to some extent the patient’s daily activities. Counsel stated that Dr. Liscum’s prognosis may have predisposed Claimant toward a path of pain that was out of proportion to his diagnosis. There is no evidence that Claimant was aware of this prognosis or whether it had any affect on him.↑
- The record does not contain any documentation about the referral to Dr. Varone.↑