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At a Glance:
Title:
453-02-1692-m5
Date:
July 16, 2002
Status:
Retrospective Medical Necessity

453-02-1692-m5

July 16, 2002

DECISION AND ORDER

I. Summary

Claimant ____suffered a compensable injury to her left knee in ___. After having had numerous surgical procedures that did not cure the injury or relieve the resultant pain, Claimant resorted to taking medications that were prescribed by her doctors. Transportation Insurance Company (Petitioner or Carrier) paid for the prescription medication claims that were submitted. However, after November 1999, it refused to pay such claims, indicating the medications were not shown to be medically necessary for the original injury. Because the pain resulting from the injury persisted, Claimant continued taking the medications and paid for them herself. She then sought medical dispute resolution from the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) seeking payment of $1,228.44 for prescription medications that she had purchased from June 26, 2000, through June 5, 2001. The Carrier denied the claim, urging the medications (1) had not been prescribed by the treating doctor, and (2) were not medically necessary according to peer review. After considering the parties’ arguments, the MRD found the medications were prescribed by Claimant’s treating doctor, were medically necessary and ordered payment of $845.96, which represented reimbursement for most of the medications in the claim.

Petitioner timely appealed the MRD’s decision arguing that medical necessity had not been established, and therefore, the medication costs should not be reimbursed. Based on the evidence presented, the Administrative Law Judge (ALJ) concludes that Petitioner proved by a preponderance of the evidence that medical necessity for the medications had not been shown in accordance with the Medical Fee Guideline, and therefore, reimbursement is not required.

II. Notice, Jurisdiction, and Statement of the Case

There were no contested issues of notice or jurisdiction. Therefore, those issues are addressed in the Findings and Conclusions without further discussion here.

A hearing was convened in this matter on May 13, 2002, at the State Office of Administrative Hearings (SOAH), William P. Clements Office Building, 300 W. 15th Street, Austin, Texas, with ALJ Ruth Casarez presiding. Petitioner appeared through its attorney, James Loughlin. The Claimant appeared on her own behalf, with assistance of Anthony Walker, Ombudsman with the Commission. The record was left open to receive relevant medical literature from Petitioner, with an opportunity for Mr. Walker to file objections concerning Petitioner’s submission. The record closed on May 28, 2002.[1]

The issue in this case is whether the prescribed medications, purchased and paid for by Claimant during the period indicated above, were shown to be medically necessary in accordance with the post tertiary provisions of the Lower Extremities Treatment Guideline[2] (LETG), thus entitling Claimant to reimbursement.

The MRD found that Dr. O’Neill, who began treating Claimant in March 1995, had referred Claimant to Edward A. Lewis, M.D., for pain management treatment in November 1998. Dr. Lewis continued to treat Claimant until the first half of 2000.[3] The MRD thus found the medications had been prescribed by her treating doctor. It also found that Dr. Lewis’ letter of March 2, 2000, established the medical necessity for many of the prescriptions that had been paid for by Claimant, and ordered the Carrier to pay Claimant $845.96.

In its appeal of the MRD decision, Petitioner argued that it was unreasonable for Claimant to continue taking the prescription medications, given the length of time that had elapsed since the original injury. Further, it urged there were other less dangerous treatments (without the potential of habituation) that had not been tried, and that until a reasoned determination had been made that no other viable alternatives were available, the dangerous narcotic medications should not be prescribed to and taken by Claimant because of their harmful side effects. Therefore, the claim should not be reimbursed.

III. Evidence

The record of the hearing included the testimony of the Claimant and of Petitioner’s witness, Samuel Bierner, M.D. Additionally, the certified record (C.R.) of the MRD proceeding and Petitioner’s Exhibit No. 2 were admitted into evidence.[4] Claimant relied on the certified record and her testimony to support her contention that she should be reimbursed for the medications she had purchased between June 26, 2000, and June 5, 2001.

Claimant’s Evidence

Claimant injured herself on the job on______, when she hit her left knee against a metal desk, as she sat on a chair that had rollers on it. As a result of that injury, she reported having had four arthroscopies, two total knee replacements, one synovectomy, one total knee revision, and a number of nerve blocks and injections to help control the pain. Appendix A includes a comprehensive listing of the various treatments Claimant received during the past ten years.[5] On June 11, 1993, after performing the third arthroscopy on Claimant’s left knee, Dr. Moore indicated she had reached maximum medical improvement (MMI) and gave her a 56% impairment rating (IR) for the left leg and a 22% whole person IR. Five months later, in November 1993, Claimant underwent an independent medical examination (IME) to determine if she had reached MMI. J. Clark Race, a certified orthopedic surgeon, found that Claimant had a 24% IR for the left knee and a 9% whole person rating. Despite the MMI rating, Claimant continued to receive further surgical interventions, such as another arthroscopy of the left knee to debride all three compartments and the lateral meniscus (9/93); total knee replacement (2/94); and revision of the total knee replacement (1/96). The surgical procedures, however, did not eliminate her symptoms, and in 1996, she showed signs of having reflex sympathetic dystrophy (RSD).[6] In May 1996, partly to confirm whether she had RSD, Dr. Gerger, a pain management doctor, administered lumbar nerve blocks. While, the blocks gave Claimant some relief, they proved to be temporary and her symptoms recurred.[7] Finally, sometime in 2000, Claimant’s doctors decided that further surgical interventions would not help her condition any longer, and they resorted almost exclusively to prescribing medications to control her pain and help maintain her daily functions. Claimant has taken prescription medications steadily since 1991. Although several of her doctors have expressed concern about her prolonged use of so many prescription medications (she takes a minimum of five different and strong prescription medications), she continues to obtain prescriptions for them.

Petitioner’s Evidence

In October 1999, Petitioner’s peer review doctor, David Trotter, M.D., a board-certified orthopedic surgeon, recommended that treatment for the left knee injury be limited to occasional anti-inflammatory medication and nothing more. The Carrier requested another peer review, and on November 29, 1999, Curtis J. Spier, M.D., prepared a report in which he detailed the various treatments Claimant had undergone since her injury. He opined that prolonged use of the prescription medications, without any clear indication of their effectiveness or a clear plan for their cessation was not medically sound or prudent. In his opinion, Claimant should have been directed toward alternative rehabilitative therapy to help her manage her condition. In addition, if inflammation of the knee occurred, she should take over-the-counter anti-inflammatory medications. Dr. Spier firmly believed that Claimant should be weaned off the many prescriptions she was currently taking because the medications were likely causing a decrease in her activities and functions, in general, and because there was no evidence rehabilitative actions had recently been tried.

In 2001, when Dr. Trotter updated his earlier peer review report, he reiterated that there appeared to be no documentation that Claimant needed further surgery, and that, at most, Claimant would need prescriptions for appropriate nonsteroidal anti-inflammatory medications and periodic laboratory assessments related to potential adverse effects and/or systemic problems due to the chronic use of anti-inflammatory medications. He also stated that Soma and Methadone were not medically necessary as related to the original injury, and that Claimant had been documented to have had significant likelihood of ongoing symptom magnifications and/or habituation to narcotic analgesics.[8] He also believed Claimant suffered from a documented autoimmune-type disease, and such disease should be considered a major contributor to her ongoing complaints.[9]

In his testimony, Dr. Bierner agreed with Dr. Trotter’s and Dr. Spier’s opinions that medications (such as Ambien, OxyContin, Robaxin, Neurontin, MS Contin, and/or Vicoprofen, Wellbrutin, Paxil, Darvocet-N100 and Vicodin Extra-Strength) that Claimant was taking were not medically necessary because they were not for pain associated with the original injury. Dr. Bierner concurred with Dr. Trotter that the only medications Claimant should take were nonsteroidal anti-inflammatories whenever inflammation of the left knee developed. In addition, she should undergo laboratory assessments two or three times per year for potential adverse effects of such long-term use of the anti-inflammatory medications.

Petitioner further argued that because Claimant’s husband was off work on medical disability, it was more likely that Claimant would want to remain on disability also because there was no incentive to go to work. If they are both considered disabled, they could stay at home and tend to each other. Claimant married her disabled husband in1993. He had been injured in 1989 and had been off work since then. After Claimant injured her left knee, she returned to work for two or three weeks in November 1991, but for all intents and purposes, she has been off work since June 1991. In the past ten years, the only jobs she has had have been with the Census Bureau for a few months in 2000 and with Dairy Queen on a part-time basis for about four weeks in 2001.

IV. Discussion

The question in this case is whether long-term use of prescription medications is appropriate post- tertiary treatment for Claimant in compliance with the Lower Extremities Treatment Guideline (LETG), so that the medications should be reimbursed by the Carrier. The Ground Rules to the LETG provide general guidance concerning requirements that apply to providers who treat claimants with injures to the lower extremities. Ground Rule (e)(2)(A) provides, in pertinent part, that treatment of a work-related injury must be:

  1. (1)adequately documented;
  2. (2)evaluated for effectiveness and modified based on clinical changes;
  3. (3)provided in the least intensive setting;
  4. (4)cost effective;
  5. (5)consistent with this guideline which may include providing a documented

clinical rationale for deviation from this guideline

  1. (1)objectively measured and demonstrate functional gains; and
  2. (2)consistent in demonstrating ongoing progress in the recovery process by

appropriate re-evaluation of the treatment.

Ground Rule (e)(3) relates more specifically to the type of documentation that is required. Section (e)(3)(B) provides as follows:

  1. (1)Documentation shall be provided by the health care provider to determine the level of care to be provided and the necessity for that care. The elements of the documentation may include:
  2. (1)a description, including the events surrounding that injury and the extent and severity of that injury;
  3. (2)a description of any pre-existing condition(s), complicating conditions and/ or any non-related conditions;
  4. (3)a treatment plan, including proposed methods of treatment, expected outcomes, and probable duration of treatment;
  5. (4)updates to the treatment plan as needed, including the clinical progress of the injured worker, and any revisions needed to the treatment plan based on the injured worker’s response to treatment;
  6. (5)education/information provided to the injured worker regarding his or her injury and treatment plan, and the injured worker’s compliance with this treatment plan; and
  7. (6)documentation substantiating the need for deviation from the guideline, if necessary.

There is no question Claimant injured her left knee in 1991 while at work and that the injury required medical services. Indeed, as is reflected in Appendix A, Claimant has had many surgical procedures and other treatments related to her left knee injury during the past ten years. After the second arthroscopy, she did quite well, and Dr. Reynolds reported in April 1992 that she was walking four miles per day, but that she was having problems with the right knee. Apparently, Dr. O’Neill performed a total knee replacement of the right knee in 1995 that worked very well; thus, when he performed the revision of her total left knee replacement in 1996, he was hopeful she would have similar results with the left knee and recover fully. However, Claimant continued to report pain in her knees and legs, and eventually her doctors began to suspect she had developed RSD. Her pain management doctors began administering lumbar sympathetic nerve blocks, and later, RFTC of sympathetic nerve groups in efforts to diminish or stop the pain in her knees and legs. Throughout all of the procedures, Claimant received prescription medications, which increased in number and quantity with the years.

At this point, it is impossible to know if the many procedures performed on Claimant have helped or hurt her. For the past several years there have been few, if any, objective signs or symptoms that relate to the original left knee injury. However, Claimant reports she continues to have pain in her left and right knees.[10] And it is very likely her reports of pain in both knees led to the diagnosis of RSD. Thus, RSD has been added as yet another of Claimant’s many ailments, but it is impossible to know if Claimant, in fact, developed RSD as a result of the injury to the left knee, or if the pain in her right knee occurred because of the prior right knee injury and the multiple surgeries she had on that knee. In addition, she reported having fallen and hurt her back in _____on her last day on the job, and again in ______after having had a successful nerve block. She has been diagnosed with various other conditions that are unrelated to the left knee injury, but yet result in pain and health problems for her. And of course, she also experienced her body’s general deterioration caused by the natural aging process. In short, ten years after Claimant injured her left knee, her physical condition has become so complicated due to the various injuries and diseases she has suffered that it is impossible for anyone to determine what is, or is not, the cause of her chronic knee and leg pain.

One thing is certain, however: she has been prescribed and has taken many medications throughout the past ten years. And although it appears that several of her treating doctors have been concerned about her prolonged and heavy use of prescription medications, the medical records do not reflect that any doctor has taken a good hard look at the variety and quantity of medications she has been taking. Consequently, there has been no treatment plan that charted (a) which medications would be tried, (b) which medications proved effective or ineffective, (c) which medications should not be taken with certain other medications, (d) what tests would be given to detect any harmful side effects caused by the medications (e) what results certain medications should have, and (f) when, if ever, the prescribing of medications would end. In addition, there is no evidence whatsoever that any doctor ever performed a comprehensive analysis of the medications Claimant has taken to assess the positive or negative effects they were having on Claimant’s condition. No evidence was presented that the medications increased or improved Claimant’s functioning. Indeed, the record appears to show that medications were prescribed to Claimant whenever she visited the doctor’s office and reported having pain. Occasionally, she also requested injections and the treating doctor accommodated her with those as well. This approach does not comply with the LETG.

The ALJ shares the concerns expressed by Carrier’s peer review doctors that prolonged use of the many prescription medications Claimant has taken is not medically reasonable. If the evidence indicated her doctors had exhausted other alternative treatments and there were no other treatments available to Claimant, and if documentation showed safeguards were being taken to prevent or monitor for dangerous side effects of such use, the ALJ might have reached a different conclusion. But there was no such evidence. Thus, because Carrier showed that no treatment plan had been developed, as required by the LETG, related to the use of the prescription medications that are the subject of this case, and because there was no evidence that use of the medications was objectively measured and showed functional gains in Claimant’s condition, the ALJ finds the medications were not shown to be medically necessary.

V. Findings of Fact

  1. Claimant sustained an injury to her left knee in a work-related accident on __________
  2. At the time of the injury, Claimant’s employer had its workers' compensation insurance through Transportation Insurance Company (the Carrier).
  3. Claimant initially saw Ian Reynolds, M. D., an orthopedic surgeon, in Webster, Texas.
  4. Dr. Reynolds performed two arthroscopies on Claimant’s left knee on ___, and on February 2, 1992.
  5. In the fall of 1992, Claimant moved to central Texas and began treatment by Frosty Moore, M.D. Dr. Moore performed the following procedures on Claimant’s left knee or prescribed the following treatment:
  6. (1)another (third) arthroscopy on the left knee on December 10, 1992;
  7. (2)prescribed physical therapy post operative for strengthening of knee, hip and leg;
  8. (3)referred Claimant to a rheumatologist in April 1993 for gold therapy for arthritis;
  9. (4)performed another (fourth) arthroscopy on September 30, 1993;
  10. (5)prescribed home exercises for Claimant throughout 1993;
  11. (6)performed a total left knee arthroplasty on February 22, 1994;
  12. (7)prescribed various medications to Claimant throughout 1993 and 1994.
  13. On June 13, 1993, Dr. Moore determined Claimant had reached maximum medical improvement (MMI) and assigned a 56% impairment rating for the left leg and a 22% whole person impairment rating.
  14. On November 30, 1993, Dr. Race conducted an independent medical examination of Claimant to determine if she was at MMI. He determined Claimant had reached maximum medical improvement (MMI) and assigned a 23% impairment rating for the left leg and a 9% whole person impairment rating.
  15. In early 1995, Claimant moved back to the Houston area and began treatment by Daniel B. O’Neill, M.D. Dr. O’Neill, an orthopedic surgeon, performed procedures or prescribed treatment or medications as follows:
  16. On January 16, 1996, performed a left revision total knee replacement, using totally cemented system;
  17. In April 1995, referred Claimant to the Texas Pain Center for pain management treatment;
  18. Prescribed medication post operatively and throughout 1996, 1997 and 1998.
  19. On November 4, 1998, referred Claimant to Mainland Pain Clinic’s Edward Lewis for pain management treatment;
  20. On January 7, 2000, performed arthroscopic synovectomy of left knee;
  21. Prescribed medication post operatively through February 24, 2000.
  22. Dr. Gerger began treating Claimant in April 1996 and performed the following procedures:
  23. Lumbar sympathetic block, right L2-3; L4 on May 9, 1996;
  24. A second lumbar sympathetic block, right L2-3; L4 on June 6, 1996;
  25. A third lumbar sympathetic block, right L2-3; L4 on June 14, 1996;
  26. A forth lumbar sympathetic block, right L2-3; L4 on June 20, 1996 and
  27. considers doing a radiofrequency thermocoagulation (RFTC);
  28. A fifth lumbar sympathetic block, right L2-3; L4 on June 27, 1996;
  29. A RFTC of the sympathetic paravertebral nerves of lumbar plexus;
  30. Dr. Gerger left Texas and transferred his patients to Drs. D’Agostino and Alvarez.
  31. Dr. D’Agostino began treating Claimant in February 1997; he diagnosed her with sympathetically maintained pain in left leg post RFTC; rheumatoid arthritis; hypothyroid. He prescribed Neurontin for pain and considered doing a neurolytic block with phenol.
  32. Dr. D’Agostino performed the following procedures and prescribed medications as follow:
  33. Lumbar sympathetic plexus block L2, L4 for RSD left leg on March 20, 1997;
  34. Neurolysis with phenol of left lumbar sympathetic plexus block L3, L4 on April 3, 1999;
  35. Prescribed Norco plus weekly Catapres patches because Neurontin and Ultram not effective;
  36. Averaging about every three to four weeks, prescribed various quantities of Norco, Carisoprodol, Soma, Percodan, Roxiprin, Paxil and Catapres patches from July 3 through June 24, 1998.
  37. Dr. Alvarez took over Claimant’s treatment in July 1998 and continued prescribing Carisoprodol and Paxil and added OxyContin through September 16, 1998.
  38. On November 4, 1998, pain management specialist Dr. Lewis began treating Claimant. He diagnosed her with myofascial problems in her upper back, which could be fibromyalgia polyarthritis or simple myofascial problems, and indicated the knees did not show signs of RSD, but that her knee pain was somatic and would not go away.
  39. Dr. Lewis wrote in his office visit notes that he (a) did not want to keep her on methotrexate;
  40. (b) wanted to wean her off Soma because it was a sedative and not effective for pain; (c) would keep her on her current medications, but would not increase them; and (d) would impose strict restrictions about from whom and from which pharmacy she obtained her prescriptions.
  41. From November 4, 1998 through June 3, 2000, Dr. Lewis wrote prescriptions to the Brookshire Pharmacy for the following and other medications: OxyContin 120 tabs, Triazolam 40, Soma 90, Paxil 30, Neurontin (45, 60, 90), Robaxin 120, MSContin 240, Wellbutrin 70, Methadone 180, Carisoprodol 90. (See Appendix A, pages 7-10 for more detailed prescription information).
  42. Dr. O’Neill also prescribed medications, such as Vicoden, Darvocet, Propoxyphene/APAP, Neurontin, Skelexain, and Paxil, to Claimant in 2000. Some prescriptions during that period were filled by pharmacies other than Brookshire Pharmacy.
  43. Dr. Sims began treating Claimant on June 7, 2000. He diagnosed her with chronic pain syndrome (CRPS) Type I; chronic fibromyalgia; chronic arthritis requiring methotrexate. He continued to refill the prescriptions she had been getting from Dr. Lewis.
  44. Dr. Sims performed the following procedures or prescribed medications as follow:
    1. Prescribed Methadone 180 and Carisoprodol 90 from June 9 to August 24, 2000;
    2. Administered DepoMedrol/Marcaine injection;
    3. Prescribed Methadone 180, Carisoprodol 90 from September 1 to December 27, 2000;
    4. Performed lumbar sympathetic block L2, L4on January 11, 2001;
    5. Injected right knee with deltoid on May 17, 2001, (Claimant wanted DepoMedrol injection, but Sims had none);
    6. Prescribed Methadone 180, Carisoprodol 90, Ambien and Paxil (not all at the same time) from January22 through May 11; 2001;
    7. Prescribed Methadone 180, Carisoprodol 90, Ambien 45, and Paxil 60 on June 5, 2001.
  45. Among the medications that Claimant has taken over the years to relieve or control her knee pain are: Soma, Methadone, Ambien, OxyContin, Robaxin, Neurontin, MSContin, Vicoprofen, Wellbutrin, Paxil, Darvocet-N 100 and Vicodin Extra Strength.
  46. No evidence was presented that any of Claimant’s doctors ever prepared a treatment plan to explain the reasons for the specific medications and quantities that were being prescribed, their intended results, any side effects they might have and what safeguards or precautions would be taken to deal with such side effects, what changes would be made in the medications depending on their effectiveness, and the intended duration of the medication plan.
  47. No evidence was presented that showed Claimant’s doctors ever objectively assessed or measured the effectiveness of the prescribed medications, or that the doctors reported functional gains in Claimant’s condition as a result of the medications.
  48. Claims were submitted for reimbursement of the prescription medications and were paid for by the Carrier until November 1999, when it began denying such claims, indicating its peer reviews indicated the medications were not medically necessary.
  49. Claimant continued to take the medications (Ambien, Soma, Methadone, Carisoprodol, and Paxil) and paid for them herself from June 26, 2000, through June 5, 2001. She paid $1,228.44 for the noted medications purchased during that period.
  50. Claimant requested reimbursement for the medications, but the Carrier denied the claim.
  51. On June 18, 2001, Claimant requested review of the denial by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission).
  52. On November 28, 2001, the MRD issued its decision ordering reimbursement of $845.96, which represented payment for many of the medications listed in Finding No. 23.
  53. On December 3, 2001, the Carrier appealed the MRD decision.
  54. The Commission sent a notice of hearing to the parties on February 5, 2002. The notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved in the matter.
  55. The hearing on the merits was held on May 13, 2002. Attorney James Loughlin represented the Petitioner. Respondent ___ appeared on her own behalf, with the assistance of AnthonyWalker, ombudsman with the Commission. The Commission did not participate in the hearing.
  56. The record of the hearing closed on May 28, 2002, after receipt of additional medical evidence from the Carrier. However, the additional evidence was not admitted.

VI. Conclusions of Law

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers' Compensation Act, Tex. Lab. Code Ann. § 413.031.
  2. 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 Tex. Lab. Code Ann. §§402.073 and 413.031(d) and Tex. Gov't Code Ann. ch. 2003
  3. The Carrier requested a hearing, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov't Code Ann. ch. 2001 and 28 TAC § 148.4(b).
  5. The Carrier had the burden of proving by a preponderance of the evidence, pursuant to 28 TAC §148.21(h) and (i), that the medications at issue were not medically necessary and should not be reimbursed.
  6. Pursuant to the Lower Extremities Treatment Guideline (LETG) (e)(2)(A), . . . “treatment of a work-related injury must be (i) adequately documented; . . .; (vi) objectively measured and demonstrate functional gains;”
  7. The Carrier proved that the prescription medications Claimant had taken had not been objectively measured and had not demonstrated functional gains in Claimant’s condition.
  8. The Carrier proved that there had been no treatment plan prepared for the use of prescription medications to relieve Claimant’s condition or control her pain, as is required in the LETG (e)(3)(B)(iii) and (iv).
  9. Based on Conclusion Nos. 7 and 8, the Carrier met its burden of showing that the prescription medications for which reimbursement is sought did not meet the requirements set out in the LETG and 28 TAC § 134.201.
  10. Therefore, the prescribed medications were not medically necessary, as required by Tex. Lab. Code Ann. § 408.021, and the Carrier is not liable for their reimbursement.

ORDER

It is hereby ordered that Transportation Insurance Company is not required to reimburse for the prescription medications that were purchased and paid for by Claimant between June 26, 2000, and June 5, 2001.

Signed this 16th day of July, 2002.

. RUTH CASAREZ
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Petitioner submitted a number of abstracts of medical studies and one complete article. However, the ALJ found the abstracts were so cursory as to be of little help. In addition, the ALJ found the article was not properly documented (its source was not clearly indicated nor was its date of publication); therefore, the ALJ issued an order not admitting Petitioner’s Exhibit 3.
  2. The LETG is codified at 28 Tex. Admin. Code §134.1003.
  3. It appears that Claimant saw Dr. Edwards at the Mainland Center for Pain Medicine from November 1998 through early June 2000. However, when Claimant moved to Trinity, Texas, Dr. O’Neill referred her to Stephen Sims, M.D., in Huntsville, Texas because he was closer to her new home. Dr. Sims also wrote a letter of medical necessity for Claimant on March 6, 2000. See Petitioner’s Ex. 2, pp. 319-320 and 324.
  4. Petitioner’s Ex. 2 consisted of 389 pages of Claimant’s medical records maintained by the Carrier. It also included copies of the following: an IME report by Dr. J. Clark Race dated 11/30/93; a peer review report by Dr. Trotter dated 10/28/99; peer review report by Dr. R. Igou dated 10/3/96; peer review report by Dr. Spier dated 11/29/99 recommending prescription medications be discontinued (pp. 299-302); an updated peer review report by Dr. Trotter, dated 2/7/01, reiterating that Claimant should be taken off narcotic medications (p. 373).
  5. Appendix A provides a chronology of the various treatments Claimant has received over the past ten years. It also indicates who her treating doctors were, what their diagnoses and observations were, and what they recommended and/or prescribed for her. The chronology was prepared from the summary at the beginning of Petitioner’s Ex. 2.
  6. According to Stedman’s Medical Dictionary (27th Ed.), Reflex Sympathetic Dystrophy is defined as “diffuse persistent pain usually in an extremity often associated with vasomotor disturbances, trophic changes, and limitation or immobility of joints; frequently follows some local injury.”
  7. In April 1996, Dr. Gerger requested authorization to perform lumbar sympathetic block at L2-3 and L-4, in efforts to confirm the RSD diagnosis. A peer review for the Carrier recommended the block be done, and Dr. Gerger performed it on May 9, 1996. Because the block gave Claimant some relief, Dr. Gerger gave her five more blocks between May 20 and June 27, 1996. He then suggested doing a radiofrequency thermocoagulation (RFTC) of sympathetic paravertebral nerves of the lumbar plexus. The RFTC, was performed on August 8, 1996. Dormand’s Medical Dictionary, 28th Edition, defines RFTC as the use of electronmagnetic waves in the radio frequency range to coagulate tissue in stereotactic surgery, i.e.,that is surgery that involves precise positioning or contact of the waves with the precise area or space being targeted.
  8. See C.R. p. 64 and Petitioner’s. Ex. 2, pp. 371-373 for Dr. Trotter’s updated report.
  9. Dr. Trotter relied on a June 7, 2000, note from Pain Management Clinic that described Claimant’s injury to her left knee: “Apparently, she developed reflex sympathetic dystrophy (RSD) in her left lower extremity that has spread to her right lower extremity and her left arm. . . . She had some tenderness in the left forearm. There were no appreciable hyperalgia or allodynia. She was felt to be neurologically intact. The impression was that of chronic pain syndrome, complex regional pain syndrome type I, chronic fibromyalgia, and chronic arthritis requiring methotrexate. It seems like an auto-immune type . . . .” (See C.R. p. 64).
  10. Claimant also had problems with her right knee prior to the ___ injury to the left knee. She has also been found to suffer from fibromyalgia (a rheumatic disorder affecting soft tissues rather than joints, and is characterized by pain, tenderness and stiffness of muscles), arthritis, back problems, hypothyroidism, and a lymph gland problem that required an excision in the neck. She has also had a hysterectomy and is a heavy smoker. (See Petitioner’s Ex. 2, pp. 243-247).
End of Document
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