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At a Glance:
Title:
453-03-2012-m2
Date:
June 17, 2003
Status:
Pre-Authorization

453-03-2012-m2

June 17, 2003

DECISION AND ORDER

Positive Pain Management (Petitioner) appealed the decision of an Independent Review Organization (IRO) upholding the denial by the City of Conroe (Carrier) of preauthorization for a 20-day chronic pain management program (CPM). This decision reverses the IRO, because almost three years since her accident, the injured worker (Claimant) is still incapacitated by pain, and the intensive, multidisciplinary approach of CPM will improve her ability to carry out functions of daily living and could empower her to return to work. Therefore, it is medically necessary and should be preauthorized.

I. PROCEDURAL HISTORY

The hearing was convened by Barbara C. Marquardt, Administrative Law Judge (ALJ), on May 12, 2003, on the fourth floor of the William P. Clements Building, 300 West Fifteenth Street, Austin, Texas. Peter Rogers, attorney, appeared and represented Petitioner. Steven M. Tipton, attorney, appeared and represented Carrier. The record consists of five documentary exhibits and the telephonic testimony of James F. Wildermuth, D.C. The record remained open until May 23, 2003, for submission of an additional exhibit and closed on that day.[1]

II. LEGAL STANDARDS

General Law

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: (1) cures or relieves the effects naturally resulting from the injury; (2) promotes recovery; or (3) enhances the ability to return to or retain employment. "Health care" includes "all reasonable and necessary medical . . . services."[2]

Certain categories of health care identified by the Texas Workers’ Compensation Commission (TWCC) require preauthorization, which is dependent upon a prospective showing of medical necessity.[3] Referral to CPM requires preauthorization.[4]

TWCC Guidelines

Medical Fee Guideline

There is presently one guideline that addresses CPM - Medical Fee Guideline, Medicine Ground Rules (MFG).[5] Generally, MFG states that the purpose of CPM is to reduce pain, improve functioning, and decrease the dependence on the health care system of persons with chronic pain syndrome. Chronic pain syndrome involves the complaint of enduring pain, differs from the worker’s premorbid status, has not responded to previous appropriate treatments, and interferes with the worker’s physical, psychological, social and/or vocational functioning. To qualify for such a program, the worker must be likely to benefit and not have conditions that would prohibit participation in the program. An initial mental health evaluation to determine a worker’s readiness for CPM may be performed.

Mental Health Treatment Guideline (repealed, eff. August 15, 2002)

The Commission’s Mental Health Treatment Guideline (MHTG)[6] listed more specific criteria for referral to outpatient CPM programs. Because the Claimant’s injury in this case, her mental status evaluation, and several of her referrals to CPM, were made while the MHTG was in effect, it is a useful tool for looking more closely at criteria pertinent to this case, which include the following:

(i)a Global Assessment of Functioning (GAF) rating of 40 - 90 with any psychosocial stressor (PSS) rating;

(ii)the patient has not responded to . . . outpatient physical therapy and/or mental health treatment in a reasonable period of time (e.g. within four to six months) and/or:

(iii)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:

(I)the patient is facing significant, permanent loss of functioning that requires major physical, vocational, and psychological readjustment;

(II)diagnostic findings are insufficient to explain the pain or further invasive medical treatment is not an option;

(III)the pain has persisted beyond the expected tissue healing time;

** *

(V)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;

Appendix A in the MHTG described the Severity of Psychosocial Stressor Scale (PSS), which lists six codes for stress factors of a duration longer than six months ranging from:

1 – “None” (no enduring circumstances relevant to the disorder); to

** *

3 – “Moderate” (serious financial problems); to

** *

6 – “Catastrophic” (captivity as hostage; concentration camp experience).

Appendix B in the MHTG described the GAF scale as a tool that “(c)onsider(s) psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.” The GAF codes range from:

(A) 90 - 81 absent or minimal symptoms; to

** *

(D) 60 - 51 (m)oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g., few friends, conflicts with co-workers); to

** *

(I) 10 - 1 A(p)ersistent danger of severely hurting self or others . . . .

III.IRO DECISION

The IRO decision, written by a physician who is board-certified in anesthesiology with a specialty in pain management, was very brief. It concluded that the counseling and chiropractic care already given the Claimant provided therapy similar to that given in CPM. Additionally, the decision suggested that the Claimant should be treated with an aggressive anti-depressant regimen.

IV. EVIDENCE

Background

On________, Claimant was driving a pickup truck for her employer, the City of Conroe, and had stopped at a red light. She was wearing a seatbelt, when a vehicle hit the truck, giving her a significant jolt resulting in a whiplash type injury. Subsequently, she lost her job, and almost three years later she is still unemployed.

Proposed Treatment

Highlights of the Positive Pain Management treatment plan (with the goal of reducing subjective pain, increasing functioning, decreasing depressive symptoms, and reducing use of narcotics) for the Claimant included these features:

  • Physical Rehabilitation (four hours daily) B use of multiple modalities (cervical/thoracic, lumbarsacral stretching and stabilization exercise, isotonic exercise, individual kinetic exercises, active and active-assisted exercise, moist heat and ice, and aquatic exercise) to increase strength, endurance, function, and range of motion.
  • Individual Psychotherapy (two hours daily) B to facilitate the resolution of injury related depression, anxiety, and compromised coping skills, by addressing maladaptive behavioral responses to pain while implementing behavioral alternatives.
  • Educational/Didactic Group Therapy (one or two hours daily) B to educate the group on pain management techniques, coping skills, behavioral monitoring or modification, transactional analysis, meditation, Tai Chi, yoga, wellness, nutrition, ergonomics, communication, responsibilities under TWCC, personal goal development, vocational planning & preparation, identifying residual marketability, and ADA.
  • EMG Biofeedback Training (two or three sessions weekly) B to help the person’s ability to self-regulate the body and more effectively manage pain without the need to overuse medications by: increasing blood flow, decreasing the hyper-sensitive nervous response, developing an appropriate relaxed physiological state, and giving the patient more appropriate avenues to pursue for pain flare-ups other than visiting the emergency room.
  • Medication Management (daily by a physician) B to decrease inappropriate use of narcotic analgesics, centrally acting muscle relaxants, benzodiazapines, and other habit-forming medications; develop a safer, more appropriate medication regimen.

Treatment in 2001

An MRI revealed that Claimant had a herniated C5/C6 disc, and David E. Tomaszek, M.D., tried an epidural steroid injection (ESI), which did not provide significant pain relief. Then, she had an anterior C5/C6 discectomyy with inter-body fusion on May 29, 2001. At that point, Dr. Tomaszek referred the Claimant to Kevin J. Keyes, D.C., for a consultation to establish a regimen for post-operative therapy. Dr. Keyes treated the Claimant with electrical stimulation, moist heat, ultrasound and massage. Over time, the Claimant has also had both active and passive physical therapy and a TENS unit.

On October 5, 2001, when Claimant was 18 weeks post surgery, Dr. Keyes sought permission to refer her to CPM from Randall V. Martin, the family physician who had treated the Claimant (apparently with pain medication and referrals for chiropractic care) since her injury. Dr. Keyes based his request on these factors:

  • significant cervical myofascial pain and spasms, and restricted range of motion;
  • near constant stiffness and tightness in the neck and upper trapezius region;
  • occasional numbness in the right arm;
  • several signs of psychological distress including unrestful sleep, depression, anxiety, anger (at the loss of her job and need for neck surgery), and feelings of despair regarding her inability to perform her normal activities around the home.

At Dr. Martin’s request, Ron Ziegler, PhD, gave the Claimant a pain management inventory on October 19, 2001, and he diagnosed her with Atypical Depression and Psychological Disorder Associated with a Medical Condition. Her GAF rating was 55, and her PSS or AXIS IV rating was 3 (moderate). Her medications at the time included Hydrocodone, Tiprazalam, and Neurontin. Among other things, Dr. Ziegler stated that:

  • Individual modalities utilized singularly would not be effective in treating the Claimant.
  • She needed a multi-disciplinary program with a component to improve her coping skills and her self-regulation ability.
  • She was at significant risk of furthering her sense of disablement.

Thus, Dr. Ziegler recommended CPM, which Dr. Martin requested in November. While CPM was denied by the Carrier, it preauthorized eight psychological counseling sessions for the Claimant, which she began in December.

Treatment in 2002

Rachel Phelps, the licensed psychologist at Dr. Ziegler’s clinic who counseled the Claimant, described the sessions as involving cognitive restructuring and biofeedback training to reduce anxiety and the amount of tension in her neck and shoulders to minimize pain. She described the Claimant as very eager to establish effective coping skills in order to return to a productive lifestyle. While some of her depressive characteristics had subsided as of February 2, 2002, Ms. Phelps felt the Claimant displayed characteristics of post-traumatic stress disorder, making it very difficult for her to live a normal life. Thus, Ms. Phelps concluded she needed the more intensive treatment given in CPM to enable her to gain control over her problem areas and to return to work in a timely fashion. Dr. Ziegler described why CPM might make the difference for the Claimant as follows:

Participation . . . that would replicate an eight-hour work-week would set the stage for her returning to work. It would get her used to an eight-hour-day schedule, and would again slowly begin to shift her belief system from one of helplessness and disablement to empowerment and being productive. Through . . . exposure to such a wide array of treatment modalities, she would undoubtedly report a significant reduction in pain complaints in terms of frequency and intensity. . . . Without such program activities, we can expect this patient to protract, ad infinitum, across the health care system.[7]

On February 7, 2002, Benjamin Agana, M.D., who is board-certified in physical medicine and rehabilitation, as well as electrodiagnostic medicine, gave the Claimant a required medical examination (RME) at the Carrier’s request. Her pain level was 5 on a scale of 1 B 10, and her other symptoms included the following: feeling a pulling and popping sensation when she turned her head; headaches; numbness and tingling on the left side to the shoulder area. Dr. Agana felt the Claimant was not over-reacting or displaying pain behavior. He stated that she had exhausted all chiropractic treatment and thought the Claimant was enrolled at that time in a pain management program. Once she completed the program, he felt she should be released to home exercises, and he recommended that she undergo a functional capacity evaluation (FCE).[8]

On Februry 18, 2002, Dr. Martin wrote to the Carrier, Dr. Agana, and Dr. Ziegler, complaining that the Claimant had returned for a refill of her Vicodin prescription, which he did not want to refill Aon an open-ended basis. Instead, he wanted her to have CPM and, hopefully, reduce or rid herself of the need for addictive painkillers. He explained the following to the Carrier:

I do not do chronic pain management and do not intend to continue to do so for this patient. . . We tried to refer this patient for chronic pain management in November of last year, and I find it unconscionable for you to continue to delay on this referral. I wish you to immediately transfer her care to a Workman’s Comp physician who is comfortable with chronic pain management.[9]

On March 14, 2002, Dr. Agana wrote back to Dr. Martin, indicating that no further surgery was indicated, according to the Claimant’s surgeon. Dr. Agana noted the Claimant had been placed at maximum medical improvement and given an impairment rating (5% whole body).[10] He stated in the letter: Ain my report, I indicated the patient should complete chronic pain management.[11]

The Claimant began seeing James F. Wildermuth, D.C., on June 7, 2002. At a June 28 examination, she reported pain to Dr. Wildermuth at level 6 out of 10 in the neck, low and upper back, and bilateral arm pain. Her depression was rated at 6/10; anxiety rated at 6/10; and aggravation/irritability rated 6/10. She also reported sleep patterns that were interrupted and restless. Dr. Wildermuth further described her psychological status as follows:

The patient has been in an extended period of time with the level of pain that she is experiencing, she has been on medication for an extended period of time, she has had alterations in her daily activities of living, she is experiencing interruptions in her personal interactions, she is under stress related to her financial status and she is concerned about future life. All these factors are complicating factors creating a situation that is slowing her physical progress.[12]

Dr. Wildermuth, who described the Climant as having Asevere complications related to her injury, noted the Claimant’s Adocumentation shows strong indications of need for a CPM program, which he had requested at the time of her last evaluation. Dr. Wildermuth felt CPM was indicated to address the psychological factors that continued to hamper her physical progress. A Dr. Jerry Keepers was continuing medication therapy with the Claimant at the time. The Claimant saw Dr. Wildermuth, revealing a similar status on the following dates: July 12 and 26 (at which point CPM had been denied by the Carrier for a second time), and August 2.

An FCE done on November 13, 2002, found the Claimant had a moderate to severe functional deficit and would only be able to perform at a sedentary or light duty level. It recommended work hardening.

Another peer reviewer, Dr. Buczak, indicated in late December 2002 that the five manipulations under anesthesia done on the Claimant that fall had been worthless. Instead of CPM, he felt she needed interventional pain management.

Treatment in 2003

Dr. Agana gave the Claimant a third RME at the Carrier’s request on February 26, 2003. Consistent with the other doctors who have examined the Claimant, Dr. Agana noted she had no evidence of over-reaction or exaggerated pain responses. In his report, Dr. Agana again mentioned that he thought the Claimant had undergone pain management the prior year and should have been released to home exercises upon completion. All medications, except Lopressor (for her non-injury-related hypertension), had been stopped after December 2002. She reported that her pain was similar to that of the year before B 7 or 8/10. She had all of the following problems:

  • bilateral upper and lower extremity pain, numbness, and tingling;
  • numbness on the left side of the face;
  • catches and pops in her neck;
  • pain extending from the neck down into the thoracic and lumbar areas; and
  • global weakness.

Dr. gana agreed with Dr. Buczak that no further passive modalities, manipulation under anesthesia, or chiropractic care was warranted. He felt work hardening would not assist the Claimant, because she had no job and the original injury took place two and a half years ago. His only other recommendation was continuation of home exercises. Dr. Agana was also negative about CPM, which he described as a Aconsideration back in 2002, but no longer likely to help her. He summarized that she had reached a stable clinical plateau and did not feel her condition would change with or without further intervention.[13]

The Claimant presented for care at Dr. Wildermuth’s clinic frequently in December 2002 and January and February 2003, and his progress notes of those visits can be summarized as follows:

  • 12/23/02 B improved pain level and more active; treated that day with manipulative treatment and showed a good overall response; likely a candidate for return to altered work status in near future;
  • 12/26/02 B improved pain level; decrease in palpable findings; likely a candidate for return to altered work status in near future;
  • 12/27/02 B increased pain levels; good overall levels of improvement in discomfort; candidate for trial work releaser with restrictions in very near future;
  • 1/02/03 B light duty release to be considered in next two weeks, given her level of function and pain tolerance; still feels she has psychological factors, but that the Carrier is recognizing them and may assist her;
  • 1/03/03 B progressing well and pain level substantially decreased; to refer for another FCE to determine level of capability of full return to work.
  • 1/06/03 B progressing well; good improvement since manipulation under anesthesia procedure with minimum setbacks; interested in a work trial release;
  • 1/08/03 B very depressed and irritated;doing well regarding level of pain she is experiencing; candidate for work trial release;
  • 1/10/03 B improved level of pain; more active; less dependent on drugs; decrease in palpable findings; to be evaluated for return to work;
  • 1/13/03 B improved level of pain; more active; decreased palpable findings; candidate for return to work; and
  • 2/28/03 B benefitting from prescription for EMS unit for home usage; decreased muscle spasms; slight decrease in medications for muscle spasm and pain control; decreased pain.

On February 28, 2003, Dr. Wildermuth evaluated the Claimant again. He described her as very despondent, concerned and depressed. He found notable swelling in her inferior cervical spinal region and the superior thoracic spinal region and decreased range of motion. He concluded that she was not well enough to work and that CPM would be the treatment of choice for her.[14]

V. PARTIES’ ARGUMENTS

Regarding the evidence, the Carrier noted that the psychological testing done on the Claimant in 2001 was not likely to be accurate now. In fact, in February 2003 Dr. Agana concluded it was then too late for her to benefit from CPM. The Carrier also noted that the peer review by Dr. Buczak on December 16, 2002, stated that interventional pain management would be more appropriate than CPM for the Claimant.

Additionally, the Carrier made three basic points. First, the Claimant has undergone massive amounts of therapy and treatment since her injury. Second, the eight sessions of psychotherapy and various chiropractic modalities she has received were an adequate substitute for CPM. Third, the Carrier claims Dr. Wildermuth has been inconsistent in his documentation B indicating the Claimant was regressing on February 28 of this year, and, therefore, needs CPM, while justifying other treatments he has given the Claimant from December 2002 B February 2003 by reporting about her improved symptoms.

Dr. Wildermuth testified that requests for preauthorization for CPM for the Claimant have been made and denied at least three times. Prior to her injury, she did not have other major medical problems or depressive episodes. Clearly, she is a person with poor coping skills. In the six months prior to the hearing, she had 20 visits to doctors and 9 other health care providers. She has enduring pain, and it interferes with her activities of daily living. According to Dr. Wildermuth, the Claimant has attempted to stop pain medication a number of times, but ultimately she ends up taking strong medications to treat her symptoms. She sees doctor Jerry Keepers for her medication issues monthly. Her pain level is difficult to explain and has persisted beyond the normal healing time for her type of injury.

In summary, Dr. Wildermuth stated CPM would remove the Claimant’s psychological barrier (depression) to recovery. While she will not fully recover, she can attain a much higher level of functioning.

VI. ANALYSIS & CONCLUSION

Looking at the law applied to the evidence in this case, the Claimant is the type of patient who would qualify for, and benefit from, CPM under the MFG. There is nothing in the record to contradict her doctors’ conclusion that she suffers from chronic pain syndrome, and even Dr. Agana made it clear that she is not exaggerating her symptoms. Her symptoms are different from her pre-injury status; she has not responded to multiple treatments over a long period of time; and they interfere with most of the functional areas in her life.

The Carrier’s argument that the physical therapy and psychological counseling the Claimant has already received were an adequate substitute for CPM is specious. According to the MHTG:

A subset of patients with chronic or complex medication conditions, such as chronic pain, will not respond to outpatient psychotherapy conducted in conjunction with primary and secondary phases of treatment. These patients will require referral to a treatment program with multi disciplinary, individualized and intensive treatment to deal with the complex mixture of medical and mental problems associated with chronic disability.[15]

Applying the MHTG, it is clear that CPM is appropriate for the Claimant. She had a GAF rating of 55; had a moderate PSS factor (3); did not respond to outpatient physical therapy and eight sessions of psychological counseling; exhibits pain behavior in that she has not worked for almost three years, has pain persisting beyond the expected tissue healing time, and further invasive treatment is not an option. While Respondent is correct that the psychological testing on the Claimant is somewhat dated, the current version of the MFG does not require psychological testing at all B it says that an initial mental health evaluation may be performed.

Looking at the weight of the evidence, the record is clear that all of the following health care workers who have encountered the Claimant since 18 months post injury have recommended CPM: Kevin J. Keyes, D.C.; Randall V. Martin, M.D.; Ron Ziegler, PhD; Rachel Phelps, M.A., LPC-I; and James F. Wildermuth, D.C. In contrast, a peer review doctor who never treated the Claimant, Dr. Buczak, opined without explanation that CPM would not work for her. Even Dr. Agana, the Carrier’s RME doctor, concluded for two years in a row that CPM would be the treatment of choice

for the Claimant. While he changed his mind in February 2003, because he did not think CPM two and one-half years post injury would be helpful, he offered no explanation for that conclusion.

The inconsistency Carrier noted in Dr. Wildermuth’s recent progress notes does not strike the ALJ as problematic given the record as a whole. Rather, it demonstrates that the Claimant is compliant and seeks treatment, which gives her temporary relief. Nonetheless, depression and her poor coping skills block her recovery. For example, even when she described her pain symptoms as lessened on January 8, 2003, she simultaneously appeared very depressed and irritated. Her regression on February 28, 2003, is consistent with the pattern she has had since the first time CPM was recommended B October 5, 2001.

In sum, the preponderance of evidence in this case supports the conclusion that a CPM course is treatment reasonably required to relieve the effects of the work-related injury the Claimant suffered, as mandated by Section 408.021(a) of the Labor Code. The cost of this treatment program constitutes a reasonable and necessary medical cost which shouldbe preauthorized.

VII. FINDINGS OF FACT

  1. On_______, ____ (Claimant), was driving a pickup truck for her employer, the City of Conroe, and had stopped at a red light.
  2. She was wearing a seatbelt, when a vehicle hit the truck, giving her a significant jolt resulting in a whiplash type injury.
  3. .Subsequently, she lost her job, and almost three years later she is still unemployed because of the injury.
  4. An MRI revealed that Claimant had a herniated C5/C6 disc, and she had an anterior C5/C6 discectomy with inter-body fusion on May 29, 2001.
  5. The chiropractor treated Claimant with electrical stimulation, moist heat, ultrasound and massage.
  6. Over time, Claimant has also had both active and passive physical therapy and a TENS unit.
  7. On October 5, 2001, when Claimant was 18 weeks post-surgery, her chiropractor sought permission to refer her to a chronic pain management program (CPM) based on these factors:
    1. her significant cervical myofascial pain and spasms, and restricted range of motion;
    2. her near constant stiffness and tightness in the neck and upper trapezius region;
    3. her occasional numbness in the right arm; and
    4. several signs of psychological distress including unrestful sleep, depression, anxiety, anger (at the loss of her job and need for neck surgery), and feelings of despair regarding her inability to perform her normal activities around the home.
  8. A psychologist gave Claimant a pain management inventory on October 19, 2001.
  9. Her diagnosis was Atypical Depression and Psychological Disorder Associated with a Medical Condition.
  10. Her GAF rating was 55, and her PSS rating was 3 (moderate).
  11. The psychologist and her treating physician requested preauthorization for CPM in November 2001, which the City of Conroe, a self-insured corporation (Carrier), denied. At least two other requests for CPM have been made since that initial request, and the Carrier has denied them also.
  12. Claimant suffers from chronic pain syndrome B even the physician whom the Carrier has referred Claimant to three times for required medical examinations concluded after two of those exams that Claimant should undergo CPM.
  13. Claimant’s current chiropractor, whom she has been seeing since June 7, 2002, has found many indicators for CPM that have slowed her physical healing process, including:
    1. her pain reports at level 6/10 in the neck, low and upper back, and bilateral arm pain;
    2. depression rated at 6/10;
    3. anxiety rated at 6/10;
    4. aggravation/irritability rated 6/10;
    5. sleep patterns that were interrupted and restless;
    6. alterations in her daily activities and interruptions in her personal interactions; and
    7. stress related to her financial status and concern about future life.
  14. As of the end of February 2003, the Claimant, who was still not well enough to work, had all of the following symptoms, which CPM would help alleviate:
    1. very despondent, concerned and depressed;
    2. notable swelling in her inferior cervical spinal region and the superior thoracic spinal region;
    3. decreased range of motion;
    4. pain at 7 or 8/10;
    5. bilateral upper and lower extremity pain, numbness, and tingling;
    6. numbness on the left side of the face;
    7. catches and pops in her neck;
    8. pain extending from the neck down into the thoracic and lumbar areas; and
    9. global weakness.
  15. CPM also would be beneficial for Claimant, because:
    1. Individual modalities utilized singularly, including physical therapy and individual psychological counseling sessions, have not been effective in treating Claimant’s complex set of problems.
    2. She needs a multi-disciplinary program with a component to improve her coping skills and her self regulation ability.
    3. She has developed a sense of disablement that blocks her ability to function as fully as possible.
    4. It would help to reduce or eliminate her dependency on prescription medications, which she has been treated with off and on since her injury.
    5. Despite being eager to establish effective coping skills in order to return to a productive lifestyle, Claimant displays characteristics of post-traumatic stress disorder, making it very difficult for her to live a normal life.
    6. Participation in CPM would replicate an eight-hour work-week, would get her used to an eight-hour-day schedule, and would slowly begin to shift her belief system from one of helplessness and disablement to empowerment and being productive.
    7. Through exposure to a wide array of treatment modalities, she would undoubtedly report a significant reduction in pain complaints in terms of frequency and intensity.
    8. Without such program activities, Claimant will rely on the health care system indefinitely and to her detriment.

VIII. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act (the 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 ' 413.031(d) of the Act and Tex. Gov’t. Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t. Code Ann. ' 2001.052.
  4. Based on the Findings of Fact, Claimant qualifies for CPM under the Medical Fee Guideline, Medicine Ground Rules, 28 Tex. Admin. Code '134.201B IIG., and the recently repealed Mental Health Treatment Guideline, which was codified at 28 Tex. Admin. Code '134.1000.
  5. Based on the Findings of Fact, CPM is health care reasonably required to relieve the effects of the work-related injury Claimant suffered within the meaning of '' 401.011(19) and 408.021 of the Act.
  6. Based on the Findings of Fact, the cost for CPM constitutes a reasonable and necessarymedical cost that shouldbe preauthorized in accordance with ' 413.014 of the Act and 28 Tex. Admin Code ' 134.600(h)(10).

ORDER

IT IS, THEREFORE, ORDERED that the decision of the Independent Review Organization is reversed, and a 20-day chronic pain management program for Claimant____ is preauthorized.

Issued June 17, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

BARBARA C. MARQUARDT
Administrative Law Judge

  1. Exhibit 5 is admitted into the record in full. Carrier’s objection to Dr. Wildermuth’s February 28th narrative (at 19-20) as “not simply a progress note like all the others” is inaccurate. It appears from a review of Exhibit 3, that Dr. Wildermuth does full evaluations like the February 28th one periodically, and then he writes shorter office notes whenever the Claimant comes in for care. See, e.g., Ex. 3 at 43-47.
  2. Tex. Lab. Code Ann. §§'408.021 and 401.011(19).
  3. Tex. Lab. Code Ann. §413.014; 28 Tex. Admin. Code §134.600.
  4. 28 Tex. Admin. Code §134.600(h)(10).
  5. 28 Tex. Admin. Code §134.201B IIG.
  6. It was codified at 28 Tex. Admin. Code §134.1000.
  7. Ex. 3, 22. Emphasis added.
  8. Id. at 6 - 79.
  9. Id. at 50-51.
  10. Dr. Novak did the rating in spring 2002.
  11. Ex. 3 at 48. Emphasis added.
  12. Id at 39. Emphasis added.
  13. Ex. 4.
  14. Ex. 5.
  15. 28 Tex. Admin. Code '134.1000(i)(3)(A). Emphasis added.
End of Document
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