DECISION AND ORDER

Service Lloyds Insurance Company (Carrier) appealed the decision of the Independent Review Organization (IRO) approving the preauthorization request of HealthPartners Group, Inc. (Provider) for 30 sessions of chronic pain management for M.T., an injured worker. After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that Carrier has shown by preponderance of the evidence that the requested chronic pain management sessions are not medically necessary treatment for M.T.’s work-related, compensable injury. Accordingly, the ALJ finds that the 30 sessions of chronic pain management should not be preauthorized.

I. BACKGROUND FACTS AND PROCEDURAL HISTORY

M.T. (Claimant) is a 64-year-old woman who suffered a compensable, work-related injury on February 2, 2002, when she slipped and fell injuring her right ankle. Claimant was taken to the emergency room of a nearby hospital, where it was determined that she had suffered a fracture of her ankle. Claimant was referred to Dr. Arnold Ravdel, who performed surgery on her ankle on February 28, 2002. After her surgery, Claimant participated in a physical therapy program from April 25, 2002, through June 24, 2002, and also began taking pain medications. When Claimant continued to complain of pain, Dr. Ravdel performed a second surgery in March 2003. After the second surgery, Claimant discontinued the use of pain medications but remained off work.

On September 2, 2003, Provider examined Claimant to determine whether she was an appropriate candidate for a chronic pain management program. After examining Claimant and reviewing her injury history, Provider recommended and sought preauthorization for 30 eight-hour sessions in a chronic pain management program. Carrier denied preauthorization and Provider requested a lower level of treatment involving six individual therapy sessions and six biofeedback sessions. After this request was also denied, Provider reasserted its request for chronic pain management and requested reconsideration by the Carrier.

When the Carrier denied the preauthorization request again, Provider requested medical dispute resolution by the Texas Workers= Compensation Commission (Commission). The matter was referred to an IRO designated by the Commission for the review process. The IRO determined that 30 days of chronic pain management was medically necessary and should be authorized. Carrier then requested a hearing before SOAH, resulting in this proceeding.

II. DISCUSSION AND ANALYSIS

The sole issue in this case is whether 30 chronic pain management sessions are medically necessary to treat M.T.’s work-related injury. This matter is governed by the Texas Workers= Compensation Act (Act) and the Commission’s rules.^[1] Section 408.021(a) of the Act governs an injured worker’s entitlement to benefits for compensable injuries under the Act, and provides that an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. Certain healthcare, however, must be preauthorized before it can be provided within the strictures of the Act, and such preauthorization will be granted if there is a prospective showing of medical necessity.^[2] Chronic pain management is one type of treatment for which preauthorization is required.^[3]

As noted, before treatment will be preauthorized, it must be shown to be medically reasonable and necessary. In disputing the medical necessity of such treatment, Carrier presented the documented medical opinions of numerous physicians. Dr. Gary Freeman conducted an independent medical examination of Claimant on August 25, 2003, and noted that Claimant was at maximum medical improvement (MMI) with her fractured ankle healed with excellent alignment. He also concluded that she should be able to return to work and should not need any additional treatment going forward.^[4] Of particular interest, Dr. Freeman noted that the Claimant herself expressed confusion over her treatment. Specifically, Dr. Freeman noted that the Claimant Astates she does not know why she is being maintained off work. She doesn=t know why she just goes to the doctor and nothing is done.^[5]

Relying on Claimant’s medical records and Dr. Freeman’s documented examination, physician advisor Dr. Brian Buck determined that chronic pain management treatment was not necessary for Claimant. Carrier also had Dr. John Obermiller consider Provider’s request for chronic pain management. Dr. Obermiller concluded that, because the sole parameter focused on was the Claimant’s pain complaints, the predictability for failure was high and there was no reasonable expectation for success from such treatment.^[6] As such, Dr. Obermiller agreed that chronic pain management was not appropriate for Claimant. In November 2003, the Commission’s designated doctor, Dr. Marshall Frumin, examined Claimant and found her to be at MMI with a 3% whole person impairment rating.^[7] Dr. Frumin noted that Claimant had pain daily, but was generally handling it well, continuing to work and engage in daily living activities without the need of any prescription pain medications. Given these various determinations, Carrier argues that chronic pain management is not medically necessary for Claimant. If Claimant does need additional treatment for pain, Carrier argues that prescription medications or other less intensive treatments should be attempted first.

Provider did not appear at the hearing and did not present specific arguments in support of its position. However, like Carrier, Provider offered documents reflecting medical opinions from numerous doctors. First, Claimant’s treating doctor, Dr. Ravdel, concluded that Claimant had limited functioning, ongoing pain, and depression and therefore would benefit from a chronic pain management program. Also, Dr. Erica Burden examined Claimant and found her to be an appropriate candidate for chronic pain management treatment. Dr. Burden noted that Claimant had continual pain, often rating six on a scale of 10 in severity.^[8] Further, Dr. Burden noted that Claimant had difficulty sleeping, was often anxious or frightened because of concerns of re-injuring herself, experienced nausea and headaches associated with her pain, and was limited in her ability to work or engage in light household tasks.^[9]

After considering the documentary evidence, the ALJ concludes that Carrier has shown that 30 days of chronic pain management treatment is not medically necessary for M.T.’s work-related injury. Specifically, the ALJ finds more persuasive the medical opinions of the doctors relied on by Carrier. First, Dr. Burden, who recommends chronic pain management for Claimant, is a psychologist and not a medical doctor, and based her conclusions on her examination of Claimant in September 2003. However, much of her conclusions are not supported by the notes of the designated doctor, Dr. Frumin, who examined Claimant two months later, in November 2003. By that time, Claimant had returned to work and appeared to be functioning fairly well. Moreover, while Claimant has had regular pain associated with her injury, she has not shown other significant psychosocial or work functioning problems warranting such extensive treatment as a pain management program. As Dr. Obermiller notes, when the sole parameter focused on is the Claimant’s pain complaints, the predictability for failure is high and the expectation for success from such treatment is limited. Further, to the extent that any treatment is needed, less intensive treatment such as prescription pain medications should be attempted first.

Therefore, the ALJ finds that chronic pain management treatment should not be preauthorized. In support of this conclusion, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. M.T. (Claimant) is a 64-year-old woman who suffered a compensable, work-related injury on February 2, 2002, when she slipped and fell injuring her right ankle.
2. Service Lloyds Insurance Company (Carrier) is the provider of workers= compensation insurance covering M.T. for her compensable injury.
3. Immediately after the injury, Claimant was taken to the emergency room of a nearby hospital, where it was determined that she had suffered an ankle fracture.
4. Claimant was referred to Dr. Arnold Ravdel, who performed surgery on her ankle on February 28, 2002.
5. After her surgery, Claimant started on a physical therapy program (lasting from April 25 through June 24, 2002) and took some pain medication for a limited time.
6. When Claimant continued to complain of pain, Dr. Ravdel performed a second surgery in March 2003.
7. After her second surgery, Claimant remained off work but was not using pain medications.
8. On September 2, 2003, Claimant was seen by Provider for purposes of determining whether she was an appropriate candidate for a chronic pain management program. After examining her and reviewing her injury history, Provider concluded that a chronic pain management program was appropriate for Claimant and recommended 30 eight-hour sessions in such a program and sought preauthorization for this level of treatment.
9. Carrier denied preauthorization and Provider requested a lower level of treatment involving six individual therapy sessions and six biofeedback sessions.
10. When Provider’s request for a lower level of treatment was denied, Provider reasserted its request for chronic pain management and requested reconsideration by the Carrier.
11. Carrier again denied the request for preauthorization for the 30 sessions of chronic pain management treatment.
12. Provider requested medical dispute resolution by the Texas Workers= Compensation Commission’s Medical Review Division (MRD), which referred the matter to an Independent Review Organization (IRO).
13. On November 26, 2003, after conducting medical dispute resolution, the IRO physician reviewer determined that the requested 30 days of chronic pain management was medically necessary and should be authorized.
14. On December 21, 2003, Carrier requested a hearing on the IRO decision and the case was referred to the State Office of Administrative Hearings (SOAH).
15. The hearing convened on February 12, 2004, with ALJ Craig R. Bennett presiding. Carrier appeared through its representative, Tom W. Lueders, II.
16. Provider filed a pleading before the hearing, offering documents to be included in the evidentiary record and waiving its appearance at the hearing. At the hearing, Carrier did not object to the documents being admitted and they were included in the evidence in this case.
17. The record closed on February 12, 2004.
18. No parties have raised challenges to notice or jurisdiction.
19. Claimant returned to work in September 2003.
20. The primary reason for seeking chronic pain management treatment for Claimant is Claimant’s continued complaints of pain.
21. Claimant has not attempted to resolve her ongoing complaints of pain with any intermediate-term pain medications.
22. When the sole parameter focused on is pain complaints, the predictability for failure of a chronic pain management program is high and there is little expectation for success from such treatment.
23. Claimant has not shown significant psychosocial or work functioning problems warranting intensive treatment such as a pain management program.
24. 30 days of chronic pain management is not likely to provide any benefit to M.T.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers= Compensation Act (the Act), specifically Tex. Labor Code Ann. ‘413.031(k), and Tex. Gov=t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code ‘ 148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
5. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code ” 148.21(h) and 133.308(v).
6. Carrier established, by a preponderance of the evidence, that the requested 30 sessions of chronic pain management are not medically necessary for the treatment of M.T.’s work-related injury.
7. Provider’s request for preauthorization should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the requested 30 sessions of chronic pain management are not medically necessary, and preauthorization for such is denied.

Signed February 18, 2004.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The Act is found at Tex. Lab. Code Ann. ch. 401 et seq.↑
2. Tex. Labor Code Ann. ‘ 413.014; 28 Tex. Admin. Code ‘ 134.600.↑
3. 28 Tex. Admin. Code ‘ 134.600(h)(10)(B).↑
4. Ex. 1, at 42.↑
5. Id.↑
6. Ex. 1, at 8.↑
7. Ex. 1, at 78-81.↑
8. Ex. 2, at 5.↑
9. Id.↑