Just Say No! DE IAB Decision Affirming UR Denial of a Spinal Cord Stimulator Based on Addiction

"One drug is too many and a thousand not enough." (Anonymous)  

Luciana Gorum sent me today's decision because she thought I needed a good laugh.  And while there is nothing funny about addiction, this case does prompt a chuckle over the comedy of missteps surrounding the injured worker being recommended for a spinal cord stimulator....and the blind eye turned at the treating physician level to what is an individual clearly in need of a lift to the nearest AA/NA Meeting.  And a household perhaps in need of a referral to Child Protective Services.

The case is Beverly Sehn v. Immaculate Cleaning Connection, IAB#1285472 (December 5, 2012) and while my friends in the recovery community like to say (and stay) "Clean and Serene", this injured worker was anything but.

Ms. Sehn had a low back injury in 2006 which prompted two back surgeries.  She came under the care of Dr. Ganesh Balu for pain management and came to be recommended for a spinal cord stimulator ("SCS").  She even passed the psych eval with Dr. Dettwyler (and under his regime, is anyone not cleared for a SCS?)

Here is where the case gets crazy:

  • There is reference to Dr. Frank Falco having been involved as a defense medical examiner (Is that even possible? Really?)

  • The injured worker tested positive for marijuana on every drug screen since 2010-Dr. Balu did not think this was a big deal

  • The injured worker further violated Balu's office narcotic policy by running concurrent prescriptions with Dr. Balu and Dr. Chan so she could double-dip her Percocets and Oxycodone-Dr. Balu did not think this was a big deal

  • The injured worker lied about the nature of her treatment to obtain extra meds (toothache versus low back)-Dr. Balu did not think this was a big deal

  • This individual was also raising two grandchildren in her home - shouldn't this be a big deal?

Dr. James Brokaw served as the defense medical expert.   He testified that from a psychiatric standpoint there are significant contraindications for the use of a spinal cord stimulator including abuse of narcotics, receipt of opioids from two providers, and illegal use of marijuana.  Moreover, the SCS is deemed more appropriate for resolution of limb, as opposed to back, pain thus suggesting in this case the SCS was not destined to ameliorate the symptoms.   Dr. Brokaw also highlighted that Dr. Dettwyler, in clearing the injured worker for the SCS, "failed to identify that he properly screened the claimant for narcotics abuse..... and failed to complete any forms typically used to determine if patients have abuse issues." Section 7.112.4 of the Practice Guidelines indicates that a viable SCS candidate should have no evidence of addictive behavior.

The Board denied the spinal cord stimulator in a decision well worth reading for its reliance on the Practice Guidelines-the discussion contained therein would be most instructive to any practitioner arguing the case either for or against the recommendation for an SCS.  My personal observation is that there is little more than a slap on the hand with regard to Dr. Balu's ongoing willingness to tolerate the injured worker's flagrant and consistent violation of the pain management contract (his bills were awarded).  Not much of a deterrent to the craziness that occurred in this case happening again in the future.

Returning to Dr. Dettwyler's conclusion, presumably to a level of reasonable medical probability, that there was no evidence of addictive behavior.....  well, that one would give my friends in the AA/NA community a real chuckle.  As for those grandkids-remember, active addicts don't have relationships...they take hostages.  Hope everyone involved in this case gets their act together.

Reverently yours.....but just for today,
Cassandra Roberts

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