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LexisNexis has selected some recently issued noteworthy IMR decisions that illustrate the criteria that must be met to obtain authorization for a variety of different medical treatment modalities. LexisNexis Commentary for each selected IMR is provided below. Many of these IMR decisions were reprinted in California Compensation Cases, which can be accessed on Lexis Advance. Lexis Advance subscribers can access those particular decisions online.
The list discusses specific IMR opinions which explain how physicians should best apply treatment guidelines utilizing the “Medical Evidence Search Sequence” for the treatment of injured workers as set forth in 8 Cal. Code Reg. § 9792.21.1, and include the MTUS at 8 Cal. Code Reg. § 9792.21.1(d)(1), other medical treatment guidelines such as the ACOEM and ODG at 8 Cal. Code Reg. § 9792.21.1(d)(2) and peer reviewed studies at 8 Cal. Code Reg. § 9792.21.1(d)(3). Topics of these selected IMR decisions include medical necessity of home health care, continued challenges relating to requests for medical marijuana and visits with physicians specializing in cannabis to treat pain, the availability of tertiary pain programs for patients that have failed conventional treatments, and a rare IMR decision addressing the necessity of high-quality hearing aids.
■ 2019 Cal. Wrk. Comp. LEXIS 45. H-Wave Unit—Low Back Pain—IMR reviewer overturned UR denial of treating physician’s request for an H-Wave unit to treat applicant’s chronic lumbar pain and radiculopathy, based on the MTUS 2016 guidelines for low back disorders and on the ODG addressing H-Wave stimulation for the treatment of pain. The IMR reviewer noted that there is no recommendation for or against using the H-Wave device for treatment of acute, subacute or radicular pain syndromes due to insufficient evidence. According to the IMR reviewer, the H-Wave may be used on a one-month trial basis if other noninvasive, conservative treatments, including medication, physical therapy and TENS, have proven unsuccessful. Use may be extended if there is a reduction of pain and functional improvement. Applicant here used the H-Wave on a trial basis and had documented decrease in pain and improvement in function allowing full-time work. He reported that the H-Wave worked better than medication. The records submitted by applicant’s physician indicated that applicant had previously tried medications, physical therapy and TENS, which failed to relieve his pain. Assessing applicant’s needs based on the applicable guidelines, the IMR reviewer concluded that the H-Wave was medically necessary in this case.
LexisNexis Commentary: This IMR decision is helpful in that the IMR reviewer discusses use of the H-Wave when other conservative treatment modalities have failed, and the device reduces pain and improves function. The reviewer notes, however, that the device can be costly.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-03012019/CM19-0018506.PDF. Hearing Aids—Hearing Loss—IMR reviewer overturned UR denial of request for right and left hearing aids to treat 69-year old applicant’s industrially-related binaural sensorineural hearing loss. In finding that the hearing aids were medically necessary, the IMR reviewer cited the MTUS 2017 guidelines applicable to traumatic brain injuries indicating that use of hearing aids is the most effective treatment for hearing loss. The IMR reviewer concluded that fitting applicant with the hearing aids in question (Miracle-Ear ReadyFit) was justified given that applicant’s word recognition was poor with his current hearing aids and in light of the fact that applicant’s audiologist reported that a trial of the Miracle-Ear ReadyFit hearing aids at issue demonstrated a significant improvement in applicant’s word recognition scores.
LexisNexis Commentary: This IMR is a rare decision addressing the use of hearing aids. The IMR reviewer recognized that good quality hearing aids are necessary for applicant’s hearing to improve and provided a good rationale for why the requested hearing aids should be authorized.
HOME HEALTH CARE
■ 84 Cal. Comp. Cases 565. Home Health Care—Antibiotic Treatment—Post-Surgery Infection—IMR reviewer overturned UR decision denying treating physician’s request for home health care antibiotic treatment to help combat a persistent infection following 80-year old applicant’s bilateral knee replacement surgery. Applicant’s infection had improved with wound care and intravenous antibiotics; however, treatments had stopped, and applicant’s infection worsened. The IMR expert noted that the MTUS 2017 guidelines for the treatment of chronic pain recommend short-term home health care following major surgery for some patients, and also selectively recommend home health care to prevent hospitalization, to overcome deficits in ADLs and to provide supportive/nursing care at home for those individuals who would otherwise require inpatient care. Although the ODG requires specific documentation regarding the underlying condition that necessitates home health care and the specific services being requested, in this case the IMR expert noted that the available medical documentation was unclear as to some aspects of the treating physician’s request, including the precise nature of applicant’s infection. However, given that the treatment request was for intravenous Cubicin, the IMR expert presumed that applicant had a staph or strep infection and determined that it was in applicant’s best interest to provide the intravenous antibiotic in light of the potentially life-threatening seriousness of a bacteremia. As such, the IMR reviewer concluded that the request for home health care antibiotic treatment was medically necessary.
LexisNexis Commentary: This IMR decision presents a situation in which failure to provide the requested antibiotic treatment could cause applicant’s infection to become life-threatening, and/or could result in the need for hospitalization. To avoid these potential consequences, the IMR reviewer decided to allow the antibiotics as medically necessary despite the limited information provided in the medical documentation.
■ 84 Cal. Comp. Cases 577. Home Health Care—Chronic Pain—IMR expert overturned UR decision denying treating physician’s request for home health care services for 6 hours per day, 5 days per week to assist 75-year old applicant who suffered from chronic pain in her neck, back and knees and related functional deficits. The MTUS 2017 guidelines for the treatment of chronic pain recommend short-term home health care following major surgery for some patients, and also selectively recommend home health care to prevent hospitalization, to overcome deficits in ADLs and to provide supportive/nursing care at home for those individuals who would otherwise require inpatient care. Frequency of the care is individualized by the provider’s assessment and evaluation of the patient’s health care needs. To justify home health care, the ODG require that the medical records document the medical condition that necessitates home health services, including objective deficits in function and the specific activities precluded by such deficits; the expected kinds of services that will be required, with an estimate of the duration and frequency of such services; and the level of expertise and/or professional licensure required to provide the services. In weighing home health services versus inpatient care, home health services should generally be no more than 8 hours per day and no more than 28 hours per week. In this case, the medical record provided documentation that applicant is “homebound” and requires assistance with a full range of ADLs. The IMR reviewer noted that although home health care requests that do not specify the anticipated duration of the requested services are generally not supported, such requests are not specifically prohibited. The IMR reviewer found that, despite the unspecified duration, home health care services were medically necessary in this case under the applicable criteria because without these services, applicant would require some form of inpatient care. However, the IMR reviewer emphasized that medical necessity must be assessed at regular intervals to determine applicant’s continued need for home health care services.
LexisNexis Commentary: This IMR is helpful because the IMR reviewer applied the MTUS and ODG guidelines to applicant’s specific circumstances and found that home health care should be allowed despite the fact that the anticipated duration of the home health care services was not specified in the request, because without such services applicant would require inpatient care.
INTERFERENTIAL CURRENT STIMULATION THERAPY
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-03012019/CM19-0020752.PDF. Interferential Current Stimulation Therapy—Cervical Pain and Radiculopathy—IMR reviewer overturned UR denial of treating physician’s request for R5-4i interferential stimulator rental for 30 days, based on the MTUS 2017 chronic pain guidelines. The reviewer noted that the guidelines do not recommend for or against interferential current stimulation (ICS) therapy as an isolated intervention, that there are no standardized protocols for use of such therapy, and that the evidence does not support clear value to treatment. However, the reviewer pointed out that ICS therapy may be used when medication is ineffective or is not tolerated due to side effects or a history of substance abuse, or when conservative treatments such as physical therapy cannot be employed due to pain or have failed to relieve pain. The IMR reviewer found that ICS therapy generally may be considered for a 1-month trial to assess its benefits and concluded that in this case a trial is reasonable, but that future requests must be supported by objective evidence of functional improvement.
LexisNexis Commentary: The IMR reviewer found that rental of an ICS device for a 1-month trial is reasonable especially if it reduces applicant’s need for medications or more expensive therapies, however, emphasizes that use of the device for a longer period must be supported by objective evidence of improvement.
■ 84 Cal. Comp. Cases 465. Medical Marijuana—Referral to Physician Specializing in Cannabis for Pain—IMR expert upheld UR decision denying treating physician’s request for referral of 65-year old applicant to a pain physician who specializes in prescribing cannabis for chronic pain control. The IMR expert noted that the 2017 MTUS is silent with regard to office visits and with respect to the use of cannabinoids. While the ODG encourages office visits for evaluation and management of injured workers’ conditions as dictated by their specific needs, these guidelines recommend against cannabinoids to treat pain. The IMR reviewer noted that although some states have legalized medical marijuana, there are no quality studies supporting cannabinoid use, and there are serious risks associated with its usage, including modest decline in cognitive performance especially in higher doses. The medical documentation provided in this case indicated that applicant is undergoing treatment for degeneration of lumbar or lumbosacral intervertebral discs, degeneration of cervical intervertebral discs, brachial neuritis or radiculitis, cervical spondylosis without myelopathy, neck pain, muscle spasms, and spondylosis at an unspecified cite without mention of myelopathy. Because the guidelines recommend against the use of cannabinoids for chronic pain and the treating physician did not provide a rationale to go against the guideline recommendations, the IMR reviewer concluded that the request for referral to a pain physician who specializes in prescribing cannabis for pain control is not medically necessary at this time.
LexisNexis Commentary: This IMR decision is useful to the workers’ compensation community in that it allows practitioners to understand the rationale behind a denial of certification for a referral to a pain physician who specializes in prescribing cannabis. Although marijuana is now legal in some states, it is still illegal under federal law and the applicable ODG guidelines recommend against its use for treatment of chronic pain. Here, the treating physician did not put forth any rationale to go against the guidelines in this particular case.
■ 2019 Cal. Wrk. Comp. LEXIS 45. Neurosurgical Consult—Spine Injury—IMR reviewer overturned UR decision denying treating physician’s request for consultation with neurosurgeon to evaluate 59-year old applicant with chronic lumbar pain and radiculopathy due to industrial injury. An MRI revealed progression of previous low back disease, and the treating physician requested a neurosurgical consult to determine whether applicant needed surgery. Because the MTUS and ODG do not provide specific guidelines regarding neurosurgical referrals, the IMR reviewer relied on the ACOEM guidelines, which encourage providers to recognize when they should refer patients to a specialist in a timely manner or when their capabilities have been exceeded or progress has stalled, and to “ensure that referrals are made to specialists whose approaches and quality of care are known and acceptable.” The IMR reviewer observed that the most recent note submitted by applicant’s treating physician after the previous UR denial of the requested treatment provided clarification regarding the treatment request. Based on the clarifications and the fact that applicant’s back condition was worsening, the IMR reviewer found that the request for neurological consultation was in applicant’s best interest, was reasonable and was medically necessary.
LexisNexis Commentary: The IMR reviewer here considered the fact that the treating physician wrote a clear rebuttal to UR’s previous denial of the requested treatment, together with the fact that applicant’s condition was worsening, to determine that a neurological consultation was in applicant’s best interests in this case.
■ 84 Cal. Comp. Cases 459. Opioid Medications—Kadian and Morphine Sulfate—Spine Injury/Chronic Pain—IMR reviewer overturned treating physician’s request for Kadian ER 30mg #60 and Morphine Sulfate IR 15mg #45 based on the 2017 MTUS guidelines addressing opioid use for chronic pain. Here, 69-year old applicant suffered an industrial injury in 1997 and was undergoing treatment for post-laminectomy syndrome, lumbar intervertebral disc disorders with radiculopathy, dorsalgia, and chronic low back pain. She had been taking Kadian and Morphine Sulfate IR for at least 6 months. With medication usage, applicant rated her pain at 3 out of 10, and without medication her pain was rated at 9.5 out of 10. Applicant was able to walk and sit for short periods when using medication but could do neither without the medications. The ACOEM practice guidelines recommend opioid medications for the treatment of subacute or chronic severe pain such as the pain that occurs with CRPS, severe radiculopathy and advanced degenerative joint disease. The guidelines recommend use of opioids for treatment of both function and pain impaired by subacute or chronic severe pain when other treatments for functional restorative pain therapy have been attempted without adequate effect, and continuation of opioid use when there is at least a 30 percent improvement in pain and function. Ongoing doctor visits to monitor efficacy of the opioid treatment and improvement in functional status and to perform urine drug screening is recommended. In this case, applicant reported that the medications were working well and that she had no negative side effects. Further, there was no evidence of dependency, abuse of the medications or any adverse behaviors to indicate addiction. Applicant demonstrated an improved capability for ADLs while using the medications, including improved capability for self-care and household tasks. Further, applicant signed an opioid agreement, and periodic weaning has been attempted. Applicant’s treating physician documented applicant’s improvement in pain and function and has addressed medication compliance. Under the circumstances, the IMR reviewer found that both the requested Kadian and Morphine Sulfate prescriptions were medically necessary.
LexisNexis Commentary: This IMR decision is instructive because the IMR reviewer provided a good discussion of the guideline requirements for approval of opioid medication and explained why applicant in this case satisfied the applicable criteria.
TERTIARY PAIN PROGRAMS
■ 84 Cal. Comp. Cases 470. Tertiary Pain Programs—Multidisciplinary Evaluation—Chronic Pain—IMR expert overturned treating physician’s request for multidisciplinary evaluation in case of 47-year old applicant who was undergoing treatment for chronic pain syndrome, personality disorder, bilateral carpal tunnel syndrome, and bilateral shoulder sprain. In addition to the pain from her physical injuries, applicant had psychiatric symptoms, including depression. Previous treatment included diagnostic studies, physical therapy, massage therapy, cognitive behavioral therapy, a pain management consult, psychological evaluation, biofeedback and treatment, follow up appointments, and medication including Cymbalta. Pursuant to the 2017 MTUS chronic pain guidelines, tertiary pain programs such as interdisciplinary pain rehabilitation programs, multidisciplinary rehabilitation programs, chronic pain management programs, and functional restoration programs, are selectively recommended for patients who have failed conventional treatments and remain significantly incapacitated. Prior to beginning a tertiary pain program, a patient must be thoroughly assessed by multiple specialists to establish the patient’s appropriateness for the program and to determine whether there may be any potential barriers to recovery that must be addressed. To be admitted to a tertiary pain program, the following criteria must be met: the patient must be off work or on modified duty for at least 3 months, with unusually slow recovery; the patient’s pain must have known physical etiology; other appropriate and less expensive medical care has not adequately restored function; the patient has at least some behavioral or psychosocial issues affecting his or her recovery; the patient is committed to recovery and has the ability to benefit from the program; there is a substantial gap between the patient’s physical capable and his or her projected job demands; and, there are no known contraindications to the treatment program. The IMR reviewer noted that applicant in this case has chronic pain with associated psychological issues. Conservative treatment has failed, and applicant is not a surgical candidate. Based on the guideline criteria, the IMR expert concluded that a multidisciplinary evaluation is reasonable and medically necessary.
LexisNexis Commentary: This IMR decision is instructive as the IMR reviewer explained the purpose behind tertiary pain programs and specifically detailed the criteria that must be met for an injured worker to be recommended for such a program, including demonstrated psychological symptoms in addition to physical symptoms.
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