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LexisNexis has selected some noteworthy IMR decisions issued over the past year 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 opioid medications and chiropractic care, challenges relating to requests for medical marijuana, and efficacy of conservative treatments such as aqua therapy, ergonomic furniture and service dogs.
■ 83 Cal. Comp. Cases 1628. Acupuncture—Lower Back Pain—IMR reviewer upheld UR decision denying treating physician’s request for acupuncture treatment for applicant’s lumbar spine 2 times weekly over 3 weeks. The IMR expert relied on the 2016 MTUS guidelines for acupuncture treatment related to low back disorders, which support acupuncture for patients with moderate to severe low back pain for up to 12 sessions if objective functional improvement is reported. Here, 6 acupuncture sessions were previously authorized, but the number of treatments completed to date was not documented. Additionally, specific objective functional improvement with the acupuncture treatment was not documented. Therefore, the IMR expert found that the guidelines were not satisfied, and the requested acupuncture treatment was not medically necessary.
LexisNexis Commentary: This IMR decision illustrates the importance of submitting proper documentation to support medical treatment requests.
■ 83 Cal. Comp. Cases 1862. Aqua Therapy—Chronic Pain—Knee Injury—IMR expert overturned UR decision denying authorization for 6 supervised aqua therapy sessions to treat pain associated with 57-year old applicant’s right knee injury. The IMR expert found that the requested aqua therapy sessions were medically necessary and appropriate based on the 2017 MTUS chronic pain guidelines, which recommend a trial of 3 to 4 sessions of aqua therapy for treatment of chronic persistent or neuropathic pain with documented comorbidities that preclude effective participation in a weight-bearing physical activity. They also recommend continued treatment with documented objective evidence of functional improvement after aqua therapy sessions are completed. Here, applicant was treated for right knee and shoulder pain and was diagnosed with right quadriceps rupture, right RCT and right patella fracture. His physician documented obesity and believed that applicant would benefit from aqua therapy due to decreased impact on his knee. Applicant’s physician believed that applicant required supervision because he had never done aqua therapy before and was unable to perform the exercises on his own.
LexisNexis Commentary: This IMR decision provides guidance regarding the criteria that needs to be met for authorization of supervised aqua therapy, which is not a commonly requested treatment but is one that has many positive effects.
■ 83 Cal. Comp. Cases 1628. Bariatric Surgery—Weight Loss—IMR reviewer upheld UR decision denying treating physician’s request for bariatric surgery based on the Official Disability Guidelines (ODG), diabetes chapter. Here, 42-year old applicant suffered industrial injury to her lumbar spine with pain radiating to her right leg and symptoms in her right knee causing an abnormal gait. Bariatric surgery was recommended to control applicant’s significant weight problem, as her weight was putting a lot of stress on her lower back and right knee. There was no documentation indicating that applicant attempted self-management of her weight through use of medication, exercises, or behavior modification. The ODG guidelines recommend gastric bypass weight loss surgery for patients with Type 2 diabetes, BMI of 35 or more (applicant’s BMI was 44.3) or BMI over 30 for those that have poorly controlled diabetes, and if a patient is not achieving the recommended treatment targets (AIV<6.5%) with exercise and change in diet. In this case, applicant did not have Type 2 diabetes, and there was no indication she had tried other methods of controlling her weight, or documentation of how much weight applicant had lost to date. Therefore, the IMR reviewer found that the request for bariatric surgery was not medically necessary.
LexisNexis Commentary: This IMR decision illustrates that conservative treatments must be attempted before bariatric surgery will be authorized.
■ 84 Cal. Comp. Cases 253. Chiropractic Treatment—Cervical Spine—IMR reviewer overturned UR denial of treating physician’s request for 6 sessions of chiropractic treatment based on the 2016 MTUS guidelines and the Non-MTUS ODG guidelines addressing chiropractic care for neck and upper back conditions. The MTUS guidelines recommend chiropractic manipulation for short-term relief of cervical pain or as a component of an active treatment program focusing on active exercises for acute cervicothoracic pain. According to the guidelines, patients with severe spine conditions may receive up to 12 visits. The guidelines state that the chiropractic treatment should be discontinued after 6 sessions if there is no functional improvement. The ODG guidelines recommend a trial of 6 chiropractic visits for moderate neck pain or nerve root compression with radiculopathy, and a greater number of visits for more severe pain and/or when functional improvement is demonstrated. Here, applicant had significant pain in his neck and lower back with radiculopathy. He was diagnosed with compression fractures in the lumbar spine and thoracic spine, and conservative therapy failed. The treating physician provided documentation of physical exam findings to provide a rationale for the requested treatment, and the treatment was within the guideline criteria. Therefore, the IMR reviewer found the requested treatment medically necessary.
LexisNexis Commentary: This IMR decision is helpful because it involves an applicant who suffered a recent back injury and continues to work modified duty while aggressively pursuing treatment for his condition. Conservative treatment was not working, and the treating physician requested different treatment modalities to help with applicant’s pain and restore function. These treatments included acupuncture, which was authorized by UR, Kyphoplasty, steroid injections, and chiropractic treatment. The IMR reviewer provides a very comprehensive discussion of the guideline criteria for each of the treatments requested and why they were met in this case.
■ 84 Cal. Comp. Cases 262. Chiropractic Treatment—Cervical Spine—IMR reviewer overturned UR denial of treating physician’s request for 6 sessions of chiropractic treatment based on the 2016 MTUS guidelines addressing chiropractic care for the cervical and/or thoracic spine. The MTUS guidelines recommend chiropractic manipulation for short-term relief of cervical pain or as a component of an active treatment program focusing on active exercises for acute cervicothoracic pain. According to the guidelines, patients with severe spine conditions may receive up to 12 visits. The guidelines state that the chiropractic treatment should be discontinued after 6 sessions if there is no functional improvement. However, progress should be reassessed at 2-week intervals to determine whether the continuation of the treatment is indicated. Applicant here had cervical pain and objective findings after industrial injury to her neck and other body parts. Because the guidelines recommend a trial of chiropractic therapy in such cases, the IMR reviewer determined that medical necessity was established.
LexisNexis Commentary: This IMR decision is helpful because it provides guidance as to how to evaluate the effectiveness of chiropractic treatment and determine whether continued treatment is recommended.
COMPUTED TOMOGRAPHY (CT) SCANS
■ 83 Cal. Comp. Cases 1957. Computed Tomography (CT) Scan—Head/Skull—IMR reviewer overturned UR denial of treating physician’s request for Radionuclide cisternogram CSF, ear, nasal pledget study with CT of the skull based on the 2016 MTUS guidelines related to diagnostic tests for cervical and spine disorders, and Non-MTUS ODG pertaining to head CT scans. The MTUS and ODG recommend head CT scans for abnormal mental status and focal neurologic deficits or acute seizures and indicate that they should also be considered where there are signs of basilar skull fracture, physical evidence of trauma above the clavicles, acute traumatic seizures, age above 60, disturbed consciousness, pre-or post-event amnesia, drug or alcohol intoxication, or any recent history of TBI, including MTBI. Additionally, patients presenting to the emergency department with headaches and abnormal neurologic examinations (i.e., focal deficit, altered mental status and/or altered cognitive function) should undergo emergent non-contrast head CT scan. Here, 44-year old applicant reported balance problems with dizziness, blurred vision, headaches, memory problems, and jaw pain. Applicant was diagnosed with cataplexy, narcolepsy and bilateral cataracts, and objective findings included right cranial nerve VI with diplopia, right ptosis, and positive vermis atrophy. The IMR expert concluded that applicant met the MTUS and ODG criteria for a CT scan and, therefore, the request was medically necessary.
LexisNexis Commentary: This IMR decision provides a very detailed and useful list of the criteria that should be met when a head CT scan is required.
■ 83 Cal. Comp. Cases 1151. Driving School—Quadriplegia—IMR reviewer upheld UR decision denying treating physician’s request for driving school consultation in order to help 49-year old applicant with quadriplegia with home maintenance and adequate function. The IMR reviewer noted that neither the MTUS or ODG guidelines discuss or suggest the use of driving school for treatment of injured patients and relied on the 2016 MTUS guidelines for home health services, which discuss the use of home health services for patients who are homebound and need help with activities of daily living and activities such as shopping and cleaning. The IMR reviewer opined that home health aide may be a better option for maintaining applicant at his home and concluded that the requested consultation for driving school was not medically necessary and appropriate.
LexisNexis Commentary: This IMR provides good rationale for determination that home health services may be better option than driving school consultation for applicant who is quadriplegic.
ELECTROMYOGRAPHY (EMG)/NERVE CONDUCTION STUDIES (NCS)
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2018/IMR-10012018/CM18-0153424.PDF. Electromyography (EMG)/Nerve Conduction Study (NCS)—Upper Extremities—IMR reviewer overturned UR decision denying provider’s request for EMG/NCS for bilateral upper extremities of 53-year old applicant who was undergoing treatment for chronic pain syndrome, myofascial pain, neck pain, chronic bilateral thoracic back pain, and cervical radiculitis. The IMR reviewer relied on the MTUS 2017 guidelines for chronic pain and the Non-MTUS ODG for electrodiagnostic testing. The MTUS and ODG recommend needle EMG/NCS to diagnose the source of neurological symptoms and to diagnose nerve entrapments such as carpal tunnel syndrome or radiculopathy that may contribute to CRPS II. The ODG clarifies that NCS is not recommended, but needle EMG is recommended to obtain unequivocal evidence of radiculopathy, after 1-month of conservative therapy, but EMGs are not necessary if radiculopathy is already clinically obvious. In this case, conservative treatment was well-documented, and the rationale for the requested EMG/NCS was to aid in diagnosis and treatment. As such, the IMR reviewer found the requested treatment medically necessary.
LexisNexis Commentary: This IMR decision provides a good example of the circumstances under which EMG/NCS evaluation is appropriate.
EPIDURAL STEROID INJECTIONS
■ 84 Cal. Comp. Cases 253. Epidural Steroid Injection—Lumbar Spine—IMR reviewer overturned UR denial of treating physician’s request for lumbar transforaminal epidural steroid injection at applicant’s left and right L4-5, based on the 2016 MTUS guidelines and Non-MTUS ODG guidelines for low back/thoracic spine injections. The MTUS guidelines recommend epidural steroid injections as an “option” for treatment of acute or subacute radicular pain. Its purpose is to provide temporary partial pain relief and allow some activity while awaiting further improvement in pain and function. The IMR reviewer noted that an “option” means there should be no requirement that a patient receive and fail treatment with steroid injections, especially repeated injections, prior to surgery. Criteria for use of epidural steroid injections per the ODG guidelines include documented radiculopathy confirmed by objective imaging studies and/or electrodiagnostic testing and failed conservative treatment. Here, applicant had significant pain in his neck and low back with radiation to the upper and lower extremities and numbness and tingling, causing functional deficits. An MRI showed multilevel degenerative disc disease and canal stenosis with mild cord compression at multiple levels. He was diagnosed with compression fractures in the lumbar spine and thoracic spine, and conservative therapy failed. The IMR reviewer concluded that the treating physician provided sufficient rationale for requesting a steroid injection at left and right L4-5 and, as such, the treatment was medically necessary.
■ 83 Cal. Comp. Cases 1628. Ergonomic Desk Chair—Lower Back and Knee Pain—IMR reviewer overturned UR decision denying treating physician’s request that applicant be provided with an ergonomic desk chair to help with her back and knee pain. UR denied the request on the bases that it was unclear if applicant’s prior ergonomic desk chair provided benefit and that the documentation did not indicate applicant was unable to perform proper body mechanics or exercises that would alleviate exacerbation of her symptoms. However, the 2017 MTUS Initial Approaches to Treatment 2017 Guidelines, Workplace Issues, relied upon by the IMR reviewer indicate that it is often helpful to discuss practical strategies for modifying the worksite to accommodate the worker and strategies to reduce the risk of recurrent injury, including ergonomic factors. Here, applicant had a flare-up of symptoms, and the IMR expert found that the requested ergonomic chair qualified as a practical strategy for reducing the risk of recurrent injury. Therefore, the requested treatment was deemed medically necessary.
LexisNexis Commentary: This IMR decision is helpful in that there is a good discussion of why UR denied the treatment request and why the IMR expert believed that the treatment was medically necessary.
INPATIENT REHABILITATION PROGRAMS
■ 84 Cal. Comp. Cases 163. Inpatient Rehabilitation Program—Traumatic Brain Injury—IMR reviewer overturned UR decision allowing only 14 days of requested 30 days (with weekends home) participation in inpatient rehabilitation program for 41-year old applicant who suffered a traumatic brain injury when a carpet roll thrown from the second floor hit him in the head. As a result of the injury, applicant suffers from physical and cognitive symptoms, including headaches, impaired motor coordination and vision, behavioral problems, and speech and reasoning/processing deficits. He also suffers from increased anger, irritability, severe depression, and suicidal ideation. The 2017 MTUS guidelines addressing rehabilitation programs for patients with traumatic brain injuries, as relied upon by the IMR expert in this case, recommend inpatient rehabilitation for moderate to severe traumatic brain injury patients with ongoing symptoms and need for daily treatment, where the patient is unlikely to make functional gains in an outpatient setting. Here, the documentation showed that applicant continued to improve with the current treatment regimen and was nearly ready to transition to a residential rehabilitation setting. Applicant had already transitioned to an independent living program and was making functional gains that were less likely to be made in an outpatient setting. Less than the recommended 30-day period put applicant’s gains at risk. Based on the applicable guidelines and documentation provided, the IMR reviewer found that the 30-day inpatient program was medically necessary.
LexisNexis Commentary: This IMR decision provides an interesting analysis of the criteria that must be met in traumatic brain injury cases to justify an inpatient rather than outpatient rehabilitation program and emphasizes the importance of continuing treatment that will facilitate functional gains. The decision also emphasizes that use of “probative phrases” such as “functional limitations” and “functional gains” by treating physicians in the supporting documentation can be important to establish that the requested treatment meets the applicable guideline criteria.
■ 84 Cal. Comp. Cases 253. Kyphoplasty—Spinal Fractures—IMR reviewer overturned UR denial of treating physician’s request for Kyphoplasty at T12 and L2 based on Non-MTUS ODG guidelines, which recommend Kyphoplasty as an option for patients with pathologic fractures due to vertebral body neoplasms, or patients who have significant unremitting pain and functional deficits from osteoporotic compression fractures and do not responded to other medical interventions. Here, 64-year old applicant was working modified duty and undergoing treatment for significant chronic low back pain as well as pain in the thoracic spine and cervicalgia following a 2018 fall. He was diagnosed with compression fractures in the lumbar spine and thoracic spine, and conservative therapy, including medications and bracing, failed. The IMR reviewer concluded that the treating physician provided sufficient rationale for Kyphoplasty at T12 and L2 and, as such, the treatment was medically necessary.
■ 83 Cal. Comp. Cases 1169. Medical Marijuana/Anti-Emetics—Marinol—Opioid-Induced Nausea and Chronic Pain—IMR reviewer upheld UR decision denying treating physician’s request for Marinol 5mg #15 to treat 43-year old applicant’s opiate-induced nausea, chronic pain related to reflex sympathetic dystrophy in the upper extremity and neuropathic arm pain. The IMR expert relied on the Non-MTUS ODG guidelines, pain chapter, for anti-emetics (for opioid nausea), which state that anti-emetics are not recommended for nausea and vomiting secondary to chronic opioid use. The IMR reviewer also cited the Non-MTUS ODG guidelines, pain chapter, for cannabinoids, which state that cannabinoids are not recommended for pain because, while 23 states have legalized medical marijuana, there are no quality studies supporting cannabinoid use and there are serious risks associated with its usage. Given the lack of guideline support for use of cannabinoids to treat chronic pain and use of anti-emetics for opiate-induced nausea, the IMR expert concluded that the medical treatment requested in this case is not medically necessary.
LexisNexis Commentary: This IMR decision provides an example of a circumstance where medical marijuana was prescribed for both pain and nausea and did not meet the ODG guideline criteria for either condition.
■ 83 Cal. Comp. Cases 1151. Medical Marijuana—Marinol—Anorexia—IMR reviewer upheld UR decision denying treating physician’s request for Marinol 2.5mg #60 to treat applicant’s anorexia. In upholding the UR decision, the IMR reviewer relied on the 2016 MTUS chronic pain guidelines addressing cannabinoids, which do not recommend use of cannabinoids to treat pain especially given their potential negative side effects, including decrease in cognitive performance and possibility of psychotic symptoms in vulnerable persons. The IMR reviewer also noted that the American Society of Addiction Medicine has taken a position against medical marijuana because it is dangerous and addictive. The IMR reviewer concluded that because cannabinoids are addictive and can be dangerous, and because for every disease and disorder in which these drugs are recommended there is a better FDA approved medication, the request for Marinol 2.5mg #60 was not medically necessary and appropriate.
LexisNexis Commentary: This IMR decision illustrates the difficulty in getting authorization for use of cannabinoids especially because, as pointed out by the IMR reviewer, cannabinoids can be addictive and there are FDA approved medications that provide better treatment options.
■ 83 Cal. Comp. Cases 1769. Medical Marijuana—Cannabidol—Chronic Pain—IMR reviewer upheld UR denial of Cannabidol (CBD) 5mg BID for 30 days based on Non-MTUS Official Disability Guidelines (ODG), which indicate that CBD is not recommended for pain. The IMR reviewer noted that even though many states have legalized medical marijuana, there are no quality studies supporting cannabinoid use, and its use poses potentially serious risks. The IMR reviewer blamed the lack of research on the fact that marijuana is illegal under federal law and on the difficulty blinding the effects of marijuana given its psychoactive properties. As CBD is not recommended by the ODG guidelines, the IMR reviewer found that medical necessity was not established.
LexisNexis Commentary: This IMR decision provides an interesting discussion regarding the lack of quality studies addressing the effects if cannabis and why CBD is not recommended for pain.
■ 83 Cal. Comp. Cases 1769. Opioid Medications—Norco—IMR expert upheld UR denial of Norco 10/325mg #90 to treat applicant’s pain from upper extremity and shoulder strains. Although applicant reported significant pain, the objective findings on examination were minimal. Furthermore, according to applicant, his prior use of Norco had minimal effect on his shoulder pain. The IMR reviewer recited the 2017 opioid guidelines, which, in part, recommend use of opioids to improve pain and function, indicate that both pain and function goals should be established, and state that before opioids are prescribed there should be plans for discontinuation of the medication if the established treatment goals are not met. Under the guidelines, there should be at least 30 percent improvement in both pain and function to continue opioids, and other treatment modalities must fail. The IMR expert found that here there was no ongoing documentation of measurable and sustained functional improvement with applicant’s previous use of Norco. Additionally, the guidelines recommend the use of generic equivalents. The IMR reviewer concluded that applicant’s continued use of Norco was not supported by the guidelines and was not medically necessary.
LexisNexis Commentary: This IMR decision provides a detailed discussion of the guidelines applicable to opioid medication use and discontinuation. Also, the IMR reviewer specifically recommended that the treating physician refer to the MTUS opioid guidelines and other relevant guidelines regarding appropriate methods for weaning applicant from opioids.
■ 84 Cal. Comp. Cases 362. Opioid Medications—Norco—Chronic Pain—IMR reviewer overturned UR decision denying treating physician’s request for Norco 10/325mg #150 based on the 2017 MTUS guidelines addressing opioid use for chronic pain. Here, 65-year old applicant suffered an industrial injury in 1975 and continues to suffer chronic back pain. 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. Ongoing usage of opioid treatment beyond a trial period is dependent on its efficacy during the trial. Further, the guidelines require a number of specific criteria to be met for continued usage, including significant monitoring and screening for misuse of the medication and eventual weaning from the opioids. In this case, applicant was beyond the acute phase of injury. His physician documented comprehensive screening evaluation and the CURES was consistent. According to the IMR reviewer, the medical records showed that applicant’s use of opioid medication reduced his pain and restored function to a degree that allowed him to continue working full time. As such, the request for Norco 10/325mg #150 was found to be medically necessary.
LexisNexis Commentary: The IMR reviewer here provided a very detailed recitation of the guidelines for prescribing opioids and emphasized that the IMR decision addressed the medical necessity of opioids as they have been prescribed to this injured worker. This illustrates that the MTUS guidelines should not be applied mechanically but rather must be applied based on the needs of the particular patient. In this case, applicant’s quality of life would have been significantly diminished if the opioid prescription were denied.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-01012019/CM18-0232657.PDF. Opioid Medications—Hydroco/APAP—IMR reviewer overturned UR decision denying provider’s request for Hydroco/APAP 10/325mg #60, based on the MTUS 2017 opioid guidelines applicable to subacute and chronic pain. Here, 34-year old applicant was undergoing treatment for carpal tunnel syndrome in her right upper extremity and tenosynovitis. Her treatment included use of Norco, 1 pill daily for approximately 8 hours of pain relief. Applicant was unable to take NSAIDs due to allergies and was not interested in trying neuropathic medications due to their potential side effects. The guidelines recommend a trial period of opiates to achieve functional improvement, with ongoing visits scheduled to monitor efficacy, improved function, adverse effects, compliance, and non-compliance. According to the MTUS, opioids should be discontinued if they are not providing improvement in pain and function, if they are having adverse effects, or if the medications are being misused in some way. The MTUS states that in order to continue opioid treatment for chronic pain the provider must document a decrease in pain and increase in function, noting specific activities, and also must document monitoring for aberrant drug behavior and side effects. Applicant’s provider in this case ordered 1-2 tablets daily of the combination of Hydroco/APAP to treat applicant’s chronic pain. The documentation submitted reflected a secondary decrease in pain and increase in applicant’s function, including the ability to work full time and care for children and increased ability to perform ADLs without side effects. Aberrant drug behavior was also being monitored for and CURES reporting checked. The IMR expert concluded that the provider fulfilled the MTUS criteria for ordering opioids to treat chronic pain, and that the treatment was medically necessary and appropriate.
LexisNexis Commentary: The IMR reviewer here approved an extra tablet of medication, which appears reasonable given applicant’s pain and functioning problems. If monitoring reveals problems the medication can be reduced or discontinued when the current prescription runs out.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2018/IMR-10012018/CM18-0153424.PDF. Physical Therapy—Cervical Spine—IMR reviewer overturned UR decision denying provider’s request for 6 sessions of physical therapy to treat applicant’s cervical spine condition based on the MTUS 2016 guidelines for physical therapy addressing cervical and thoracic spine disorders and the Non-MTUS ODG for physical therapy related to neck and upper back disorders. Although fewer physical therapy are recommended for mild to moderate pain, for subacute or chronic spine pain or more severe debilitation, 4 to 6 appointments may be necessary to initiate and reinforce an independent exercise program. For neck pain, the ODG recommends 9 visits and formal assessment after a 6-vist trial to assess whether there has been any improvement or any negative effects. In this case applicant’s treating physician provided medical documentation explaining why a home exercise program was not sufficient for applicant. As such, the IMR expert found that the request for 6 physical therapy sessions for the cervical spine was medically necessary.
LexisNexis Commentary: The IMR reviewer here approved physical therapy when a home exercise regime was insufficient; if applicant improves with PT, the necessity of more costly medical treatment may be avoided.
PLATELET RICH PLASMA INJECTIONS
■ 84 Cal. Comp. Cases 262. Platelet-Rich Plasma (PRP) Injection—Shoulder/Wrist Injury—IMR reviewer upheld UR denial of treating physician’s request that 50-year old applicant with industrial injuries to her neck, shoulders and wrist be referred to an orthopedic surgeon for right shoulder and right wrist PRP injection. Per the Non-MTUS ODG guidelines, upon which the IMR reviewer relied, PRP injections for the shoulder are not recommended. The IMR reviewer found that, while the treatment is popular among professional athletes, there is no evidence-based support for PRP injection to improve pain or function, and since PRP injection is not recommended for the shoulder, the treatment was not medically necessary in this case.
LexisNexis Commentary: The discussion regarding the efficacy of PRP injection in this IMR is interesting. Although the treatment is not supported by evidence-based studies, the American Academy of Orthopaedic Surgeons indicates that there is no downside to the PRP injection but for the fact that it may not be covered by insurance.
■ 83 Cal. Comp. Cases 1169. Prescription Medications—Lidocaine Topical Patch—Neuropathic Pain—IMR reviewer overturned UR decision denying treating physician’s request for Lidocaine 5% topical patch #60 to treat applicant’s reflex sympathetic dystrophy of the upper extremity, arm neuropathy and muscle pain. The IMR expert relied on the 2017 MTUS guidelines for chronic persistent pain and chronic pain syndrome, which state that Lidocaine patches are selectively recommended for treatment of chronic persistent localized pain amenable to topical treatment or moderate to severe chronic persistent pain. Progress notes submitted by applicant’s treating physician indicated that the Lidocaine patches were to treat applicant’s neuropathic pain, and that Lidocaine lotion was not effective. Regarding Lidoderm patches, the IMR reviewer noted that the 2017 MTUS/ACOEM guidelines generally require that patients have failed NSAID treatment, therapeutic exercise, tricyclic antidepressants, anticonvulsants, and topical NSAID medications. The record in this case revealed that applicant failed trials of oral and topical NSAID medications, therapeutic exercise and antidepressants. Given applicant’s diagnosis, failure of first-line options and lack of prior Lidoderm patch use, the IMR expert found the request for a trial of Lidocaine patches to be reasonable and medically necessary.
LexisNexis Commentary: This IMR is helpful for its thorough discussion of the criteria that must be met to obtain authorization for Lidocaine patches.
■ 83 Cal. Comp. Cases 1758. Prescription Medications—IMR reviewer upheld UR determination modifying treating physician’s requests for Meclizine, Marinol and Butrans patches by allowing these medications for shorter duration than requested, but overturned UR modification of requests for Norco and Elavil. Here, 66-year old applicant reported neck pain and headaches after being kicked in the face by a horse. With respect to the medication Meclizine used to treat nausea/dizziness from motion sickness, the IMR reviewer noted that there was a lack of documentation regarding applicant’s objective response to prior usage of Meclizine such that continuation of the medication was not supported. As to the request for Marinol, the IMR reviewer reasoned that although applicant reported an overall decrease in pain with use of the prescribed medications, the Non-MTUS Official Disability Guidelines (ODG) state that cannabinoids such as Marinol are not recommended for pain and, therefore, Marinol was not medically necessary to treat applicant. With respect to the Butrans patches, the IMR reviewer relied on the 2017 MTUS opioid guidelines requiring improvements in both pain and function to continue opioid treatment. Despite applicant’s reduced pain, the IMR reviewer concluded that use of the Butrans patches was not supported by the applicable guidelines when there was no documentation of objective improvement in applicant’s function with prior use of the patches. In contrast, the IMR reviewer determined that Norco for 90 days as requested was medically necessary where applicant reported that use of Norco reduced his pain and allowed him to increase his daily activity levels and perform household chores more easily. Therefore, the IMR reviewer overturned the UR recommendation authorizing only 60 days of Norco. The IMR reviewer also overturned the UR recommendation authorizing Elavil for 15 days rather than the requested 30 days, based on the 2017 MTUS chronic pain guidelines recommending norepinephrine reuptake inhibitor anti-depressants for treatment of chronic persistent pain. Given applicant’s indication that Elavil relieved his neuropathic pain and allowed him to be more active, the IMR reviewer found that continuation of Elavil was supported by the guidelines.
LexisNexis Commentary: This IMR decision is a good example of a case where the IMR reviewer considered applicant’s improvement in both pain and function to uphold UR’s reduction of several medications and overturn the reduction of others.
■ 83 Cal. Comp. Cases 1957. Service Dogs—Narcolepsy—IMR reviewer overturned UR denial of request for service dog for 44-year old applicant with vision problems, balance and dizziness issues, and narcolepsy. Because use of service dogs is not addressed in the MTUS or ODG, the IMR reviewer relied on a US Service Animals website that explained the benefits of service dogs. According to the website, service dogs trained for narcolepsy can help by warning if an afflicted person is about to have an episode, fetching help if the person suffers an injury after suddenly falling asleep and waking a person who sleeps through an alarm. Additionally, service dogs can help with anxiety and depression that often accompanies narcolepsy. The IMR reviewer noted that although service dogs cannot predict when someone is falling asleep, it is possible that dogs may come to recognize triggers and hurry to their owner’s side prior to a collapse. The IMR reviewer concluded that applicant would benefit from a service dog as described on the website and, therefore, the request was medically necessary.
LexisNexis Commentary: Service dogs are being used for more conditions now, including psychiatric conditions, and their use is not addressed in the MTUS or ODG. This decision explains the benefits of service dogs and why a service dog would be helpful to an injured worker who suffers from narcolepsy.
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