California: Noteworthy Independent Medical Review (IMR) Decisions (10/2022)

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). These selected IMR decisions address, among other topics, the different treatment modalities for chronic pain and mental health disorders, the MTUS criteria that must be satisfied for approval of home healthcare, and various treatments for COVID-19 symptoms, including pulmonary symptoms, chronic stress, and long COVID.

ANTI-DEPRESSANTS FOR CHRONIC PAIN AND SLEEP

■ 87 Cal. Comp. Cases 956. Antidepressants—Amitriptyline—Chronic Neuropathic Pain and Sleep Impairment—Applicant, 37-years old, suffered an industrial back injury on 11/20/2019. He received medical treatment for a chronic lumbosacral strain with degenerative disc disease, radiculitis, and chronic lumbago secondary to the industrial injury. In March of 2022, applicant reported 4/10 radiating low back pain into the left buttock, upper thigh and left hip, along with sleep interference which was partially relieved by Amitriptyline. His treating physician requested authorization to continue Amitriptyline 50mg #30 at bedtime. The request was non-certified by UR based on the MTUS 2020 treatment guidelines for low back/radicular pain and on the non-MTUS, ODG treatment guidelines. The IMR reviewer overturned the UR determination and found that the requested medication was medically necessary based on the MTUS 2017 treatment guidelines for chronic neuropathic pain, which moderately recommend tricyclic antidepressants (such as Amitriptyline) as a first-line agent for treatment of neuropathic pain sufficiently severe to require medication, and as a sleep aid for nighttime sleep disturbance due the neuropathic pain. Here, the IMR reviewer noted, there was documentation of neuropathic pain in applicant’s lower extremity that improved with use of Amitriptyline, allowing for increased ability to ambulate by 30 percent and improved duration and quality of sleep. Thus, the IMR reviewer found that the request complied with the MTUS guideline criteria, and that continuation of Amitriptyline was reasonable at this point. [LexisNexis Commentary: The UR reviewer in this case relied on the incorrect MTUS guidelines and non-certified applicant’s request for Amitriptyline, despite evidence that the medication was effective in relieving applicant’s neuropathic pain. The IMR reviewer, citing the correct MTUS guidelines, did a good job of explaining why the record and the guidelines supported the request for Amitriptyline.]

CHIROPRACTIC TREATMENT

■ 87 Cal. Comp. Cases 853. Chiropractic Treatment—Back Injury—Applicant, 50 years old, suffered an industrial injury on 7/25/2019, and was placed on modified duty. He reported low back pain that radiated to the right lower extremity, and daily numbness and tingling in the right foot with walking and standing for longer periods. The treating physician requested six sessions of chiropractic treatment to help with his symptoms. UR denied the requested treatment. The IMR reviewer overturned the UR denial based on the 2020 MTUS guides addressing treatment for low back disorders with radicular pain. The guidelines suggest a maximum of six appointments, with the potential of additional appointments if there is demonstrated functional improvement. Here, the IMR noted, applicant underwent a course of treatment after his 2019 injury. He was determined to be permanent and stationary in May 2020. In June 2021 he complained of an exacerbation. Applicant participated in physical therapy that failed to resolve his complaints. The IMR reviewer found that a course of chiropractic treatment was appropriate given the clinical findings and the fact that the guidelines support periodic chiropractic treatment for exacerbations. Additionally, applicant noted overall improvement with prior chiropractic treatment. Therefore, consistent with MTUS guidelines, the IMR reviewer concluded that the request for six sessions of chiropractic treatment was medically necessary. [LexisNexis Commentary: This IMR describes the guideline criteria that must be met to support a request for chiropractic treatment. The fact that applicant underwent prior chiropractic treatment that did not resolve his complaints was not fatal to his subsequent request for chiropractic care based on an exacerbation of back pain, where applicant noted an improvement after the prior chiropractic treatment.]

■ 87 Cal. Comp. Cases 849. Chiropractic Treatment—Back Injury—Applicant, 32 years old, suffered an industrial injury on 2/27/2017, and was diagnosed with cervicalgia, low back pain and thoracic spine pain. He underwent several periods of chiropractic treatment with noted improvement in pain and function.  However, after completion of chiropractic treatment, applicant complained of neck pain rated at 6/10. Applicant’s treating physician requested additional chiropractic treatment twice per week for four weeks for applicant’s cervical spine, thoracic spine, and lumbar spine. UR certified the requested for the cervical spine and thoracic spine but denied chiropractic treatment for the lumbar spine. The 2020 MTUS guidelines for low back disorders with radicular pain support chiropractic care for exacerbations of low back pain if chiropractic treatment improves pain and function. In this case, the request for lumbar spine treatment was denied by UR based on the rational that there was limited functional benefits noted in the lumbar spine as there was still pain and facet tenderness. The IMR reviewer, however, noted that the documentation indicated there was, in fact, improvement in all body parts previously treated with chiropractic therapy, including the lumbar spine. Given the improvement noted following the initial course of care and the residual complaints, the IMR reviewer found that chiropractic treatment of the lumbar spine as requested was medically necessary. [LexisNexis Commentary: In this IMR decision, UR denied the treatment request based on its erroneous finding that applicant’s prior chiropractic treatment did not produce functional improvement. In fact, the documentation noted improvement with previous chiropractic sessions. The IMR reviewer corrected the error, potentially avoiding an IMR appeal based on a plainly erroneous express or implied finding of fact under Labor Code § 4610.6(h).]

COVID-19

■ 2022 Cal. Wrk. Comp. LEXIS 55. Pulmonary Rehabilitation Therapy—COVID-19—Applicant, 46 years old, suffered an industrial injury on 7/17/2020 in the form of COVID-19. She underwent treatment for mild persistent asthma with acute exacerbation, pneumonia, shortness of breath, and post-COVID-19 syndrome. Applicant’s current work status was unclear, but as of 12/9/2021 she was working full duty. Previous treatment included medication, physical therapy, and pulmonary rehabilitation respiratory therapy. Applicant reported that since stopping treatment, her respiratory status has worsened with respect to wheezing and shortness of breath, fatigue has continued, and her exercise capacity was limited. On 8/9/2022, applicant’s treating physician requested approval for 36 sessions of pulmonary rehabilitation therapy in the forms of physical therapy to include neuromuscular re-education, dynamic activities to improve functional performance, manipulation of the chest wall, and therapeutic procedures to increase strength or endurance of respiratory muscles and improve respiratory function. UR approved six sessions of pulmonary rehabilitation therapy but denied the remaining 30 sessions. The IMR reviewer upheld the UR determination based on the MTUS Coronavirus (COVID-19) 2021 guidelines. The MTUS guidelines recommend pulmonary physical therapy for COVID-19 patients with pulmonary dysfunction and/or dyspnea, especially when combined with activity reductions or exercise intolerances attributed to the infection’s pulmonary complications. They further recommend that an individualized interdisciplinary treatment regimen be formulated based on a comprehensive baseline assessment, usually comprising exercise sessions one to three times per week for four weeks. Here, the IMR reviewer noted that there was no recent or clear indication of medical necessity for the 30 sessions of pulmonary rehabilitation non-certified by UR because applicant had post-COVID syndrome and already completed at least 28 sessions of pulmonary physical therapy, which the IMR reviewer found was “well above a reasonable duration of standard therapy.” The IMR reviewer believed that it was reasonable to first reassess applicant’s condition after completion of the approved portion of the original request to guide a more informed decision about the medical necessity of further pulmonary therapy sessions. [LexisNexis Commentary: This IMR provides much needed information about the current treatment protocols for COVID-19 and post-COVID syndrome. It is noteworthy that the MTUS guidelines make no specific recommendations regarding the duration or number of pulmonary therapy sessions, yet the IMR reviewer found that the request was “well above a reasonable duration of standard therapy.” Regarding termination of pulmonary therapy, the ACOEM guidelines say only that it should end upon “[c]ompletion of a treatment course, noncompliance,” or “reaching a plateau in recovery” (ACOEM Coronavirus (COVID-19) guidelines, p. 80). Thus, it appears the IMR reviewer went beyond MTUS/ACOEM criteria by determining that the number of pulmonary sessions requested was excessive, without evidentiary basis.]

■ 87 Cal. Comp. Cases 357. Mental Health Disorders—Post-Traumatic Stress/Adjustment Disorder—Simultaneous Exercise and Psychotherapy (STEP) Program—Applicant, 52 years old, sustained an industrial injury on 4/28/2021 and is undergoing treatment for post-traumatic stress disorder (PTSD) and an adjustment disorder with anxiety. He reported that his injury was due to stress related to his employment as a frontline healthcare worker caring for COVID patients in a hospital setting. An examination revealed that applicant was motivated and interested in resolving his psychological difficulties and returning to his job. Upon his return to work, however, applicant had a relapse of symptoms and was placed on restricted duty. Applicant’s treating physician requested twelve STEP therapy sessions, which would involve structured group cognitive behavioral therapy in combination with an aerobic exercise program. UR denied the request, finding that the documentation lacked evidence of a formal diagnosis of applicant’s condition to support the requested therapy. Citing the non-MTUS ODG for group psychotherapy, the IMR reviewer overturned the UR denial of treatment. Although the IMR reviewer noted that the record lacked information regarding whether applicant had participated in individual therapy sessions following a psychological evaluation in 2021, and, if so, whether there was subjective/objective functional and symptomatic improvement in his condition, the reviewer concluded that the request to overturn the UR decision was reasonably satisfied based on the existing record describing applicant’s condition and that treatment is medically necessary and appropriate. [LexisNexis Commentary: This IMR provides an example of a case where the IMR reviewer gave applicant the benefit of the doubt regarding medical necessity, even though the record lacked a formal diagnosis and history of prior therapy. Applicant’s status as a frontline healthcare worker caring for COVID patient was likely considered by the IMR reviewer in deciding to allow the requested therapy sessions.]

ELECTRICAL STIMULATION FOR CHRONIC PAIN

■ 87 Cal. Comp. Cases 463. Electrical Stimulation—H-Wave Device—Lumbar Spine Injury—Applicant, 37 years old, suffered an industrial injury on 4/17/2021 and underwent treatment for a lumbar spine strain. An MRI showed bilateral pars defect at L5 and grade 1-2 spondylolisthesis at L5-S1, with moderately severe bilateral foraminal stenosis. Applicant used an H-Wave device for a 22-day trial, during which time his pain decreased by 40-50 percent, he had increased function and activity, could perform housework, and experienced greater symptom relief than he did with medications, TENS unit and physical therapy. Applicant’s treating physician subsequently requested approval for rental/purchase of an H-Wave for 10-months of use. UR non-certified the request. Citing the 2020 MTUS guidelines for the treatment of low back disorders, and the non-MTUS ODG addressing use of an H-Wave for pain relief, the IMR reviewer overturned the UR decision. The IMR reviewer noted that the MTUS guidelines give no recommendation for or against H-Wave treatment. The ODG, however, states in the pain section that the device is conditionally recommended for pain relief, although not as a first-line therapy or as an isolated intervention. To support use of the H-Wave under the ODG, conservative treatments for chronic pain must prove unsuccessful, including at least two of the following: medication, physical therapy, behavioral therapy, and TENS. In this case, applicant’s one-month trial of the H-Wave resulted in less pain, increased functional improvement, and pain medication reduction. The IMR reviewer found that applicant satisfied all the criteria for provision of an H-Wave, and that a 10-month rental of the device was reasonable and medically necessary. [LexisNexis Commentary: This IMR determination is interesting in that it construes the MTUS provisions of “no recommendation” in favor of, and not against, the extension of benefits. The reviewer appropriately turned to the ODG for guidance, and thoughtfully indicated how all the criteria were met to justify use of the H-Wave.]

HOME HEALTHCARE

■ 87 Cal. Comp. Cases 724. Home Healthcare—Post-Surgery—Applicant, 57 years old, sustained an industrial injury on 2/14/2019 and underwent surgery, including a left heel shift osteotomy and attempted first tarsometatarsal (TMT) joint fusion. Applicant subsequently reported sensitivity at the site of the incision and pain shooting up and down the left leg, with limited range of motion and weakness of the left ankle. Applicant’s treating physician requested approval for a heel and first TMT joint hardware removal with revision of the original TMT fusion and bunion correction. The physician also requested two weeks of home healthcare for four hours per day post-operatively. UR denied the request for home healthcare. Citing the 2017 MTUS/ACOEM guidelines and non-MTUS ODG, the IMR reviewer overturned the UR denial. The IMR reviewer noted that the MTUS/ACOEM guidelines selectively recommend short-term home healthcare following hospitalization for major surgical procedures, and to prevent rehospitalization. Home healthcare also selectively recommended in cases where the patient is unable to leave home without major assistance, for example requiring a wheelchair, walker, or third-party transportation. Here, the IMR reviewer observed, applicant was scheduled to undergo a second left foot surgery including fusion of the tarsometatarsal joint, a procedure that requires non-weightbearing of the surgical foot for many weeks postop. The IMR reviewer felt that following surgery applicant would require major assistance leaving the house and that home healthcare would be beneficial in this respect. The IMR reviewer concluded that applicant’s postsurgical situation met the guideline criteria, and that the request for home healthcare four hours per day for two weeks was medically reasonable and necessary. [LexisNexis Commentary: This IMR concisely explains why applicant needs home health care post-operatively, and how the request for short-term home health care complies with the applicable MTUS/ACOEM guidelines. The case also exemplifies a situation where the claims examiner could have considered overriding the UR non-certification of home health care because the short duration of care was requested in anticipation of a change in circumstances (post-surgical recovery), per Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910 (Appeals Board significant panel decision) and would not be indefinite.]

■ 87 Cal. Comp. Cases 667. Home Healthcare—Traumatic Brain Injury—Applicant, 60 years old, suffered a gunshot wound to the head on 5/2/2013, resulting in a traumatic brain injury. His treating physician requested 3600 hours (equating to 20 hours per day over 180 days) of home healthcare, 480 hours (equating to fewer than three hours per day over 180 days) of which were authorized by UR. The IMR reviewer, overturning the UR decision, found that the 3600 hours of care requested was supported by the applicable 2017 MTUS guidelines, which selectively recommend home healthcare in cases where the injured worker has limited function with respect to ADLs and/or is homebound. To establish medical necessity the request for authorization should include documentation of the medical condition requiring home healthcare, objective functional deficits, specific activities precluded by such deficits, necessity of skilled or unskilled services, and duration and frequency of home healthcare services required. The claims administrator in this case noted that applicant lives with his wife, who could provide some of his care needs. However, the IMR reviewer pointed out that the MTUS guidelines do not specifically require an assessment of family or other support systems to determine how much care is needed nor do they set a specific limit to the amount of home healthcare that can be authorized. The IMR reviewer indicated that the ability of family to provide some of the required care must be assessed by the treating physician in deciding how much home healthcare is requested. The IMR reviewer observed that applicant has hemiplegia with spasticity and is functionally unable to perform most ADLs independently. He has had home health care previously and continues to require 24/7 care per his treating neurologist. The request for 3600 hours of home healthcare was for approximately six months, which the IMR reviewer found to be a reasonable duration based on the severity and chronicity of applicant’s injury. The IMR reviewer concluded that ongoing home healthcare as requested was supported by the guidelines and was medically necessary. [LexisNexis Commentary: This IMR explains how and why 3600 of home healthcare for applicant with a traumatic brain injury following a gunshot wound meets the MTUS criteria for medical necessity. The decision is also illuminating in that it explains that the family of an injured worker is under no obligation to provide home healthcare which would otherwise be the employer’s responsibility. See Henson v. W.C.A.B. (1972) 27 Cal. App. 3d 452, 103 Cal. Rptr. 785, 37 Cal. Comp. Cases 564.]

MENTAL HEALTH DISORDERS

■ 87 Cal. Comp. Cases 367. Mental Health Disorders—Post-Traumatic Stress Disorder/Depression—Intensive Outpatient Program—Applicant, 36 years old, suffered an industrial injury on 11/9/2021 while working as a first responder, resulting in anxiety, major depressive disorder, chronic post-traumatic stress disorder (PTSD), substance abuse disorder, and insomnia. He participated in eight to ten sessions of cognitive behavioral therapy (CBT), cognitive processing therapy, and an employer-assisted PTSD program, with minimal benefit. Applicant’s treating physician requested that applicant see a clinical psychiatrist for immediate evaluation, and, additionally, start an intensive outpatient PTSD rehab program (IOP) for 80 hours, which would be distributed between multiple treatment modalities. UR non-certified the request for the IOP. The IMR reviewer overturned the UR denial, noting that per the MTUS 2018 guidelines for PTSD treatments, CBT is recommended, in conjunction with relaxation therapy and various types of exposure therapy, including mind-body interventions, to achieve stress relief and improve health and functioning. Per the ODG, group therapy is also recommended in PTSD cases. The IMR reviewer reasoned that applicant is a first responder whose symptoms of anxiety, depression, PTSD, distraction, and impaired judgment impede his medical skills. Treatment to date has been only minimally effective, and there is the confounding issue of alcohol abuse. The IMR reviewer found, as did the treating physician, that non-certification prevents applicant from alternative treatments and would inappropriately require him to continue treatments that have not been effective. Additionally, the IMR reviewer noted that the appropriate goal of functional improvement is to allow applicant to return to work, and that the IOP rehab program would further this goal by providing ongoing CBT, group therapy, and psychiatric care, among other things. The IMR reviewer also pointed out that as a first responder, applicant has a great deal of responsibility and often must make critical medical decisions. Based on the documentation submitted, the IMR reviewer found that the IOP was medically necessary and appropriate under the applicable guidelines. [LexisNexis Commentary: The IMR reviewer’s assessment in this case of all the surrounding circumstances to decide what would best achieve the goal of returning applicant to his profession was appropriate and served the purpose of the workers’ compensation system better than an approach that evaluates MTUS criteria without context. Of additional interest, is the IMR reviewer’s consideration of the level of function required to return an injured employee to a particular profession—in this case, a first responder—and the corresponding need to control applicant’s PTSD symptoms without alcohol abuse to return to work.]

■ 87 Cal. Comp. Cases 468. Transcranial Magnetic Stimulation—Treatment-Resistant Major Depressive Disorder—Applicant, 56 years old, suffered an industrial injury on 7/19/2019, and underwent treatment for major recurrent depressive disorder and post-traumatic stress disorder. He was prescribed multiple different anti-depressants and participated in psychotherapy without benefit. Applicant reported continued feelings of depression, anxiety, crying spells, poor appetite, flashbacks, and difficulty sleeping. Testing placed his condition in the severe range for both depression and anxiety, with a high degree of hopelessness and psychomotor slowing. Given the persistence of Applicant’s severe depression, his treating physician requested approval for 30 initial sessions and six taper-off sessions of transcranial magnetic stimulation (TMS), a non-invasive brain stimulation treatment. UR denied the request. The IMR reviewer overturned the UR denial, citing the 2020 MTUS guidelines for the treatment of depressive disorders, which suggest TMS for treatment of numerous neuropsychiatric conditions, including anxiety and suicidal ideation, and is used extensively to combat treatment-resistant depression. The IMR reviewer noted that applicant in this case has persistent symptoms of anxiety and depression, and has tried and failed Zoloft, Prozac, Elavil, and Cymbalta, representing four antidepressants from three different classes, for adequate durations and doses, thereby meeting the MTUS criteria for approval of TMS. [LexisNexis Commentary: This IMR, approving transcranial magnetic stimulation for applicant’s treatment-resistant severe depression, addresses medical treatment with which the legal community may be unfamiliar, and provides guidance regarding the MTUS criteria that must be met for approval of the treatment.]

OPIOID MEDICATION FOR CHRONIC PAIN

■ 87 Cal. Comp. Cases 573. Opioid Medication—Oxycodone—Chronic Pain—Applicant, 49 years old, suffered an industrial injury on 2/9/2001. He underwent treatment for lumbar radiculopathy, neck sprain, chronic pain syndrome, post-laminectomy syndrome, thoracic radiculopathy, and gait abnormalities, and was off work. Applicant’s treating physician requested Oxycodone 10mg #90 (down from his previous dosage of Oxycodone #125) but did not suggest an opioid weaning plan. UR modified the original request, and authorized Oxycodone 10mg #90 for weaning purposes. The IMR reviewer upheld the UR modification based on the 2017 MTUS opioids guidelines, noting that the documentation submitted did not indicate the achievement of pain treatment SMART (Specific, Measurable, Achievable, Realistic, and Time-based) goals, and that there was no weaning plan provided as recommended by the guidelines. While there was some indication of functional improvement in applicant’s recreational ADLs with opioid use, the IMR reviewer concluded that the non-SMART goal documentation of improvement was not specific enough to meet guideline requirements and did not warrant authorization of the additional pills. Because the requested treatment did not meet the MTUS guideline criteria, and the treating physician did not provide basis for deviation from the guidelines, the IMR reviewer found that the additional Oxycodone pills were not medically necessary. The IMR reviewer advised the treating physician and applicant to consult the 2017 MTUS guidelines and any other relevant guidelines addressing the discontinuation and tapering of opioids most appropriate to wean applicant from Oxycodone. [LexisNexis Commentary: The IMR reviewer in this case did a good job of explaining the MTUS criteria and why the treating physician failed to satisfy the criteria by sufficiently documenting applicant’s recent improvement and showing how it outweighed the potential harms of opioid use. As indicated by the IMR reviewer’s comments on weaning, it is important for applicant’s well-being that the parties in this matter comply with the instructions to wean or taper the Oxycodone, and that the treating physician request an appropriate weaning plan.]

STEROID INJECTION FOR CHRONIC PAIN

■ 87 Cal. Comp. Cases 568. Caudal Epidural Steroid Injection—Chronic Pain—Applicant, 61 years old, suffered an industrial injury on 7/27/2009. She underwent treatment for post-laminectomy syndrome with low back-left leg regional sympathetic dystrophy symptoms and lower extremity chronic regional pain syndrome (CRPS), among other complaints, and is not working. Applicant had previously undergone a caudal epidural objection, and her treating physician requested approval for a repeat epidural injection under fluoroscopy. The request was denied by UR based on the non-MTUS ODG for the treatment of low back conditions, without citation to the MTUS guidelines. The IMR reviewer upheld the UR denial based on the 2019 MTUS guidelines for low back disorders, which incorporate guidelines for epidural steroid injections, and on the non-MTUS ODG for low back conditions. The MTUS guidelines do not recommend epidural injections for chronic conditions. To support repeat injections, the ODG requires documentation that previous blocks produce a minimum of 50-70 percent pain relief and improved function for at least 6-8 weeks. Here, the IMR reviewer noted, applicant had multiple complaints, including lower extremity pain, but the source of her lower extremity pain was unclear. The IMR reviewer further observed that there was no documentation indicating that applicant’s prior caudal epidural injection provided the minimum pain relief and improved function necessary to support a repeat injection under the ODG. The IMR reviewer found that there was no compelling rationale or extenuating circumstances to support the medical necessity of the treatment request as an exception to the guidelines. Therefore, the IMR reviewer found that the request was not medically necessary. [LexisNexis Commentary: This IMR decision provides an example of a situation in which the IMR reviewer relied largely on the non-MTUS ODG to deny applicant’s request for a caudal epidural injection, even though the MTUS clearly addresses epidural steroid injections. Unless the ODG recommendations are being used to rebut the MTUS/ACOEM guidelines, reliance on the ODG appears to be a misapplication of the medical evidence search sequence requirements outlined in 8 Cal. Code Reg. § 9792.21.1(a)(2). This could potentially render the IMR appealable per Labor Code § 4616.6(h)(1), as being in excess of the AD’s powers under the current regulations.]

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