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CALIFORNIA COMPENSATION CASES
Vol. 88, No. 11 November 2023
A Report of En Banc and Significant Panel Decisions of the WCAB and Selected Court Opinions of Related Interest, With a Digest of WCAB Decisions...
By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Workers’ Compensation Appeals Board
Nearly two decades ago Senate Bill 899 was enacted and ushered in a...
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...
By Hon. Susan V. Hamilton, Former Assistant Secretary and Deputy Commissioner, California Workers’ Compensation Appeals Board
Early in the COVID-19 pandemic we learned that nursing care facilities...
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, various medications used to treat psychiatric disorders, the use of opioid medication with proper monitoring, and different scenarios under which temporary housing/assisted living may be approved.
■ 88 Cal. Comp. Cases 1022. Antipsychotics/Antidepressants—Latuda and Zoloft—Traumatic Brain Injury—Applicant, 50 years old, suffered a work-related traumatic brain injury (TBI) on 1/4/2017, and underwent treatment for symptoms including severe depression, psychotic episodes, change in personality, PTSD, generalized anxiety disorder, occipital pain, and multiple fractures. He experienced severe cognitive symptoms, auditory and visual hallucinations, and ongoing nightmares, and remained off work. On 6/16/2022, applicant reported symptoms of depression, feelings of unhappiness, and becoming easily argumentative, irritable, frustrated, anxious, and agitated, with problems sleeping at night. Lexapro was discontinued, Zoloft 50mg was started, and Latuda was increased to 40mg. On 07/08/2022, applicant’s treating physician requested authorization for Latuda 40mg #30 with 2 refills (increase dose), and Zoloft 50mg #30 with 2 refills. UR non-certified both requests. With respect to the Latuda, the IMR reviewer overturned the UR denial based on the MTUS TBI 2018 guidelines, which selectively recommend antipsychotics such as Latuda in TBI patients with agitation from mood disorders. The IMR reviewer noted that applicant continued to experience depression with irritability and becomes easily frustrated. According to the IMR reviewer, Latuda was an appropriate choice for mood instability, and a dose increase was indicated where the prior dose of 20mg was not adequately treating applicant’s symptoms. The IMR reviewer concluded that the request for Latuda 40mg #30 with 2 refills (increase dose) was medically necessary and appropriate. Regarding Zoloft, the IMR reviewer overturned the UR non-certification based on the MTUS 2020 guidelines for depressive disorders, which recommend SSRIs such as Zoloft for use in both depression and anxiety. Here, the IMR reviewer noted, the provider switched applicant to Zoloft due to insufficient efficacy of Lexapro. The IMR reviewer concluded that this type of medication switch is appropriate when a medication is not working adequately. Refills are appropriate as well to prevent a lapse in treatment and to allow for upwards titration should that be necessary. Under these circumstances, the IMR reviewer concluded that the request for Zoloft 50mg #30 with 2 refills was medically necessary and appropriate. [LexisNexis Commentary: Traumatic brain injury cases appear to be on the rise post-COVID, and this IMR decision overturning the UR denial of Latuda and Lexapro provides guidance regarding how to treat this type of injury. Note, both medications approved by the IMR reviewer, Latuda and Zoloft, are exempt drugs on the MTUS Formulary.]
■ 88 Cal. Comp. Cases 1018. Antipsychotics/Antidepressants—Vraylar—Applicant, 52 years old, suffered an industrial orthopedic injury on 9/4/2008 and was being treated for back pain in addition to various psychiatric symptoms, including depression, anxiety disorder, and adjustment disorder. He had been prescribed Vraylar since at least 4/2021. The medication was discontinued but restarted after applicant reported increased mood swings and depression, leading to hospitalization for depression with suicidal ideation. On 08/26/2021, it was noted that applicant’s depression continued, and he was experiencing auditory hallucinations. Vraylar was increased to 4.5mg at night, which resulted in improvement of applicant’s symptoms. On 1/20/2022, applicant’s treating physician requested authorization for Vraylar 4.5mg #30. UR non-certified the request. The IMR reviewer overturned the UR non-certification, noting that the MTUS guidelines and ODG are silent regarding the usage of Vraylar. The IMR reviewer thus consulted Drugs.com, which indicates that Vraylar is an atypical antipsychotic indicated for treatment of schizophrenia, manic or mixed episodes associated with bipolar I disorder, or depressive episodes associated with bipolar I disorder. The IMR reviewer acknowledged that applicant did not suffer from schizophrenia or bipolar disorder, and that no mood swings were documented in the progress notes. However, the IMR reviewer observed that applicant did report hallucinations, which caused his doctor to increase the dosage of Vraylar. After the dosage was increased, applicant’s symptoms improved. According to the IMR reviewer, the fact that the Vraylar lead to an improvement in symptoms supported its efficacy and its medical necessity. [LexisNexis Commentary: Although applicant did not specifically suffer from any of the psychiatric conditions for which Vraylar is typically used, the IMR reviewer relied on the fact that the medication was effective in reducing applicant’s psychiatric symptoms to support its medical necessity. Note, The IMR reviewer’s path to authorization may be of interest to the community because Vraylar is relatively expensive (about $1,500 for the 30 capsules prescribed here) and is probably not available in generic form.]
■ 88 Cal. Comp. Cases 95. Chiropractic Treatment—Spine and Shoulder Injuries—Applicant, 59 years old, suffered an industrial injury in a motor vehicle accident on 6/8/2021 and underwent treatment, including physical therapy and vestibular therapy, for cervical and lumbar radiculopathy, neck pain, and bilateral shoulder joint pain. He also participated in an initial course of 18 chiropractic sessions, which he reported improved his condition in that he could stand up straighter, stay seated in a car for a longer period and experienced reduced pain with ADLs. Applicant’s treating physician requested approval for an additional six sessions of chiropractic treatment for the cervical spine, lumbar spine and shoulders. UR denied the request. Relying on the MTUS 2016 guidelines for shoulder disorders, the MTUS 2020 guidelines for low back disorders, and the MTUS 2019 guidelines for cervical and thoracic spine disorders, the IMR reviewer overturned the UR decision and found that the six additional chiropractic sessions were medically necessary. The applicable MTUS guidelines recommend additional chiropractic sessions to relieve chronic pain or exacerbations of pain if the initial course of treatment results in substantial functional improvement. They further recommend periodic reassessments of the treatment’s efficacy. In this case, the IMR reviewer noted that applicant reported functional improvement after his initial course of chiropractic treatment, as described in the medical reports, and was able to return to modified work. Given the improvement noted following the initial course of care and the residual complaints, the IMR reviewer concluded that the requested six additional chiropractic treatments were medically justified. [LexisNexis Commentary: This IMR decision is a useful reminder that the standard for additional chiropractic treatment after an initial course is functional improvement. Despite applicant’s reports of functional improvement after his initial chiropractic treatment, the UR reviewer non-certified the additional sessions. However, the IMR reviewer concluded that the functional improvement reported by applicant supported the medical necessity of additional chiropractic sessions.]
■ 88 Cal. Comp. Cases 87. Chiropractic Treatment—Spine and Shoulder Injuries—Applicant, 66 years old, suffered an industrial injury on 9/13/2017 and was diagnosed with a cervical sprain, left shoulder sprain, and lumbar sprain. In 2022, applicant was evaluated by an orthopedist for complaints of increased neck, lower back, and shoulder pain at a level of 8/10. An examination revealed tenderness to palpation in the cervical and lumbar paraspinal muscles and left trapezius. There was also a decreased range of motion in the lumbar spine. A home exercise program was initiated, and the applicant’s physician sought approval for four weeks of chiropractic treatment, twice per week. UR non-certified the requested chiropractic treatment based on the MTUS 2017 chronic pain guidelines. Relying on the MTUS 2016 guidelines for shoulder disorders, the MTUS 2020 guidelines for low back disorders, and the MTUS 2019 guidelines for cervical spine and thoracic spine disorders, the IMR reviewer overturned the UR decision and found that the requested chiropractic treatment was medically necessary. The IMR reviewer noted that the applicable MTUS guidelines recommend an initial course of up to 12 chiropractic sessions for chronic or acute cervical and thoracic spine symptoms and up to six sessions for lumbar spine symptoms, with additional sessions considered based on functional improvement during the initial course of treatment. The IMR reviewer further observed that the basis for UR’s denial of chiropractic treatment in applicant’s case was lack of evidence that applicant had a deficit that would improve with chiropractic treatment as opposed to a home exercise program. However, as recognized by the IMR reviewer, applicant was participating in a home exercise program but still experienced pain and functional limitation. Thus, the IMR reviewer concluded that an initial course of chiropractic treatment twice per week for four weeks was medically justified based on the applicable guideline criteria. [LexisNexis Commentary: This IMR decision shows that UR’s faulty rationale for denying treatment may result in the UR decision being overturned. Here, UR denied chiropractic treatment on the basis that applicant would get the same results from a home exercise program. However, the documentation showed that applicant was engaged in a home exercise program that was not improving his symptoms. Consequently, the IMR reviewer found that eight sessions of chiropractic treatment were warranted.]
COVID-19-RELATED PSYCHOLOGICAL ASSESSMENTS
■ 88 Cal. Comp. Cases 203. Psychological Assessments—COVID-19—Cognitive Deficits—Applicant, 38 years old, suffered an industrial injury in the form of COVID-19 on 1/10/2021. She underwent treatment for memory deficit related to COVID-19, and per a 3/23/2022 progress report was not working. Applicant’s treating physician requested five appointments for neurological assessment, which were denied by UR based on the MTUS 2021 Covid-19 guidelines. The IMR reviewer noted that the COVID-19 guidelines recommend cognitive screening and rehabilitation for patients with evidence of ongoing cognitive problems attributed to the infection. Additionally, the guidelines recommend sets of appointments (for example, 6-8) and testing to determine the areas of deficits, followed by rehabilitation that targets, measures, and tracks progress for those specific areas. The IMR reviewer in this matter found that while a neurological assessment of applicant was reasonable given the subjective reports of memory deficits, the request for five sessions was excessive because the memory deficits were yet identified. Accordingly, the IMR reviewer upheld the UR non-certification, concluding that medical necessity for the treatment request was not established. [LexisNexis Commentary: IMRs such as this, involving work-related COVID-19, are of ongoing interest to the community. Note, however, the IMR reviewer’s determination in this case appears to be based on a plainly erroneous finding of fact because the MTUS guidelines clearly support neuropsychological assessments, including sets of appointments (e.g., 6-8), as was requested in this case. Further, the reviewer’s own finding that a neuropsychological assessment was reasonable in applicant’s case es inconsistent with the reviewer’s ultimate denial of all the requested assessments. At least one assessment should have been recommended. Arguably, this IMR determination could be successfully appealed under Labor Code § 4610.6(h)(5).]
■ 88 Cal. Comp. Cases 191. Diagnostic Tests—CT Scans—Lumbar Spine—Applicant, 58 years old, suffered an industrial injury on 2/11/2020, and was being treated for orthopedic symptoms following lumbar spine surgery on 3/18/2021. X-rays of the lumbar spine dated 07/21/2021 and a 3/2/2022 lumbar MRI showed loss of disc space height, borderline hypertrophy, and moderately severe central canal stenosis at the L4-L5 levels. In a 2/16/2022 progress report, applicant reported an unchanged pain level rated at 8/10. The physical examination revealed a limited range of lumbar spine motion, with radiculopathy and diminished sensation to the right leg. Applicant’s treating physician requested authorization for a CT scan of the lumbar spine to rule out hypertrophic bone formation as a cause of applicant’s severe stenosis. UR denied the request. The IMR reviewer overturned the UR denial based on the MTUS 2020 guidelines for low back disorders, which support CT scans in tandem with CT myelography if surgery is being strongly considered. The IMR reviewer noted that the prior MRI showed stenosis but it was not clear if this was from soft disk herniation or heterotopic bone formation. Given that revision surgery was being considered by applicant’s physician, the IMR reviewer concluded that the lumbar CT was medically necessary and supported by the MTUS guidelines. [LexisNexis Commentary: The IMR reviewer in this case found that a CT scan was supported based on the fact that applicant’s physician was considering further lumbar surgery and needed to clarify applicant’s diagnosis before performing the surgery. Although the MTUS guidelines recommend CT scans in conjunction with CT myelography in such cases, the IMR reviewer thoroughly evaluated applicant’s request and found that the CT scan was medically necessary.]
■ 88 Cal. Comp. Cases 195. Diagnostic Tests—MRIs—Wrists—Applicant, 67 years old, sustained an industrial injury on 9/22/2017 and was undergoing treatment for shoulder and wrist symptoms. Per a 1/26/2022 progress report, applicant was temporarily partially disabled from working during the period 1/26/2022 to 3/9/2022. Applicant reported constant aching, burning, stabbing, and cramping pain in the right hand/wrist, constant radiating pain in the right hand, and constant numbness, tingling, stiffness, clicking, weakness, and muscle spasms in the right wrist. Applicant also demonstrated decreased range of motion in the shoulders and wrists and decreased grip strength. Applicant’s treating physician requested authorization for an MRI of the right wrist/hand, which UR denied. The IMR reviewer noted that the MTUS does not directly address wrist/hand MRIs and, therefore, relied upon the non-MTUS ODG guidelines for MRIs of the forearm, wrist and hand in overturning the UR non-certification. The ODG guidelines advocate MRI for chronic wrist pain based on its global diagnostic utility. In this case, the IMR reviewer determined that an MRI was warranted to evaluate soft tissue pathology and correlate MRI findings with findings on physical examination. Based on applicant’s symptoms and physical examination, the IMR reviewer concluded that the request for an MRI of the right wrist/hand was medically necessary and supported by the ODG. [LexisNexis Commentary: The IMR reviewer in this case recognized that an MRI was necessary to make a proper diagnosis of applicant’s condition. The IMR decision provides a good example of how treatment not addressed by MTUS/ACOEM (or perhaps not addressed exactly on point with a given case) may be addressed by resort to ODG under the Medical Evidence Search Sequence set forth in 8 Cal. Code Reg § 9792.21.1.]
DURABLE MEDICAL EQUIPMENT
■ 88 Cal. Comp. Cases 322. Durable Medical Equipment—Power Wheelchair Car Lift—Applicant, 42 years old, sustained an industrial injury on 1/30/2019, and was temporarily totally disabled. He was being treated for a spinal cord injury, paraplegia and traumatic brain injury which resulted in significant physical and cognitive impairment. Applicant, who experienced ongoing shoulder, hip, groin, knee, and spine pain, had received prior authorization for a power wheelchair. Motor testing revealed decreased strength in applicant’s upper and lower extremities. The treatment plan included a rehabilitation program five days per week, continuation of medication and consultations with multiple medical specialists. Applicant’s treating physician submitted an RFA dated 5/18/2022 for a power wheelchair car lift, which UR denied. The IMR reviewer noted that neither the MTUS nor non-MTUS ODG address power wheelchair car lifts specifically, although the ODG discusses durable medical equipment (DME) in general and recommends DME if there is a medical need and if the device meets Medicare’s definition of DME. DME is defined as equipment that (1) can withstand repeated use (i.e., could normally be rented and used by successive patients); (2) is primarily and customarily used to serve a medical purpose; (3) is generally not useful to a person in the absence of illness or injury; and (4) is appropriate for use in a patient's home. Applying this definition, the IMR reviewer overturned the UR non-certification, concluding that the power wheelchair car lift to help facilitate applicant’s transportation with the authorized power wheelchair was medically necessary. [LexisNexis Commentary: The IMR reviewer’s explanation for finding the DME medically necessary is succinct and helpful. Given applicant’s need to travel five or more days per week to rehabilitation and various medical appointments, defendant likely must provide the power lift and a modified vehicle, provide medical transportation with a company that uses this kind of lift, or provide access to an inpatient or outpatient program for applicant. The power lift is probably the least expensive of these options.]
■ 88 Cal. Comp. Cases 83. Opioid Medication—Oxycodone—Chronic Pain—Applicant, 57 years old, suffered an industrial back injury on 6/7/2007, and subsequently underwent surgery, diagnostic testing, injections, and physical therapy. He was also prescribed medications, including Oxycodone acetaminophen. An examination and follow-up of the lumbar spine in 2021 revealed tenderness to the paraspinal muscles and 50 percent limited range of motion. Applicant reported low back pain rated at 4/10. The treating physician requested authorization for Oxycodone acetaminophen 10/325mg #30, which UR denied. The IMR reviewer overturned the UR denial based on the MTUS 2017 opioid guidelines, which recommend opioid medication in disorders such as CRPS, severe radiculopathy and advanced degenerative joint disease. Additionally, the MTUS indicates that opioid therapy is recommended when first-line functional restorative pain therapies provide inadequate improvement in function. Continuation of opioids, with monitoring and drug testing, is appropriate if there is at least 30 percent improvement in pain and function. The IMR reviewer noted that applicant here was able to work with the use of Oxycodone, which demonstrated significant functional improvement. Further, the IMR reviewer pointed out, the treating physician addressed medication compliance, indicating that applicant signed an opioid treatment agreement, completed a risk assessment, and underwent a drug screen which was positive for Oxycodone and THC. A urine drug test was requested to assess for abuse and guide future prescriptions. Given appropriate documentation, the IMR reviewer concluded that the requested treatment complied with the guidelines and was medically necessary. [LexisNexis Commentary: This IMR decision serves as an important reminder that opioids, while potentially dangerous, can, with appropriate monitoring, play a useful role in the management of chronic pain. The applicant in this case was able to return to work with the use of opioid medication, which demonstrated to the IMR reviewer that there was significant functional improvement. Further, the treating physician adequately addressed opioid compliance.]
■ 88 Cal. Comp. Cases 91. Opioid Medication—Oxycodone—Chronic Pain—Applicant, 53 years old, suffered an industrial back injury on 5/8/2018 and was on modified work. In a 9/8/2022 ER report applicant reported a flareup of back pain, and an examination revealed tenderness of the right lower lumbar region and a negative straight leg raise bilaterally. Applicant’s treating physician requested authorization for Oxycodone 5mg #8, which was denied by UR. The IMR reviewer overturned the UR denial based on the MTUS 2017 opioid guidelines. The guidelines recommend short-term use of opioids at the lowest effective dose if first-line chronic pain treatments fail. Here, the IMR reviewer observed, applicant tried NSAIDs and gabapentin in the past with no benefit. His doctor recommended discontinuation of acetaminophen due to “liver toxicity.” The IMR reviewer determined that based on the failure/contraindication of first-line medications, the amount of opioid medication prescribed was appropriate for a short-term flare. Thus, the IMR reviewer concluded that the request for Oxycodone 5mg #8 was medically necessary but noted that any longer term use of the medication would require full assessment by the treating doctor, including utilization of CURES and urine drug screening. [LexisNexis Commentary: The IMR reviewer overturned the UR non-certification of Oxycodone because the prescription was for a short-term flareup and allowed applicant to continue working. The fact that the prescription was for short-term use, mitigated the typical concerns regarding long-term opioid usage and abuse.]
■ 88 Cal. Comp. Cases 331. Assisted Living Facility—Traumatic Brain Injury—Applicant, 64 years old, sustained work-related traumatic brain and spinal cord injuries on 9/12/2018, and lived on-and-off in assisted/transitional living facilities due to his impairments, which included spasticity, muscle spasms, chronic pain syndrome, and psychological factors. Applicant required a wheelchair for ambulation. In a 6/20/2022 discharge summary from a transitional living center, applicant reported continued weakness in the left lower extremity and feeling as though the leg would not support his weight with standing. Applicant was, at his own expense, living in a hotel with nursing assistance and paying out of pocket for medication. He was subsequently re-admitted to transitional living secondary to an unsafe living situation. On 9/26/2022, applicant’s treating physician requested authorization for continued assisted living for a period of three months due to applicant’s cognitive and physical deficits. UR denied the request. The IMR reviewer overturned the UR denial based on the MTUS 2018 traumatic brain injury (TBI) guidelines, which selectively recommend outpatient home and community-based rehabilitation for TBI patients who continue to experience symptoms requiring ongoing medical treatment, physical therapy, occupational therapy, or other types of intervention. The documentation submitted indicated that applicant lacked awareness of how to move his body and required modified assistance for stretching secondary to tone and spasticity problems. His outside activities were limited based on use of a manual wheelchair and the fear of falling. Applicant also required supervision for rolling and sitting and assistance with upper extremity support on elevated surfaces, stretching and mobility activities. The IMR reviewer noted symptoms and physical findings severe enough to necessitate ongoing medical treatment, physical therapy and occupational therapy. Based on the severity of applicant’s functional impairments, the IMR reviewer found that the request for three months of continued assisted living was medically necessary. [LexisNexis Commentary: This IMR decision is well-reasoned and concisely explains why applicant needed assisted living at the time of the request. Note, under the rationale in Patterson v. The Oaks Farm (2014) 79 Cal. Comp. Cases 910 (Appeals Board significant panel decision), it would be unnecessary for the assisted living facility to submit a second RFA to continue such care absent a change in applicant’s circumstances, which defendant would have the burden of proving.]
■ 88 Cal. Comp. Cases 335. Post-Operative Temporary Housing—Homelessness—Applicant, 72 years old, sustained an industrial injury on 5/24/2019 and was scheduled to undergo right shoulder surgery. The surgery was initially delayed for a number of reasons, including the fact that applicant was homeless and there was difficulty securing him post-operative temporary housing. Apparently, the provider received verbal authorization for temporary housing, but needed to determine a surgical date to obtain formal authorization from defendant. Applicant was eventually approved to undergo right shoulder arthroscopy, and his treating physician submitted an RFA dated 10/14/2022 for eight weeks of post-operative temporary housing. UR non-certified the request. The IMR reviewer noted that neither the MTUS guidelines nor the non-MTUS ODG address the issue. However, the IMR reviewer overturned the UR denial based on a peer-reviewed study involving use of outpatient surgical care services by homeless patients, which indicated that current outpatient services may not meet the surgical care needs of homeless patients. Consequently, alternative approaches to outpatient care must be considered, particularly among high-need services such as orthopedics, to support surgical care access among the homeless population. The IMR reviewer reasoned that applicant in this case was approved for shoulder surgery and eight weeks of temporary housing following surgery due to applicant’s homelessness was medically necessary. [LexisNexis Commentary: This IMR decision addresses an issue that does not frequently arise—whether to provide temporary housing to a homeless applicant post-operatively. Neither the MTUS guidelines nor ODG address the issue, so the IMR reviewer relied on a peer-reviewed study consistent with the medical evidence search sequence under 8 Cal. Code Reg. § 9792.21.1(a)(2)(C), to find that temporary housing was medically necessary to facilitate applicant’s successful recuperation from shoulder surgery. This approach may also be beneficial to defendants who wish to avoid failed surgeries that may be compensable without apportionment per Hikida v. W.C.A.B. (2017) 12 Cal. App. 5th 1249, 219 Cal. Rptr. 3d 654, 82 Cal. Comp. Cases 679.]
■ 88 Cal. Comp. Cases 318. Post-Operative Temporary Housing—Applicant, 30 years old, suffered an industrial injury on 3/1/2021, and was undergoing treatment for a left tibia fracture. As of 5/23/2022, applicant reported doing well following removal of hardware from his tibia and left ankle surgery but was residing in a hotel due to an inability to use the stairs in his apartment. The post-operative treatment plan included, among other things, two months (60 days) of hotel accommodations from the time of surgery. UR non-certified the hotel request. The IMR reviewer noted that the MTUS and ACOEM are silent on the issue of post-operative hotel accommodations and also regarding inpatient rehabilitation facilities. Therefore, the IMR reviewer relied on the ODG guidelines for inpatient rehabilitation facilities in cases of knee/leg conditions. The ODG recommends admission to a skilled nursing facility or an inpatient rehabilitation facility after post-surgery discharge from the hospital if documentation shows inadequacy of less expensive therapy settings, two or more medically active conditions, and the necessity of three or more medical interventions. Here, the IMR reviewer pointed out, applicant had ongoing complaints of pain in the left ankle following surgery. The physical examination revealed a healing incision of the left ankle with mild to moderate swelling and limited range of motion. According to the IMR reviewer, this documentation sufficiently established significant disability preventing applicant from returning to his home with stairs. The IMR reviewer concluded that post-operative hotel accommodations with elevator access was a reasonable alternative to inpatient rehabilitation, and that it was medically necessary based on the guideline criteria. [LexisNexis Commentary: The IMR reviewer in this case did a good job of analogizing the much more costly in-patient rehabilitation facility recommended in the ODG, to authorize a hotel room with an elevator for applicant who was unable to climb stairs following surgery. Because the MTUS and ACOEM are silent on this issue, the reviewer utilized the most current version of the ODG, consistent with the medical search sequence in 8 Cal. Code Reg. § 9792.21.1(a)(2)(A), to find that using an in-patient rehabilitation facility after surgery was the recommendation most applicable to applicant’s medical condition, and the reviewer chose this recommendation as the one that was supported with the best available evidence.]
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