California: Noteworthy Independent Medical Review (IMR) Decisions (August 2020) (Part One)

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.

EPIDURAL STEROID INJECTIONS

■ 85 Cal. Comp. Cases 434. Lumbar Epidural Steroid Injection—Chronic Low Back Pain—IMR reviewer overturned UR decision denying treating physician’s request for lumbar epidural steroid injection at L4-5 with fluoroscopy, and post-injection follow-up visit with a neurologist. Although the MTUS does not specifically address chronic pain, the ODG guidelines recommend epidural steroid injections for patients with subjective and objective findings consistent with radiculopathy to help reduce pain and avoid surgery. In this case, 58-year old applicant suffered an industrial back injury in 2018 and subsequently developed moderate to severe thoracic/lumbar spine pain with numbness and tingling in her lower extremities and difficulty with ADLs. Objective findings were evident from imagining, and conservative treatments did not relieve applicant’s symptoms. Therefore, the IMR reviewer concluded that there was sufficient evidence to support the requested injection and a follow-up to document its outcome, as medically necessary and appropriate treatment.

LexisNexis Commentary: The IMR reviewer in this case found that applicant had sufficient objective findings and pain to support the request for an epidural injection.

HOME HEALTH CARE

■ 85 Cal. Comp. Cases 357. Home Health Care—Visiting Nurse for Safety Checks and Home Assistance—IMR reviewer upheld UR decision denying treating physician’s request for a visiting nurse to perform safety checks and provide 60-year old applicant with home assistance following a 2017 industrial injury. Citing the MTUS 2017 guidelines for initial approaches to treatment, the IMR reviewer noted that home health care is recommended on a short-term basis following hospitalization and major surgical procedures, to prevent re-hospitalization, to overcome deficits in ADLs, and to provide nursing, therapy and/or supportive care services for those who would otherwise require inpatient care. To support home care, the guidelines require that the patient be homebound either due to limitations or contraindications in leaving home. Here, the documentation indicated that applicant had pain in his neck, right upper extremity, low back, and left knee. Right shoulder surgery was requested, but not yet approved. Further, the documentation indicated that applicant could walk without assistance. The IMR reviewer concluded that the criteria for the recommended home care was not supported by the documents submitted, as there was no information indicating that applicant would require assistance following shoulder surgery, no showing as to why applicant would be homebound or restricted to home, and no clinical reason that would necessitate a “safety check” for a patient receiving shoulder surgery who could ambulate without issues. Finally, the provider requested non-specific services with no associated frequency or length of services, as required under the applicable guidelines. As such, the IMR reviewer determined that the request was not medically necessary. LexisNexis Commentary: This IMR decision represents a situation where the RFA and documentation submitted by the provider to support a request for home care/nursing assistance was insufficient. The decision illustrates the need for specificity in the information provided to UR and describes the type of information and documentation that should be submitted.

HOUSE CLEANING SERVICES

■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-09012019/CM19-0119912.PDF. House Cleaning Services—IMR reviewer upheld UR decision denying treating physician’s request for house cleaning services 8 hours per week for 3 months for 70-year old applicant following cervical fusion related to 5/25/2017 industrial injury. According to the IMR reviewer, the MTUS chronic pain guidelines do not specifically address house cleaning services. However, the IMR reviewer noted that the 2017 MTUS treatment guidelines for home health care selectively recommend home health care on a short-term basis following hospitalization and major surgical procedures for those patients who are homebound without access to necessary assistance. In this case, the treating physician did not provide documentation indicating that applicant was homebound or had inadequate necessary assistance and, therefore, the IMR reviewer concluded that the guideline criteria to support house cleaning services were not met, and the services were not medically necessary.

LexisNexis Commentary: The IMR reviewer in this case regarded house cleaning services as a form of home health care and denied the request for house cleaning services based on the sole criterion that there was insufficient documentation that applicant was homebound. This IMR illustrates the importance that treating physicians provide sufficient documentation to justify the requested services.

MEDICAL MARIJUANA

■ 85 Cal. Comp. Cases 527. Medical Marijuana—Cannabinoids—Dronabinol—IMR expert upheld UR decision denying provider’s request for Dronabinol 2.5mg #90 for treatment of 65-year old applicant’s chronic neck pain following 2005 industrial injury. Although the treating physician indicated that the Dronabinol prescription may be useful in limiting applicant’s reliance on opiates, the IMR reviewer concluded that the ODG guidelines do not support use of cannabis for chronic pain. The reviewer acknowledged that 23 states had legalized marijuana as of 2014 but explained that there are no quality studies to support cannabinoid use, and there are serious risks associated using the drug. Further, the IMR reviewer noted that most states do not require insurers, including workers’ compensation carriers, to provide reimbursement for medical marijuana. Given the lack of guideline support for cannabinoid use, the IMR reviewer found that the request for Dronabinol was not medically necessary.

LexisNexis Commentary: The IMR reviewer in this case provided a detailed explanation for why the UR denial of a cannabis drug was upheld. The reviewer pointed out that use of cannabis for pain is not supported by studies and is risky. Further, marijuana use is still illegal under federal law, and insurers generally are not required to pay for the drug.

MULTIDISCIPLINARY PAIN REHABILITATION PROGRAMS

■ 85 Cal. Comp. Cases 451. Multidisciplinary Pain Rehabilitation Program—Burn Injury and Neuropathic Pain—IMR reviewer overturned UR denial of treating physician’s request for a one-time multidisciplinary evaluation to evaluate and determine applicant’s candidacy for a functional restoration program (FRP). Under the MTUS guidelines cited by the IMR reviewer, FRPs, including multidisciplinary rehabilitation programs, are recommended for patients with chronic pain who have not responded well to conventional treatments and who remain significantly incapacitated. However, prior to beginning a tertiary pain program, a patient must complete a thorough evaluation which should include a record review and assessment by program personnel including a pain physician, a medical history and physical, a comprehensive evaluation by a psychologist, and an evaluation by a physical and/or occupational therapist. In order to qualify for these type of rehabilitation programs, patients must meet the following criteria: (1) be off work or on modified duty for at least 3 months, with slow recovery, (2) have substantial ability to benefit from the program, (3) fail to respond to cheaper treatment, (4) have at least some behavioral or psychosocial issues affecting recovery, (5) have no contra-indications to the treatment program, and (6) be committed to recovery. The IMR reviewer noted that the ODG guidelines also recommend FRPs (which emphasize the importance of function over the elimination of pain) and incorporate components of exercise progression with disability management and psychosocial intervention, for patients with chronic disabling pain. In this case, the treating physician sufficiently documented physical examination findings, failure of conservative therapy and ongoing subjective complaints to provide a rationale and support a finding of medical necessity for this treatment request.

LexisNexis Commentary: The IMR reviewer in this case did an excellent job of explaining the request for a one-time evaluation of applicant’s candidacy for a multidisciplinary pain rehabilitation meets the MTUS and ODG guideline criteria. Also, the IMR reviewer noted that the treating physician thoroughly documented his or her findings and the aspects of applicant’s condition that supported the treatment request, which is key to getting treatment approved.

■ 85 Cal. Comp. Cases 446. Multidisciplinary Pain Rehabilitation Program—Chronic Pain and Head Injury—IMR reviewer overturned UR denial of treating physician’s request for 80 hours of a multidisciplinary pain rehabilitation program, citing the MTUS chronic pain 2017 guidelines for rehabilitation and the ODG chronic pain guidelines applicable to functional restoration programs (FRPs). Under the MTUS guidelines, FRPs, including multidisciplinary rehabilitation programs, are recommended for patients with chronic pain who have not responded well to conventional treatments. In order to qualify for these type of rehabilitation programs, patients must meet the following criteria: (1) be off work or on modified duty for at least 3 months, with slow recovery, (2) have substantial ability to benefit from the program, (3) fail to respond to cheaper treatment, (4) have at least some behavioral or psychosocial issues affecting recovery, (5) have no contra-indications to the treatment program, and (6) be committed to recovery. ODG guidelines limit treatment in such programs to 2 weeks unless there is demonstrated objective and subjective evidence of improvement. Additionally, treatment duration beyond 20 sessions requires a clear rationale for the specified extension and reasonable goals to be achieved. The medical documentation provided in this case showed that 42-year old applicant is currently undergoing treatment for lumbar spine ligament sprain, chronic pain syndrome, a chest contusion, a head injury with post-concussive syndrome, sacroiliac joint sprain, and headaches. He has already attended 30 hours of FRP with documented functional improvement in ADLs but is still unable to complete tasks without breaks and has mild depressive symptoms. Because the treating physician provided documentation of ongoing objective findings to support continuation of the program, and the request was within guideline recommendations, the IMR expert found the request for a multidisciplinary pain rehabilitation program of 80 hours to be medically necessary.

LexisNexis Commentary: This IMR decision is an example of a situation where the applicant had already participated in a multidisciplinary rehabilitation program and achieved functional improvement. The treating physician explained why applicant needed additional hours of multidisciplinary rehabilitation, and why the requested treatment was consistent with the MTUS and ODG guidelines, and the IMR expert concluded that the documentation provided by the physician was adequate to justify the requested treatment.

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