California: Noteworthy Independent Medical Review (IMR) Decisions (December 2024)

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+. Lexis+ 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, non-invasive and low-cost treatment modalities such as aquatic therapy, massage and Pilates. The decision addressing Pilates is particularly useful because it correctly treats Pilates as a form of exercise and, although there are no treatment guidelines specifically addressing Pilates, exercise is generally recommended for the treatment of chronic pain. Also discussed below are two IMR decisions involving requests for durable medical equipment, including an ergonomic desk and chair and an orthopedic bed. The desk and chair were deemed medically necessary based on the applicable MTUS/ACOEM guidelines. Further, the employer was legally required to provide these accommodations. On the other hand, the request for an orthopedic bed was denied. According to the guidelines, there is no medical basis for a physician to prescribe any particular bed for the prevention or treatment of chronic pain; rather, a patient must choose a bed based on personal comfort.

AQUATIC THERAPY

■ 89 Cal. Comp. Cases 1141. Aquatic Therapy—Back Pain/Radiculopathy—Applicant, 55 years old, suffered an industrial injury on 8/20/2021 and was undergoing treatment for cervicalgia, lumbago, cervical radiculopathy, and a sprain of the thoracic spine ligaments. In a 4/25/2024 progress report, applicant reported low back pain rated at 7/10 that radiated to the left lower extremity and foot. She also reported difficulty with sitting, standing and walking for more than 30-60 minutes, and with lifting. Applicant’s treating provider requested six aquatic therapy sessions for the lower back, which UR denied. The IMR reviewer overturned the UR denial based on the MTUS 2021 guidelines for low back/radicular pain, which recommend a trial of aquatic therapy for the treatment of subacute or chronic low back pain in certain patients that meet the criteria for supervised exercise therapy and have co-morbidities (e.g., extreme obesity, significant degenerative joint disease, etc.) that preclude effective participation in weight-bearing physical activity. The IMR reviewer noted that aquatic therapy is not recommended for all other subacute or chronic low back pain patients or for all acute low back pain, as other therapies are believed to be more effective. The documentation in this case reflected that applicant had lower extremity weakness and an antalgic gait that adversely impacted her ability to engage in land-based physical therapy. There was also documentation of obesity, a previous trial of land-based therapy and a home exercise program. The IMR reviewer observed that the treating physician outlined clear treatment goals for the requested course of aquatic therapy. Accordingly, the IMR reviewer concluded that aquatic therapy was reasonable and medically necessary to treat applicant’s lower back pain. [LexisNexis Commentary: This IMR decision provides a good example of a non-invasive treatment, aquatic therapy, prescribed to alleviate pain. These types of non-invasive treatments often result in functional improvement and may reduce the need for medication.]

BRAIN INJURY PROGRAMS

■ 89 Cal. Comp. Cases 282. Brain Injury Program—Initial Evaluation—Applicant, 54 years old, sustained a traumatic brain injury on 7/26/2022, resulting in chronic post-traumatic headaches, post-concussion syndrome, cervicalgia, and right shoulder pain. An MRI of applicant’s brain revealed tiny bifrontal white matter lesions consistent with microvascular disease. A subsequent physical examination revealed a laceration scar over the vertex of applicant’s head, mild scalp allodynia, mild guarding on cervical spine movements, and absent deep tendon reflexes in the bilateral Achilles. Treatment included chiropractic treatments, psychotherapy, physical therapy, medications, and activity modifications. As of 7/18/2023, applicant was working modified duty. He reported constant headaches with pain, rated at 6-9/10, radiating to his neck and bilateral trapezii, along with occasional photophobia. Applicant’s provider requested authorization to have applicant evaluated for participation in a brain injury program. The request was denied by UR. The IMR reviewer overturned the UR denial based on the 2018 MTUS traumatic brain injury guidelines, which selectively recommend outpatient home and community-based rehabilitation for TBI patients with sufficient residual symptoms or signs of post-traumatic brain injury necessitating ongoing treatment. The guidelines indicate that there may be select patients with mild TBI that may be candidates for a brain injury program based on ongoing symptoms. The guidelines also state that selective and integrated rehabilitation programs are designed to help the individual work on specific tasks in order to retrain the body to accomplish said tasks, and that not all patients need all program components, so programs should be tailored to the specific patient’s needs. Based on applicant’s symptoms and physical examination, the IMR reviewer concluded that the request for a brain injury program, initial evaluation, was medically necessary under the applicable MTUS criteria. [LexisNexis Commentary: In this case, the request for authorization was for an initial evaluation, not enrollment in the brain injury program itself. This IMR reviewer correctly concluded that there is more than enough evidence of “[s]ufficient residual symptoms and/or signs of post-TBI to necessitate ongoing treatment” (MTUS/ACOEM Traumatic Bain Injury Guideline, 11/15/2017, p. 208) to look more closely at the appropriateness of a brain injury program. Since the guidelines state that the brain injury programs must be tailored to the particular patient, this non-invasive initial evaluation appears to be justified.]

■ 89 Cal. Comp. Cases 602. Brain Injury Outpatient Program—Applicant, 56 years old, suffered an industrial brain injury on 2/15/2023, and was undergoing treatment for post-concussion syndrome and post-traumatic headaches. Her symptoms included dizziness, headaches, blurry vision, double vision, balance problems, poor concentration, memory loss, tinnitus, phonophobia, sleep disturbances, brain fog, depression, anxiety, aphasia, agnosia, and sensitivity to loud sounds, which resulted in heightened anxiety and difficulty multitasking. A mental status examination revealed occasional difficulty pronouncing words with mild slurred speech, unsteady gait, and appearance of being imbalanced. A physical exam identified tautness of the bilateral trapezii muscles with reduced cervical spinal mobility due to muscular strain. On 10/4/2023, applicant’s medical provider requested authorization for a brain injury outpatient day program (four hours per day of treatment, four days a week for five weeks), with 20 days overnight stay due to the long distance between applicant’s residence and the program’s location. The request was denied by UR. The IMR reviewer overturned the UR denial based on the 2018 MTUS traumatic brain injury guidelines, which selectively recommend outpatient home and community-based rehabilitation for TBI patients with sufficient residual symptoms or signs of post-traumatic brain injury necessitating ongoing treatment. The guidelines note that an outpatient program is more appropriate for those with a “greater” mismatch between current abilities and the cognitive and physical demands of the patient’s job, although it could be justified even in a mild case where the symptoms are ongoing. Based on applicant’s symptoms and given the distance applicant would have to travel, the IMR reviewer concluded that the request for the outpatient brain injury program with 20 days of lodging was medically necessary. [LexisNexis Commentary: The  applicant in this case had a serious brain injury and her physician believed that the brain injury program would be immensely helpful in restoring function, with no downside. The IMR reviewer was correct in overturning the UR noncertification of the requested treatment given applicant’s symptoms and did an excellent job explaining the reasons for doing so based on the applicable MTUS/ACOEM guidelines.]

CHIROPRACTIC TREATMENT

■ 89 Cal. Comp. Cases 610. Chiropractic Treatment—Lumbar Spine—Applicant, 36 years old, suffered an industrial low back injury on 4/20/2013, and reported low back pain. A physical examination revealed tenderness to palpation in the lumbar spine, with palpable trigger points, decreased range of motion, and decreased sensation at L4-5, bilaterally. Applicant had completed eight sessions of chiropractic treatment on 10/30/2023 and requested additional sessions based on improvement in his pain. According to applicant, his back pain could reach 8/10 in intensity, but with chiropractic treatment the pain decreased by 30 percent to 5/10, allowing him to decrease his medication usage. On 11/1/2023, applicant’s medical provider requested eight additional sessions of chiropractic treatment to the lumbar spine to improve applicant’s range of motion and function and alleviate pain, with a subsequent transition to an independent home exercise program. UR noncertified the requested treatment, citing the MTUS 2021 guidelines for low back disorders. The IMR reviewer overturned the UR noncertification based on the MTUS 2021 guidelines for low back disorders and the non-MTUS ODG addressing treatment for low back disorders. The MTUS low back chapter recommends manipulation or mobilization of the lumbar spine for short-term relief of chronic pain or as a component of an active treatment program focusing on active exercises for acute exacerbations. The guidelines provide that if there is a significant positive response to the treatment, additional sessions may be considered. The ODG chiropractic guidelines recommend a total of 18 treatment sessions if there is evidence of functional improvement with treatment. However, the Delphi recommendations allow up to 24 visits based on documented improvement at two points during the course of therapy. The IMR reviewer noted that applicant initially underwent a course of physical therapy that failed to resolve his complaints. He was then referred for a course of chiropractic treatment, which decreased his pain and medication usage. Given the improvement noted with the initial course of chiropractic treatment and the residual complaints, the IMR reviewer found that the guidelines supported the request for additional chiropractic sessions. [LexisNexis Commentary: In this case, the IMR reviewer relied on the MTUS guidelines and the non-MTUS ODG to address applicant’s need for additional chiropractic treatment after completing an initial course of treatment. Given applicant’s improvement in pain and decreased medication use after completing eight sessions, the IMR reviewer correctly concluded that additional sessions were supported by the MTUS and ODG criteria.]

DURABLE MEDICAL EQUIPMENT

■ 89 Cal. Comp. Cases 720. Ergonomic Adjustable Desk and Work Chair—Applicant, 36 years old, suffered an industrial injury on 4/29/2021 and was undergoing treatment for left shoulder pain, bilateral wrist pain, left elbow pain, bilateral hand pain, myalgia, left elbow lateral epicondyle, low back pain, lumbar region intervertebral disc degeneration, and cervicalgia. In a 6/6/2023 progress report, applicant reported persistent left upper extremity pain and right hand and wrist pain rated at 9/10. The pain increased with activities and slightly improved with rest. Applicant reported a small improvement in the neck and shoulder symptoms, but worsening paresthesias and numbness in the left hand and upper extremities. She was temporarily totally disabled from work. Applicant’s physician requested an ergonomic adjustable desk and work chair to improve applicant’s symptoms and help her return to work. Citing no MTUS guidelines, UR denied the request. The IMR reviewer overturned the UR denial based, in part, on the MTUS 2017 chronic pain guidelines, which recommend participatory ergonomics programs for select patients with subacute and chronic pain who remain off work or on a different job, have apparent workplace barriers to return to work, and where there is managerial support and interest in analyzing and addressing barriers. The IMR reviewer also cited the MTUS 2019 guidelines for elbow disorders, which recommend ergonomic interventions in settings with combinations of risk factors, and specifically to reduce factors for epicondylalgia. The IMR reviewer noted that applicant underwent an ergonomic evaluation in 2021 and was recommended for ergonomic intervention at that time. Given applicant’s symptoms, work status and the prior recommendation for ergonomic intervention, the IMR reviewer concluded that the request for an ergonomic adjustable desk and work chair was medically necessary. [LexisNexis Commentary: Not only was the ergonomic desk and chair medically necessary for applicant in this case, but the employer was legally required to provide these accommodations. Also, as applicable here, the ergonomic intervention was supported by the 2023 MTUS/ACOEM Shoulder Disorder guidelines and the 2023 MTUS/ACOEM Hand, Wrist, and Forearm Disorders guidelines, although, surprisingly, it is not addressed in the 2018 Cervical and Thoracic Spine Disorders guidelines or the 2020 Low Back Disorders guidelines.]

■ 89 Cal. Comp. Cases 732. Orthopedic Beds—Back Pain—Applicant, 71 years old, suffered an industrial injury on 5/1/2000, and was undergoing treatment for lumbar radiculopathy, post-laminectomy syndrome following surgery and osteoarthritis in his knees, among other conditions. In an 11/22/2023 progress report, applicant reported pain in the lower back, hips/thighs knees/legs, ankles, and feet. According to applicant, the pain was sharp, achy, burning, throbbing, and shooting, and was present 75 percent of the time. Applicant’s provider requested authorization for a Queen size orthopedic adjustable bed to help applicant sleep better. UR denied the request. The denial was upheld by the IMR reviewer, who noted that the MTUS 2021 guidelines for low back disorders states that specific beds are not recommended for the prevention or treatment of acute, subacute or chronic low back pain, and there is no recommendation for or against the use of mattresses or any other specific sleeping surfaces for the treatment of such pain. Further, the IMR reviewer observed, the guidelines provide that patients should select the sleeping option most comfortable for them, and in cases where there is sufficient pain to interfere with sleep, recommendations by the provider for the patient to explore the effect of different surfaces in the home is appropriate. However, the guidelines provide that it is not appropriate for medical providers to order mattresses or bedding for patients. The IMR reviewer also cited the MTUS chronic pain 2017 guidelines, which do not recommend specific sleep products for prevention or treatment of chronic pain. These guidelines do, notably, state that there are no quality studies evaluating specific commercial products for treatment of chronic persistent pain syndrome. Based on the MTUS guidelines, the IMR reviewer concluded that there was no rationale to support the treatment request and, therefore, the request for a Queen size orthopedic adjustable bed was not medically necessary. [LexisNexis Commentary: This IMR is useful in that it discusses the MTUS/ACOEM guidelines applicable to sleeping surfaces for patients with chronic back pain. According to the guidelines, there is no medical basis for a physician to prescribe any particular bed for the prevention or treatment of chronic pain, and the patient must choose a bed based on personal comfort. However, physicians should note that in cases where there is sufficient pain to interfere with sleep, recommendations by the provider for the patient to explore the effect of different surfaces in the home is appropriate.]

ELECTRODIAGNOSTIC STUDIES

■ 89 Cal. Comp. Cases 183. Electrodiagnostic Studies—Carpal Tunnel Syndrome—Applicant, 34 years old, suffered an industrial injury on 12/14/2017, and was undergoing treatment for cervical radiculopathy. In 2019, applicant underwent a cervical discectomy with fusion at C5-C6. Following the first surgery, applicant had increased numbness in the right hand. In 2023, applicant’s treating physician requested an EMG/NCS study to document the current findings in advance of proposed cervical discectomy and fusion surgery at C6-C7. UR denied the requested treatment, citing the MTUS 2019 cervical and thoracic spine guidelines. The IMR reviewer overturned the UR non-certification and found the electrodiagnostic testing medically necessary based on the MTUS 2019 guidelines for carpal tunnel syndrome, which recommend electrodiagnostic studies to assist in securing a firm diagnosis for those patients without a clear diagnosis of carpal tunnel syndrome, and to objectively secure a diagnosis of carpal tunnel syndrome prior to surgical release. Given applicant’s previous post-operative neurologic signs and symptoms, the IMR reviewer believed it was reasonable to conduct the requested electrodiagnostic testing, at least as a baseline documentation, and the request was found to be medically necessary. [LexisNexis Commentary: The MTUS/ACOEM guidelines recommend electrodiagnostic studies “to objectively secure a diagnosis of carpal tunnel syndrome prior to surgical release” (ACOEM Hand, Wrist, and Forearm Disorders Guideline, June 28, 2023, p. 34, last paragraph). In this case, applicant’s treating physician proposed an additional anterior cervical discectomy and fusion, recognizing the importance of distinguishing whether the source of applicant’s symptoms was the cervical spine or the carpal tunnel.]

FUNCTIONAL RESTORATION PROGRAMS

■ 89 Cal. Comp. Cases 606. Tertiary Pain Programs—Functional Restoration Program—Initial Evaluation—Applicant, 68 years old, suffered an industrial injury on 6/6/2007, and was undergoing treatment for lumbar radiculopathy and right foot drop. Applicant had a longstanding history of chronic pain and, on 10/2/2023, his medical provider requested approval for a multidisciplinary evaluation prior to use of a functional restoration program. UR denied the request. The IMR reviewer overturned the UR non-certification based on the MTUS 2017 chronic pain guidelines addressing use of tertiary pain programs, which selectively recommend functional restoration programs for patients with chronic pain who have failed conventional treatments and remain significantly incapacitated. Prior to beginning a tertiary pain program, the guidelines require that a patient go through a thorough evaluation which should comprise 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. Although applicant in this matter appeared to be retired, he remained incapacitated with limited function. The IMR reviewer noted that applicant’s treatment over the course of many years failed to resolve his pain and facilitate return to unrestricted work. Given applicant’s incapacitation with limited function, the medical provider believed he was a candidate for a functional restoration program. Given the time that has elapsed since applicant’s injury and his extensive prior treatment amidst ongoing functional deficits, the IMR reviewer concluded that evaluation for a tertiary program was medically necessary and reasonable based on the MTUS guidelines. [LexisNexis Commentary: The IMR reviewer in this case did a good job explaining why applicant should be evaluated for participation in a functional restoration program, based on the criteria from the MTUS/ACOEM 2017 chronic pain guidelines. Although there are nine criteria for referral to tertiary programs, which include functional restoration programs, not all of these criteria are discussed in this case despite language in the ACOEM that “all” nine criteria must be used as the basis for referral to a pain management program (ACOEM Chronic Pain Guidelines, May 15, 2017, p. 340). However, the ACOEM guidelines are ultimately guidelines to be applied using the reviewer’s expert discretion, and, here, the request for authorization is simply for an initial evaluation to determine whether a functional restoration program would be appropriate. From the clinical case summary, it can be inferred that applicant likely meets all of the ACOEM criteria for a tertiary rehabilitation program.]

MASSAGE THERAPY

■ 89 Cal. Comp. Cases 1133. Massage Therapy—Back and Shoulder Pain—Applicant, 59 years old, sustained an industrial injury on 08/18/2020, and underwent treatment for neck, shoulder and low back pain. Imaging studies revealed a mild bulging disc in applicant’s lumbar spine and degenerative disc disease in the cervical spine. However, no abnormalities were detected in applicant’s shoulder. On 3/21/2024, applicant reported persistent pain in his low back and right shoulder. He indicated that a previous course of massage therapy provided significant pain relief. Applicant’s treating physician requested six additional one-hour massage therapy sessions. UR denied the request. The IMR reviewer overturned the UR denial, citing the “MTUS Cervical and Thoracic Spine 2019 Guidelines, Section(s): Cervicothoracic Pain: Treatment Rec’s: Allied Health” and the “MTUS Shoulder Disorders 2023 Guidelines, Section(s): Rotator Cuff Tendinopathies: Treatment Rec’s: Allied Health Interventions.” The IMR reviewer noted that the shoulder guidelines make no recommendation for or against the use of massage therapy for the treatment of shoulder pain or tendinopathies, but the cervicothoracic treatment guidelines recommend massage, as an adjunct to aerobic and strengthening exercise programs, for use in chronic cervicothoracic pain patients without underlying serious pathology to assist in increasing functional activity levels more rapidly. In this case, the IMR reviewer noted, applicant completed six massage sessions with benefit. Applicant also had a history of medication use for chronic pain, and the goals of message therapy included the reduction in oral medications, which was especially pertinent due to applicant’s use of oral medications causing gastrointestinal upset. The IMR reviewer found the requested number of treatments appropriate for periodic assessment and concluded that the request for six sessions of massage therapy was medically necessary. [LexisNexis Commentary: This case is a good example of a situation in which the IMR reviewer considered applicant’s reduction in pain medication to be an important factor in approving massage therapy to increase applicant’s functionality. The fact that applicant previously benefited from massage therapy provided additional support for approval.]

OPIOIDS

■ 89 Cal. Comp. Cases 598. Prescription Medication—Opioids—Tramadol—Applicant, 59 years old, suffered an industrial injury on 4/27/2018 and was treated for, among other things, pain in the lumbosacral spinal region with radiculopathy. A progress report dated 11/4/2022 reflected that applicant was experiencing chronic pain in the low back radiating to the left lower extremity and bilateral knee pain. He was using Tramadol 50 mg #30 and ibuprofen cream. On 11/17/2022, the provider requested approval for Tramadol HCI 50mg #45. UR modified the request, allowing 27 of the 45 tablets requested. However, the IMR reviewer found that 45 tablets were medically necessary based on the MTUS 2017 opioid guidelines. The guidelines provide that continued use of opioid pain medications for treatment of subacute or chronic severe pain should be considered if the patient has at least 30 percent improvement in both pain and function with use of the medication. Applicant here reported up to 30 percent pain reduction impacting activity performance across personal care tasks, functional mobility, community management, productivity related tasks, household management, recreation, and socializing. He denied any side effects. Applicant’s provider had a signed controlled substance agreement in the chart, and a CURES report was reviewed and found to be compliant. Because the documentation submitted indicated that applicant had improvement in function and pain that aligned with the criteria for continued use of opioid pain medications in the applicable MTUS guidelines, and applicant’s opioid use was being properly monitored, the IMR reviewer determined that continued use was appropriate. [LexisNexis Commentary: The UR physician in this case approved only a portion of the requested opioid tablets for applicant’s chronic back pain, likely in an effort to have applicant weaned from opioid medication. However, the IMR reviewer determined that the full dosage requested was appropriate based on applicant’s functional improvement, consistent with the opioid guidelines, and the fact that applicant’s opioid usage was being properly monitored by his provider.]

■ 89 Cal. Comp. Cases 594. Prescription Medication—Opioids—Acetaminophen/Codeine—Applicant, 54 years old, sustained an industrial injury on 8/31/2009 and began undergoing treatment for, among other things, pain in the lumbosacral spinal region with radiculopathy. Applicant underwent lumbar decompression surgery in 2021, after which he reported that he was doing “okay” and rated his pain at 4-7/10. Medications included acetaminophen/codeine 300/30 mg tablets (since at least 10/19/2022), Narcan 4 mg nasal spray, Bupropion 100 mg tablets, Duloxetine 60 mg capsules, and Trazodone 100 mg tablets. On 11/24/2022, applicant’s medical provider requested approval for acetaminophen/codeine 300/30mg #120. UR denied the request. However, the IMR reviewer found the request medically necessary based on the MTUS 2017 opioid guidelines. The guidelines provide that continued use of opioid pain medications for treatment of subacute or chronic severe pain should be considered if the patient has at least 30 percent improvement in both pain and function with use of the medication. The IMR reviewer noted that, according to the documentation submitted, use of acetaminophen/codeine “took the edge off” of applicant’s pain and allowed him to engage in ADLs such as household chores, meal preparation, and exercises. An opioid agreement was signed by applicant on 06/09/2022. CURES was checked on 11/11/2022 and it was consistent with the provider’s treatment plan. Because the documentation submitted indicated that applicant had improvement in function and pain that aligned with the criteria for continued use of opioid pain medications in the applicable MTUS guidelines, and applicant’s opioid use was being properly monitored, the IMR reviewer determined that the requested prescription was reasonable and appropriate. [LexisNexis Commentary: The IMR reviewer in this case determined that applicant had sufficient functional improvement with the use of acetaminophen/codeine to satisfy the MTUS guideline criteria for opioid usage. Applicant’s use of the medication allowed him to engage in ADLs he may have been precluded from without the medication, such as household chores, meal preparation and exercise. If applicant uses the medication judiciously and he is appropriately monitored, the claims examiner may avoid having to provide more costly (and potentially less effective) treatment for applicant’s pain.]

PILATES

■ 89 Cal. Comp. Cases 1129. Pilates—Back Pain—Applicant, 44 years old, sustained an industrial injury on 3/29/2021, and underwent treatment for intervertebral disc disorders with lumbar radiculopathy, pain in the right wrist, cervicalgia, and dorsalgia. On 12/12/2023, applicant reported ongoing low back pain rated at 7-9/10 and was on modified work duty. Applicant’s treating physician requested approval for eight sessions of Pilates to improve applicant’s core strength and help her chronic low back pain. UR denied the request. The IMR reviewer noted that the MTUS has no recommendation regarding the use of Pilates. However, the MTUS 2021 guidelines for the treatment of low back disorders/pain moderately recommend exercise programs for acute, subacute, chronic, post-operative or radicular low back pain with a frequency of one to three sessions per week for up to four weeks, as long as there is objective functional improvement and symptom reduction. Under the guidelines, evaluation for an exercise prescription involves consideration of five critical components: (1) stage of (theoretical) tissue healing (acute, subacute, chronic); (2) severity of symptoms (mild, moderate, severe), (3) identification of the presence or absence of a directional preference, (4) degree and type of deconditioning (flexibility, strength, aerobic, muscular endurance), and (5) psychosocial factors (e.g., medication dependence, fear-avoidance, secondary gain, mood disorders). The IMR reviewer observed that applicant had not previously attended Pilates, and that the MTUS recommends up to 12 sessions of an exercise program. As such, the IMR reviewer concluded that eight sessions of Pilates to improve applicant’s core strength was medically necessary. [LexisNexis Commentary: This case is useful because it correctly treats Pilates as a form of exercise and, although there are no guidelines specifically addressing Pilates, exercise is generally recommended for the treatment of low back pain. The IMR reviewer appropriately applied the available criteria for exercise programs in the absence of criteria specifically applicable to Pilates.]

SPINAL CORD STIMULATORS

■ 89 Cal. Comp. Cases 403. Spinal Cord Stimulators—Chronic Pain—Applicant, 60 years old, sustained an industrial injury on 9/8/95 and was undergoing treatment for chronic pain and radiculopathy in her lumbar region. Diagnoses included lumbar radiculitis, post-laminectomy syndrome, and chronic pain syndrome. Previous treatments included physical therapy, injections, nerve blocks, medications (including opioids), and L3-S1 fusion with L2-L5 laminectomy. In addition to the lumbar surgery, applicant had undergone rotator cuff repair, two knee surgeries, meniscus repair, and surgery on both hands. On 9/8/2023, applicant’s treating physician requested authorization for a spinal cord stimulator trial. UR denied the request. The IMR reviewer overturned UR’s non-certification based on the MTUS 2021 treatment guidelines for low back disorders with radicular pain, which recommend spinal cord stimulators only in highly selective circumstances when all other indicated treatments have failed, the patient has inadequate function, and “the provider wishes to seek approval from a worker´s compensation carrier for consideration of possible coverage despite the lack of quality evidence of efficacy in these patients.” Criteria for implantable spinal cord stimulator in a chronic radiculopathy patient include, but are not limited to (1) clear diagnosis of chronic radiculopathy, in which leg pain is predominant, (2) poor or inadequate response to surgical treatment, (3) poor or inadequate response to a functional restoration program, with treatment for at least six months, (4) remedial surgery is inadvisable or not feasible, (5) major psychiatric disorders have been treated with expected responses, (6) the patient has had successful results of at least 50 percent pain reduction from a trial of a temporary external stimulator of approximately two to three days, and (7) reduction of use of opioid medication or other medication with significant adverse effects, or functional improvement such as return to work. The IMR reviewer noted that applicant has had severe, intractable pain in her lumbar spine radiating to her legs, causing significant functional limitations since the time of her work-related injury. She has exhausted multiple conservative and invasive procedures in the past, including multiple injections and prior lumbar surgeries. The IMR reviewer observed that applicant had a psychological evaluation and was deemed an appropriate candidate for a spinal cord stimulation trial. Based on the extenuating circumstances noted above, the IMR reviewer concluded that applicant met the criteria for the highly selective use of spinal cord stimulation, and that the requested treatment was medically necessary. [LexisNexis Commentary: This case is useful to show that IMR reviewers have some discretion to interpret the strict criteria of the guidelines, as there was no clear indication in the clinical case summary that applicant had participated in a functional restoration program per the guidelines. However, the reviewing doctor in this case was aware of the MTUS/ACOEM requirements as summarized in the IMR opinion, and apparently felt that applicant’s history of treatment provided equivalent proof of failure of multidisciplinary treatment over a long period of time, even if not in the exact kind of program described in the applicable MTUS/ACOEM guidelines.]

SURGICAL PROCEDURES

■ 89 Cal. Comp. Cases 412. Surgical Procedures—Lumbar Laminectomy—Spinal Stenosis—Applicant, 79 years old, suffered an industrial injury on 3/21/91, resulting in ongoing severe (rated at 9/10) and chronic pain in her low back and buttock, radiating down her left leg. Applicant was also undergoing treatment for complex regional pain syndrome of her upper limb, spinal stenosis with neurogenic claudication and other comorbid conditions. On 8/30/2023, applicant’s physician requested authorization for an L1-2 laminectomy. The request was denied by UR. The IMR reviewer overturned the UR non-certification based on the MTUS 2021 guidelines for the treatment of low back disorders, which moderately recommend decompression surgery for patients with symptomatic spinal stenosis that is not responsive to conservative treatment and also have radicular pain or weakness, confirmation of spinal stenosis on imaging tests, and ongoing significant pain and functional impairment for at least four to six weeks after attempting non-surgical options. However, the guidelines expressly suggest caution in cases of elderly patients with comorbidities. The IMR reviewer noted that, per the documentation submitted, applicant suffered from buttock and leg paresthesia resulting in multiple falls. She also had poor balance and 40 percent of the normal range of motion. The MRI imaging of applicant’s lumbar spine showed 8mm retrolisthesis of L1 and L2 and severe disc space narrowing with degenerative endplate irregularities and a circumferential disc bulge at L1-2, mild bilateral neural foraminal narrowing, and moderate to severe spinal canal stenosis. The IMR reviewer pointed out that applicant had tried but failed conservative treatments with continued, progressive findings. Notwithstanding applicant’s advanced age and comorbidities, the IMR reviewer concluded that applicant met the guideline criteria, and, therefore, the request for L1-2 laminectomy was medically necessary. [LexisNexis Commentary: The MTUS guidelines for spine decompression surgery advise using caution in cases of elderly patients with comorbidities. Applicant here was 79 years old and had multiple comorbidities, including complex regional pain syndrome. However, all other criteria were met and applicant’s pain of 9/10 seemed to justify the risk of undergoing a complicated surgery. The IMR reviewer did a good job of explaining why the surgery should be approved.]

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