California: Noteworthy Independent Medical Review (IMR) Decisions (February 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, various medications used to treat psychiatric disorders, the use of imaging tests and nerve condition studies as diagnostic tools, the criteria that must be met to support recommended tertiary pain programs, and the MTUS guidelines applicable to requests for home health care.

ANTIPSYCHOTICS/ANTIDEPRESSANTS

■ 88 Cal. Comp. Cases 207. Anti-Depressants—Chronic Pain—Applicant, 59 years old, suffered an industrial spine injury on 6/15/2012. As of 11/16/2021, applicant reported neck and low back pain rated at 8/10 without medication and 5/10 with medication. The pain was described as burning, aching, shooting, throbbing, squeezing, pressure-like, deep and constant. Aggravating factors included sitting, standing, lifting and walking. Applicant also reported depression, anxiety, stress and insomnia. Applicant’s treatment included a home exercise program in addition to various pain medications. On 5/12/2022, applicant’s treating physician requested authorization for Nortriptyline cap 10mg #60. Applying the 2018 MTUS guidelines for post-traumatic stress disorder and acute stress disorder, UR non-certified the requested treatment. IMR overturned the UR non-certification based on the criteria set forth in the MTUS 2017 chronic pain guidelines, which recommend Norepinephrine reuptake inhibitor anti-depressants (TCAs) for treatment of chronic persistent pain of sufficient severity to require medication. Based on the documentation submitted in this case, the IMR reviewer concluded that applicant met the MTUS criteria for the requested treatment. Notably, the IMR reviewer found clear objective documentation of ongoing chronic persistent pain. As TCAs are considered a first line medication under the guidelines, the IMR reviewer concluded that the current request was consistent with the MTUS criteria and that the treatment was medically necessary. [LexisNexis Commentary: This IMR decision provides an example of how UR non-certifications may be based on use of the incorrect MTUS/ACOEM guidelines. In this case, UR applied the 2018 MTUS/ACOEM for PTSD to deny the requested medication, when the prescription for Nortriptyline was clearly for chronic pain, not PTSD.]

■ 88 Cal. Comp. Cases 1014. Antipsychotics/Antidepressants—Geodon—Applicant, 63 years old, suffered an industrial injury on 11/14/2019, and underwent treatment for major depression and an anxiety disorder. As of 10/11/2021, she was not working. Applicant had been prescribed the antipsychotic medication Geodon since at least 10/2020. In late 2021, she reported severe symptoms of anxiety and depression. She also indicated a history of hearing voices, which had reportedly subsided with the use of Geodon. Applicant’s treating physician requested authorization for Geodon 80 mg #30, which was denied by UR on 11/11/2021. The IMR reviewer reversed the UR non-certification based on the MTUS 2020 guidelines for depressive disorders, which recommend antipsychotics for the treatment of patients with depression. The IMR reviewer noted that applicant had a history of auditory hallucinations, which were ameliorated with Geodon, demonstrating the efficacy of that medication and supporting its medical necessity. [LexisNexis Commentary: This IMR is particularly interesting because the medication Geodon, which was at issue here, was the subject of a $301 million settlement between Pfizer, Inc. and the U.S. DOJ, because Pfizer marketed Geodon for “off-label” uses [See https://www.justice.gov/archive/usao/pae/News/2009/sep/pfizerrelease.pdf)]

CHIROPRACTIC TREATMENT

■ 88 Cal. Comp. Cases 104. Chiropractic Treatment—Spine Injury—Applicant, 58 years old, suffered an industrial back injury on 8/29/2020 and was out of work. She completed 12 sessions of chiropractic treatment with significant improvement of her symptoms, including resolution of tingling in her feet and legs, and dissipation of neuropathic pain in her right leg. The shaking/restless sensation in her right leg had also resolved, and her sleep had improved due to less pain. In an 8/16/2022 progress report, applicant reported continued low back pain, radiating to her legs. Her treating physician requested an additional six sessions of chiropractic treatment, which UR denied based on its finding that there was no documentation of functional improvement with prior chiropractic care. The provider submitted a “supplemental appeal report” pointing out that applicant, in fact, reported significant improvement in symptoms and function after her initial course of chiropractic treatment. The IMR reviewer overturned the UR non-certification of additional chiropractic treatment, noting that the MTUS 2020 guidelines for low back disorders recommend additional chiropractic sessions to relieve chronic pain or exacerbations of pain if the initial course of treatment resulted in substantial functional improvement. Given the functional improvement reported by applicant, as laid out in the provider’s supplemental report, the IMR reviewer found that the additional six sessions requested were supported by the guidelines and were medically necessary. [LexisNexis Commentary: This IMR corrects the UR reviewer’s error in failing to recognize evidence of applicant’s functional improvement in the documentation submitted. After UR denied the treatment request, the provider diligently submitted a supplemental report describing applicant’s functional improvements with the initial course of chiropractic treatment, which was likely helpful in getting the treatment certified by IMR.]

■ 88 Cal. Comp. Cases 100. Chiropractic Treatment—Spine Injury—Applicant, 30 years old, suffered an industrial injury on 8/20/2021, resulting in neck and low back pain and decreased range of motion. After applicant reported increased pain in 2022, his treating physician requested authorization for four chiropractic sessions for the lumbar spine and cervical spine. UR denied the requested treatment, noting that the documentation did not identify any recent specific event causing a flareup or exacerbation of applicant’s pain with associated functional decline, and that more than one-year post-injury, applicant should be independent in a home exercise program to address residual or fluctuating symptoms. Notwithstanding UR’s opinion that there were no significant clinical findings to justify chiropractic treatment, UR approved a pain management consultation based on significant clinical findings of neurologic compromise. Citing the MTUS 2020 guidelines for low back disorders and the MTUS 2019 guidelines for the cervical and thoracic spine, which 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, the IMR reviewer overturned the UR denial of the requested chiropractic treatment. The IMR reviewer found that medical necessity was established based on evidence of chronic low back pain and limited range of motion, and the fact that the pain management evaluation was approved given the significant clinical findings on examination. Considering that there was no documentation of prior chiropractic treatment and that applicant’s complaints, including tenderness to palpation in the cervical and lumbar paraspinal muscles with decreased range of motion, the IMR reviewer concluded that a trial of four chiropractic treatments for the lumbar spine and cervical spine was medically necessary. [LexisNexis Commentary: This IMR decision provides a useful guideline regarding the initiation of chiropractic treatment and also observes that a UR determination may be internally inconsistent.]

FUNCTIONAL RESTORATION PROGRAMS

■ 2023 Cal. Wrk. Comp. LEXIS 76. Functional Restoration Program—Chronic Pain Syndrome—Applicant, 58 years old, suffered an industrial injury on 9/26/2020, and was undergoing treatment for chronic pain syndrome, which involved physical as well as psychological symptoms. Previous treatments included chiropractic treatment, physical therapy, acupuncture, massage therapy, TENS, home exercise program, pain medications, and activity modifications. In 2023, applicant reported low back pain radiating to her lower extremities, right upper extremity pain and headaches. A physical examination revealed restricted lumbar and cervical range of motion with pain, and decreased strength in the lower extremities. Psychological testing identified severe somatic problems, depression and anxiety. Applicant’s treating physician request 80 hours of functional restoration program for applicant’s lumbar spine, but the request was denied by UR. The IMR reviewer overturned the UR denial, finding the request medically necessary based on the criteria set forth in the MTUS 2017 chronic pain guidelines addressing tertiary pain programs. Based on the documentation submitted, the IMR reviewer concluded that applicant in this case met the criteria identified in the applicable guidelines for tertiary pain programs, including functional restoration, where there was an indication that a thorough evaluation, record review, and assessment by program personnel had been completed from appropriate program providers, including a pain physician, a psychologist, and an evaluation by a therapist (physical therapist and/or occupational therapist), who opined that applicant had appropriate rehabilitation potential. Multiple other treatments had been tried and had failed. Applicant has a known etiology of chronic pain and significant behavioral health issues affecting her recovery. Finally, the IMR reviewer found no contraindications to the recommended treatment program, and recommendations from program providers supported this intervention for applicant. [LexisNexis Commentary: The IMR reviewer in this case set forth the MTUS criteria that must be satisfied to support a functional restoration program, and clearly explained why applicant in this case met those criteria. It is also interesting to note that the ACOEM Chronic Pain Guideline, incorporated into the MTUS, seems to indicate that it is not only the patient’s suitability for a functional restoration program that should be reviewed, but also the suitability of the exact program to which the patient is being referred.]

HOME HEALTH CARE SERVICES

■ 88 Cal. Comp. Cases 1230. Home Health Care Services—Applicant, 78 years old, suffered an industrial injury on 7/23/87, and underwent treatment for injuries to his hip, shoulder, knees, back, and carpal tunnel. He reported 6/10 pain in his shoulders, aggravated by overhead activities, lifting, and pushing, 3/10 pain in the left elbow, 9/10 low back pain that radiated into both hips and down both legs into the feet, 8/10 pain in his knees, and 5/10 bilateral hip pain. The medical records revealed that applicant was sitting in a wheelchair during his most recent physical examination and had difficulty rising. Additionally, applicant ambulated with a slow and labored gait using a cane. Applicant had decreased range of motion in his lumbar spine and knees, a recent history of debilitating pain, instability, and multiple falls. Applicant’s treating physician requested a home health aide to assist applicant four hours per week for six months, totaling 96 visits. The request was denied by UR. The IMR reviewer overturned the UR denial based on the 2022 MTUS guidelines for home health care services. Among other criteria, the applicable guidelines recommend home health care services if a patient requires assistance with ADLs, is unable to leave the home without major assistance (e.g., requiring wheelchair, walker, 3rd party transportation), leaving home is not medically advised, and/or the patient is normally unable to leave home and leaving home is a major effort. Here, the IMR reviewer noted that applicant had severely limited physical capacity and could not safely leave his home or complete several ADLs.  Applying the guideline criteria, the IMR reviewer concluded that medical necessity for home health care assistance was established. [LexisNexis Commentary: The IMR reviewer in this case correctly noted that applicant satisfied several of the MTUS criteria for entitlement to home health assistance, i.e., applicant could not leave his home without major assistance given his use of a wheelchair, leaving home was not advisable, and applicant had ADL deficits. In addition to the straightforward application of the MTUS guidelines, the case serves as a cautionary tale as to the potential of an applicant’s increasing, rather than decreasing, medical needs long after sustaining an industrial injury.]

IMAGING TESTS

■ 88 Cal. Comp. Cases 199. Diagnostic Imaging Tests—MRIs—Spine—Applicant, 59 years old, suffered an industrial injury on 9/8/2012, and underwent treatment for lumbar degenerative disc disease, stenosis, facet pain, degenerative joint disease, and facet arthropathy. A 3/9/2021 MRI identified multi-level disc disease and degenerative joint disease at L4-5, and high-grade extraforaminal nerve root compression. In a 4/4/2022 progress report, applicant reported new radicular low back pain rated at 2-8/10. The physical examination revealed tenderness over the lumbar paraspinals and facet joints, and there was pain with lumbar flexion and extension. Applicant’s treating physician requested authorization for another lumbar spine MRI to evaluate the etiology of applicant’s worsening pain complaints. UR denied authorization for the MRI based on the MTUS 2020 guidelines for low back disorders, which generally do not support repeat MRIs. However, the medical record indicated a recent worsening of low back pain as well as pain radiating to the left leg and neurogenic claudication. The IMR reviewer explained that although the use of repeat MRIs is generally not supported, in this case the presence of new symptoms warranted additional imaging. As such, the IMR reviewer deemed the request for another MRI of the lumbar spine to be medically necessary. [LexisNexis Commentary: The IMR reviewer here explains that while repeat MRIs are generally not supported by the MTUS/ACOEM guidelines, new symptoms may justify a repeat MRI. It is also worth remembering that new symptoms could justify the use of repeat MRIs not only as reasonable and necessary for treatment purposes, but also potentially to address disputes over TD, PD, or causation of need for further medical care. If the repeat MRI is needed to address a medical-legal dispute, it would not be subject to UR and IMR.]

■ 88 Cal. Comp. Cases 195. Diagnostic Imaging 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.]

NERVE CONDUCTION STUDIES

■ 88 Cal. Comp. Cases 1235. Nerve Conduction Studies—Carpal Tunnel Syndrome—Applicant, 65 years old, suffered an industrial injury on 3/21/2007, resulting in chronic neck pain. In 2023, she was evaluated for persistent upper extremity pain and paresthesias, with more severe symptoms on the left side than on the right. Applicant had previously undergone an unsuccessful right carpal tunnel release procedure. Both carpal tunnel syndrome and cervical radiculopathy were listed by the treating physician in his treatment notes as differential diagnoses. On 2/9/2023, the physician submitted an RFA for electrodiagnostic testing (EMG/NCS) of applicant’s bilateral upper extremities, noting that he was unable to offer applicant further treatment options without obtaining updated electrodiagnostic testing. UR denied the request, citing the 2017 MTUS chronic pain guidelines. The IMR reviewer overturned the UR denial based on the carpal tunnel syndrome section of the MTUS Hand, Wrist, and Forearm Disorders 2019 Guidelines, which recommend electrodiagnostic studies to make an accurate diagnosis in patients without a clear diagnosis of carpal tunnel syndrome. The guidelines further state that if electrodiagnostic studies are elected, needle EMG is important to differentiate between cervical radiculopathy and nerve entrapment. The IMR reviewer noted that in this case it was unclear if applicant’s symptoms resulted from entrapment or cervical radiculopathy. Therefore, obtaining updated electrodiagnostic testing to determine whether there was median nerve entrapment and/or the presence of superimposed cervical radiculopathy was appropriate, particularly given commentary by applicant’s treating physician that the results of the electrodiagnostic testing would potentially influence his decision regarding whether or not to offer applicant surgical treatment. Based on the reasons above, the IMR reviewer concluded that the request for electrodiagnostic testing (EMG/NCS) was medically necessary. [LexisNexis Commentary: In this case, IMR used the MTUS/ACOEM to correct an erroneous UR noncertification. Because applicant was diagnosed with cervical radiculopathy and had a history of neck pain, an EMG was appropriate under the guidelines to differentiate between cervical radiculopathy and median nerve entrapment for purposes of medical treatment.]

OPIOIDS

■ 88 Cal. Comp. Cases 109. Opioid Medication—Tramadol—Chronic Pain—Applicant, 52 years old, suffered an industrial injury on 1/3/2011 and was diagnosed with lumbar/lumbosacral spondylolisthesis and post-laminectomy syndrome. He had undergone various treatments, including surgery, injections, chiropractic manipulation, and use of medications. He had also been taking Tramadol for pain since at least 10/14/2021. In a 9/8/2022 progress report, applicant reported continued low back pain with radiation into the legs rated at 7/10 and associated numbness and tingling. The physical examination revealed tenderness over the right L5, decreased range of motion with pain, left L5 motor weakness, and diminished sensation along the left L4-5 distribution. A urine drug screen was positive for THC. The treating physician requested authorization for Tramadol Hcl 50mg #30, which UR denied. The IMR reviewer overturned the UR denial, noting that the while the MTUS 2017 guidelines do not support the long-term use of opioid medications, they also do not support discontinuation of these medications if there is ongoing improvement related to their use. In this case, the IMR reviewer noted, the treating physician submitted medical records documenting consistent monitoring for aberrant use and 50 percent improvement in pain and function, as evidenced by increased exercise and work tolerance. Further, the IMR reviewer noted that the “A’s” of continued opioid use were met in this case. As such, the IMR reviewer concluded that the request for Tramadol Hcl 50mg #30 was medically necessary. [LexisNexis Commentary: This IMR decision reminds the community that long-term opioid us, while potentially dangerous, may be appropriate if it is closely monitored by a physician and results in functional improvement.]

■ 88 Cal. Comp. Cases 1035. Opioids—Percocet—Applicant, 60 years old, sustained an industrial back injury on 3/30/2001, and underwent lumbar spine surgery in 2014. She was able to work full-time with the use of medication, including Percocet which had been prescribed since at least June 2022. In December 2022, applicant’s treating physician requested Percocet 10/325mg #79 to treat applicant’s chronic low back pain with radiculopathy. The request was denied by UR. However, the IMR reviewer overturned the UR denial and found the requested Percocet prescription medically necessary and supported by the MTUS Opioids 2017 guidelines, which indicate there should be at least 30 percent improvement in both pain and function to continue opioid treatment. The IMR reviewer noted that there was documentation showing applicant’s pain was reduced from 7/10 to 4/10 with the use of medication, allowing her to continue working. Applicant also reported improved function with medications. Specifically, her lifting capacity increased from 10 pounds to 20 pounds, walking one-half block increased to 3 blocks, sitting 30 minutes increased to 60 minutes, standing 5 minutes increased to 15 minutes, and performing household tasks for 10 minutes at a time increased to 45 minutes at a time. The IMR reviewer found these functional improvements sufficient to satisfy the 30 percent functional improvement requirement set forth in the applicable guidelines. [LexisNexis Commentary: In this IMR decision, the treating physician provided detailed documentation of applicant’s functional improvement with the use of opioid medication and showed that with minimal use of medication applicant could continue working full-time. The percentage of functional improvement is only one of many criteria that must be satisfied to support continued opioid use to treat chronic pain. Although the IMR reviewer did not address all of the other indications, it is implied that the other criteria were met in this case.]

STEROID INJECTIONS

■ 88 Cal. Comp. Cases 211. Steroid Injections—Radicular Pain—Applicant, 40 years old, sustained an industrial injury on 9/18/2021, and underwent treatment for lumbago with right-sided sciatica, lumbar degenerative disc disease, and L5-S1 spondylolisthesis. In a 7/7/2022 progress report, applicant reported right-sided low back pain extending into the lateral hip/buttock and thigh. The report described new neurologic findings of “sensation to light touch decreased on the right at L5. Seated SLR is positive on the right.” However, there was indication that applicant may be able to return to work with restrictions. Applicant’s treating physician requested authorization for a right L5 transforaminal epidural steroid injection, which UR denied. The IMR reviewer overturned the UR denial based on the MTUS 2020 guidelines for low back disorders recommending epidural glucocorticosteroid injection for treatment of acute or subacute radicular pain syndromes not responsive to conservative care. The guidelines generally do not recommend epidural steroid injections for chronic low back pain. The IMR reviewer noted that while applicant’s condition was described as a chronic low back pain condition without acute or subacute radicular pain syndrome, applicant did in fact experience persistent pain despite conservative care. Based on applicant’s radicular symptoms and the failure of conservative care, the IMR reviewer concluded that the requested epidural injection was supported by the applicable guidelines and was medically necessary. [LexisNexis Commentary: This IMR decision shows when a steroid injection may be useful to relieve pain, including if it helps return an injured employee to work. The IMR reviewer took a nuanced and thoughtful approach to the facts presented to find an exception to the general rule that epidural steroid injections are not appropriate for chronic pain and concluded that the injection could be useful to treat applicant’s radicular pain after conservative care failed.]

TRANSITIONAL LIVING

■ 88 Cal. Comp. Cases 326. Outpatient Transitional Living—Traumatic Brain Injury—Applicant, 64 years old, suffered a traumatic brain injury (TBI) at work. He was subsequently diagnosed with post-concussion syndrome, which significantly affected his physical, emotional and cognitive functioning. On 9/26/2022 his physician submitted an RFA requesting authorization for 20 visits to an outpatient transitional living center day treatment program, which included up to six hours of per day of physical, occupational, and speech therapy, as well as neuropsychology services. UR denied the request, stating that applicant should exhaust all conservative measures prior to considering this type of program. The IMR reviewer overturned the UR non-certification based on the MTUS 2018 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. According to the MTUS guidelines, these outpatient programs are especially beneficial in cases where the patient’s deficits make it difficult for the patient to perform their job duties. The IMR reviewer pointed out that the documentation submitted here demonstrated applicant’s need for an interdisciplinary team approach to treat his various functional and cognitive deficits. The MTUS guidelines state that outpatient appointments are generally scheduled at least two to three times per week, but frequency varies depending on the clinical status and functional outcomes of the overall prognosis. The non-MTUS ODG guidelines state that total treatment duration typically ranges between four and six months. The IMR reviewer concluded that applicant met the guideline criteria for the requested treatment and submitted documentation supporting its medical necessity. [LexisNexis Commentary: The IMR reviewer in this case clearly laid out why applicant’s participation in the outpatient program was consistent with the MTUS guidelines, given the extent of applicant’s functional and cognitive deficits. Ultimately, it makes sense for defendants to authorize this kind of care in order to reduce ADL deficits and facilitate an injured worker’s return to work, without the much greater cost of inpatient rehabilitation programs.]

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