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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). The IMR decisions summarized below explore different avenues providers utilize to treat chronic pain, ranging from opioid medications and muscle relaxants to more conservative aqua, massage and behavioral/cognitive therapies.
Other topics addressed include home health care in a variety of circumstances, including in cases of traumatic brain injury. In a particularly interesting decision, the IMR reviewer was creative in applying other sources to evaluate applicant’s request for childcare expenses because neither the MTUS/ACOEM nor ODG addressed childcare. A number of these decisions serve as an important reminder that physicians must provide adequate documentation to support treatment requests or risk non-approval.
■ 85 Cal. Comp. Cases 172. Aqua Therapy—knee Injury—IMR reviewer overturned UR decision denying request for 8 aqua therapy visits as an alternative to physical therapy for treatment of 48-year old applicant’s chronic knee pain and dysfunction following meniscal surgery. Although the MTUS does not discuss aqua therapy, the ODG recommends aquatic therapy as an alternative to land-based exercise/physical therapy in order to minimize the effect of gravity, especially when decreased weight bearing is desirable. Applicant in this case was limited by her treating physician to 5 pounds of weight bearing and was making progress with aqua strengthening. Given that the aqua therapy was beneficial, and that applicant needed to minimize weight bearing, the IMR reviewer concluded that the request for another 8 sessions of aqua therapy was supported by the ODG and was medically necessary and appropriate. LexisNexis Commentary: This IMR decision presents a case in which the treating physician believed that applicant would benefit more from aqua therapy than from land-based exercise/physical therapy given her weight bearing restriction following knee surgery. Although the MTUS guidelines do not discuss aquatic therapy, the IMR reviewer found that additional aqua therapy was medically necessary based on the ODG, which recommend aqua therapy to minimize the effect of gravity in cases where weight bearing is limited.
■ 85 Cal. Comp. Cases 349. Childcare Expenses—IMR reviewer overturned UR denial of a request for 25 days of childcare and deemed the request medically necessary and appropriate. This case involved a 31-year old woman who suffered an industrial spine injury in 2017 requiring her to undergo spinal surgery. Applicant was subsequently enrolled in a one-month functional restoration program, and required childcare for her 3 children, ages 8-12. Neither the MTUS/ACOEM nor the ODG address childcare expenses, so the IMR reviewer relied on New York regulations pertaining to childcare services, and an article discussing policies to assist parents with young children. The IMR reviewer recited the definition of “daycare” or “childcare,” and found that a caretaker seeking childcare services to enable her/him to participate in an approved training program must provide documentation including: (1) the name of the institution conducting the training program, (2) the nature of the program, (3) the patient’s vocational or rehabilitative goal, (4) the duration of the program, including commute time, and (5) progress reports. Here, the IMR reviewer concluded, applicant’s participation in the functional restoration program fulfilled the requirements for childcare services.
LexisNexis Commentary: The IMR reviewer in this case relied on New York childcare regulations and policy considerations to find that applicant was entitled to childcare expenses while she participated in a functional restoration program following her industrial back injury. This decision is a good example of a case where neither the MTUS nor ODG addressed the requested treatment, and the IMR reviewer was creative in applying other sources to evaluate applicant’s request.
FOOT AND ANKLE BRACES
■ 85 Cal. Comp. Cases 99. TriLok Foot/Ankle Brace—Chronic Regional Pain Syndrome—IMR reviewer upheld UR decision denying provider’s request for a TriLok foot/ankle brace to support 50-year old applicant’s left foot/ankle. Applicant in this case reported chronic leg pain following a 2017 industrial injury, which was attributed to CRPS. The IMR reviewer noted that the MTUS 2018 guidelines for ankle and foot disorders, specifically foot drop, recommend use of foot/ankle orthotics for the treatment of foot drop to facilitate a patient’s ability to work. In this case, the IMR reviewer noted that applicant’s reported pain was highly variable, ranging from a 6 to a 9 on a scale of 10. Applicant was out of work on TTD through January 2020. Although the provider alluded to applicant’s use of various pain medications, and use of a walker, he/she failed to elaborate on the extent of applicant’s ambulatory deficits and made no mention of foot drop, instability, or related issues for which usage of the TriLok brace would be indicated. Given the sparsity of documentation supporting the provider’s treatment request, the IMR reviewer found that the request was not medically necessary under the applicable guidelines.
LexisNexis Commentary: This IMR decision is a reminder that to get treatment approved physicians must provide adequate documentation detailing why the requested treatment is necessary to treat an applicant’s particular condition. Here, the treatment was denied on the basis that the physician did not adequately explain or clarify why it was medically necessary to improve applicant’s condition.
HOME HEALTH SERVICES
■ 85 Cal. Comp. Cases 94. Home Health Services—Registered Nurses—Nightly Care—IMR reviewer overturned UR decision denying treating physician’s request for ongoing nighttime home care by a registered nurse. In this case, 52-year old applicant suffered an industrial injury in 2010 and was undergoing treatment for chronic pain and various other conditions, including non-hereditary angioedema, severe asthma and GERD. The applicable MTUS guidelines, for which the IMR reviewer provided a link, recommend home health care services for short-term purposes following hospitalizations or surgical procedures and in other specific circumstances for those patients who would otherwise require inpatient care. Applicant here had difficulty leaving his home and completing ADLs. The documentation indicated that home health care was necessary to avoid placing applicant in a supervised inpatient facility mainly due to her angioedema complications and frequent need for changing her permanent tracheostomy. Because applicant had comorbid issues with sleep and possibly apnea related to her condition, it was appropriate to have an experienced person at home with applicant at night. The IMR reviewer concluded that based on applicant’s condition and the MTUS guidelines, the request for a registered nurse was reasonable and medically necessary.
LexisNexis Commentary: The IMR reviewer did an exceptional job documenting applicant’s medical condition as set forth in the medical records and carefully explained why the request for a night nurse was compliant with the MTUS guidelines. If applicant does not get the care she needs at night, the only alternative would be to transfer her to a supervised inpatient care facility, which would cost significantly more money and could cause applicant to undergo additional medical issues due to being forced to leave her home.
■ 2019 Cal. Wrk. Comp. LEXIS 141. Home Health Services—Custodial Care—Traumatic Brain Injury—IMR reviewer overturned UR decision denying treating physician’s request for 6 months of 24/7 custodial care for 34-year old applicant with 2009 traumatic brain injury resulting in spasticity and mild cognitive dysfunction. Applicant also developed degenerative arthritis in his knees and ultimately underwent foot and ankle surgeries. The IMR reviewer cited the MTUS 2017 guidelines pertaining to the initial approaches to treatment, which recommend home health care on a short-term basis to help with functionality in home-bound patients such as applicant and reduce the risk of re-hospitalization. Home health care includes services provided by skilled professionals in addition to unskilled services, such as help with basic ADLs like feeding, bathing and toileting, that do not require the skill of medical professionals, and domestic care to help with essential household tasks such as laundry, shopping and cleaning. The IMR reviewer noted that authorization for home health care services should document the medical necessity for the care and include the medical condition for which the care is required, the objective functional deficits, the specific activities precluded by such deficits, the necessity of skilled or unskilled services, and the duration and frequency of the service required. The IMR reviewer concluded that applicant was completely disabled with multiple body parts not functioning and, therefore, the request for home health services in the form of 24/7 custodial care for 6 months was medically necessary.
LexisNexis Commentary: This IMR decision provides a good example of when home health care should be approved, and cites the appropriate rules supporting medical necessity for the treating physician’s request in the case of a severely disabled injured worker.
■ 85 Cal. Comp. Cases 90. Home Care Services—Nursing Visits for Wound Care—IMR reviewer overturned UR decision denying treating physician’s request for 3 months or more of nursing visits to care for 75-year old applicant’s left knee laceration, post-repair. The submitted records indicated that applicant was undergoing treatment for an infection associated with an internal left knee prosthesis and laceration with packing that required daily changing. Citing the MTUS 2015 guidelines for the care of knee disorders, the IMR reviewer noted that home health services are recommended for medical treatment of homebound patients on a part-time or intermittent basis, generally for up to no more than 35 hours per week. Here, applicant was homebound with worsening pain, an inability to perform dressing changes, and an infection with need for packing and pus drainage. The IMR expert found that, under these circumstances, the request for 3 months of nursing visits to care for applicant’s wound was medically necessary under the guidelines.
LexisNexis Commentary: This IMR decision presents a situation in which an elderly applicant was entitled to nursing care at his home to treat his infected knee wound where the documentation submitted supported a finding that applicant was home bound due to his age and medical condition and, therefore, he met the criteria for home health services under the applicable MTUS guidelines.
■ 85 Cal. Comp. Cases 176. Massage Therapy—Upper Extremity—IMR reviewer overturned UR decision denying treating physician’s request for 8 sessions of massage therapy to treat 68-year old applicant’s right shoulder and both wrists and hands. The medical documentation indicated that applicant was currently being treated for bilateral carpal tunnel syndrome, right shoulder pain following surgery, neuropathy of the right upper extremity, myalgia, osteoarthritis of the lumbar region, and chronic pain syndrome. The MTUS 2016 guidelines addressing shoulder conditions, upon which the IMR reviewer relied, recommend massage for trigger points/myofascial pain in patients with moderate to severe chronic pain and no serious underlying pathology as an adjunct to aerobic, stretching and strengthening programs. Applicant in this case recently attended 4 massage therapy sessions, which was within the recommended trial under the MTUS and ODG treatment guidelines cited by the IMR reviewer. The MTUS and ODG authorize additional sessions based upon ongoing objective improvement. The IMR reviewer noted that applicant had decreased pain and increased function with prior therapy, and the treating physician provided sufficient rationale for requesting additional massage therapy. As such, the IMR reviewer concluded that the request for 8 sessions of massage therapy was medically necessary.
LexisNexis Commentary: This IMR decision describes a variety of manual therapies and provides insight into what types of therapy will be authorized for different musculoskeletal conditions.
■ 84 Cal. Comp. Cases 1121. Prescription Medications—Muscle Relaxants—Tizanidine HCl— IMR reviewer upheld UR decision denying treating physician’s request for 120 tablets of the muscle relaxant Tizanidine HCl 4mg to treat applicant’s back pain. Citing the MTUS 2017 guidelines for chronic pain and the ODG, the IMR reviewer noted that muscle relaxants are selectively recommended for brief use as a second- or third-line medication for exacerbations of chronic low back pain with muscle spasms but are generally not recommended for ongoing usage (more than a few weeks). Although the ODG states that Tizanidine has been shown to be effective for low back pain and is, in fact, recommended as a first-line option to treat myofascial pain, in this case the medication was prescribed far in excess of the guideline recommendations. The IMR reviewer pointed out that the treating physician provided no rationale for prescribing Tizanidine in excess of its recommended use. As such, the IMR reviewer concluded that the request for Tizanidine HCl 4mg #120 was not medically necessary.
LexisNexis Commentary: This IMR decision provides significant guidance regarding the criteria that must be met to support a request for muscle relaxants to treat chronic pain. The IMR reviewer detailed both the MTUS and ODG criteria that must be met and ultimately concluded that the provider’s request for Tizanidine far exceeded the recommended usage of the medication and was, therefore, not medically necessary.
■ 85 Cal. Comp. Cases 176. Prescription Medications—Muscle Relaxants—Flexeril—IMR reviewer upheld UR decision approving 54 of the 60 Flexeril 7.5 mg tablets requested by the treating physician, based on the MTUS guidelines which approve brief use of muscle relaxants, including Flexeril (cyclobenzaprine), as a second- or third-line treatment for acute exacerbations of chronic persistent pain with muscle spasms. Due to the potential for abuse, the guidelines recommend against long term use of muscle relaxants. The recommended duration of use for exacerbations of chronic pain is 2-3 weeks. Here, the documentation indicated that applicant was far outside the initial treatment period and had been prescribed the medication in excess of the guideline recommendations. Moreover, as noted by the IMR reviewer, the treating physician did not provide any rationale to support going against the guideline recommendations. UR approved 54 tablets for the purpose of weaning, and the IMR reviewer found that the remaining 6 tablets of Flexeril requested were not medically necessary.
LexisNexis Commentary: This IMR decision illustrates a situation in which the applicant had been using the muscle relaxant Flexeril far beyond the recommended limits. However, instead of denying the treating physician’s request for 60 pills, UR authorized 54 pills for the purpose of weaning, and the IMR reviewer upheld UR’s attempt to impose a reasonable weaning program.
■ 84 Cal. Comp. Cases 1121. Opioid Medications—Oxycodone HCl—IMR reviewer overturned UR decision denying treating physician’s request for 120 tablets of Oxycodone HCl 10mg. In this case, 51-year old applicant suffered a 2017 industrial back injury and was undergoing treatment for low back pain, thoracic spine pain, cervicalgia, and cervical spondylosis without myelopathy or radiculopathy. Part of his treatment regime since at least May of 2019 included a prescription for the opioid medication Oxycodone. The IMR reviewer noted that the MTUS 2017 guidelines for subacute and chronic pain recommend an opioid trial if other evidence-based approaches to improve pain and restore function have failed. Ongoing opioid treatment beyond a trial period depends on the results of the trial. Additionally, the MTUS provides a number of criteria that must be met to support ongoing treatment. The MTUS further states that opioids should be discontinued if there is no functional benefit, resolution of pain, improvement to the point of not requiring opioids, intolerance or adverse effects, non-compliance, surreptitious medication use, medication misuse, aberrant drug screening results, diversion, or ill-advised concomitant consumption of medications or substances. The IMR reviewer noted that applicant here was beyond the acute phase of injury. The treating physician documented failure of other treatment methods, improvement in both pain and function with Oxycodone use, and comprehensive screening for aberrant usage of the medication through CURES and urine drug screening as required by the MTUS guidelines. Accordingly, the IMR reviewer found that the treating physician provided a convincing rationale for ongoing use of Oxycodone and concluded that Oxycodone HCl 10mg was medically necessary.
LexisNexis Commentary: In this decision, the IMR reviewer summarized the MTUS requirements for approval of opioids and also enumerated each of the MTUS criterion that must be met to support ongoing usage of opioid medication for chronic pain. Indeed, the IMR expert’s rationale could be used as a template for medical providers seeking authorization for opioid prescriptions.
■ 85 Cal. Comp. Cases 262. Psychotherapy—Cognitive Behavioral Therapy—Chronic Pain—IMR reviewer overturned UR determination denying treating physician’s request for 6 additional psychotherapy sessions to treat 42-year old applicant who suffered an industrial injury while working as a bus driver, resulting in multilevel cervical disc displacement with neck pain and radiculopathy, cervical facet syndrome, right shoulder impingement, and bilateral trapezius sprain. Applicant was also undergoing treatment for mental health issues including major depression, chronic pain syndrome, and pain disorder with related psychological factors, and had completed 5 psychotherapy sessions. The IMR expert noted that the MTUS/ACOEM 2017 guidelines recommend cognitive behavioral therapy (CBT) for the treatment of subacute and chronic pain. The guidelines support an initial set of 6 therapy sessions, with an additional 16-24 subsequent sessions contingent upon documentation of symptoms and functional progress in treatment. In this case, UR had denied the additional sessions of psychotherapy notwithstanding documentation of improved sleep, because there was no clear documentation that the therapy was producing functional improvement. The IMR reviewer acknowledged that the submitted documentation identified treatment goals but, other than to note improved sleep, did not discuss applicant’s progress on each of the goals and instead merely repeated the treatment goals verbatim. However, after reviewing approximately 275 pages of medical records, the IMR reviewer found there had not been a substantive amount of therapy to date and, therefore, even though the documentation of applicant’s progress was very minimal, it was marginally acceptable given the limited number of therapy sessions in which applicant had participated. Overall, the IMR reviewer concluded that the request for 6 additional sessions of psychotherapy was sufficiently supported and was medically necessary and appropriate.
LexisNexis Commentary: Although the documentation of applicant’s progress in psychotherapy was “marginal,” the IMR reviewer used the limited documentation in combination with the fact that applicant had fewer than 6 therapy sessions to justify approval of additional sessions. This was a creative approach that certified additional sessions even though the medical record, strictly speaking, did not justify the extra sessions.
■ 85 Cal. Comp. Cases 99. Transportation Costs—Medical Appointments—IMR reviewer upheld UR decision denying provider’s request for transportation services to and from medical appointments. The IMR reviewer noted that while the ODG knee chapter recommends transportation to appointments in the same community for patients with disabilities preventing them from self-transport, there was no documentation in this case regarding why applicant could not transport himself to medical appointments, either through a personal vehicle or through public transportation. The IMR reviewer commented that it was unclear whether the transportation services were being ordered for applicant’s convenience or whether applicant had a bona fide medical impairment or disability preventing self-transport. Given the lack of information, the IMR reviewer concluded that the request was not medically necessary. LexisNexis Commentary: In this case, the provider failed to explain why applicant was unable to transport himself to and from medical appointments and, therefore, the request for transportation was denied. Another example of the importance of providing adequate bases to support requests for medical services.
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