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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.
■ 85 Cal. Comp. Cases 512. Muscle Relaxants—Flexiril (Cyclobenzaprine)—IMR reviewer upheld UR decision approving only 60 of the 90 10mg Flexeril pills requested by provider to treat applicant’s chronic pain stemming from 2017 industrial neck and back injuries. The MTUS/ACOEM 2017 guidelines for chronic pain recommend brief use of muscle relaxants as a second- or third-line treatment for acute exacerbations of chronic, persistent pain when NSAIDs and exercise are not adequately controlling symptoms. Muscle relaxants, however, are not indicated for prolonged use. The MTUS states that these medications should be used only for a couple of weeks due to the risk of sedation and being abused. Based on the guideline criteria, the IMR reviewer concluded that UR appropriately authorized 60 instead of 90 pills and urged applicant’s physician to start a weaning regiment as clinically indicated.
LexisNexis Commentary: The IMR reviewer did a good job applying the MTUS guidelines and sensibly determined that the request for 90 pills of the muscle relaxant Flexeril was excessive given the guideline recommendation that the medication be used only for “a couple weeks” given its sedative effect and potential for abuse.
■ 85 Cal. Comp. Cases 434. Opioid Medication—Norco—Chronic Low Back Pain—IMR reviewer upheld UR denial of treating physician’s request for Norco 10/325mg #60, based on MTUS 2017 guidelines recommending an opioid trial if other treatments attempted do not adequately reduce pain and increase function. However, the guidelines recommend screening prior to initiating a trial of opioids for treatment of subacute or chronic pain. Although applicant in this case had objective findings and exhausted multiple forms of conservative treatment with ongoing symptoms, there was no indication that she underwent an initial urine drug screening for baseline documentation prior to requesting Norco. As such, there was a lack of evidence to warrant the requested medication under the guideline criteria, and medical necessity was not established.
LexisNexis Commentary: In this example, applicant’s current medication was not adequately relieving her pain, yet she will have to wait to make another request for opioids due to lack of urine drug screening. This IMR is a good reminder that providers should make every attempt to ensure guideline criteria is met and documented prior to requesting authorization for treatment.
OPIOID RECEPTOR ANTAGONIST MEDICATIONS
■ 85 Cal. Comp. Cases 512. Opioid Receptor Antagonist Medications—Symproic (Naldemedine)—Opioid-Induced Constipation—IMR reviewer overturned UR decision denying provider’s request for medication Symproic 0.2mg #45, an opioid receptor antagonist, to treat 48-year old applicant’s constipation caused by opioids used for chronic pain associated with 2017 industrial back and neck injuries. The MTUS does not discuss Symproic, so the IMR reviewer relied on Up to Date guidelines, which recommend the medication to treat opioid-induced constipation and state that it may produce side effects in some patients. The IMR reviewer noted no side effects or contraindications in applicant’s case, and concluded that since applicant, a chronic opioid user, responded well to treatment with Symproic, the medication was medically necessary and appropriate.
LexisNexis Commentary: The IMR reviewer in this case overturned the UR decision when applicant had no negative side effects and was benefitting from use of the prescribed medication.
■ 85 Cal. Comp. Cases 183. Physical Therapy—Post Shoulder Surgery—IMR reviewer overturned UR decision approving only 10 out of the 12 requested physical therapy sessions to treat 55-year old applicant’s post-operative shoulder condition. Citing the ACOEM guidelines for shoulder disorders, the IMR reviewer explained that physical therapy programs need to be individualized based on a range of factors such as age, pre-operative condition, surgical results, contraindications, and other medical conditions. Further, the IMR reviewer emphasized that continuation of physical therapy must depend on individual progress. The IMR reviewer pointed out that the ODG physical therapy guidelines recommend varying levels of physical therapy for different conditions, which the IMR reviewer specifically listed along with the number of physical therapy sessions recommended for each one. For post-surgical treatment, the ODG recommends 24 visits over 14 weeks. In this case, the IMR reviewer noted, applicant was treated with a left shoulder arthroscopy with supralabral repair and decompression of paralabral cyst and participated in 12 sessions of physical therapy. The IMR reviewer concluded that the 12 additional sessions of post-operative physical therapy requested were within the ACOEM and ODG treatment guidelines and were, therefore, medically necessary.
LexisNexis Commentary: The IMR reviewer in this case, who specialized in orthopedic surgery, emphasized that physical therapy programs need to be individualized based on medical condition and a variety of factors, which are specifically identified in the decision. The IMR reviewer also noted that the duration of physical therapy is dependent on an individual’s progress. Overall, the IMR reviewer provides a very solid rationale for allowing the physical therapy sessions decertified by UR.
■ 85 Cal. Comp. Cases 268. Psychotherapy—Cognitive Behavioral Therapy—Chronic Pain—IMR reviewer overturned UR determination denying treating physician’s request for 12 one-hour sessions of patient/family psychotherapy. In this case, 62-year old applicant suffered an industrial injury in 2005 and was undergoing treatment for low back pain, lumbar spondylosis with radiculopathy, and major depressive disorder, anxiety and insomnia. Her physician prescribed 12 sessions of psychotherapy for chronic pain management with an emphasis on cognitive behavioral therapy (CBT) and stress management. The IMR expert noted that the MTUS/ACOEM 2017 guidelines recommend 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. Additionally, the guidelines state that while 4 to 6 sessions of CBT should be sufficient to provide evidence of symptom improvement, functional improvement is generally not seen without additional sessions. Here, UR had denied the request for psychotherapy based on the finding that applicant’s depression was at least in part caused by opioid dependence. In reviewing UR’s decision, the IMR expert noted that prior to the current request, applicant had not received any psychotherapy treatment despite her lengthy history of depression and anxiety. The IMR expert acknowledged that the current request was for twice the number of initial sessions recommended under the MTUS and ODG guidelines, but nonetheless found the request to be supported by the medical records, which included a QME report, and reasonable given applicant’s history of depression and anxiety and the lack of prior psychological treatment for these disorders. Therefore, the IMR reviewer concluded that the treatment request was medically necessary and appropriate even though it required a “one-time rare exception” to bypass the recommended MTUS/ODG guidelines setting forth an initial treatment trial of 6 sessions at most.
LexisNexis Commentary: In this case, the IMR expert made a rare decision to bypass the MTUS and ODG guidelines recommending a maximum of 6 initial psychotherapy sessions and approved an initial request for 12 sessions, where applicant had a significant history of depression and anxiety yet had never received psychological treatment for her condition. In getting the treatment approved, it was helpful that the documentation submitted contained a QME report, which is often more comprehensive than reports provided by the treating physician and likely provided additional information to support the treatment request.
TOPICAL NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
■ 85 Cal. Comp. Cases 451. Lidocaine Ointment—Burn Injuries—IMR reviewer upheld UR decision denying treating physician’s request for lidocaine 5% ointment 50gm #2 to treat 42-year old applicant’s neuropathic pain following severe burn injuries and multiple skin grafts. The IMR reviewer cited the MTUS chronic pain 2017 guidelines, which recommend topical NSAIDs for treatment of neuropathic pain but no other topical creams, and the ODG guidelines recommending use of topical analgesics for neuropathic pain only when trials of antidepressants and anticonvulsants have failed. With respect to lidocaine, the ODG recommends use of the medication in the form of a dermal patch for neurological pain, however, notes that lidocaine has not been approved for neuropathic pain, other than post-herpetic neuralgia, in any topical forms such as creams, lotions or gels. The medical documentation in this case indicated that applicant was currently undergoing treatment for sequelae of burns, peripheral neuropathy of the lower extremities and chronic pain syndrome. There was no indication that applicant was unable to take oral medications, or that applicant suffered from post-herpetic neuralgia. The IMR reviewer, accordingly, found that based on the MTUS and ODG guideline criteria, the request for lidocaine 5% ointment 50gm #2 was not medically necessary.
LexisNexis Commentary: The IMR reviewer upheld the UR denial where the treating physician’s request for lidocaine ointment to treat applicant’s burn-related neuropathic pain was not supported by the MTUS or ODG guidelines.
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