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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).
These selected IMR decisions provide guidance to the workers’ compensation community regarding the necessary criteria that must be met for approval of home health care in a variety of circumstances, and how to tailor an RFA to meet the injured worker’s specific needs. Other topics discussed include opioid medications and when the MTUS guidelines support their use, how patients should be monitored, and why regular screenings are important. Finally, there are several IMRs addressing medical transportation costs, including one interesting decision in which the IMR reviewer, in a novel application of the guidelines, equated applicant’s lack of funds for transportation to and from medical appointments to an inability to self-transport per the ODG and approved the cost of gas money and travel expenses to enable applicant to attend TMS treatments.
HOME HEALTH SERVICES
■ 2019 Cal. Wrk. Comp. LEXIS 102. In-Home Care—Traumatic Brain Injury—IMR reviewer overturned UR denial of home-care assistance for 3 hours per visit, 4 times per week, where applicant had residual functional deficits following a traumatic brain injury (intracranial hemorrhage), including expressive aphasia, altered gait, balance problems, and partial loss of extremity function. The applicable MTUS guidelines recommend short-term home health care services following hospitalizations or surgical procedures and in other specific circumstances for those who would otherwise require inpatient care. Here, applicant was able to leave his home as needed for appointments only with significant assistance. He also had problems with ADLs and other tasks. Applicant’s wife was his primary caretaker, but she herself was becoming more debilitated with painful arthritis in her hands and stress from caring for her husband and was unable to continue performance of caretaking duties at the level she had been performing. Under the circumstances, the IMR reviewer found the provider’s request for part-time help for a few hours 4 days per week to assist applicant with bathing, ambulation and other basic activities his spouse could no longer perform to be reasonable, compliant with the MTUS guidelines, and medically necessary in the short-term.
LexisNexis Commentary: This IMR decision provides guidance to the community regarding the showing that must be made for approval of home assistance. Here, applicant’s spouse could no longer care for applicant due to her own poor physical condition, and the IMR reviewer found that, under the circumstances, home assistance with daily activities while applicant’s condition continued to improve was reasonable.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-08012019/CM19-0104779.PDF. Home Health Aide—Post-Surgery—IMR reviewer overturned UR denial of treating physician’s request for a home health aide 5 days per week for 4 weeks following 54-year old applicant’s spine surgery. Applicant here suffered an industrial injury in 2012 and underwent treatment for chronic neck pain, arm pain/weakness and left-sided C7 foraminal stenosis. After conservative treatments failed, applicant was scheduled for cervical spine fusion surgery. The MTUS chronic pain 2017 guidelines relied upon by the IMR reviewer selectively recommend home health care on a short-term basis following hospitalization and major surgical procedures, to prevent re-hospitalization, to overcome deficits in ADLs, and/or to provide nursing, therapy and/or supportive care services for those individuals who would otherwise require inpatient care. To justify medical necessity of home health care, the MTUS guidelines and ODG require medical documentation describing the patient’s specific medical conditions and deficits in function, the type of services needed, and the estimated duration and frequency of such services. Further, the physician’s treatment plan should include a home health care evaluation by a registered nurse to assess the extent of care necessary. Per the ODG, home health services should generally be limited to 8 hours per day. The IMR reviewer found that use of home health assistance post-surgically was clearly indicated in this case but noted that the treating physician’s RFA did not include the number of hours and specific needs to be addressed in applicant’s case. Nonetheless, the IMR reviewer believed that it was inappropriate to penalize applicant for her treating physician’s lack of specificity, and in the interest of applicant’s post-surgical needs deemed the request for a home health aide 5 days per week for 4 weeks to be medically necessary.
LexisNexis Commentary: The IMR reviewer in this case explained that the treating physician’s request for home health care was deficient under the MTUS guidelines and ODG, but felt that it would be unfair to penalize applicant, who clearly needed a home health aide post-surgically, for the physician’s failure to draft a sufficient RFA. In this case, the IMR reviewer overturned the UR denial to serve applicant’s best interests. However, the IMR decision serves as a reminder that if there is insufficient specificity in an RFA, per the applicable guidelines, the request may be denied by UR on that basis.
■ 2019 Cal. Wrk. Comp. LEXIS 101. Skilled Nursing Facilities—Total Knee Revision—IMR reviewer overturned UR decision authorizing 65-year old applicant to spend only 7 days in skilled nursing facility following total knee revision, rather than 14 days as requested by applicant’s treating physician. In this case, applicant was travelling from her home to undergo right knee arthroscopy and planned to stay in an RV after the surgery, with no available caregivers. According to her treating physician, applicant needed skilled nursing placement for 2 weeks post-surgery as she would be at risk for a fall living in the RV, especially given that she would have to climb 5 steps to enter the RV. The IMR reviewer cited the ODG for skilled nursing facilities in cases of low back and knee injuries, which recommend skilled nursing or rehabilitation services on a 24-hour basis after at least 3 days of hospitalization if needed by a patient who has undergone major trauma or surgery such has spinal surgery or total hip/knee replacement. To support a request for a skilled nursing facility, the guidelines require, among other things, certification by a physician that the patient has functional limitations post-operatively that preclude lower levels of care, and that the patient has significant new functional limitations such as the inability to ambulate more than 50 feet or the inability to perform ADLs. The IMR reviewer found that applicant’s treating physician provided sufficient documentation and rationale to meet the guideline recommendations, and that the request for 14 days of a skilled nursing facility was medically necessary in this case.
LexisNexis Commentary: In this IMR decision, the IMR reviewer thoroughly explained why applicant needs 14 days in a skilled nursing facility post-knee replacement surgery, instead of the 7 days authorized by UR. The explanation provides significant guidance for the community regarding how to properly request skilled nursing care and clearly describes the criteria that must be met to get the requested care approved.
■ 84 Cal. Comp. Cases 879. Opioid Medications—Buprenorphine HCL—IMR reviewer overturned UR decision allowing only 54 of the 60 tablets of Buprenorphine HCL 8mg requested by the treating physician. In this case, 53-year old applicant was being treated for chronic low back pain radiating to his right leg, following 2006 industrial injury to his lumbar spine and lumbar fusion. He had been using Buprenorphine HCL 8mg #60 for approximately 5 months prior to the current request, with decreased pain and functional improvement. The IMR reviewer cited the MTUS 2019 guidelines for opioid prescriptions, which require appropriate documentation of pain, ADLs, adverse effects, and screening for aberrant usage of the medication through CURES and urine drug screening (UDS). The opioid guidelines recommend short-term use if possible and periodic attempted weaning. Here, the IMR reviewer noted that there was documentation of improvement in applicant’s pain and function with use of Buprenorphine HCL, and that applicant was considered to be at low risk for opioid abuse. The IMR reviewer further noted that UR modified the original request for Buprenorphine HCL 8mg #60 based on lack of UDS results/reports submitted by the treating physician. Although the UDS result was not provided, the documentation submitted indicated that the test was conducted, and the result was found to be “appropriate.” The IMR reviewer concluded that the Buprenorphine HCL 8mg #60 was medically necessary, but strongly recommended that the provider consistently submit UDS reports for review to prevent disruption in care.
LexisNexis Commentary: This IMR is instructive with regard to the MTUS guidelines to cite to get approval for opioid medication to relieve chronic pain. The decision also illustrates the importance of submitting the screening reports with the UR documentation.
■ 84 Cal. Comp. Cases 874. Opioid Medications—Hysingla—IMR reviewer overturned UR decision allowing only 15 of the 30 tablets of Hysingla ER 20 mg requested by applicant’s treating physician. In this case, 73-year old applicant was being treated for lumbar spondylosis and lumbar disc degeneration following 3/7/2002 industrial injury. He was prescribed Hysingla ER 20 mg for pain and, according to the provider, was on the lowest possible dose. Applicant reported a decrease in pain with use of the Hysingla from a 5/10 to 1-2/10 on a scale of 10 and stated that the medication allowed him to perform ADLs. The MTUS/ACOEM guidelines relied upon by the IMR reviewer state that opioid prescriptions should be limited to cases in which other treatments are insufficient and recommend regular assessment of the patient’s function after starting opioid treatment for pain reduction. Under the guidelines, there should be at least 30 percent improvement in pain and function to justify continuation of opioid treatment. The guidelines also recommend regular urine drug screening in addition to an opioid treatment agreement between doctor and patient. Here, the IMR reviewer found that the requesting provider adequately documented all of the necessary criteria to continue opioid pain management, including improvement in function and at least 30 percent reduction in pain. Additionally, periodic urine drug testing was noted, the CURES database was searched to monitor for “doctor shopping” behavior, and an opioid pain agreement was utilized. The IMR reviewer concluded that, under these circumstances, the treatment requested was medically necessary.
LexisNexis Commentary: This IMR decision provides an example of a situation in which the requested medicine was found to be medically necessary, but UR reduced the number of pills requested by the provider. The UR reviewer found that where applicant had decreased pain, increased function and was able to perform ADLs, the requested supply of pills was medically necessary.
■ 2019 Cal. Wrk. Comp. LEXIS 102. Physical Therapy—Traumatic Brain Injury—IMR reviewer overturned UR denial of 12 physical therapy (PT) sessions, once or twice per week for 6 weeks, to treat 72-year old applicant’s injuries to his head, right leg, left arm, left shoulder, and mild gait disorder. Applicant in this case had residual functional deficits after a traumatic intracranial hemorrhage in late 2017. He had previously undergone physical therapy both outside and inside the workers’ compensation system but was denied additional PT based on the perception that his condition was not significantly improving. The IMR reviewer relied on the MTUS traumatic brain injury 2017 guidelines, which support trial therapy for traumatic brain injury patients with functional deficits and noted that PT should be discontinued when there is desired improvement, clinical plateau or failure to improve. Although applicant’s progress in this case was been slow, his treating neurologist and spouse recently noticed some improvement in his gait and balance. Based on the fact that applicant had improvement with recent PT, and the fact that he had some remaining functional deficits that were still improving, the IMR reviewer found that an additional 12 visits of PT was consistent with the guideline criteria and was medically necessary.
LexisNexis Commentary: The IMR reviewer in this case did a very good job explaining why additional PT was reasonable and necessary under the MTUS guidelines when applicant, who had a traumatic brain injury affecting his gait and balance, had slowly improved with prior PT and was continuing to improve.
■ 2019 Cal. Wrk. Comp. LEXIS 103. Prescription Medication—Anticonvulsants—Topiramate (Topamax)—IMR reviewer overturned UR decision reducing the number of Topiramate (Topamax) pills from the requested 90 pills to 81 pills. Here, 50-year old applicant had chronic pain involving her cervical/upper back region and right shoulder. The MTUS/ACOEM 2019 guidelines cited by the IMR reviewer recommend the anticonvulsant Topiramate to treat cervical/thoracic pain after failure of other modalities, including trials of different NSAIDs, aerobic exercise, stretching exercise, strengthening exercise, tricyclic antidepressants, and manipulation. The documentation in this case indicated that applicant had been using the prescribed anticonvulsant medication for approximately 2 months, and her level of pain was decreased by half. Applicant had tried multiple other first-line modalities with only limited or short-term benefit. The IMR reviewer noted that the provider was weaning applicant’s dose upwards from 50mg once per day to 100mg once per day, meeting the criteria for titration upwards and continued trial of the medication. The IMR reviewer concluded that the requested prescription of Topiramate (Topamax) 50mg #90 was medically necessary. [LexisNexis Commentary: This IMR decision provides guidance regarding situations in which UR finds that a prescribed medication is medically necessary, but reduces the quantity allowed. In this case, UR reduced the number of pills by 9 and, at a cost of approximately $1.50 per pill, the cost savings was less than $15.00 over one and a half months.]
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-07012019/CM19-0083353.PDF. Transportation Costs—Gas Money/Travel Expenses—Medical Appointments—IMR reviewer overturned UR denial of provider’s request for medical transportation costs in the form of weekly gas money/travel expenses. Here, 55- year old applicant was diagnosed with a pain disorder and major depression. UR certified a request for Transcranial Magnetic Stimulation (TMS) to treat the depression, but non-certified a request for weekly gas money and travel expenses for TMS attendance. Citing the ODG, the IMR reviewer noted that roundtrip transportation may be allowed if it is medically necessary and if the patient’s disability prevents self-transport. The ODG transportation reference specifically applies to patients age 55 or older and in need of a nursing home level of care. Based on the documentation provided by applicant’s treating physician indicating that applicant had lost his home, was estranged from his family and did not have enough funds to travel to and from medical appointments, the IMR reviewer concluded that the request for gas money and travel expenses was reasonable and medically necessary under the guideline criteria.
LexisNexis Commentary: This IMR decision illustrates a situation in which the IMR reviewer equated applicant’s lack of funds for transport to and from medical appointments to an inability to self-transport per the ODG guidelines and approved the cost of gas money and travel expenses to enable applicant to attend TMS treatments.
■ https://www.dir.ca.gov/dwc/imr/imr-decisions/IMR-Decisions2019/IMR-08012019/CM19-0114644.PDF. Transportation Costs—Medical Appointments—IMR reviewer upheld UR decision denying provider’s request for transportation costs to 1 medical appointment. In this case, 55-year old applicant suffered an industrial injury spine injury in 2009, and a subsequent related injury in 2018 due to gait derangement. Applicant was morbidly obese, had significant orthopedic injuries that caused chronic pain and functional deficits, and required use of a cane. Applicant’s treatment plan included a request for authorization for orthopedic evaluation of the left ankle and left knee and platelet rich plasma injection. The IMR reviewer noted that the ODG recommend transportation for medically necessary medical appointments in the same community for patients with disabilities preventing self-transport. According to the IMR reviewer, applicant did not reside in a community with individuals who had similar disabilities and, therefore, did not meet the guideline criteria for medical transportation.
LexisNexis Commentary: This IMR decision is a reminder that to get medical transportation costs certified, it is crucial that the provider explain why self-transport is not possible. Here, applicant had significant injuries that would seemingly make self-transport difficult, if not impossible. Although applicant’s treating physician detailed applicant’s injuries and objective findings, he/she did not specifically spell out why applicant could not transport herself to a medical appointment, and transportation costs were denied. Note, the IMR expert’s precise rationale for upholding UR’s denial was unclear.
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