LexisNexis has chosen some not too long ago issued noteworthy IMR selections that illustrate the standards that have to be met to acquire authorization for quite a lot of completely different medical therapy modalities. LexisNexis Commentary for every chosen IMR is supplied beneath. Many of those IMR selections had been reprinted in California Compensation Instances, which could be accessed on Lexis+. Lexis+ subscribers can entry these specific selections on-line. The checklist discusses particular IMR opinions which clarify how physicians ought to finest apply therapy pointers using the “Medical Proof Search Sequence” for the therapy of injured employees as set forth in 8 Cal. Code Reg. § 9792.21.1, and embody the MTUS at 8 Cal. Code Reg. § 9792.21.1(d)(1), different medical therapy pointers such because the ACOEM and ODG at 8 Cal. Code Reg. § 9792.21.1(d)(2) and peer reviewed research at 8 Cal. Code Reg. § 9792.21.1(d)(3). These chosen IMR selections tackle, amongst different matters, non-invasive and low-cost therapy modalities comparable to aquatic remedy, therapeutic massage and Pilates. The choice addressing Pilates is especially helpful as a result of it appropriately treats Pilates as a type of train and, though there are not any therapy pointers particularly addressing Pilates, train is mostly advisable for the therapy of persistent ache. Additionally mentioned beneath are two IMR selections involving requests for sturdy medical tools, together with an ergonomic desk and chair and an orthopedic mattress. The desk and chair had been deemed medically vital primarily based on the relevant MTUS/ACOEM pointers. Additional, the employer was legally required to supply these lodging. Then again, the request for an orthopedic mattress was denied. In line with the rules, there isn’t any medical foundation for a doctor to prescribe any specific mattress for the prevention or therapy of persistent ache; relatively, a affected person should select a mattress primarily based on private consolation.
AQUATIC THERAPY
■ 89 Cal. Comp. Cases 1141. Aquatic Remedy—Again Ache/Radiculopathy—Applicant, 55 years previous, suffered an industrial harm on 8/20/2021 and was present process therapy for cervicalgia, lumbago, cervical radiculopathy, and a sprain of the thoracic backbone ligaments. In a 4/25/2024 progress report, applicant reported low again ache rated at 7/10 that radiated to the left decrease extremity and foot. She additionally reported issue with sitting, standing and strolling for greater than 30-60 minutes, and with lifting. Applicant’s treating supplier requested six aquatic remedy periods for the decrease again, which UR denied. The IMR reviewer overturned the UR denial primarily based on the MTUS 2021 pointers for low again/radicular ache, which advocate a trial of aquatic remedy for the therapy of subacute or persistent low again ache in sure sufferers that meet the standards for supervised train remedy and have co-morbidities (e.g., excessive weight problems, vital degenerative joint illness, and so forth.) that preclude efficient participation in weight-bearing bodily exercise. The IMR reviewer famous that aquatic remedy is just not advisable for all different subacute or persistent low again ache sufferers or for all acute low again ache, as different therapies are believed to be more practical. The documentation on this case mirrored that applicant had decrease extremity weak point and an antalgic gait that adversely impacted her capability to have interaction in land-based bodily remedy. There was additionally documentation of weight problems, a earlier trial of land-based remedy and a house train program. The IMR reviewer noticed that the treating doctor outlined clear therapy objectives for the requested course of aquatic remedy. Accordingly, the IMR reviewer concluded that aquatic remedy was affordable and medically essential to deal with applicant’s decrease again ache. [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. Mind Damage Program—Preliminary Analysis—Applicant, 54 years previous, sustained a traumatic mind harm on 7/26/2022, leading to persistent post-traumatic complications, post-concussion syndrome, cervicalgia, and proper shoulder ache. An MRI of applicant’s mind revealed tiny bifrontal white matter lesions according to microvascular illness. A subsequent bodily examination revealed a laceration scar over the vertex of applicant’s head, gentle scalp allodynia, gentle guarding on cervical backbone actions, and absent deep tendon reflexes within the bilateral Achilles. Remedy included chiropractic remedies, psychotherapy, bodily remedy, drugs, and exercise modifications. As of seven/18/2023, applicant was working modified obligation. He reported fixed complications with ache, rated at 6-9/10, radiating to his neck and bilateral trapezii, together with occasional photophobia. Applicant’s supplier requested authorization to have applicant evaluated for participation in a mind harm program. The request was denied by UR. The IMR reviewer overturned the UR denial primarily based on the 2018 MTUS traumatic mind harm pointers, which selectively advocate outpatient house and community-based rehabilitation for TBI sufferers with enough residual signs or indicators of post-traumatic mind harm necessitating ongoing therapy. The rules point out that there could also be choose sufferers with gentle TBI that could be candidates for a mind harm program primarily based on ongoing signs. The rules additionally state that selective and built-in rehabilitation packages are designed to assist the person work on particular duties with the intention to retrain the physique to perform stated duties, and that not all sufferers want all program parts, so packages needs to be tailor-made to the particular affected person’s wants. Primarily based on applicant’s signs and bodily examination, the IMR reviewer concluded that the request for a mind harm program, preliminary analysis, was medically vital underneath the relevant MTUS standards. [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 signs and/or indicators of post-TBI to necessitate ongoing therapy” (MTUS/ACOEM Traumatic Bain Damage Guideline, 11/15/2017, p. 208) to look extra carefully on the appropriateness of a mind harm program. Because the pointers state that the mind harm packages have to be tailor-made to the actual affected person, this non-invasive preliminary analysis seems to be justified.]
■ 89 Cal. Comp. Cases 602. Mind Damage Outpatient Program—Applicant, 56 years previous, suffered an industrial mind harm on 2/15/2023, and was present process therapy for post-concussion syndrome and post-traumatic complications. Her signs included dizziness, complications, blurry imaginative and prescient, double imaginative and prescient, stability issues, poor focus, reminiscence loss, tinnitus, phonophobia, sleep disturbances, mind fog, despair, anxiousness, aphasia, agnosia, and sensitivity to loud sounds, which resulted in heightened anxiousness and issue multitasking. A psychological standing examination revealed occasional issue announcing phrases with gentle slurred speech, unsteady gait, and look of being imbalanced. A bodily examination recognized tautness of the bilateral trapezii muscle tissues with lowered cervical spinal mobility on account of muscular pressure. On 10/4/2023, applicant’s medical supplier requested authorization for a mind harm outpatient day program (4 hours per day of therapy, 4 days every week for 5 weeks), with 20 days in a single day keep as a result of lengthy distance between applicant’s residence and this system’s location. The request was denied by UR. The IMR reviewer overturned the UR denial primarily based on the 2018 MTUS traumatic mind harm pointers, which selectively advocate outpatient house and community-based rehabilitation for TBI sufferers with enough residual signs or indicators of post-traumatic mind harm necessitating ongoing therapy. The rules be aware that an outpatient program is extra applicable for these with a “higher” mismatch between present talents and the cognitive and bodily calls for of the affected person’s job, though it could possibly be justified even in a gentle case the place the signs are ongoing. Primarily based on applicant’s signs and given the gap applicant must journey, the IMR reviewer concluded that the request for the outpatient mind harm program with 20 days of lodging was medically vital. [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 Remedy—Lumbar Backbone—Applicant, 36 years previous, suffered an industrial low again harm on 4/20/2013, and reported low again ache. A bodily examination revealed tenderness to palpation within the lumbar backbone, with palpable set off factors, decreased vary of movement, and decreased sensation at L4-5, bilaterally. Applicant had accomplished eight periods of chiropractic therapy on 10/30/2023 and requested further periods primarily based on enchancment in his ache. In line with applicant, his again ache may attain 8/10 in depth, however with chiropractic therapy the ache decreased by 30 p.c to five/10, permitting him to lower his treatment utilization. On 11/1/2023, applicant’s medical supplier requested eight further periods of chiropractic therapy to the lumbar backbone to enhance applicant’s vary of movement and performance and alleviate ache, with a subsequent transition to an impartial house train program. UR noncertified the requested therapy, citing the MTUS 2021 pointers for low again issues. The IMR reviewer overturned the UR noncertification primarily based on the MTUS 2021 pointers for low again issues and the non-MTUS ODG addressing therapy for low again issues. The MTUS low again chapter recommends manipulation or mobilization of the lumbar backbone for short-term reduction of persistent ache or as a part of an energetic therapy program specializing in energetic workouts for acute exacerbations. The rules present that if there’s a vital constructive response to the therapy, further periods could also be thought-about. The ODG chiropractic pointers advocate a complete of 18 therapy periods if there’s proof of purposeful enchancment with therapy. Nevertheless, the Delphi suggestions enable as much as 24 visits primarily based on documented enchancment at two factors through the course of remedy. The IMR reviewer famous that applicant initially underwent a course of bodily remedy that did not resolve his complaints. He was then referred for a course of chiropractic therapy, which decreased his ache and drugs utilization. Given the advance famous with the preliminary course of chiropractic therapy and the residual complaints, the IMR reviewer discovered that the rules supported the request for extra chiropractic periods. [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 previous, suffered an industrial harm on 4/29/2021 and was present process therapy for left shoulder ache, bilateral wrist ache, left elbow ache, bilateral hand ache, myalgia, left elbow lateral epicondyle, low again ache, lumbar area intervertebral disc degeneration, and cervicalgia. In a 6/6/2023 progress report, applicant reported persistent left higher extremity ache and proper hand and wrist ache rated at 9/10. The ache elevated with actions and barely improved with relaxation. Applicant reported a small enchancment within the neck and shoulder signs, however worsening paresthesias and numbness within the left hand and higher extremities. She was quickly completely disabled from work. Applicant’s doctor requested an ergonomic adjustable desk and work chair to enhance applicant’s signs and assist her return to work. Citing no MTUS pointers, UR denied the request. The IMR reviewer overturned the UR denial primarily based, partly, on the MTUS 2017 persistent ache pointers, which advocate participatory ergonomics packages for choose sufferers with subacute and persistent ache who stay off work or on a distinct job, have obvious office limitations to return to work, and the place there’s managerial assist and curiosity in analyzing and addressing limitations. The IMR reviewer additionally cited the MTUS 2019 pointers for elbow issues, which advocate ergonomic interventions in settings with combos of danger components, and particularly to cut back components for epicondylalgia. The IMR reviewer famous that applicant underwent an ergonomic analysis in 2021 and was advisable for ergonomic intervention at the moment. Given applicant’s signs, work standing and the prior suggestion for ergonomic intervention, the IMR reviewer concluded that the request for an ergonomic adjustable desk and work chair was medically vital. [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—Again Ache—Applicant, 71 years previous, suffered an industrial harm on 5/1/2000, and was present process therapy for lumbar radiculopathy, post-laminectomy syndrome following surgical procedure and osteoarthritis in his knees, amongst different circumstances. In an 11/22/2023 progress report, applicant reported ache within the decrease again, hips/thighs knees/legs, ankles, and ft. In line with applicant, the ache was sharp, achy, burning, throbbing, and capturing, and was current 75 p.c of the time. Applicant’s supplier requested authorization for a Queen measurement orthopedic adjustable mattress to assist applicant sleep higher. UR denied the request. The denial was upheld by the IMR reviewer, who famous that the MTUS 2021 pointers for low again issues states that particular beds should not advisable for the prevention or therapy of acute, subacute or persistent low again ache, and there’s no suggestion for or towards the usage of mattresses or every other particular sleeping surfaces for the therapy of such ache. Additional, the IMR reviewer noticed, the rules present that sufferers ought to choose the sleeping possibility most comfy for them, and in instances the place there’s enough ache to intrude with sleep, suggestions by the supplier for the affected person to discover the impact of various surfaces within the house is suitable. Nevertheless, the rules present that it isn’t applicable for medical suppliers to order mattresses or bedding for sufferers. The IMR reviewer additionally cited the MTUS persistent ache 2017 pointers, which don’t advocate particular sleep merchandise for prevention or therapy of persistent ache. These pointers do, notably, state that there are not any high quality research evaluating particular business merchandise for therapy of persistent persistent ache syndrome. Primarily based on the MTUS pointers, the IMR reviewer concluded that there was no rationale to assist the therapy request and, due to this fact, the request for a Queen measurement orthopedic adjustable mattress was not medically vital. [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 Research—Carpal Tunnel Syndrome—Applicant, 34 years previous, suffered an industrial harm on 12/14/2017, and was present process therapy for cervical radiculopathy. In 2019, applicant underwent a cervical discectomy with fusion at C5-C6. Following the primary surgical procedure, applicant had elevated numbness in the best hand. In 2023, applicant’s treating doctor requested an EMG/NCS examine to doc the present findings prematurely of proposed cervical discectomy and fusion surgical procedure at C6-C7. UR denied the requested therapy, citing the MTUS 2019 cervical and thoracic backbone pointers. The IMR reviewer overturned the UR non-certification and located the electrodiagnostic testing medically vital primarily based on the MTUS 2019 pointers for carpal tunnel syndrome, which advocate electrodiagnostic research to help in securing a agency analysis for these sufferers and not using a clear analysis of carpal tunnel syndrome, and to objectively safe a analysis of carpal tunnel syndrome previous to surgical launch. Given applicant’s earlier post-operative neurologic indicators and signs, the IMR reviewer believed it was affordable to conduct the requested electrodiagnostic testing, no less than as a baseline documentation, and the request was discovered to be medically vital. [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 Ache Applications—Purposeful Restoration Program—Preliminary Analysis—Applicant, 68 years previous, suffered an industrial harm on 6/6/2007, and was present process therapy for lumbar radiculopathy and proper foot drop. Applicant had a longstanding historical past of persistent ache and, on 10/2/2023, his medical supplier requested approval for a multidisciplinary analysis prior to make use of of a purposeful restoration program. UR denied the request. The IMR reviewer overturned the UR non-certification primarily based on the MTUS 2017 persistent ache pointers addressing use of tertiary ache packages, which selectively advocate purposeful restoration packages for sufferers with persistent ache who’ve failed typical remedies and stay considerably incapacitated. Previous to starting a tertiary ache program, the rules require {that a} affected person undergo a radical analysis which ought to comprise a document evaluate and evaluation by program personnel together with a ache doctor, a medical historical past and bodily, a complete analysis by a psychologist, and an analysis by a bodily and/or occupational therapist. Though applicant on this matter gave the impression to be retired, he remained incapacitated with restricted perform. The IMR reviewer famous that applicant’s therapy over the course of a few years did not resolve his ache and facilitate return to unrestricted work. Given applicant’s incapacitation with restricted perform, the medical supplier believed he was a candidate for a purposeful restoration program. Given the time that has elapsed since applicant’s harm and his in depth prior therapy amidst ongoing purposeful deficits, the IMR reviewer concluded that analysis for a tertiary program was medically vital and affordable primarily based on the MTUS pointers. [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. Therapeutic massage Remedy—Again and Shoulder Ache—Applicant, 59 years previous, sustained an industrial harm on 08/18/2020, and underwent therapy for neck, shoulder and low again ache. Imaging research revealed a gentle bulging disc in applicant’s lumbar backbone and degenerative disc illness within the cervical backbone. Nevertheless, no abnormalities had been detected in applicant’s shoulder. On 3/21/2024, applicant reported persistent ache in his low again and proper shoulder. He indicated {that a} earlier course of therapeutic massage remedy supplied vital ache reduction. Applicant’s treating doctor requested six further one-hour therapeutic massage remedy periods. UR denied the request. The IMR reviewer overturned the UR denial, citing the “MTUS Cervical and Thoracic Backbone 2019 Pointers, Part(s): Cervicothoracic Ache: Remedy Rec’s: Allied Well being” and the “MTUS Shoulder Problems 2023 Pointers, Part(s): Rotator Cuff Tendinopathies: Remedy Rec’s: Allied Well being Interventions.” The IMR reviewer famous that the shoulder pointers make no suggestion for or towards the usage of therapeutic massage remedy for the therapy of shoulder ache or tendinopathies, however the cervicothoracic therapy pointers advocate therapeutic massage, as an adjunct to cardio and strengthening train packages, to be used in persistent cervicothoracic ache sufferers with out underlying critical pathology to help in rising purposeful exercise ranges extra quickly. On this case, the IMR reviewer famous, applicant accomplished six therapeutic massage periods with profit. Applicant additionally had a historical past of treatment use for persistent ache, and the objectives of message remedy included the discount in oral drugs, which was particularly pertinent on account of applicant’s use of oral drugs inflicting gastrointestinal upset. The IMR reviewer discovered the requested variety of remedies applicable for periodic evaluation and concluded that the request for six periods of therapeutic massage remedy was medically vital. [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 Remedy—Opioids—Tramadol—Applicant, 59 years previous, suffered an industrial harm on 4/27/2018 and was handled for, amongst different issues, ache within the lumbosacral spinal area with radiculopathy. A progress report dated 11/4/2022 mirrored that applicant was experiencing persistent ache within the low again radiating to the left decrease extremity and bilateral knee ache. He was utilizing Tramadol 50 mg #30 and ibuprofen cream. On 11/17/2022, the supplier requested approval for Tramadol HCI 50mg #45. UR modified the request, permitting 27 of the 45 tablets requested. Nevertheless, the IMR reviewer discovered that 45 tablets had been medically vital primarily based on the MTUS 2017 opioid pointers. The rules present that continued use of opioid ache drugs for therapy of subacute or persistent extreme ache needs to be thought-about if the affected person has no less than 30 p.c enchancment in each ache and performance with use of the treatment. Applicant right here reported as much as 30 p.c ache discount impacting exercise efficiency throughout private care duties, purposeful mobility, group administration, productiveness associated duties, family administration, recreation, and socializing. He denied any unintended effects. Applicant’s supplier had a signed managed substance settlement within the chart, and a CURES report was reviewed and located to be compliant. As a result of the documentation submitted indicated that applicant had enchancment in perform and ache that aligned with the standards for continued use of opioid ache drugs within the relevant MTUS pointers, and applicant’s opioid use was being correctly monitored, the IMR reviewer decided that continued use was applicable. [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 Remedy—Opioids—Acetaminophen/Codeine—Applicant, 54 years previous, sustained an industrial harm on 8/31/2009 and commenced present process therapy for, amongst different issues, ache within the lumbosacral spinal area with radiculopathy. Applicant underwent lumbar decompression surgical procedure in 2021, after which he reported that he was doing “okay” and rated his ache at 4-7/10. Medicines included acetaminophen/codeine 300/30 mg tablets (since no less than 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 supplier requested approval for acetaminophen/codeine 300/30mg #120. UR denied the request. Nevertheless, the IMR reviewer discovered the request medically vital primarily based on the MTUS 2017 opioid pointers. The rules present that continued use of opioid ache drugs for therapy of subacute or persistent extreme ache needs to be thought-about if the affected person has no less than 30 p.c enchancment in each ache and performance with use of the treatment. The IMR reviewer famous that, in keeping with the documentation submitted, use of acetaminophen/codeine “took the sting off” of applicant’s ache and allowed him to have interaction in ADLs comparable to family chores, meal preparation, and workouts. An opioid settlement was signed by applicant on 06/09/2022. CURES was checked on 11/11/2022 and it was according to the supplier’s therapy plan. As a result of the documentation submitted indicated that applicant had enchancment in perform and ache that aligned with the standards for continued use of opioid ache drugs within the relevant MTUS pointers, and applicant’s opioid use was being correctly monitored, the IMR reviewer decided that the requested prescription was affordable and applicable. [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—Again Ache—Applicant, 44 years previous, sustained an industrial harm on 3/29/2021, and underwent therapy for intervertebral disc issues with lumbar radiculopathy, ache in the best wrist, cervicalgia, and dorsalgia. On 12/12/2023, applicant reported ongoing low again ache rated at 7-9/10 and was on modified work obligation. Applicant’s treating doctor requested approval for eight periods of Pilates to enhance applicant’s core energy and assist her persistent low again ache. UR denied the request. The IMR reviewer famous that the MTUS has no suggestion relating to the usage of Pilates. Nevertheless, the MTUS 2021 pointers for the therapy of low again issues/ache reasonably advocate train packages for acute, subacute, persistent, post-operative or radicular low again ache with a frequency of 1 to a few periods per week for as much as 4 weeks, so long as there’s goal purposeful enchancment and symptom discount. Underneath the rules, analysis for an train prescription includes consideration of 5 important parts: (1) stage of (theoretical) tissue therapeutic (acute, subacute, persistent); (2) severity of signs (gentle, average, extreme), (3) identification of the presence or absence of a directional choice, (4) diploma and kind of deconditioning (flexibility, energy, cardio, muscular endurance), and (5) psychosocial components (e.g., treatment dependence, fear-avoidance, secondary achieve, temper issues). The IMR reviewer noticed that applicant had not beforehand attended Pilates, and that the MTUS recommends as much as 12 periods of an train program. As such, the IMR reviewer concluded that eight periods of Pilates to enhance applicant’s core energy was medically vital. [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 Wire Stimulators—Continual Ache—Applicant, 60 years previous, sustained an industrial harm on 9/8/95 and was present process therapy for persistent ache and radiculopathy in her lumbar area. Diagnoses included lumbar radiculitis, post-laminectomy syndrome, and persistent ache syndrome. Earlier remedies included bodily remedy, injections, nerve blocks, drugs (together with opioids), and L3-S1 fusion with L2-L5 laminectomy. Along with the lumbar surgical procedure, applicant had undergone rotator cuff restore, two knee surgical procedures, meniscus restore, and surgical procedure on each fingers. On 9/8/2023, applicant’s treating doctor requested authorization for a spinal twine stimulator trial. UR denied the request. The IMR reviewer overturned UR’s non-certification primarily based on the MTUS 2021 therapy pointers for low again issues with radicular ache, which advocate spinal twine stimulators solely in extremely selective circumstances when all different indicated remedies have failed, the affected person has insufficient perform, and “the supplier needs to hunt approval from a employee´s compensation service for consideration of doable protection regardless of the dearth of high quality proof of efficacy in these sufferers.” Standards for implantable spinal twine stimulator in a persistent radiculopathy affected person embody, however should not restricted to (1) clear analysis of persistent radiculopathy, during which leg ache is predominant, (2) poor or insufficient response to surgical therapy, (3) poor or insufficient response to a purposeful restoration program, with therapy for no less than six months, (4) remedial surgical procedure is inadvisable or not possible, (5) main psychiatric issues have been handled with anticipated responses, (6) the affected person has had profitable outcomes of no less than 50 p.c ache discount from a trial of a short lived exterior stimulator of roughly two to a few days, and (7) discount of use of opioid treatment or different treatment with vital opposed results, or purposeful enchancment comparable to return to work. The IMR reviewer famous that applicant has had extreme, intractable ache in her lumbar backbone radiating to her legs, inflicting vital purposeful limitations because the time of her work-related harm. She has exhausted a number of conservative and invasive procedures prior to now, together with a number of injections and prior lumbar surgical procedures. The IMR reviewer noticed that applicant had a psychological analysis and was deemed an applicable candidate for a spinal twine stimulation trial. Primarily based on the extenuating circumstances famous above, the IMR reviewer concluded that applicant met the standards for the extremely selective use of spinal twine stimulation, and that the requested therapy was medically vital. [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 previous, suffered an industrial harm on 3/21/91, leading to ongoing extreme (rated at 9/10) and persistent ache in her low again and buttock, radiating down her left leg. Applicant was additionally present process therapy for advanced regional ache syndrome of her higher limb, spinal stenosis with neurogenic claudication and different comorbid circumstances. On 8/30/2023, applicant’s doctor requested authorization for an L1-2 laminectomy. The request was denied by UR. The IMR reviewer overturned the UR non-certification primarily based on the MTUS 2021 pointers for the therapy of low again issues, which reasonably advocate decompression surgical procedure for sufferers with symptomatic spinal stenosis that isn’t aware of conservative therapy and now have radicular ache or weak point, affirmation of spinal stenosis on imaging checks, and ongoing vital ache and purposeful impairment for no less than 4 to 6 weeks after trying non-surgical choices. Nevertheless, the rules expressly counsel warning in instances of aged sufferers with comorbidities. The IMR reviewer famous that, per the documentation submitted, applicant suffered from buttock and leg paresthesia leading to a number of falls. She additionally had poor stability and 40 p.c of the conventional vary of movement. The MRI imaging of applicant’s lumbar backbone confirmed 8mm retrolisthesis of L1 and L2 and extreme disc house narrowing with degenerative endplate irregularities and a circumferential disc bulge at L1-2, gentle bilateral neural foraminal narrowing, and average to extreme spinal canal stenosis. The IMR reviewer identified that applicant had tried however failed conservative remedies with continued, progressive findings. However applicant’s superior age and comorbidities, the IMR reviewer concluded that applicant met the rule of thumb standards, and, due to this fact, the request for L1-2 laminectomy was medically vital. [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.]
© Copyright 2024 LexisNexis. All rights reserved.
