Matt Lewis Law Dallas Texas - ODG - July 11, 2008

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ODG: Medical Treatment For Back And Neck Injuries - 2008 Matthew Lewis (972) 644-1111 Telephone matt@mattlewislaw.com

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Rule 137.100 Treatment Guidelines HCP’s shall provide treatment in accordance with the current edition of the Official Disability Guidelines – Treatment in Workers’ Comp unless the treatment requires preauthorization under Rule 134.600

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Services provided in accordance with the Guidelines is presumed reasonable and reasonably required (medically necessary).

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Carrier is not liable for services that exceed the Guidelines unless provided in an emergency or preauthorized under Rule 134.600

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§ 408.021(a). ENTITLEMENT TO MEDICAL BENEFITS An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.

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The employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.

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Low Back “The focus of treatment should not be symptom reduction, but improving function with a goal of return to work” Not necessarily about healing Tape’m up, shoot’em up, and get’em back in the game

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Low Back X-Rays are generally not recommended until the third visit, and only then if the patient is still disabled. X-Rays may be performed on the first visit if there is evidence of significant trauma. Reimbursement may be denied if there is a question about the "significance" of any trauma. ODG parenthetically provides an example of significant trauma as a fall.

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Low Back ODG Chiropractic Guidelines: Therapeutic care – Mild: up to 6 visits over 2 weeks Severe: Trial of 6 visits over 2 weeks Severe: With evidence of objective functional improvement, total of up to 18 visits over 6-8 weeks, if acute, avoid chronicity Elective/maintenance care – Not medically necessary Recurrences/flare-ups – Need to re-evaluate treatment success, if RTW achieved then 1-2 visits every 4-6 months  

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Low Back ODG Physical Therapy Guidelines – Allow for fading of treatment frequency (from up to 3 or more visits per week to 1 or less), plus active self-directed home PT. Lumbar sprains and strains (ICD9 847.2): 10 visits over 8 weeks Sprains and strains of unspecified parts of back (ICD9 847): 10 visits over 5 weeks Sprains and strains of sacroiliac region (ICD9 846): Medical treatment: 10 visits over 8 weeks Lumbago; Backache, unspecified (ICD9 724.2; 724.5): 9 visits over 8 weeks

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Low Back Intervertebral disc disorders without myelopathy (ICD9 722.1; 722.2; 722.5; 722.6; 722.8): Medical treatment: 10 visits over 8 weeks Post-injection treatment: 1-2 visits over 1 week Post-surgical treatment (discectomy/laminectomy): 16 visits over 8 weeks Post-surgical treatment (arthroplasty): 26 visits over 16 weeks Post-surgical treatment (fusion): 34 visits over 16 weeks Intervertebral disc disorder with myelopathy (ICD9 722.7) Medical treatment: 10 visits over 8 weeks Post-surgical treatment: 48 visits over 18 weeks Spinal stenosis (ICD9 724.0): 10 visits over 8 weeks

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Low Back Sciatica; Thoracic/lumbosacral neuritis/radiculitis, unspecified (ICD9 724.3; 724.4): 10-12 visits over 8 weeks See 722.1 for post-surgical visits Work conditioning 10 visits over 8 weeks

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Low Back No referral consults are recommended in the absence of radiculopathy. If radiculopathy is clinically indicated, a referral to a nonsurgical musculoskeletal physician is recommended following the second visit. Surgical consult with fellowship trained spine surgeon (orthopedist or neurologist) recommended after three months

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Low Back MRI, EMG, ESI & Psych Testing are all recommended after the fourth visit, if radicular symptoms are present. MRI or CT not indicated without obvious clinical level of nerve root dysfunction, clear radicular findings, or before 3-4 weeks

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Low Back The purpose of ESI is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs, but this treatment alone offers no significant long-term functional benefit May be a way to obtain preauthorization for additional active therapy

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Low Back Criteria for admission to a Work Hardening Program: (1) Work related musculoskeletal condition with functional limitations precluding ability to safely achieve current job demands, which are in the medium or higher demand level (i.e., not clerical/sedentary work). An FCE may be required showing consistent results with maximal effort, demonstrating capacities below an employer verified physical demands analysis (PDA). (2) After treatment with an adequate trial of physical or occupational therapy with improvement followed by plateau, but not likely to benefit from continued physical or occupational therapy, or general conditioning. (3) Not a candidate where surgery or other treatments would clearly be warranted to improve function.

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Low Back (4) Physical and medical recovery sufficient to allow for progressive reactivation and participation for a minimum of 4 hours a day for three to five days a week. (5) A defined return to work goal agreed to by the employer & employee: (a) A documented specific job to return to with job demands that exceed abilities, OR (b) Documented on-the-job training

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Low Back (6) The worker must be able to benefit from the program (functional and psychological limitations that are likely to improve with the program). Approval of these programs should require a screening process that includes file review, interview and testing to determine likelihood of success in the program. (7) The worker must be no more than 2 years past date of injury. Workers that have not returned to work by two years post injury may not benefit.

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Low Back (8) Program timelines: Work Hardening Programs should be completed in 4 weeks consecutively or less. (9) Treatment is not supported for longer than 1-2 weeks without evidence of patient compliance and demonstrated significant gains as documented by subjective and objective gains and measurable improvement in functional abilities.

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Low Back (10) Upon completion of a rehabilitation program (e.g. work hardening, work conditioning, outpatient medical rehabilitation) neither re-enrollment in nor repetition of the same or similar rehabilitation program is medically warranted for the same condition or injury.

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Low Back Criteria for the general use of multidisciplinary pain management programs: Outpatient pain rehabilitation programs may be considered medically necessary when all of the following criteria are met: (1) An adequate and thorough evaluation has been made, including baseline functional testing so follow-up with the same test can note functional improvement; (2) Previous methods of treating the chronic pain have been unsuccessful and there is an absence of other options likely to result in significant clinical improvement;

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Low Back (3) The patient has a significant loss of ability to function independently resulting from the chronic pain; (4) The patient is not a candidate where surgery or other treatments would clearly be warranted;

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Low Back (5) The patient exhibits motivation to change, and is willing to forgo secondary gains, including disability payments to effect this change; & (6) Negative predictors of success above have been addressed.

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Neck & Upper Back X-Rays are necessary on the first visit if there is any possibility of a fracture. A history of direct trauma, blow to the head, any significant whiplash type injury, or any significant fall. These patients should have an x-ray of the cervical spine.

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Neck & Upper Back On first visit, if there is an acute injury with positive neurological findings, referral to a spine surgeon or musculoskeletal physician is recommended. Otherwise, a referral to a spine surgeon is not recommended until the fourth visit if there is no improvement in neurological complaints.

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Neck & Upper Back Indications for MRI of the cervical spine include the following: Any suggestion of abnormal neurologic findings below the level of injury. Progressive neurologic deficit. Persistent unremitting pain with or without positive neurologic findings. Previous herniated disk within the last two years and radicular pain with positive neurologic findings. Patients with significant neurologic findings and failure to respond to conservative therapy despite compliance with the therapeutic regimen.  Recommended after three to four weeks of no response to conservative care.

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Neck & Upper Back ODG Chiropractic Guidelines – Regional Neck Pain: 9 visits over 8 weeks Cervical Strain (WAD): Mild (grade I - Quebec Task Force grades): up to 6 visits over 2-3 weeks Moderate (grade II): Trial of 6 visits over 2-3 weeks Moderate (grade II): With evidence of objective functional improvement, total of up to 18 visits over 6-8 weeks, avoid chronicity Severe (grade III & auto trauma): Trial of 10 visits over 4-6 weeks Severe (grade III & auto trauma): With evidence of objective functional improvement, total of up to 25 visits over 6 months, avoid chronicity

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Neck & Upper Back Cervical Nerve Root Compression with Radiculopathy: Patient selection based on previous chiropractic success -- Trial of 6 visits over 2-3 weeks With evidence of objective functional improvement, total of up to 18 visits over 6-8 weeks, if acute, avoid chronicity and gradually fade the patient into active self-directed care Post Laminectomy Syndrome: 14-16 visits over 12 weeks

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Neck & Upper Back ODG Physical Therapy Guidelines – Cervicalgia (neck pain); Cervical spondylosis (ICD9 723.1; 721.0): 9 visits over 8 weeks Sprains and strains of neck (ICD9 847.0): 10 visits over 8 weeks

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Neck & Upper Back Displacement of cervical intervertebral disc (ICD9 722.0): Medical treatment: 10 visits over 8 weeks Post-injection treatment: 1-2 visits over 1 week Post-surgical treatment (discetomy/laminectomy): 16 visits over 8 weeks Post-surgical treatment (fusion): 24 visits over 16 weeks

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Neck & Upper Back Degeneration of cervical intervertebral disc (ICD9 722.4): 10-12 visits over 8 weeks Brachia neuritis or radiculitis NOS (ICD9 723.4): 12 visits over 10 weeks

Summary: Rule 137.100 Treatment Guidelines HCP’s shall provide treatment in accordance with the current edition of the Official Disability Guidelines – Treatment in Workers’ Comp unless the treatment requires preauthorization under Rule 134.600

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