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

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ODG Medical Treatment For Back And Neck
Injuries - 2008

• Matthew Lewis
• [phone] Telephone
• matt_at_mattlewislaw.com

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Rule 137.100Treatment Guidelines

• HCPs 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).

4

• 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
• Tapem up, shootem up, and getem 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/radiculiti
  s, 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