LexisNexis has chosen some not too long ago issued noteworthy IMR choices that illustrate the standards that should be met to acquire authorization for quite a lot of completely different medical remedy modalities. LexisNexis Commentary for every chosen IMR is offered beneath. Many of those IMR choices had been reprinted in California Compensation Instances, which might be accessed on Lexis+. Lexis+ subscribers can entry these explicit choices on-line. The checklist discusses particular IMR opinions which clarify how physicians ought to finest apply remedy tips using the “Medical Proof Search Sequence” for the remedy of injured staff as set forth in 8 Cal. Code Reg. § 9792.21.1, and embrace the MTUS at 8 Cal. Code Reg. §9792.21.1(d)(1), different medical remedy tips 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 choices tackle, amongst different subjects, the medical necessity of sure migraine drugs. IMRs involving migraine medicine are notably attention-grabbing in gentle of the current CWCI report addressing the Migraine Drug Utilization and Reimbursement Traits within the California staff’ compensation trade. The report highlights the fast progress of migraine medicine and associated expenditures within the staff’ compensation sector and raises considerations over the dangers related to these medicine, the prolonged checklist of nonindustrial and work-related migraine triggers, the prices related to long-term remedy of migraines, and the massive share of people who are suffering from the situation. Such considerations, the report noticed, make it incumbent upon physicians, claims directors, and UR reviewers to substantiate migraine diagnoses and their relation to work, and make sure that the usage of the actual migraine drug prescribed is supported by the MTUS or different evidence-based tips.
ACUPUNCTURE
■ 89 Cal. Comp. Cases 1137. Acupuncture—Again and Neck Ache—Applicant, 65 years previous, suffered an industrial damage on 9/23/2021, and underwent remedy for her neck and decrease again which included a house train program, steroid injection, bodily remedy, chiropractic remedy, exercise modifications, and oral remedy. As of 4/12/2024, Applicant was not working and complained of neck and decrease again ache rated at 8/10 with out drugs and seven/10 with drugs. Applicant’s treating doctor requested a six-session trial of acupuncture for applicant’s again and neck ache. UR denied the request. The IMR reviewer overturned the UR denial primarily based on the MTUS 2021 tips for low again/radicular ache, which suggest acupuncture for the remedy of reasonable to extreme low again ache as an adjunct to extra efficacious therapies in sufferers who’ve inadequate outcomes with remedy and train. The rules notice that acupuncture is just really helpful to help in rising purposeful exercise ranges extra quickly, and the first consideration ought to stay on conditioning applications. The IMR reviewer identified that the MTUS 2019 tips relevant to cervicothoracic ache suggest an preliminary trial of 5 to six acupuncture appointments together with cardio and strengthening workouts. As a result of applicant right here continued to expertise signs regardless of prior remedy modalities (together with bodily remedy, chiropractic remedy, oral drugs, and an ongoing dwelling train program), the IMR reviewer discovered {that a} six-session acupuncture trial for ache administration and performance enchancment was supported by the MTUS tips and was medically obligatory. [LexisNexis Commentary: This IMR decision provides another good example of a non-invasive treatment prescribed to alleviate pain. The IMR reviewer appropriately applied the relevant MTUS guidelines, which recommend acupuncture for chronic to severe pain, and emphasized that applicant met the criteria for acupuncture because she continued to experience symptoms despite undergoing prior treatment modalities.]
COLD THERAPY
■ 89 Cal. Comp. Cases 1145. Chilly Remedy—Knee Damage—Applicant, 59 years previous, sustained an industrial knee damage on 9/19/2022. He was handled for persistent left knee ache and post-traumatic osteoarthritis and had difficulties with ADLs involving squatting/kneeling and with strolling. Applicant underwent a complete left knee arthroplasty on 4/22/2024. Applicant’s treating doctor really helpful authorization for steady iceless chilly remedy for dwelling use, 30-day rental with knee wrap for buy. UR denied the request. The IMR reviewer overturned the UR denial primarily based on the MTUS 2020 tips for knee problems, which suggest the usage of cryotherapy for remedy of knee arthroplasty and surgical procedure sufferers. The IMR reviewer famous that the requested gadget match the rule of thumb standards of being reusable and non-invasive. The rules additionally suggest the usage of ace wraps, helps, or sleeves for remedy of patellofemoral joint ache. As there is a sign to be used of those therapies and the standards to be used have been met, the IMR discovered that the requested gadget was affordable and medically obligatory. [LexisNexis Commentary: This IMR decision emphasizes that the ACOEM Knee Disorders guidelines, incorporated into the MTUS by 8 Cal. Code Reg. § 9792.23.6, recommend cooling devices or cryotherapies “if efficacious for the temporary relief of osteoarthrosis or acute, subacute, or chronic knee pain” (p.85). The decision also illustrates that there are effective non-invasive treatments for pain that can be used in place of or to reduce medication intake.]
DURABLE MEDICAL EQUIPMENT
■ 89 Cal. Comp. Cases 716. Sturdy Medical Tools—Hitch Mounted Scooter Service Rack—Applicant, 68 years previous, suffered an industrial damage on 1/18/2019 and was placed on modified responsibility. His accidents included the left shoulder, low again/backbone, proper ankle, proper elbow, and left decrease leg. In a progress report dated 11/17/2022, applicant reported sharp ache within the left shoulder and left knee with related weak point that rated at 6/10. Applicant additionally experiences persistent low again ache and his knee “offers out.” Applicant acquired an electrical powered scooter as of 11/17/2022 and was in a position to transfer round safely and independently using the scooter. Resulting from applicant’s restricted capacity to convey the scooter when leaving dwelling, his supplier requested an financial system hitch mounted scooter service rack with ram to connect to his automobile. UR denied the request attributable to its lack of ability to find out if energy mobility units had been authorised by staff’ compensation. The IMR reviewer discovered this reasoning irrelevant and overturned the UR denial, noting that applicant met the non-MTUS ODG standards for an influence mobility gadget attributable to his want for a wheelchair and lack of ability to make use of his arms attributable to shoulder points. The IMR reviewer concluded that with medical necessity for an influence mobility gadget established and defendant having already authorised such gadget, a hitch to hold the scooter to be used outdoors of applicant’s dwelling was acceptable and medically obligatory. [LexisNexis Commentary: This IMR decision illustrates a situation in which evidence-based medical treatment guidelines and peer-reviewed studies need not be cited, because applicant was already provided with an electric mobility scooter and it is obvious that he would need to take the scooter outside of his home.]
■ 89 Cal. Comp. Cases 729. TV Bluetooth System—Listening to Loss—Applicant, 56 years previous, suffered an industrial damage on 3/22/97. Based on applicant, he developed traumatic listening to loss and tinnitus after having been uncovered to gunfire throughout a capturing. In 2023, Applicant reported that his listening to had been deteriorating over time, to the purpose that he had issue comprehending speech and couldn’t hear the TV until it was turned up so loudly that it will intrude along with his spouse’s sleeping. He indicated that he wanted a listening gadget that was suitable along with his new Oticon listening to aids. Applicant’s supplier requested authorization for an Oticon Bluetooth accent to allow applicant to hearken to the TV with out disturbing members of the family . UR denied the request. The IMR reviewer overturned the UR denial primarily based on the MTUS traumatic mind damage 2018 tips, which notice that “there may be little high quality proof of efficient therapies [for hearing loss] apart from listening to aids.” The IMR reviewer concluded that furnishing applicant with the Bluetooth accent in query was medically obligatory to make sure that applicant may hearken to audio from his TV at a snug quantity with out inconveniencing members of the family. [LexisNexis Commentary: Although applicant in this case did not sustain a traumatic brain injury, the IMR reviewer applied the MTUS/ACOEM guidelines for traumatic brain injuries to applicant’s hearing loss. Interestingly, the statement provided in these guidelines about hearing aids is preceded by an indication that this section of the MTUS/ACOEM pertains to “reduced hearing or tinnitus, especially but not solely if the mechanism of injury was a blast.”]
HOME HEALTHCARE
■ 89 Cal. Comp. Cases 932. House Healthcare Providers—Submit-Childbirth—Applicant, 43 years previous, sustained an industrial damage on 5/16/2023 and was present process remedy for a proper knee contusion and deep vein thrombosis of the left decrease leg. In a 12/15/2023 medical analysis, applicant reported 5/10 unchanged proper knee ache with reasonable limitations in ADLs, low again ache and pinching in the fitting hip. Applicant additionally reported 8/10 left leg ache that severely restricted ADLs and pain-related sleep disturbance. Applicant, who was pregnant on the time and had acquired dwelling healthcare beforehand, wanted help with ADLs. Her medical supplier requested authorization for post-delivery dwelling well being 4 hours per day for 3 weeks, 5 days per week. UR noncertified the request. The IMR reviewer overturned the UR denial primarily based on the MTUS 2022 remedy tips for dwelling healthcare providers, which selectively suggest dwelling healthcare on a short-term foundation following hospitalization and main surgical procedures, to beat deficits in ADLs, and to supply nursing or supportive care providers for individuals who in any other case would require inpatient care. The rules require the injured employee to be homebound both attributable to limitations or contraindications to depart dwelling. The IMR reviewer famous that, per the documentation, applicant was to ship a child by way of Caesarean part three weeks following the medical analysis and requested dwelling healthcare following the supply. The IMR reviewer additional famous that applicant was to endure vascular surgical procedure to the decrease extremity after supply. Lastly, the IMR reviewer identified that applicant wanted a wheelchair for ambulation and could be much more restricted following supply. Below these circumstances, the IMR reviewer concluded that 15 visits of dwelling healthcare post-delivery was affordable and medically obligatory primarily based on the relevant tips. [LexisNexis Commentary: This IMR decision exemplifies the longstanding legal principles that medical treatment is not apportionable to nonindustrial conditions (such as pregnancy) even if they may contribute to the need for assistance, and that an injured worker may require care on an industrial basis even for a nonindustrial condition itself where there is a relationship between the nonindustrial and industrial conditions. In this case, applicant was homebound and had previously received home healthcare, so childbirth could be merely coincidental to the renewed post-surgical need for assistance.]
MIGRAINE HEADACHE MEDICATION
■ 89 Cal. Comp. Cases 1227. Migraine Headache Treatment—Nurtec—Applicant, 56 years previous, sustained an industrial damage on 11/7/2020 and was present process remedy for persistent ache syndrome and persistent, intractable post-traumatic complications. He was recognized with post-concussion syndrome, persistent post-traumatic migraines with out aura, and cervical disc dysfunction with radiculopathy. In a 3/16/2023 progress report, applicant reported fixed and debilitating complications, tingling and weak point in the fitting hand, and ache that traveled from the bottom of his cranium to the scalp. A number of drugs, together with gabapentin, amitriptyline, muscle relaxers, triptans, opioids, acetaminophen, and topical lidocaine of the neck, had been tried and failed. Applicant’s treating doctor requested authorization for a trial of Nurtec ODT (Rimegepant Sulfate) 75mg #15. UR denied the request. The UR denial was overturned by the IMR reviewer, who famous that the MTUS/ACOEM tips don’t tackle the requested remedy and, due to this fact, the IMR reviewer relied on the rules set forth within the MTUS Medical Proof Search Sequence, ODG, Head Chapter. The ODG states that Nurtec could also be indicated for people aged 18 or older, who are suffering migraine complications 4 to 14 days monthly for 3 months or extra and have failed or couldn’t tolerate two or extra triptan medicine. Given the failure of a number of first-line drugs in applicant’s case and the documentation of better than three complications per week, the IMR reviewer decided {that a} trial of Nurtec, as requested, was affordable and medically obligatory. [LexisNexis Commentary: The migraine medication requested in this case, Nurtec (Rimegepant Sulfate), is not directly addressed in the MTUS/ACOEM guidelines. Therefore, the IMR reviewer properly applied the ODG criteria for Nurtec to determine medical necessity. These guidelines will be of great interest to the workers’ compensation community, as a recent CWCI study cites Nurtec as accounting for 41.6 percent of the money spent on migraine drugs, making it the fastest growing migraine drug in workers’ compensation both in terms of utilization and payments.]
■ 89 Cal. Comp. Cases 1220. Migraine Headache Treatment—Ubrelvy—Applicant, 65 years previous, suffered an industrial damage on 10/4/2021 and was present process remedy for persistent post-traumatic complications. In a progress report dated 11/29/2022, applicant reported that her complications weren’t bettering. She continued to have at the very least one headache day by day and extreme complications about twice per week, lasting for 2 to 3 hours. Applicant’s medical supplier requested authorization for Ubrelvy (Ubrogepant) 100mg #10, which was denied by UR. The IMR reviewer overturned the UR denial, citing the non-MTUS ODG, Head Chapter. The ODG states that Ubrelvy could also be indicated for people aged 18 or older, who are suffering migraine complications 4 to 14 days monthly for 3 months or extra and have failed or couldn’t tolerate two or extra triptan medicine. Applicant right here accomplished 3 months of Ajovy, a migraine preventative, and a course of Nurtec with no enchancment. The IMR noticed that applicant suffers from a coronary heart situation and, due to this fact, triptans are contraindicated. As such, the IMR reviewer discovered the request for Ubrelvy was supported by the ODG tips and was medically obligatory. [LexisNexis Commentary: The IMR reviewer in this case pointed out that the ODG supports use of Ubrelvy (Ubrogepant) for individuals who have demonstrated contraindication to treatment with triptans. Here, use of triptans was contraindicated based on applicant’s heart condition. According to a CWCI study, Ubrelvy prescription climbed 7 percent last year.]
PATIENT EDUCATION
■ 89 Cal. Comp. Cases 928. Nurse Visits—Affected person Training—Applicant, 70 years previous, suffered industrially-related most cancers of his neck and pores and skin. He underwent a number of procedures to deal with the illness, together with cryotherapy, pores and skin grafts and surgical procedures. In 2023, applicant reported a number of lumps in his neck along with cancerous pores and skin lesions and opted to obtain radiation remedy. The remedy plan included a clinic-based nurse schooling go to to teach him about radiation remedy. UR denied the request. The IMR reviewer overturned the UR denial primarily based on the MTUS 2022 remedy tips addressing affected person schooling, which state that affected person schooling consists of succinct data on the prognosis, prognosis, exercise ranges, work limitations, and remedy plan. They additional present that the supplier ought to tackle concern avoidant beliefs and the need of the affected person to be concerned in their very own restoration plan, with particular data tailor-made to the affected person’s background and academic stage with return to work and regular perform as main collaborative objectives. The IMR reviewer concluded that schooling for radiation remedy aligned with the relevant MTUS standards for affected person schooling, and, due to this fact, discovered that the nurse go to was medically obligatory. [LexisNexis Commentary: Applicant in this case has malignant neck cancer and needs help understanding his condition, the medical treatment involved, and the importance of being proactive in treating the condition. Under these circumstances, a nurse visit to educate applicant about radiation therapy as a treatment option was supported by the MTUS guidelines.]
PERSONAL ASSISTANTS
■ 89 Cal. Comp. Cases 724. Private Assistants—Amputations—Applicant, 52 years previous, suffered an industrial damage on 5/12/2022. His accidents included an entire traumatic amputation of his proper arm and shoulder, complications, main melancholy, and PTSD. On 5/1/2023, applicant’s medical supplier requested authorization for a private assistant to work with applicant’s animals (feeding, washing, cleansing space) for 2 hours per day for one 12 months, and for a social employee to judge the help wanted by applicant’s spouse and to itemize each exercise with which help was wanted. UR denied each requests. The IMR reviewer overturned the UR non-certification of the request for a private assistant to assist with applicant’s animals, citing the MTUS persistent ache 2017 tips and the MTUS preliminary approaches to remedy 2022 tips. The IMR reviewer famous that the MTUS preliminary approaches to remedy selectively recommends dwelling well being care providers to help with ADLs and to supply supportive care providers when wanted. Right here, the IMR reviewer noticed, applicant suffered ongoing higher extremity ache, had been using a prosthesis for 3 months with minimal coaching, and had issue with ADLs, together with bathing, dressing, grooming and greedy. The IMR reviewer decided that applicant’s treating doctor offered enough rationale to help the request for an assistant to assist look after applicant’s animals. Based mostly on the documentation submitted and the MTUS suggestion to be used of dwelling well being care to beat deficits of ADLs, the IMR reviewer concluded that the request for a private assistant to assist with the animals was medically obligatory. In distinction, the IMR reviewer discovered that it was unclear why extra analysis by a social employee was medically obligatory. As such, the IMR reviewer upheld UR’s non-certification of the request for a social employee to itemize each exercise carried out by applicant’s spouse. [LexisNexis Commentary: The IMR reviewer correctly notes that the MTUS recommends home health care services to overcome deficits in ADLs. That term of art, as it is defined under the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, excludes work. However, for purposes of either the AMA Guides or the MTUS, ADLs should not exclude anything normally done in the home. Feeding and caring for pets is akin to other kinds of housework, for which assistance can be part of reasonable and necessary medical care. Although an itemization of all the tasks with which applicant requires assistance, including those that his wife must perform due to applicant’s injury, may be helpful in determining the level of assistance needed, the documentation provided in this case did not make clear why such itemization was required.]
PROSTHESES
■ 89 Cal. Comp. Cases 936. Prosthetic Limbs—Amputations—Applicant, 36 years previous, suffered an industrial damage on 10/28/2019 leading to a below-the-knee proper leg amputation on 5/8/2020. Following the amputation, applicant acquired a prosthetic limb. By the top of 2023, the prosthesis was now not becoming correctly, inflicting applicant to expertise ache and pores and skin irritation. The ache was aggravated with exercise and stairs. A bodily examination revealed improved limb rash, and 5 round lesions on the medial calf. Applicant’s treating doctor requested substitute of the prosthetic limb. UR noncertified the request. The IMR reviewer overturned the UR denial primarily based on the non-MTUS ODG addressing prostheses for knee and leg situations, which suggest decrease limb prosthesis if the affected person will attain or preserve an outlined purposeful state inside an affordable time period and is motivated to ambulate, and if the prosthesis is furnished incident to a doctor’s providers or on a doctor’s order. The IMR reviewer famous that applicant was present process remedy for tinea, hardware-complicating wound an infection, tibial fracture, and lumbago. He reported continued proper knee and low again ache with fixed limb ache and pores and skin irritation attributable to an ill-fitting socket. The IMR reviewer additional famous that applicant was energetic and surfs frequently. The treating doctor indicated that applicant had an analysis for a substitute prosthesis and was given a check limb which was working effectively, and that the pores and skin irritation had resolved. Accordingly, the IMR reviewer concluded that the brand new prosthesis was medically obligatory primarily based on the ODG standards. [LexisNexis Commentary: This IMR decision ultimately serves the interests of both defendants and injured workers by approving the replacement of applicant’s prosthesis and avoiding the potentially more expensive compensable consequences of an ill-fitting socket, which could lead to surgical treatment and/or long-term homecare.]
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