Independent Medical Review Decisions Table for Practice Tip

IMR Decisions Table

 

The complete list includes all determinations posted on the DWC website through August 1, 2013.

 

The IMR Decisions  on the DIR website can be found here: http://www.dir.ca.gov/dwc/IMR/IMR_Decisions.asp

 

In order to look at different types of treatment requests, or at requests for different body parts, the list can be sorted alphabetically. At the top of each column, the column heading is followed by this symbol . If you left click on that symbol, the table will be sorted alphabetically according to the entries in that column. For example, if you click on the  symbol in the column headed “Part of Body” the list will be sorted so that all “Ankle” injuries are shown first, followed by all “Arm” injuries, then “Brain” injuries, “Dental,” “Depression,” “Elbow,” and so on down to “Wrist” injuries. You can then scroll down and review all of the determinations in any particular injury category.

 

Alternatively, you can search the list using the boxes in the second row. Just enter the term you want to see in the box, and all entries that match that term will be shown. For example, if you type the word “shoulder” in the box below the heading “Part of Body” you will get a listing of the 68 treatment requests that involved an injury to a shoulder. Then put in “surgery” in the box below the heading “Disputed Treatment” and the six determinations involving shoulder surgery will be listed.

 

 

No. Result    Disputed Treatm't Part of Body Guideline Cited   Rationale for Determination by IMR Reviewer

 

13-4

Aprv

MRI left wrist

Wrist, left

Amer College of Radiology criteria (deemed more appropriate than ACOEM)

Suspicion of scapholunate disruption justifies MRI

 

13-5

Deny

CT left wrist

Wrist, left

Amer College of Radiology criteria (deemed more appropriate than ACOEM)

CT not yet justified based on non-specific and clinically mild findings. Same case as 13-04; if MRI shows suspicion for fracture then CT may be indicated.

 

13-6

Aprv

MRI lumbar spine

Spine, lumbar

ACOEM

Approved because evidence of low back and lower left extremity pain for greater than 6 weeks with disc space narrowing. [Note: the IMR reviewer had more medical evidence han the UR reviewer simply because of the passage of time]

 

13-9

Deny

MRI lumbar spine

Spine, lumbar

Amer College of Radiology criteria (deemed more appropriate than ACOEM)

No fracture, no red flags, 6 weeks of conservative care is indicated before considering MRI

 

13-11

Deny

Acupuncture

Arm

ACOEM, ODG, and MTUS (Acupuncture guidelines).

Patient is working full time, no medications, minimal symptoms, no functional deficits of ADLs

 

13-12

Deny

Surgery – arthroscopic rotator cuff repair

Shoulder, right

ACOEM

There was a lack of documentation indicating rotator cuff damage that would justify surgery; and a lack of documentation of conservative care; if documentation provided surgery may be appropriate

 

13-13

Deny

MRI left knee

Knee, left

ACOEM

Patient had 6 PT following which there was no knee pain; ortho eval described improvement and ordered no further treatment

 

13-14

Aprv

MRI right shoulder

Shoulder, right

Amer College of Radiology criteria (deemed more appropriate than ACOEM)

Patient had previous rotator cuff surgery and is at risk of re-tear, there was no relief from cortisone; abnormal ultra-sound

 

13-19

Deny

MRI lumbar / thoracic spine

Spine, lumbar/thoracic

ACOEM

There are no red flags, chiropractic treatment shows some improvement; the approved plan for PT has not been completed. For thoracic, no radicular symptom complex or direct trauma

 

13-24

Deny

Chiropractic – 8 visits

Shoulders, bilateral

MTUS (ACOEM)

Manipulation is indicated only for a "frozen shoulder," there is no evidence of this condition; guidelines do not recommend manipulation for treatment to elbows

 

13-24

Deny

PT – including EMS, ultrasound, myofascial release, diathermy

Shoulders, bilateral

MTUS (ACOEM) & ODG

Physical modalities are not supported by high quality medical studies. Patient already received 5 PT with no evidence of improvement

 

13-30

Deny

Back hugger elastic strap, lumbar pillow; moist heating pad, theracane massager

Spine, lumbar

ODG

For elastic strap, pillow, and theracane massager, there are no guidelines and no evidence based studies. Hot therapy pack was already approved, so moist pack is duplicative.

 

13-31

Aprv

PT – 12 sessions to lumbar back and left knee

Spine, lumbar

ACOEM, ODG

UR denial based on lack of documentation; approval based on subsequently produced evidence

 

13-33

Deny

MRI cervical spine

Spine, cervical

ACOEM, ODG

MRI likely to show age related abnormalities; records are consistent with myofacial pain syndrome; test results not likely to alter treatment options

 

13-33

Deny

EMG/NCV (electromyography/nerve conduction) upper left extremity

Spine, cervical

ACOEM, ODG

In absense of significant focal signs or suspected distinct nerve injury yield of EMG/NCV is very low; records are consistent with myofacial pain syndrome; test results not likely to alter treatment options

 

13-35

Aprv

Solonpas patch

Ankle, right

ACOEM, Chronic Pain guidelines

With documentation of continued pain both guidelines recommend use of this medicine

 

13-36

Aprv

Medrol Dose Pack

Arm, left

MTUS (ODG)

Exam showed increased pain in RSM distribution; pain radiating to upper left extremity and swelling; pain from the neck to the fingers

 

13-36

Aprv

Vitamin C – 6 mos

Arm, left

IMR reviewer found a Journal article was more relevant than MTUS

Guideline supports use of Vitamin C to prevent occurrence of complex regional pain syndrome (CPRS)-1 after wrist fractures (UR approved only 2 months)

 

13-36

Aprv

Neuronton – 6 mos.

Arm, left

MTUS (Chronic Pain guidelines)

Symptoms consistent with radiculopathy; guidelines support use of Neurontin in neuropathic pain states (UR approved only 2 months)

 

13-36

Aprv

OT – 12 sessions

Elbow, wrist, hand, fingers

MTUS (ACOEM, Chronic Pain guidelines)

Based on surgery performed and work-related physical requirements, 12 OT is justified (UR had approved only 6)

 

13-36

Aprv

PT - 12 sessions

Arm, left

MTUS (ACOEM, Chronic Pain guidelines)

Employee had shoulder surgery, guidelines support PT as appropriate and consistent to address range of motion (UR had approved only 6)

 

13-36

Deny

Norco – 6 mos

Arm, left

MTUS (Chronic Pain guidelines)

Records are unclear as to duration of opiate use to date; no rationale for concurrent prescriptions of hydrocodone and tramadol; additional information needed to show medical necessity

 

13-38

Aprv

PT – 8 sessions of manipulation therapy

Spine, lumbar/ cervical

MTUS (ACOEM) (UR used ACOEM 3rd Ed)

Guidelines state manipulation appears safe and effective during first few weeks of back pain without radiculopathy.

 

13-38

Aprv

Acupuncture – 8 sessions

Spine, lumbar/ cervical

MTUS (ACOEM) (UR used ACOEM 3rd Ed)

Trial of acupuncture is an alternative to trigger point injections.

 

13-38

Deny

Trigger point injection

Spine, lumbar/ cervical

MTUS (ACOEM but IMR reviewer used different section than UR)

Injury still in acute phase; trigger point injections are recommended only for subacute or chronic trigger points that are not resolving

 

13-39

Deny

Facet injections, bilateral, and transforaminal epidural steroid injections, bilateral

Spine, lumbar

MTUS (Chronic Pain guidelines) and ODG

Reviewer disagreed with diagnosis; documentation lacks evidence of neurological deficits and lack of physical exam consistent with facet mediated pain. MRI of lumbar spine was normal

 

13-40

Aprv

X-ray cervical spine

Spine, cervical

ACOEM, ODG

Cervical X-ray is justified due to chronic pain and patient over 40.

 

13-40

Aprv

X-ray left elbow

Elbow, left

ACOEM, ODG

Chronic pain in elbow, positive Tinel's sign, and tenderness justify elbow X-ray.

 

13-40

Aprv

PT – 12 visits

Spine, cervical

ODG

Reasonable suspicion of work related CT, persistent chronic pain

 

13-40

Deny

Functional capacity eval and computerized range of motion/muscle test

Spine, cervical

ACOEM, ODG (and Journal article for ROM test)

No evidence of failed attempt to return to work; FCE is premature. Evidence of computerized ROM testing is lacking, study did not show superiority of computerized testing

 

13-42

Deny

Functional capacity evaluation

Neck, back, shoulder

ODG (not in MTUS) (UR used MTUS/Chronic Pain & ODG)

Records do not document a prior unsuccessful return to work; no detailed job description that includes essential job tasks; does not meet criteria for FCE

 

13-43

Aprv

MRI right hip

Hip, right

Amer College of Radiology criteria (ACOEM deemed inappropriate)

MRI is appropriate due to continued pain despite PT and conservative care; also noted suspicion of a lateral tear.

 

13-47

Deny

Chiropractic – 6 visits

Spine, leg right

MTUS (ACOEM)

Chiropractic denied due to lack of progress notes and documentation.

 

13-47

Deny

Acupuncture – 6 visits

Spine, leg right

MTUS (Acupuncture guidelines)

Acupuncture Deny because employee returned to work with no restrictions, uses only occasional pain medicine, and has shown functional improvement with no further physical rehabilitation necessary.

 

13-49

Aprv

MRI right knee

Knee, right

Amer College of Radiology criteria (ACOEM deemed inappropriate)

Chronic knee pain of more than 6 weeks despite PT is an indication for MRI. [Note: based on a review of the medical records, the IMR reviewer found a different diagnosis].

 

13-51

Deny

Chiropractic – 6 visits

Spine, lumbar

ACOEM

6 previous chiro visits produced no improvement; under ACOEM treatment should be stopped and patient re-evaluated.

 

13-52

Deny

PT – 6 visits

Hands/ wrists, bilateral

MTUS (ODG) (UR used ACOEM)

No documentation of re-injury, patient already had 9 PT, ODG supports only up to 12, so 6 additional is not authorized.

 

13-54

Deny

Norco refill

Arm/elbow, right

ACOEM, Chronic Pain guidelines

ACOEM guidelines do not support the request

 

13-54

Aprv

PT – 12 sessions

Arm/elbow, right

ACOEM, ODG

Patient's physical exam, med history, and MRI support diagnosis of cervical pain and associated radiculopathy and treatment plan

 

13-54

Deny

Lyrica refill

Arm/elbow, right

ACOEM, Chronic Pain guidelines

Long term use of opioids is not well established in the treatment guidelines

 

13-54

Deny

Soma refill

Arm/elbow, right

ACOEM, Chronic Pain guidelines

Long term use of muscle relaxants is not well established in the treatment guidelines

 

13-56

Aprv

Neurologist referral

Head, neck

MTUS (ACOEM)

Patient struck his head; CT was negative; has persistent headaches and dizziness; given persistence of symptoms evaluation by neurologic specialist is warranted; ACOEM indicate appropriate where diagnosis is uncertain

 

13-59

Deny

EMG/NCV (electromyography/nerve conduction)

Upper extremity, right

ACOEM

ACOEM advises conservative therapy first with further testing only if it will alter treatment plans.

 

13-62

Aprv

Vicodin

Spine, knee

MTUS (Chronic Pain guidelines)

Approved because documentation showed continued pain and conservative treatment had failed. [Note: UR denial was based on lack of documentation]

 

13-62

Deny

Chiropractic – 12 visits

Spine, knee

MTUS (Chronic Pain guidelines)

A trial of 4 - 6 visits is permitted, but the IMR process does not allow for modification of a request so the 12 visit request is denied. [Note: UR denial was based on lack of documentation]

 

13-62

Aprv

MRI lumbar spine

Spine, lumbar

MTUS (ODG)

Approved because there was documentation of radiculopathy despite conservative care; and positive straight leg raise. [Note: UR denial was based on lack of documentation]

 

13-62

Aprv

Zanaflex

Spine, lumbar

MTUS (Chronic Pain guidelines)

Zanaflex is recommended as a treatment option in the Chronic Pain guidelines. [Note: UR denial was based on lack of documentation]

 

13-65

Aprv

Skilled nursing – 4 visits

Hip, left

ODG, Chronic Pain and Post-Surgical guidelines

IMR reviewer stated that often patients discharged from skilled nursing facility need outpatient rehabilitation

 

13-66

Aprv

MRI lumbar spine

Spine, lumbar

Amer College of Radiology criteria (ACOEM deemed inappropriate)

Persistent pain of longer than 6 weeks is a red flag and along with prior laminectomy, disc and space loss, and radicular symptoms justifies MRI. [Note: IMR reviewer rejected UR reliance on ACOEM stating clinical condition was improperly diagnosed].

 

13-67

Deny

MRI right shoulder

Shoulder, right

ACOEM

X-ray showed no fracture. Records provided did not show evidence of conservative treatment, no red flags.

 

13-70

Deny

tennis elbow support

Elbow, left

MTUS (ACOEM)

Patient already has a Bandit Tennis Elbow strap and this support is redundant

 

13-70

Aprv

PT – 9 sessions

Elbow, left

MTUS (ACOEM) [Note: UR used different ACOEM cite]

Continuing conservative care recommended by PTP and IMR reviewer agreed on need.

 

13-70

Deny

Ketoprofen lotion

Elbow, left

MTUS (ACOEM, ODG)

Ketoprofen is not FDA approved for topical application

 

13-70

Deny

X-ray – left elbow

Elbow, left

MTUS (ACOEM, ODG)

There were two previous X-rays, and there was no new trauma or injury to change the diagnosis

 

13-70

Aprv

Acupuncture – 6 treatments

Elbow, left

MTUS (Acupuncture guidelines)

Acupuncture alone or with PT is used to promote functional improvement; guidelines allow 3 to 6 treatments to produce functional improvement

 

13-73

Aprv

NCV – nerve conduction velocity left upper extremity

Upper left extremity

Expertise of IMR reviewer; no guidelines or evidence based standards

NCV already conducted on upper right extremity showing moderate/severe CTS; documented hand dysesthesia right hand; presence of CTS in the right upper extremity warrants NCV of upper left extremity

 

13-73

Deny

EMG – electromyography upper right extremity

Upper right extremity

MTUS (ACOEM)

ODG recommends NCV; addition of EMG will not add any further clinical information

 

13-74

Deny

MRI lumbar spine

Spine, lumbar

ACOEM

IMR reviewer, based on evaluation of records received, disagreed with description of patient's condition and determined condition showed symptoms of lumbar strain and neuropathic pain. Without "unequivocal" evidence of radiculopathy and because condition is improving with conservative care, MRI is not medically necessary.

 

13-77

Aprv

EMG/NCV (electromyography/nerve conduction)

Upper extremity, right

MTUS (ACOEM)

Post UR examination showed preserved strength and altered sensation in pattern the fits CTS; treatment is effective in evaluating neuropathic conditions [Note: IMR reviewer used post-UR medical evidence to justify treatment request]

 

13-80

Deny

Acupuncture – 9 sessions

Neck, upper back

MTUS (ACOEM, Acupuncture guidelines)

9 requested sessions are in excess of the recommended 3 to 6 sessions considered adequate to produce functional improvement

 

13-82

Aprv

MRI left shoulder

Shoulder, left

MTUS (ACOEM)

Approved due to evidence of chronicity of symptoms and the failure of conservative treatment [Note: it appears the IMR reviewer had more recent evidence not available to UR reviewer]

 

13-85

Deny

MRI left leg

Leg, left

MTUS (ACOEM, ODG)

Doesn't meet guideline standards for MRI

 

13-86

Deny

MRI left ankle

Ankle, left

MTUS (ACOEM, ODG)

Patient exhibits symptoms and findings of simple acute ankle sprain, no evidence of chronic pain instability or need for surgery

 

13-87

Deny

Cortisone injection

Shoulder, right

MTUS (ACOEM, ODG)

Documentation shows patient declined steroid injection, without documentation that patient is interested and understands risks it is not necessary and appropriate

 

13-89

Deny

EMG/NCV (electromyography/nerve conduction) upper left extremity

Upper left extremity

MTUS (ACOEM)

Records show no evidence of neurologic signs to support the impression and differential diagnosis provided; request is not justified based on absense of physical signs and acuteness of injury

 

13-90

Deny

Cognitive behavior therapy

Depression

ODG, Chronic Pain guidelines

IMR reviewer disagreed with treater's diagnosis, the record contains no objective data to support a diagnosis of any serious mental disorder

 

13-92

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM)

No evidence of radiculopathy and no complaint of referred pain to the lower extremity or paraesthesia; MRI warranted only where specific nerve compromise

 

13-94

Deny

PT – 12 sessions

Elbow/wrist; left

MTUS (Chronic Pain guidelines) (UR used ODG)

Guidelines endorse up to 10 visits; a 12 session course without intervening follow-up visit with PTP to ensure functional improvement is not supported

 

13-94

Deny

TENS – unit purchase

Spine, cervical

MTUS (Chronic Pain guidelines) (UR used ACOEM and ODG)

Need documentation of 3 month duration of pain; before purchase a one month trial of rental TENS should be documented with outcomes of pain relief and functional improvement

 

13-94

Deny

Dendracin ointment

Elbow/wrist; left

MTUS (Chronic Pain guidelines, ACOEM) (UR used ODG)

Oral analgesics more appropriate, no evidence of oral analgesic intolerance or failure

 

13-100

Aprv

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

Persistent neck pain with repetitive motion, resistant to 6 weeks conservative therapy and medications and PT

 

13-100

Deny

Acupuncture – evaluation X 2

Shoulder, right

MTUS (Acupuncture guidelines)

Records do not show evidence of other attempted treatment; one acupuncture evaluation seems appropriate but not two

 

13-100

Aprv

MRI right shoulder

Shoulder, right

MTUS (ACOEM)

Persistent shoulder pain with repetitive motion, resistant to 6 weeks conservative therapy and medications and PT

 

13-101

Deny

Tramadol

Spine, cervical/ thoracic

MTUS (Chronic Pain guidelines)

Failure of first line agents such as etodolac not documented; documentation does not provide functional goals for patient

 

13-101

Deny

Polar Frost

Spine, cervical/ thoracic

MTUS (ACOEM)

No evidence based literature to support use; request is duplicative as patient already provided with cold packs

 

13-101

Deny

Thermacare, back pack

Spine, cervical/ thoracic

MTUS (ACOEM)

No guidelines; request is duplicative as patient already provided with hot packs

 

13-102

Aprv

MR Arthrogram

Wrist, right

Amer College of Radiology criteria (ACOEM deemed not applicable)

PTP suspected possible scapholunate tear; ACR guidelines state for this condition MR arthography is superior to both MRI and conventional arthography

 

13-103

Deny

PT – 16 sessions

Shoulder/ spine

ACOEM

No medical records were submitted by either party, decision was based on UR decision; 16 PT sessions are in excess of recommended number in ACOEM

 

13-104

Deny

Medial branch block – bilateral lumbar 3,4,5

Spine, lumbar

MTUS (ODG)

Patient had previous medial branch block, guidelines indicate this procedure should only be done once and no more than 2 level joints injected at one session

 

13-106

Aprv

PT – 2 sessions

Spine, lumbar

MTUS (Chronic Pain guidelines) (UR used ODG)

Chronic pain guidelines recommend physical medicine to restore flexibility, strength, endurance, function, range of motion, and can reduce discomfort; may require supervision from therapist or medical provider

 

13-113

Deny

Lidoderm patch

Spine, lower extremity

MTUS (ODG) & American Pain Society guidelines

This patch is recommended only with evidence of localized pain consistent with neuropathic etiology

 

13-114

Deny

Computerized strength and flex assessment

Spine, lumbar

MTUS (ACOEM)

No medical records were submitted by either party, decision was based on UR decision

 

13-115

Inelig

X-ray right wrist

Wrist, right

N/A

Declared ineligible for IMR because liability has not been accepted for this claim

 

13-115

Aprv

X-ray thoracic spine

Spine, thoracic

MTUS

Lumbar spinal X-ray is not recommended in absense of red flags, but spine X-ray may be appropriate if physician believes it will aid in patient management; this X-ray was taken immediately following the injury and is appropriate

 

13-115

Inelig

MRI right wrist

Wrist, right

N/A

Declared ineligible for IMR because liability has not been accepted for this claim

 

13-115

None

MRI, thoracic spine

Spine, thoracic

N/A

This MRI was previously authorized and has been performed

 

13-115

Deny

X-ray thoracic spine

Spine, thoracic

MTUS

The request is unclear; the reviewer found the first X-ray appropriate but determined a second X-ray is not medically necessary

 

13-116

Deny

Inferential Current Stimulator (ICS)

Spine/ shoulder/ knees

MTUS (Chronic Pain guidelines)

Not recommended as isolated intervention; no evidence of conservative care or conditions justifying requested treatment

 

13-118

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

Medical records show no red flag conditions and no evidence patient has entered or completed strengthening program

 

13-118

Aprv

EMG/NCV (electromyography/nerve conduction) upper extremities

Upper extremities

MTUS (ACOEM)

Only slight improvement, EMG/NCV can help identify subtle neurologic dysfunction in patients with arm or neck symptoms lasting more than 3 or 4 weeks

 

13-119

Deny

CT head

Head

MTUS (ODG)

No medical records were submitted by either party, decision was based on UR decision; neurological exam reported as without abnormal finding; CT recommended only with abnormal neurologic findings

 

13-120

Aprv

MRI cervical spine

Spine, cervical

ACOEM

Myofacial trigger points detected; decreased range of motion of cervical and lumbar spine with positive straight leg raises while sitting are signs of possible nerve impingement; MRI appropriate with evidence of tissue insult or nerve impairment

 

13-122

Deny

PT – 12 sessions

Shoulder

MTUS (ACOEM, ODG )

Patient has had 6 PT visits with no functional benefit and symptoms have worsened; PT should be extended only with functional improvement

 

13-125

Deny

Short term rehab (nursing home)

Spine

ODG (MTUS does not apply)

Placement in skilled nursing facility recommended after surgery or acute treatment when subsequent care can be provided in SNF; this case had only cursory eval in emergency dept, limited attempt at pain management, and no diagnosis

 

13-126

Deny

MRI bilateral wrists and hands

Wrists/hands

MTUS (ACOEM, ODG )

No evidence of hand or wrist trauma; no indication patient has failed to respond to conservative treatment

 

13-126

Deny

MRI bilateral hips

Hips, bilateral

MTUS (ODG)

No history of trauma, no conservative treatment

 

13-126

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM, ODG )

No documented objective neurological evidence of motor, reflex, or sensory deficit; no evidence of conservative treatment or failure of that treatment

 

13-126

Deny

MRI bilateral elbows

Elbows, bilateral

MTUS (ACOEM, ODG )

No evidence of injury or trauma to elbow or nerves (medial or ulnar); no evidence elbow complaints are refractory to conservative treatment

 

13-134

Deny

Sleep consultation

Insomnia

ODG

Records do not show evidence of 6 months of insomnia, unresponsive behavior intervention, or sedative/sleep promoting medications; psychiatric etiology has been excluded

 

13-134

Deny

Psychiatric consultation

Depression

None (cited "evidence based treatment guidelines")

No evidence of trial and failure of conservative treatment

 

13-134

Deny

Internal medicine consultation

GI upset

None applicable (cited clinical experience)

Based on records patient is suffering GI upset due to medication use, signs and symptoms are caused by medication

 

13-134

Deny

Dental consultation

Dental

None applicable (cited clinical experience)

Patient has subjective pain in jaw but no other signs or symptoms of TMJ such as tenderness or difficulty chewing/opening the mouth

 

13-135

Aprv

EMG/NCV (electromyography/nerve conduction) cervical spine

Spine, cervical

MTUS (ACOEM, ODG )

Records indicate radiculopathy suspected due to positive axial loading test and decreased sensory findings in hand, and no improvement with 4 weeks of conservative therapy

 

13-136

Aprv

EMG/NCV (electromyography/nerve conduction) lower right extremity

Lower extremity, right

MTUS (ACOEM, ODG )

Evaluation suggests possible radiculopathy, positive straight leg raising and complaints of tightness in leg and back, conservative treatment has not improved symptoms within a month

 

13-139

Aprv

PT – 12 post-operative sessions

Hand, left

MTUS (Post surgical guidelines) (UR used ODG)

The post-surgical guidelines recommend up to 16 visits of OT/PT for fractures of metacarpal bones

 

13-140

Aprv

Orthovisc injections

Knee, right

ODG (not in MTUS)

The guidelines say injection is appropriate for patients with osteoarthritis who have not responded to conservative treatments and therapies; records document these conditions

 

13-151

Deny

Cyclobenzaprine

Head/neck

MTUS (Chronic pain guidelines)

Cyclobenzaprine is recommended only when other preferred options have failed; no evidence of intolerance to, and/ or failure of, oral analgesics

 

13-151

Deny

Ondansetron

Head/neck

National Library of Medicine information

Neither the MTUS or other evidence based guidelines cover this treatment; the Nat'l Library defines Ondansetron as treatment for nausea and/ or vomiting; employee's condition does not meet this criteria

 

13-151

Deny

Omeprazole

Head/neck

MTUS (Chronic pain guidelines)

There is no documented evidence establishing the presence of reflux, dyspepsia, or risk for cardiovascular disease

 

13-151

Aprv

Orthopedic evaluation

Spine, cervical

ACOEM 3rd Ed (UR used ACOEM 2nd Ed)

Reviewer used different section of ACOEM; the ACOEM chronic pain guidelines suggest obtaining consultation with chronic pain/delayed recovery cases; employee is five months post-injury with continuing chronic pain

 

13-151

Deny

Ketoprofen/ capsaicin/ lidocane/ tramadol

Head/neck

MTUS (Chronic Pain guidelines, ACOEM)

One of the ingredients in the compound medicine, ketoprofen, is specifically not recommended by the guidelines, this gives the entire compound medicine an unfavorable rating; no evidence of intolerance to, and/ or failure of, oral analgesics

 

13-151

Deny

Flurbiprofen/ cyclobenazeprine/ capsaicin/ lidocaine

Head/neck

MTUS (Chronic Pain guidelines, ACOEM)

One of the ingredients in the compound medicine, cyclobenazeprine, is specifically not recommended by the guidelines, this gives the entire compound medicine an unfavorable rating; no evidence of intolerance to, and/ or failure of, oral analgesics

 

13-151

Deny

Epidural steroid injections – cervical spine

Spine, cervical

MTUS (Chronic pain guidelines)

Guidelines recommend epidural injection with evidence of radiculopathy; records do not indicate clinical or radiographic evidence of radiculopathy

 

13-151

Aprv

Sumatriptan Succinate

Head/neck

National Library of Medicine information

Neither the MTUS or other evidence based guidelines cover this treatment; the Nat'l Library defines Sumatriptan Succinate as treatment for migraine headaches

 

13-151

Deny

EMG/NCV (electromyography/nerve conduction)

Head/neck

MTUS (ACOEM)

ACOEM endorses electrodiagonostic testing with clinical radiculopathy not detected on MRI; records do not indicate clinical or radiographic evidence of radiculopathy

 

13-151

Deny

Toxicology-urine drug screen

Head/neck

MTUS (Chronic pain guidelines)

Retrospective review of testing performed; guidelines endorse testing to ensure no illicit drugs but completed test screened 50-75 drugs; no compelling rationale for such elaborate testing

 

13-151

Deny

Medrox ointment

Head/neck

MTUS (Chronic Pain guidelines, ACOEM)

Guidelines recommend topical analgesics only when oral analgesics have failed; no evidence of intolerance to, and/ or failure of, oral analgesics

 

13-155

Aprv

Tizanidine

Knee/spine

No guidelines applicable; used medical journal article (UR used Chronic Pain guidelines)

Tizanidine is not described in MTUS; published article references studies for radiculopathy; patient has history of bulging disc and radiculopathy

 

13-156

Aprv

Electrodes – four, and Exercise kit (Theraputty, Digiflex, Digextend, Powerweb)

Hands/shoulder, right

MTUS (ODG)

Patient received therapy and was taught to use exercise kit equipment, therapy has provided some improvement

 

13-159

Deny

Surgery – medial & lateral meniscus repair

Knee, right

ODG (MTUS found not applicable)

Medical records do not demonstrate true locked meniscus with either subjective or objective clinical findings; MRI shows small joint effusion but no change from previous MRI

 

13-166

Aprv

OT – 8 sessions

Wrist, left

MTUS (Chronic Pain Guidelines) (UR used ODG)

IMR reviewer used Chronic Pain Guidelines because the patient is beyond 3-4 months post-surgery and the condition is now chronic; employee has improved from 19 sessions of PT but has not yet reached baseline, the added OT is justified because of the delayed recovery and the range of motion and strength are improving but have not yet reached pre-injury baseline

 

13-167

Aprv

MRI thoracic spine

Spine, thoracic

MTUS (ACOEM) (UR used different section of ACOEM and ODG)

There was a positive thoracic X-ray showing an anterior wedge of a single vertebra; ACOEM lists a fracture as a red flag justifying further imaging studies

 

13-169

Deny

Manipulation under anesthesia

Elbow, left

ODG (MTUS does not apply)

ODG does not support MUA; no quality studies in support of MUA; in a case series outcomes for stiff elbow are no better than the natural history of the condition

 

13-171

Deny

PT – 8 sessions of manipulation therapy

Spine, lumbar

MTUS (ACOEM)

Records do not indicate attempts and failure to use methods suggested in ACOEM (workstation modification, stretching, exercises, cold/heat pack, relaxation techniques, aerobic exercises, and home exercise)

 

13-171

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM, ODG)

Records do not show objective evidence of focal weakness or neurologic dysfunction; without evidence of specific nerve compromise MRI is not warranted

 

13-172

Deny

MRI left knee

Knee, left

MTUS (ACOEM) (UR also used ODG)

Employee's condition does not meet any of the conditions in ACOEM for an MRI; pain went from 8 to 10 out of 10 to 2 out of 10; gait is normal; McMurray's test went from positive to negative; no mechanical knee symptoms or findings; employee showed progress after PT and has returned to work

 

13-179

Aprv

MRI upper extremity

Upper extremity

ACOEM

Allowed after failed conservative care including anti-inflammatory drugs and PT

 

13-185

Aprv

Ultracet

Spine, thoracic

MTUS (ACOEM) (UR used Chronic Pain Guidelines)

Retrospective review of Ultracet given for acute flare-up of pain; records show functional improvement and return to work after treatment; short term use of opioids is effective for severe pain

 

13-185

Deny

Norflex

Spine, thoracic

MTUS (ACOEM) (UR used Chronic Pain Guidelines)

Retrospective review of Norflex; ACOEM suggests there is no proven support for use of muscle relaxants in conjunction with NSAIDs (Toradol IM)

 

13-185

Aprv

Thermacare

Spine, thoracic

MTUS (ACOEM) (UR said MTUS did not support but provided no specific reference)

Retrospective review of Thermacare given for acute flare-up of pain; records show functional improvement and return to work after treatment; ACOEM endorses use of heat and cold to treat acute and sub-acute pain

 

13-185

Deny

Chiropractic – 6 sessions

Spine, thoracic

MTUS (ACOEM) (UR also used ODG)

Employee responded to previous chiro sessions and reports less pain; ACOEM suggests reduced therapy; request for 6 added sessions not justified in view of the lack of residual complaints

 

13-185

Aprv

Toradol IM

Spine, thoracic

MTUS (ACOEM) (UR used Chronic Pain Guidelines)

Retrospective review of Toradol given for acute flare-up of pain; records show functional improvement and return to work after treatment; ACOEM recommend NSAIDs for acute neck pain

 

13-186

Aprv

OT – up to 18 sessions

Upper extremity, left

MTUS (ACOEM) (UR also used ODG)

IMR reviewer determined condition was non-healed metacarpal fracture after 6 weeks; adjuster conditionally approved only 6 sessions; employee had some improvement after 4 sessions but still had 50% grip loss and some limits in range of motion; added sessions recommended by specialist were justified

 

13-188

Deny

Home care – 8 hrs daily

Hip, left (surgery)

ODG, Chronic Pain guidelines

HHC allowed only for homebound patients, and generally no more than 35 hrs per week; this request exceeds what is reasonable and necessary

 

13-190

Deny

PT – 12 sessions

Hand, right

MTUS (ODG)

Patient has received 12 PT which is beyond guidelines already; no evidence of complication to recovery, comorbidity, or extenuating circumstances to justify added visits

 

13-191

Aprv

Epidural steroid injections – L5-S1

Spine, lumbar

MTUS (Chronic Pain guidelines)

IMR reviewer described condition as radiculopathy with clinical and imaging corroboration; employee is 4 mos. post injury; chronic pain guidelines recommend epidural injection when radiculopathy verified

 

13-195

Deny

MRI – left shoulder

Shoulder, left

MTUS (ACOEM)

ACOEM support imaging if red flags or beyond acute phase; there is no documentation of red flags; employee is still in acute phase with no suggestion of need for surgery

 

13-198

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM)

No medical records were provided for review; UR report provides no documentation of failure of conservative treatment modalities such as aerobic and other exercise, manipulation, or acupuncture.

 

13-203

Deny

Neuro- psychological screening

Head

ODG (MTUS/ ACOEM found not applicable)

Testing is recommended where there is concussion or mild traumatic brain injury and symptoms last over 30 days; in this case there was no reported loss of consciousness, and no evidence of concussion or traumatic brain injury.

 

13-206

Deny

PT – 6 sessions

Spine, cervical

MTUS (ACOEM, ODG)

ACOEM does not support PT beyond first month for managing symptoms of neck injuries; no documentation of functional improvement with previous 12 sessions of PT.

 

13-208

Aprv

EMG/NCV

Upper extremities, bilateral

MTUS (ACOEM) (UR used different section of ACOEM)

Medical records show persistent constant tingling in hands; ACOEM recommends EMG/NCV for evaluation of paresthesias down the upper extremities.

 

13-211

Deny

Cyclobenzaprine

Elbow, left

MTUS (Chronic Pain guidelines)

Cyclobenzaprine is a muscle relaxant and would not be useful to control pain following an orthopedic procedure.

 

13-212

Deny

MRI lumbar spine

Spine, lumbar

ACOEM

ACOEM recommends MRI in first 6 wks if progressive neurological deficit, cauda equina syndrome, significant trauma, history of cancer, or other atypical presentation; employee's condition has not worsened & no evidence of radiculopathy

 

13-214

Aprv

Surgery – ventral hernia repair

Hernia

Unnamed peer reviewed scientific evidence and ODG

Patient had two hernias and UR approved repair of only the inguinal hernia; ODG recommends surgical repair for ventral hernia causing pain and discomfort; condition is unlikely to resolve without surgery.

 

13-221

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

Retrospective review; no unequivocal objective findings that identified specific nerve compromise; no evidence of severe or progressive radiculopathy; no other red flags to justify MRI

 

13-221

Deny

Acupuncture – 10 sessions

Spine

MTUS (Acupuncture guidelines) (UR used ODG)

MTUS supports acupuncture for low back/neck pain, but limits to 3 to 6 treatments to produce functional improvement; 10 sessions exceeds the recommended amount

 

13-221

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM)

Retrospective review; no unequivocal objective findings that identified specific nerve compromise; no evidence of severe or progressive radiculopathy; no other red flags to justify MRI

 

13-222

Aprv

Epidural steroid injection – lumbar

Spine, lumbar

MTUS (ODG) and citations to 4 medical journal articles on epidural steroid injections

Radiculopathy was documented by positive straight leg raise and supported by imaging studies; conservative care failed; patient has severe pain and limited range of motion.

 

13-223

Deny

MRI upper extremity

Upper extremity

MTUS (ACOEM, ODG )

MRI recommended for rotator cuff tears that are acute, subacute, or chronic; no clear cut signs or red flags indicating rotator cuff tear; no weakness; no evidence of conservative care

 

13-225

Deny

MRI right shoulder

Shoulder, right

ACOEM

No red flags; patient has improved with conservative treatment; no surgical consultation

 

13-226

Aprv

Acupuncture – 9 sessions

Spine, hand

MTUS (Acupuncture guidelines)

IMR reviewer said UR was correct at the time but new evidence shows employee plateaued in response to PT, still has muscle spasm, pain, and 20% reduction in range of neck motion; with this new evidence acupuncture is appropriate

 

13-227

Deny

PT – 12 sessions

Knee, left

MTUS (ACOEM, Post-surgical treatment guidelines)

For post-surgical PT, ACOEM recommends one-half the number of visits for a general course of therapy, that would be 6 sessions; the request for 12 sessions exceeds this and is not authorized

 

13-231

Deny

PT – 12 sessions

Hand, right

MTUS (ACOEM)

No medical records were submitted for review; employee has already had 8 PT sessions but there is no documentation of improvement; no demonstration of interim re-injury

 

13-232

Deny

Continuous Passive Motion (CPM) Machine rental or purchase

Knee, left

ODG (MTUS not applicable) (UR used Blue Cross/Shield)

ODG indicates CPM may be used for home use following total knee arthroplasty or revision; the planned surgery is arthroscopic medial menisectomy which does not meet the criteria.

 

13-232

Deny

Cryotherapy Unit (CTU) 21 day rental

Knee, left

ODG (MTUS found not applicable)

ODG recommends rental for only 7 days; UR approved 7 days and there are no extenuating circumstances justifying added days; evidence does not demonstrate active cooling devices are better than passive modalities

 

13-236

Deny

Terocin

Spine, lumbar

MTUS (Chronic pain guidelines)

One ingredient, Lidocaine, is recommended after trial of first line therapy; another, Capsaicin, is not approved for chronic pain; this medication is not indicated for chronic pain and the employee has not had a trial of first line therapy.

 

13-240

Deny

PT – 10 sessions

Spine, cervical

MTUS (Chronic pain guidelines) (UR also used ACOEM 3rd Ed.)

Guidelines recommend 8 - 10 PTsessions; 12 sessions have been completed; no documentation of supporting functional improvement

 

13-241

Deny

MRI right hip

Hip, right

ODG (MTUS found not applicable)

Employee's hip pain appears to be referred and radicular in nature; no range of motion or strength deficits; no clinical findings consistent with evidence of avascular necrosis, stress fracture, chronic acute soft tissue injuries, or tumor

 

13-241

Aprv

PT – 6 sessions

Hip, right

MTUS (Chronic Pain guidelines) (UR used ODG)

Clinical summary provided evidence of radiculopathy, guidelines support 8-10 therapy visits for exacerbations of chronic pain

 

13-242

Deny

Fluorescein anglography

Eye, right

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-242

Deny

Fundus photography

Eye, right

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-242

Deny

Computerized ophthalmic imaging

Eye, right

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-242

Deny

Indocyanine green anglography

Eyes, bilateral

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-242

Deny

Special eye exam

Eyes, bilateral

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-242

Deny

Int eye photo, fluorscein anglography

Eye, right

MTUS (ACOEM)

No medical records were provided for review; documentation does not identify any red flags meeting the criteria for the requested treatment

 

13-244

Deny

Surgery – knee arthroscopy with meniscectomy

Knee, left

MTUS (ACOEM) (UR used ODG)

No documentation that conservative treatment such as PT or exercises failed or that employee is intolerant to such treatment; no evidence of symptoms other than pain and no signs of bucket handle tear on examination

 

13-251

Deny

Epidural steroid injections – L3-5

Spine, lumbar

MTUS (ACOEM)

ACOEM does not support epidural injections without radiculopathy; records fail to document subjective symptoms of radicular pain and physical exam findings not consistent with radicular pain

 

13-253

Deny

MRI cervical spine

Spine, cervical

ACOEM

Medical record is handwritten and hard to read; does not document full neurological exam, red flags, or other criteria supporting need for MRI

 

13-256

Deny

PT – post surgical 12 visits

Shoulder, right

MTUS (Post-surgical treatment guidelines)

Since surgery was not approved, post-surgical PT is not medically necessary.

 

13-256

Deny

Surgery – biceps tenodesis with subscapularis tendon repair

Shoulder, right

MTUS (ACOEM, ODG )

Records show no evidence of full thickness tear; surgery reserved for cases failing conservative therapy for 3 months

 

13-260

Deny

Acupuncture – 12 sessions

Lower extremities, bilateral

MTUS (Acupuncture guidelines)

MTUS recommends trial of 3-6 sessions with follow up if documented functional improvement; patient has received acupuncture with no improvement.

 

13-263

Deny

Compound medication – Camphor/ Flurbiprofen/ Capsaisin/Menthol

Spine/knee/ hand

MTUS (Chronic Pain guidelines, ACOEM)

No documentation of intolerance or failure of analgesics already prescribed; topical capsaicin not recommended or endorsed except as last line measure.

 

13-263

Deny

Compound medication – Gabapentin/ Ketoprofen/ Lidocane

Spine/knee/ hand

MTUS (Chronic Pain guidelines, ACOEM)

No documentation of intolerance or failure of analgesics already prescribed; both gabapentin and ketoprofen are specifically not endorsed by MTUS or FDA for topical use.

 

13-263

Deny

Compound medication – Cyclobenazeprine/Ketoprofen

Spine/knee/ hand

MTUS (Chronic Pain guidelines, ACOEM)

No documentation of intolerance or failure of analgesics already prescribed;both cyclobenzaprine and ketoprofen are specifically not endorsed by MTUS or FDA for topical use.

 

13-266

Deny

Functional capacity evaluation

Spine

MTUS (ACOEM)

ACOEM states there is little scientific evidence confirming FCE predicts actual work capacity; performance on single day can be influenced by non-medical factors and has poor predictive value

 

13-266

Deny

ROM testing

Spine, lumbar

ODG (MTUS/ ACOEM found not applicable)

Request was to measure employee's functional improvement, but ODG states the relation between lumbar range of motion measures and functional ability is weak and nonexistent

 

13-266

Deny

3D MRI

Spine, thoracic

MTUS (ACOEM)

Guidelines recommend imaging when evidence of tissue insult or neurological dysfunction, red flags, failure of strengthening program, or pre-surgery; employee has pain but no evidence of any of these factors

 

13-266

Deny

3D MRI

Spine, lumbar

MTUS (ACOEM)

Guidelines recommend imaging when surgery is considered or there are red flags; employee has pain but no evidence of lumbar surgical lesion or red flags

 

13-266

Deny

3D MRI

Spine, cervical

MTUS (ACOEM)

Guidelines recommend imaging when evidence of tissue insult or neurological dysfunction, red flags, failure of strengthening program, or pre-surgery; employee has pain but no evidence of any of these factors

 

13-266

Deny

Lumbar orthosis

Spine, lumbar

MTUS (ACOEM)

ACOEM does not recommend use of a corset for lumbar pain

 

13-266

Deny

Chiropractic – 6 sessions

Spine

MTUS (ACOEM)

Employee had 6 chiropractic sessions without improvement; if no improvement after 3 to 4 weeks treatment should be stopped and reevalated

 

13-266

Deny

Pharmacological consultation

Spine

MTUS (ACOEM)

No documentation or rationale for consultation, provider is a medical doctor and can prescribe drugs for pain control

 

13-269

Deny

Epidural steroid injections – C-4-5

Spine, cervical

MTUS (Chronic Pain guidelines) (UR also used ACOEM)

Radiculopathy must be documented by physical examination and corroborated by imaging studies or electrodiagnostic testing; MRI report on this employee was not available; physical exam does not clearly show particular cervical radiculopathy

 

13-270

Deny

TENS/EMS unit and two months supplies

Shoulder, elbow, hand, neck, back

MTUS (Chronic Pain guidelines)

Pain has not been present for 3 mos; no evidence other pain modalities were tried and failed; two month rental not supported without one month trial

 

13-271

Aprv

MRI right shoulder

Shoulder, right

ACOEM

Documentation shows conservative treatment including PT and steroid injection failed; MRI is justified with a traumatic injury, continued pain in shoulder, and poor improvement after a month

 

13-272

Deny

MRI left knee

Knee, left

MTUS (ACOEM)

Employee does not have red flags or instability on exam; conservative treatment has just started; negative valgus or varus laxity and cruciate ligaments are felt to be intact

 

13-275

Deny

TENS purchase with electrodes and batteries

Shoulder, left

MTUS (Chronic Pain guidelines)

No medical records were provided for review; letter from patient states TENS unit helped but does not contain sufficient information to justify purchase of TENS unit; need documentation of pain and failure of other modalities and other pain treatment

 

13-278

Aprv

PT – 3 sessions

Hip, right

MTUS (Post-surgical treatment guidelines) (UR used ODG)

Employee is improving with PT; X-rays show question of delayed union more than 3 mos post surgery; based on severity and delay in healing more than 12 PT are appropriate

 

13-281

Deny

PT – 6 sessions

Foot, ankle

MTUS (ACOEM)

Two sessions are sufficient to educate patient about proper technique; records indicate injury is fully resolved, patient has returned to work with no impairment and has been discharged from care

 

13-281

Deny

MRI left foot

Foot, left

MTUS (ACOEM)

Strain and sprain injuries do not require MRI for diagnosis; records indicate injury is fully resolved, patient has returned to work with no impairment and has been discharged from care

 

13-281

Deny

MRI left ankle

Ankle, left

MTUS (ACOEM)

Strain and sprain injuries do not require MRI for diagnosis; records indicate injury is fully resolved, patient has returned to work with no impairment and has been discharged from care

 

13-283

Deny

Inferential Unit

Upper extremity, spine, elbow

MTUS (Chronic Pain guidelines)

No sensory deficit or localization of numbness or tingling; no documented spasm or muscle tightness; patient has not completed adequate trial of conservative care

 

13-283

Deny

MRI right shoulder

Shoulder, right

MTUS (ACOEM) (UR also used ODG)

Criteria for MRI are not met; notes indicate muscle weakness but no location; no sensory deficit or localization of numbness or tingling; no mention of shoulder deficit or lesion; PT and OT not completed

 

13-283

Deny

PT – 12 sessions

Upper extremity, spine, elbow

MTUS (ACOEM) (UR also used ODG)

Patient has received 3 PT and 5 OT with no improvement; cannot perform home exercise program properly; 12 sessions exceeds MTUS

 

13-283

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM) (UR also used ODG)

Criteria for MRI are not met; notes indicate muscle weakness but no location; no sensory deficit or localization of numbness or tingling

 

13-283

Deny

EMG/NCS

Upper extremities, bilateral

MTUS (ACOEM) (UR also used ODG)

Criteria for EMG/NCS are not met; no sensory deficit or localization of numbness or tingling; no clear documented neurological deficit; PT and OT not completed

 

13-283

Deny

Robaxin

Upper extremity, spine, elbow

MTUS (Chronic Pain guidelines)

No sensory deficit or localization of numbness or tingling; no documented spasm or muscle tightness which would justify use of muscle relaxant; analogesics are provided

 

13-286

Deny

MRI right hip

Hip, right

ACOEM 3rd Ed (MTUS did not cover) (Adjuster also used ODG)

Guidelines endorse MRI with subacute or chronic hip pain; documentation fails to substantiate; no objective findings that meet the criteria for an MRI

 

13-288

Aprv

Epidural steroid injections – L4-5 right transforaminal

Spine, lumbar

MTUS (ACOEM, Chronic Pain guidelines)

Conservative measures have been attempted; lumbar MRI indicates annular tear and small posterior disc bulge at L4-5.

 

13-288

Aprv

Epidural steroid injections – L5-S1 right transforaminal

Spine, lumbar

MTUS (ACOEM, Chronic Pain guidelines)

Conservative measures have been attempted; documentation of decreased sensation in lateral leg and dorsum of foot; positive straight leg raise; diminished deep tendon reflexes support signs of radiculopathy in L5 and S1.

 

13-291

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

Guidelines require red flag, failure to progress, pre-surgery, or physiologic evidence of tissue insult or definitive neurologic findings on physical exam; with lack of positive neurologic findings criteria for MRI is not met

 

13-293

Deny

PT – 30 sessions post-operative

Shoulder, right

ODG (MTUS does not apply)

Surgery was not appropriate so post-surgery PT is not needed; only 12 - 15 visits are recommended

 

13-293

Deny

Surgery – shoulder arthroscopy

Shoulder, right

ODG (MTUS does not apply) (UR used MTUS)

IMR reviewer determined adhesive capsulitis is more significant issue; request is for surgery for both impingement and capsulitis; these are not recommended together; surgery and manipulation recommended only if conservative treatment fails; no evidence all avenues of conservative treatment have been exhausted

 

13-293

Deny

Pre-operative labs and testing

Shoulder, right

Institute for Clinical Systems Improvement Guideline (MTUS not applicable)

Surgery was not appropriate so pre-operative tests and labs are not appropriate

 

13-300

Deny

Biotherm cream – capsaicin

Shoulder, right

ODG, Chronic Pain guidelines

Capsaicin recommended only after other creams failed, no evidence of failed trial of other topical formulation; no studies to support use in rotator cuff pathology.

 

13-300

Deny

Cold therapy unit

Shoulder, right

ACOEM, ODG

Recommended for post-operative use but not for non-surgical treatment.

 

13-300

Deny

Diclofenac Flex Plus – Diclofenac/ Cyclobenzeprine/ Lidocane

Shoulder, right

ACOEM, ODG

Compounded drug that contains 1 non-recommended drug is not recommended, cyckobenzaprine is not a recommended component.

 

13-302

Deny

Bio Therm – Capsaicin .002%

Shoulder, right

MTUS (Chronic Pain guidelines)

Chronic pain guidelines do not recommend topical analgesics for full thickness shoulder tears; no documentation treatment options with oral medications exhausted or contraindicated

 

13-302

Deny

Diclofenac Flex Plus – Diclofenac/ Cyclobenzeprine/ Lidocane

Shoulder, right

MTUS (Chronic Pain guidelines)

Chronic pain guidelines do not recommend topical analgesics for full thickness shoulder tears; no documentation treatment options with oral medications exhausted or contraindicated

 

13-307

Aprv

EMG/NCS

Lower right extremity, spine

ACOEM (not in MTUS)

Guidelines recognize potential value of electrodiagnostic testing in cases with no improvement after 4-6 weeks conservative therapy; documentation shows antalgic gait, tenderness, limited range of motion, and lumbar radiculopathy

 

13-309

Deny

PT – 3 sessions

Knee, chest

MTUS (Chronic Pain guidelines) (UR used ACOEM)

Guidelines endorse 8-10 PT for myalgias and/or myositis of body parts; patient has had 12 sessions with minimal benefit and no evidence of functional improvement; no justification to exceed guidelines

 

13-316

Deny

PT – 18 sessions

Spine, cervical

MTUS (ACOEM) (UR used different section of ACOEM)

No medical records were provided for review; ACOEM recommends 1-2 PT but employee has already had 8 sessions; request for 18 additional sessions is not medically appropriate

 

13-324

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM)

MTUS supports MRI with red flags or pre-surgery; no evidence of radiculopathy or myelopathy; no documentation of red flags or that surgery is being considered

 

13-340

Deny

EMG/NCV

Lower extremities

MTUS (ACOEM)

IMR reviewer described condition as myofacial low back pain, bilateral hip pain, right knee pain; no red flags, progressive deficits, or significant findings consistent with peripheral neuropathy

 

13-340

Deny

Psychological evaluation

Psyche

MTUS (ACOEM)

Medical records show history of anxiety and sleep disturbance but no mention of assessment, treatment or management of these conditions; no significant positive objective mental health or psychiatric findings, red flags, co-morbidities, or extenuating circumstances to support request

 

13-340

Deny

Chiropractic – 12 visits

Lower extremities

MTUS (ACOEM)

Past chiropractic has helped but frequency and duration of request are too long without interim verification of efficacy of treatment and compliance

 

13-341

Aprv

PT – ? sessions

Hand, left

ODG (MTUS does not apply) (UR used ACOEM)

Patient had operation on hand; ODG recommends up to 16 post-surgical PT visits for fractures of metacarpal bones; request was approved although it did not specify the number of sessions requested

 

13-342

Aprv

Acupuncture – 6 sessions

Wrist, right

MTUS (Acupuncture guidelines)

Employee significantly improved after previous acupuncture; guideline allows extension of treatment if functional improvement is documented

 

13-349

Aprv

PT – 12 sessions

Elbow, shoulder, spine

MTUS (Chronic pain guidelines) (UR used ACOEM)

Employee improved with previous conservative therapy including PT and acupuncture; more than 6 months post-injury meets criterion for chronic pain; multiple body parts and continued pain justify additional PT

 

13-357

Aprv

PT – 12 sessions

Spine, cervical, lumbar

MTUS (Chronic pain guidelines) (UR used different section)

Guidelines state treater's clinical judgment shall be applied to determine frequency and intensity of treatment and tailored to individual case; injuries to multiple body parts does not allow for application of a single guideline for a specific condition

 

13-358

Deny

Extended functional evaluation

Spine, lumbar, abdomen

ODG (not in MTUS)

MTUS does not discuss when functional evaluation is necessary; ODG states patient must be at or close to MMI; records do not show employee has reached MMI

 

13-366

Deny

PT – 15 sessions

Spine/lower extremity

MTUS (ACOEM)

ACOEM recommends 1 or 2 PT visits for education, counseling, and evaluation of home exercise for range of motion and strengthening; 15 visits is not medically necessary.

 

13-369

Deny

PT – 8 sessions post-op

Wrist, right

MTUS (Post Surgical Trtmt Guidelines)

Guidelines permit post operative PT period for 4 months with 16 visits; patient is now 5 months post surgery

 

13-373

Deny

MRI left shoulder

Shoulder, left

MTUS (ACOEM)

Guideline indicates MRI indicated after failure of strengthening program intended to avoid surgery; no documentation of failed strengthening program or evidence patient is surgical candidate

 

13-373

Deny

EMG/NCV

Upper extremities, bilateral

MTUS (ACOEM) (UR used ODG not in MTUS)

ACOEM indicates electrodiagnostic testing where peripheral nerve impingement or no improvement / worsening symptoms after 6 weeks; records show no neurologic deficits or compromise or parethesias; some evidence of carpal tunnel but no documented clinical complaints

 

13-373

Deny

X-ray lumbar spine

Spine, lumbar

MTUS (ACOEM) (UR used ODG not in MTUS)

ACOEM does not recommend X-ray in absence of red flags; records do not document neurologic deficits and multifocal pain argues against serious spinal pathology

 

13-373

Deny

X-ray cervical spine

Spine, cervical

MTUS (ACOEM) (UR used ODG not in MTUS)

Guidelines indicate need for X-ray where evidence of neurologic compromise, acute trauma, or midline vertebral tenderness after head injury; none of these criteria are present in this case

 

13-373

Deny

X-ray right elbow

Elbow, right

MTUS (ACOEM) (UR used ODG not in MTUS)

ACOEM indicates X-rays to rule out osteomyelitis and/or joint effusion; records document neither condition; multifocal pain argues against focal elbow pathology that would require X-ray

 

13-373

Deny

X-ray left shoulder

Shoulder, left

MTUS (ACOEM) (UR used ODG not in MTUS)

ACOEM indicates X-rays for AC joint shoulder separation or history of dislocations, no documentation of these criteria; previous shoulder MRI was largely negative

 

13-373

Deny

MRI right elbow

Elbow, right

MTUS (ACOEM) (UR used ODG not in MTUS)

Guideline indicates MRI indicated after failure of strengthening program intended to avoid surgery; no documentation of failed strengthening program or evidence patient is surgical candidate; diagnosis of lateral epicondylitis already established clinically

 

13-373

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM) (UR used ODG not in MTUS)

Guideline indicates lumbar MRI considered only in individuals with neurologic compromise, or have failed conservative therapies, or are surgical candidates; medical record documents none of these criteria

 

13-373

Deny

PT – 12 sessions

Neck, back, shoulder, elbow

MTUS (definitions)

The MTUS requires documentation of functional improvement; records do not document any functional improvement from previous PT

 

13-373

Deny

MRI right proximal radioulnar

Elbow, right

MTUS (ACOEM)

Based on diagnosis of lateral epicondylitis there is no need for MRI as there is no need to investigate a potential anatomic defect in the forearm

 

13-373

Deny

Acupuncture – 12 sessions

Neck, back, shoulder, elbow

MTUS (Acupuncture guidelines)

The MTUS requires documentation of functional improvement; records do not document any functional improvement from previous acupuncture

 

13-373

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM) (UR used ODG not in MTUS)

Criteria for MRI include failure of strengthening program intended to avoid surgery with persistent neurological complaints and evidence of neurologic compromise; records do not indicate evidence of radicular symptoms or complaints

 

13-380

Aprv

EMG study

Upper extremities, bilateral

MTUS (ACOEM)

Initial treatment included PT, activity modification, and splinting; parasthesia remained; guidelines state EMG/NCV may help identify subtle focal neurologic dysfunction with neck or arm symptoms lasting over 3 weeks

 

13-380

Aprv

NCV – nerve conduction velocity

Upper extremities, bilateral

MTUS (ACOEM)

Initial treatment included PT, activity modification, and splinting; parasthesia remained; guidelines state EMG/NCV may help identify subtle focal neurologic dysfunction with neck or arm symptoms lasting over 3 weeks

 

13-381

Deny

Chiropractic – 6 sessions

Shoulder, right

ACOEM, ODG

Employee has persistent right shoulder and neck pain with no evidence of localized neuropathic pain; injury was more than three months ago; guidelines recommend physical manipulation for neck pain early in care only

 

13-381

Deny

Flexeril & lidoderm patches 5% #15

Shoulder, right

MTUS (Chronic pain guidelines) (UR also used ODG)

Employee has persistent right shoulder and neck pain with no evidence of localized neuropathic pain to support use of lidoderm; previous use of flexeril did not provide any functional improvement

 

13-381

Aprv

Lodine

Shoulder, right

MTUS (Chronic pain guidelines) (UR also used ODG)

Employee has persistent right shoulder and neck pain with no evidence of localized neuropathic pain; MTUS supports use of lodine, max dose 500mg BID

 

13-385

Deny

Ondansetron

Spine, leg

FDA information (UR used Dutch guidelines)

Retrospective review; this medication is used for chemotherapy-induced nausea; no evidence in records that employee meets criteria

 

13-385

Aprv

Omeprazole

Stomach

MTUS (Chronic pain guidelines)

Retrospective review; chronic pain guidelines indicate use of proton pump inhibitor like omeprazole is indicated for individuals with confirmed history of GERD

 

13-385

Deny

Medrox ointment

Spine, leg

MTUS (Chronic pain guidelines and ACOEM)

Retrospective review; ACOEM lists oral pharmaceuticals as most appropriate first line pain control; documentation does not indicate failure of oral analgesics as first line pain control; one ingredient (capsaicin) is not recommended except as a last resort

 

13-413

Deny

MRI left shoulder

Shoulder, left

MTUS (ACOEM)

MRI not recommended without surgical indications, no evidence of conservative care

 

13-442

Deny

PT – 10 sessions

Spine, cervical

ACOEM

Records show normal neurological exam and no red flags; patient has already received some PT; ACOEM allows 8 - 12 sessions with functional improvement; adjuster approved 6 more sessions but 10 additional are not justified

 

13-442

Deny

MRI cervical spine

Spine, cervical

ACOEM

Patient has received PT and analgesics; records show normal neurological exam and no red flags; treater agreed in peer-to-peer discussion in UR that MRI was not needed at this time

 

13-443

Deny

Sleep study

Sleep apnea

Medical Journal article (UR used different Journal articles)

Patient has little objective or subjective evidence of sleep apnea; records document only one symptom (gasping arousals) but no history of snoring, witnessed apneas, sleep fragmentation, or daytime sleepiness; no record of full sleep history; nasal and throat exams do not suggest crowded airway

 

13-453

Deny

MRI upper extremity

Upper extremity

MTUS (ACOEM)

ACOEM states MRI indicated for postoperative evaluation of acute rotator cuff tear but not recommended if no surgery required; no evidence of rotator cuff injury or nerve impingement requiring surgery; symptoms indicate acute shoulder sprain

 

13-456

Deny

Acupuncture – 3 sessions

Spine, lumbar

MTUS (Acupuncture guidelines)

Employee received 6 acupuncture visits with no documentation of completed visits or functional improvement; guidelines recommend continued visits only if signficant improvement with initial trial

 

13-457

Deny

Surgery – pre-operative clearance

Elbow, left

ISCI and ODG (MTUS not applicable)

ODG indicates pre-operative testing for patients with signs of active cardiovascular disease or patients undergoing high-risk surgery; no indication of any of these scenarios to justify testing in this patient

 

13-458

Deny

MRI upper extremity

Upper extremity

ACOEM

No evidence of rotator cuff injury or nerve impingment requiring surgical intervention; MRI not recommended for evaluation of conditions not requiring surgery.

 

13-462

Deny

Surgery – left shoulder arthroscopy with rotator cuff repair

Shoulder, left

MTUS (ACOEM) (UR used ODG not in MTUS)

No evidence of conservative treatment such as range of motion or PT; guidelines support surgery only for cases failing conservative therapy for three months; MRI confirms small tear but surgery less successful than conservative care for older patients

 

13-467

Aprv

Epidural steroid injections – L5-L5 and L5-S1 transforaminal

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ACOEM)

Applicant continues to have radiating low back pain; has failed conservative treatment including analgesic medications, acupuncture, and PT; is now 5 months post injury meeting the criteria for chronic pain

 

13-474

Deny

PT – 12 sessions

Shoulder, left

MTUS (Post Surgical Trtmt Guidelines)

Since surgery was not approved, post-surgical PT is not medically necessary

 

13-474

Deny

Surgery – open rotator cuff repair

Shoulder, left

MTUS (ACOEM) (UR also used ODG)

ACOEM recommends failure of conservative care before surgery; MRI does not show evidence of a significant rotator cuff injury; no documentation of conservative care of therapy or injection

 

13-474

Deny

Complete blood count and sequential multiple analysis-7

Shoulder, left

MTUS (ACOEM) (UR also used journal article)

Since surgery was not approved, post-surgical testing is not medically necessary

 

13-483

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

Physical exam does not support need for MRI; no red flags

 

13-483

Deny

MRI brain

Brain

ODG (MTUS does not apply)

Guidelines do not support MRI without evidence of neurological deficits not explained by CT or evidence of acute changes superimposed on previous trauma or disease; the request is not supported by physical findings and does not meet this criteria

 

13-483

Deny

Acupuncture – 12 sessions

Head (aches)

MTUS (Acupuncture guidelines)

Acupuncture is recommended when pain medication is reduced or not tolerated; patient is taking Tylenol and Motrin

 

13-509

Deny

OrthoStim4 EOC1, EOC2

Shoulder, left

MTUS (Chronic pain guidelines) (UR used ODG)

Injury is greater than 4 months ago meeting criteria for chronic pain; guidelines recommend neuromuscular stimulator only for post stroke rehab; Galvanic stimulation is considered investigational and not recommended

 

13-509

Aprv

Fexmid 7.5 mg

Shoulder, left

MTUS (Chronic pain guidelines) (UR used ACOEM)

Fexmid is recommended for short course of therapy and for brief acute flare ups of pain

 

13-509

Deny

PT – 8 sessions

Shoulder, left

MTUS (Chronic pain guidelines) (UR used ACOEM)

Guidelines indicate PT for myalgias and/or myositis limited to 9 - 10 treatments; employee has had in excess of that amount; no evidence of functional improvement to justify additional treatments

 

13-516

Deny

OT – 12 sessions

Hand, left

MTUS (Chronic pain guidelines) (UR also used ODG)

Chronic pain guidelines recommend 3 sessions per week to start moving to 1 session per week with no total number recommended; ODG recommends 8 sessions with added if weakness documented; grip strength was reported but not documented in records; no documentation of strength of middle finger in records

 

13-519

Deny

Epidural steroid injections – C-7, T-1

Spine, cervical

MTUS (Chronic pain guidelines)

Guidelines recommend epidural injection with evidence of radicular pain; no subjective or objective findings along dermatomical distribution of C7-T1 that suggest neurological deficits; no evidence PT has been undertaken and patient plays golf weekly

 

13-525

Aprv

Physiotherapy – 12 visits

Knee, right

MTUS (Chronic pain guidelines) (UR used ACOEM)

Chronic pain guidelines recommend PT for pain relief during early phases of pain treatment; PT can help control pain, inflamation, and swelling during rehabilitation process

 

13-526

Deny

Inferential Unit

Spine, shoulders, hand

MTUS (Chronic pain guidelines) (UR also used ACOEM)

Limited medical records were provided; guidelines suggest inferential stimulator should be reserved for patients with history of analgesic failure or intolerance; no evidence in records so criteria for inferential stimulator have not been met

 

13-526

Deny

PT – 18 sessions

Spine, shoulders, hand

MTUS (Chronic pain guidelines) (UR also used ACOEM)

Limited medical records were provided; guidelines support PT but records do not indicate whether patient has received PT or whether there was any functional improvement

 

13-527

Deny

TENS rental 36 months supplies

Hand, finger

MTUS (Chronic pain guidelines)

Guidelines recommend TENS for 30 days post surgery; use for chronic neuropathic pain contingent on outcome of 1 month trial as adjunct to program of functional restoration; request exceeds guideline without reporting outcome of 1 month trial

 

13-532

Deny

Ketoprofen 20% in PLO gel

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ODG)

No medical records were provided for review; MTUS specifically recommends against the use of Ketoprofen as it is not currently approved by FDA for topical application

 

13-532

Deny

Cyclophene 5% PLO gel

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ODG)

No medical records were provided for review; cannot determine what medications make up compounded Cyclophene; topical analgesics are recommended only after failure of anticonvulsants and antidepressants

 

13-532

Deny

Synapryn 10mg/1ml

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ODG)

No medical records were provided for review; appears to recommend Synapryn as a first line analgesic; guidelines state Tramadol (Synapryn) is not recommended as first line oral analgesic

 

13-532

Deny

Tabradol 1mg/ml

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ODG)

No medical records were provided for review; Tabrodol is Cyclobenzaprine in oral suspension; request has no dosing information or explanation of why tablet form not attempted; tablet should be tried first

 

13-550

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM)

No frank neurologic deficits or nerve dysfunction; patient had not received conservative treatment

 

13-550

Deny

MRI thoracic spine

Spine, thoracic

MTUS (ACOEM)

No red flags relating to upper back or thoracic spine; no physiologic evidence of neurologic dysfunction; patient had not received conservative treatment

 

13-550

Deny

ART stimulator

Spine, head

MTUS (Chronic pain guidelines)

MTUS states neuromuscular electrical stimulation is not recommended; it is used primarily as part of rehab program following stroke and there is no evidence to support its use in chronic pain

 

13-550

Deny

MRI nose

Head, nose

ODG (MTUS does not apply)

No neurologic evidence not explained by CT or periods of altered consciousness

 

13-550

Deny

MRI head

Head

ODG (MTUS does not apply)

Guideline recommends MRI where findings of CT are unexplained or define evidence of acute changes; CTs show no changes; no neurologic evidence of focal deficit, changes in mental status or periods of altered consciousness

 

13-550

Deny

MRI brain

Brain

ODG (MTUS does not apply)

Guideline recommends MRI where findings of CT are unexplained or define evidence of acute changes; CTs show no changes; no neurologic evidence of focal deficit , changes in mental status or periods of altered consciousness

 

13-550

Deny

MRI face

Head

ODG (MTUS does not apply)

Guideline recommends MRI where findings of CT are unexplained or define evidence of acute changes; CTs show no changes; no acute neurologic findings or altered mental state; patient has not received conservative treatment

 

13-550

Deny

MRI cervical spine

Spine, cervical

MTUS (ACOEM)

No red flags such as arm pain or numbness; no physiologic evidence of neurologic dysfunction; patient had not received conservative treatment

 

13-553

Deny

Ambien

Spine, lumbar

ODG (MTUS does not apply)

Medical records do not provide history to show patient suffering from insomnia; latest progress report indicates patient has difficulty sleeping but does not indicate insomnia

 

13-563

Aprv

Hydrocodone/ APAP

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used different page)

Page used by UR does not describe indications for continued opioid use; page used by IMR reviewer supports continued use when improvement in pain and function; both are documented in records

 

13-563

Aprv

Naproxen Sodium

Spine, lumbar

MTUS (ACOEM)

Records supportive of a lumbar radiculopathy; guidelines indicate Naproxen is common NSAID used for low back pain

 

13-568

Deny

Heart Image 3d; Nuclear Medicine Stress Test

Heart

Outside guidelines (MTUS not applicable)

Workup for cardiac ischemia starts with tests already performed, the next step, a stress echocardiogram, has already been approved; this request is not medically necessary and appropriate

 

13-588

Deny

TENS unit – 1 month home trial

Spine, hand

MTUS (Chronic pain guidelines)

Criteria for TENS unit includes duration of pain at least 3 months; request was before 3 months

 

13-602

Deny

Hydrocodone/ Bit/Acet

Unknown

None

No medical records were provided for review; reviewer could not determine whether guidelines were applicable

 

13-602

Deny

Diclofenac Sodium ER

Unknown

None

No medical records were provided for review; reviewer could not determine whether guidelines were applicable

 

13-604

Deny

Acupuncture – 6 sessions

Shoulder, right

MTUS (Acupuncture guidelines)

Employee received 6 acupuncture visits with no documentation of functional improvement; employee remains off work; guidelines recommend continued visits only if signficant improvement with initial trial

 

13-604

Deny

Range of motion test

Shoulder, right

MTUS (ACOEM) (UR used different chapter)

ACOEM does not specifically endorse computerized ROM testing outside of the usual and customary physical examination

 

13-605

Deny

MRI lumbar spine

Spine, lumbar

MTUS (ACOEM) (UR also used ODG)

ACOEM recommends CT for bony structures, patient had lumbar CT showing bulging disc; provider suspected possible stress fracture; MRI would not alter treatment of patient

 

13-609

Aprv

Pre-operative labs and testing

Shoulder, left

Expertise of IMR reviewer; no guidelines or evidence based standards

MTUS does not address need for EKG; most hospital protocol would require pre-operative labs and EKG as part of standard of care

 

13-609

Deny

PT – 12 added sessions

Shoulder, left

MTUS (Post Surgical Trtmt Guidelines)

Additional PT is indicated if there is ongoing symptomology; that is unknown at this time

 

13-609

Deny

PT – 6 added sessions

Shoulder, left

MTUS (Post Surgical Trtmt Guidelines)

Additional PT is indicated if there is ongoing symptomology; that is unknown at this time

 

13-609

Aprv

PT – 8 sessions

Shoulder, left

MTUS (Post Surgical Trtmt Guidelines)

Most individuals can successfully rehab from this surgery with 24 visits; this first course of PT is necessary and appropriate

 

13-609

Aprv

Polar Care - post-operative

Shoulder, left

ODG (not in MTUS)

MTUS does not address; ODG recommends for up to 7 days after surgery; has been proven to decrease pain, inflammation, swelling, narcotic use

 

13-609

Aprv

Surgery – left shoulder arthroscopy with MUA

Shoulder, left

MTUS (ACOEM)

Patient has had persistent pain following 5 months of conservative therapy; medical record indicates positive impingement signs; criteria for surgery for impingement syndrome has been met

 

13-615

Deny

Diagnostic Ultrasound

Knee, left

ACOEM 3rd Ed (Adjuster used MTUS/ACOEM and ODG)

ACOEM 2nd Ed. does not discuss ultrasound, but 3rd Ed state that diagnostic ultrasound is not recommended for investigation of acute meniscal tears

 

13-615

Deny

OrthoStim4

Knee, left

MTUS (Chronic pain guidelines)

Neuromuscular stimulation is only endorsed in the post stroke rehab context, not for chronic pain; galvanic stimulation is considered investigational

 

13-620

Deny

EMG/NCV

Lower extremities

MTUS (ACOEM)

Patient had PT and acupuncture and improved gait, strength, endurance and ROM; no specific neurological deficits; further evaluative studies needed only where there are red flags, neurological dysfunction, or failure to progress, or prior to surgery

 

13-633

Aprv

Capsaicin (Bio Therm)

Neck, shoulder, wrist

MTUS (Chronic pain guidelines)

Patient has failed conservative therapies including injection;now is candidate for surgery; patient reports use of topical cream improves symptoms; guidelines allow where other options have failed or cannot be tolerated

 

13-633

Deny

Diclofenac Flex Plus – Diclofenac/ Cyclobenzeprine/ Lidocane

Neck, shoulder, wrist

MTUS (Chronic pain guidelines)

Topical NSAIDs are effective treatment for musculoskeletal pain, but effectiveness of compounded product is questionable

 

13-636

Aprv

PT – 6 sessions

Knee, left

ODG (MTUS does not apply)

ODG recommends 12 PT for conditions of the knee; patient has completed 4 of 6 originally authorized; although no documentation of functional improvement the request is within the guideline

 

13-637

Deny

Acupuncture

Shoulder, right

MTUS (Acupuncture guidelines) (UR used ACOEM & ODG)

Employee has failed to improve in activities of daily living, work status, work restrictions, or reliance on medical treatment; acupuncture may be extended with evidence of improvement but there is none in this case

 

13-637

Deny

MRI – referral to orthopedist

Shoulder, right

MTUS (ACOEM) (UR also used ODG)

While a referral for surgical consultation may be appropriate, employee has already had MRI with positive findings; there is no reason given for a repeat MRI as the prior MRI already established the presence of a lesion amenable to surgery

 

13-638

Aprv

Cognitive behavior therapy

Depression

MTUS (Chronic pain guidelines) & ODG

No medical records were provided; CONDITIONAL APPROVAL if fear avoidance belief questionnaire demonstrates risk factors to recovery and there is lack of progress after 4 weeks of PT, or a detailed assessment demonstrates severe psychological impairment of depression, anxiety, PTSD

 

13-643

Deny

H-Wave Unit purchase

Neck, arm

MTUS (Chronic pain guidelines)

Guidelines indicate criteria for H-Wave include failure of trial of TENS; medical records do not include documentation that meet criteria

 

13-657

Deny

Omeprazole 60 units

Spine, foot

MTUS (Chronic pain guidelines)

Retrospective; no documentation of any GI risk factors that warrant a proton pump inhibitor; no history of GI bleeding, ulcers, or intolerance to medicine

 

13-657

Deny

Ultram 60 units

Spine, foot

MTUS (Chronic pain guidelines)

Retrospective; initial use of Ultram is appropriate but MTUS requires ongoing monitoring of side effects, behaviors, analgesic effect; records provide no clear statement of functional benefit from Ultram

 

13-657

Deny

Trazadone 60 units

Spine, foot

ODG (MTUS does not apply)

Retrospective; guidelines suggest non-pharmacologic approaches; no documentation of non-pharmacological trial, no commentary on counseling and education on sleep hygiene

 

13-658

Deny

Drug screen

Spine, foot

ODG (MTUS does not apply)

Records do not indicate whether any initial risk stratification was carried out; without this information the necessary frequency of drug tests is unknown

 

13-667

Aprv

Medical treatment

Spine, cervical, lumbar

ODG (not in MTUS)

Request is for on-going care with the treating doctor; continued treatment for 6 weeks with this physician is within the standard of care

 

13-667

Deny

PT – 12 sessions

Spine, cervical, lumbar

ODG (not in MTUS)

ODG recommends formal assessment after initial 6 session trial; this request is in excess of that recommendation

 

13-676

Deny

H-Wave Unit purchase

Ankle, left

MTUS (Chronic pain guidelines)

H-wave not recommended except as a fourth-line treatment; following failure of analgesics, PT, and TENs; no clear evidence that all of these treatments have been attempted or failed; no evidence reduction in work restrictions, ADL deficits, or medication after introduction of H-wave device

 

13-677

Deny

PT – 8 sessions

Shoulder, right

MTUS (Chronic pain guidelines)

Patient has had extensive therapy without improvement of pain, should have been adequate to improve function and transition to home exercise

 

13-688

Deny

Facet joint injection, cervical

Spine, cervical

MTUS (ACOEM ) (UR used Chronic pain guidelines)

ACOEM indicates facet joint injections have no proven benefit in treating neck or upper back problems; patient has on-going clinical radiculopathy for which cervical epidural injection has already been approved

 

13-692

Deny

PT – 12 sessions

Spine and shoulder

MTUS (ACOEM) & ODG

Employee had 6 PT approved earlier; no medical records to document number of PT undertaken or functional improvement

 

13-693

Deny

PT – 6 added sessions

Neck, spine

MTUS (Chronic pain guidelines) (UR also used ACOEM)

Employee already received 6 PT; medical records do not document functional gains or improvement in ADLs or discuss RTW; number exceeds amount recommended by guideline

 

13-708

Deny

Inpatient hospital stay – 3.5 days

Spine, lumbar

MTUS (ACOEM)

Because criteria for lumbar fusion were not met, the issue of hospital stay is not relevant

 

13-708

Deny

Surgery – T12-L2 Posterior decompression fusion & preop

Spine, lumbar

MTUS (ACOEM)

Guidelines allow fusion when all pain generators defined, all PT completed, evidence of disc pathology or spinal instability, pathology limited to 2 levels, and psychosocial evaluation and issues addressed; records show insufficient deficit to warrant fusion for 4 month old L-1 burst fracture

 

13-714

Deny

Continuous Passive Motion (CPM) unit rental

Shoulder, left

ODG (not in MTUS)

ODG does not recommend CPM for rotator cuff tear surgery, only as option for adhesive capsulitis

 

13-714

Deny

Pain pump

Shoulder, left

ODG (not in MTUS)

ODG does not recommend the pain pump post- operatively; states insufficient evidence to show it is better than conventional pain control using oral, intra-muscular, or intravenous measures

 

13-717

Deny

Electrodiagnostic testing

Lower extremities, bilateral

MTUS (ACOEM)

Electrodiagnostic testing is considered 2nd line test to identify dysfunctions not detected on MRI; here MRI has not yet been done (see next item)

 

13-717

Aprv

MRI – lumbar spine

Spine, lumbar

MTUS (ACOEM)

Records indicate employee has failed to respond to treatment and there is evidence of neurological compromise

 

13-717

Deny

PT – 12 sessions

Spine, lumbar

MTUS (UR used ODG)

Patient has received 12 PT; records show no evidence of improvement; has not returned to work, work restrictions remain, ADL deficits remain, still reliant on medical treatment

 

13-740

Deny

Chiropractic

Unknown

None

No medical records were provided; no clinical notes to support medical necessity

 

13-764

Deny

PT – 6 sessions

Wrist, spine, shoulder

MTUS (Chronic pain guidelines)

Guidelines suggest 9-10 visits; patient has exceeded that number and there is no rationale from PTP as to functional improvement or reason why more PT would be beneficial

 

13-769

Aprv

MRI – lumbar spine

Spine, lumbar

MTUS (ACOEM) (UR used ODG)

ACOEM indicates MRI appropriate for neural / soft tissue where evidence of tissue insult or nerve impairment; records show persistent symptoms and chronic pain

 

13-769

Aprv

PT – 12 sessions

Knee, ankle, shoulder

MTUS (Chronic pain guidelines)

6 sessions have been approved, request is for other 6; active therapy is beneficial to restore flexibility, strength, endurance, function, ROM; multiple body parts to be treated; patient is non-surgical candidate

 

13-769

Aprv

MRI – left shoulder

Shoulder, left

MTUS (ACOEM) (UR used ODG)

ACOEM indicates imaging study appropriate when red flags, tissue insult or neurologic dysfunction, or failure to progress in strengthening program intended to avoid surgery; records show persistent symptoms and chronic pain

 

13-769

Aprv

MRI – left ankle

Ankle, left

MTUS (ACOEM) (UR used ODG)

ACOEM indicates MRI may be helpful to clarify diagnosis where delayed recovery; employee has chronic pain unrelieved by conservative therapy

 

13-782

Aprv

Epidural injections, anesthetic agent and/or steroid

Spine, hip

MTUS (ACOEM & Chronic Pain guidelines)

ACOEM indicates epidural steroid injections not recommended without radiculopathy, but allow as an option for radicular pain due to herniated disc; MRI revealed central protrusion and stenosis; conservative treatment has failed

 

13-796

Deny

Chiropractic – 12 visits

Spine, lumbar

MTUS (Chronic pain guidelines)

Guidelines recommend a trial of 6 chiropractic visits over 2 week period with documented evidence of functional improvement; records do not document functional improvement from completed chiropractic visits

 

13-826

Deny

H-wave device rental – 3 mos

Upper extremity, right

MTUS (Chronic pain guidelines)

H-wave not recommended except as a fourth-line treatment; following failure of analgesics, PT, and TENs; records do not show evidence of failure of TENs trial which is prerequisite to H-wave

 

13-863

Aprv

Epidural steriod injection

Spine, lumbar

MTUS (Chronic pain guidelines) (UR used ACOEM & ODG)

Epidural steriod recommended as option for radicular pain; conservative treatment has failed including PT and Flexeril and hydrocodone; persistent pain

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