February 3, 2010 – Encinitas, CA – A recent article published by Austin, TX law firm Burns Anderson Jury & Brenner, L.L.P., explained how ODG Treatment, published by Work Loss Data Institute, was used to address a carrier’s appeal from an adverse lumbar fusion decision.

According to the newsletter, “The case concerned a carrier’s challenge to an independent review organization’s (IRO’s) finding that a proposed lumbar fusion was medically necessary. The hearing officer agreed with the IRO and found that the proposed procedure was medically necessary. The Appeals Panel reversed the hearing officer’s decision and rendered a decision that the injured worker was not entitled to receive the proposed lumbar fusion. In doing so, the Appeals Panel focused on the Official Disability Guidelines (ODG).”

The case cited Texas Labor Codes which state that an employee who sustains a compensable injury is entitled to all healthcare reasonably required by the nature of the injury as and when needed. Healthcare should be clinically appropriate, considered effective for the injured employee’s injury and provided in accordance with the best practices consistent with: (A) evidence-based medicine; or (B) if that evidence is not available, generally accepted standards of medical practice recognized in the medical community. “Evidence-based medicine” is defined by Texas Labor Code as the use of current best qualities scientific and medical evidence formulated from credible scientific studies, including peer reviewed medical literature and other scientific based text, in making decisions about the care of individual patients,

The decision noted that ODG, which is qualified for use under the evidence-based medicine definition above, required, among other things, that a psychosocial screening be addressed as one of the preoperative indicators for the recommended procedure. ODG Treatment requires that a psychological evaluation be conducted before lumbar fusion because high quality evidence shows that presurgical biopsychosocial variables predict patient outcomes from lumbar fusion. The potential for ill affects of inappropriate lumbar fusion on the well-being of an injured worker is high; pre-surgical evaluations, based on referenced studies as outlined in ODG, are designed to eliminate or considerably reduce the risk of inappropriate lumbar fusion by identifying the presence of those psychological conditions that studies have found to impact recovery, so that they can be treated accordingly.

Since none of the medical reports or IRO decision references any psychosocial screening, the Appeals Panel held that the evidence was contrary to the decision of the IRO because the requirements of ODG were not met.

The Appeals Panel rendered a new decision that the Claimant was not entitled to the proposed procedure, and in doing so, the importance of evidence-based medicine and the necessity that proposed treatment comply with the ODG has been affirmed.