TITLE insurance

Part II. Texas Workers' Compensation Commission

Chapter 134. Benefits--Guidelines for Medical Services, Charges, and Payments

Subchapter K. Treatment Guidelines

28 TAC §134.1001

The Texas Workers' Compensation Commission ("Commission") proposes an amendment to §134.1001, concerning the Spine Treatment Guideline.

The Spine Treatment Guideline (STG) clarifies those services that are reasonable and medically necessary for care of the spine for the injured employees of Texas. The guideline is not to be used as a fixed treatment protocol, but rather identifies a normal course of treatment and reflects typical courses of intervention, while recognizing that there will be injured employees who will require less or more treatment than is outlined. The guideline also acknowledges that in atypical cases, treatment falling outside the guideline will occasionally be necessary. However, those cases that exceed the guideline level of treatment are subject to more careful scrutiny and review and require documentation of the special circumstances that justify the treatment. The guideline does not prescribe the type and frequency of treatment; treatment must be based on patient need and the health care provider's professional judgment. The rule is designed to function as a guideline and is not to be used as the sole reason for denial of treatments and services.

Proposed amendments to §134.1001 contain 1999 Current Procedural Terminology (CPT) codes as published in the Physician's Current Procedural Terminology, 1999, (American Medical Association, copyright 1998). These CPT Codes and nomenclature only are Copyright 1998 American Medical Association.

The guideline promotes quality health care, injury specific treatment and appropriateness of care, by identifying clinically acceptable courses of care for spine injuries, and by facilitating communication between all parties in order to achieve rapid recovery from the effects of an injury. This communication will also promote a timely return to modified or full duty work that takes into account the job demands and the functional capabilities of the injured employee.

The Commission considered all relevant statutory and policy mandates and objectives and designed this rule to achieve those mandates and objectives, including the following:

(1) the establishment of medical policies and guidelines relating to use of medical services by employees who suffer compensable injuries;

(2) the establishment of medical policies relating to necessary treatments for injuries which are designed to ensure the quality of medical care and designed to achieve effective medical cost control;

(3) the establishment of a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatment and services; and

(4) the establishment of a program for systematic monitoring of the necessity of treatments administered, for detection of practices and patterns by insurance carriers in unreasonably denying authorization of payment, and for increasing the intensity of review for compliance with medical policies or fee guidelines.

Section 134.1003 as proposed for amendment will achieve these objectives by:

(1) identifying services that are reasonable and medically necessary for treatment of spine injuries;

(2) assisting all parties with regard to the appropriate treatment and management of disorders of the spine in employees' compensation healthcare;

(3) establishing a guideline against which aspects of care can be compared;

(4) identifying clinically acceptable courses of care for spine injuries;

(5) establishing documentation standards which support the appropriateness of the level of service for assessment/evaluation and on-going treatment;

(6) providing a mechanism for prospective, concurrent, and retrospective review to ensure efficient and effective health care utilization; and

(7) establishing normal courses of treatment based on clinical indicators at different levels of healing.

In accordance with the statutory objectives and Commission policy, the Spine Treatment Guideline seeks to balance the need for cost control and review with the need for access to quality medical care by establishing typical courses of treatment, but allowing treatment outside the set parameters with additional documentation of the need for the treatment.

Quality of medical care is ensured by reliance upon input from experts and recognized studies in the field of spine treatment. The guideline ensures access to health care and that quality care will be available in each individual case by its ground rules that allow for treatment outside the stated parameters.

Effective medical cost control is achieved by establishing parameters for eligibility and termination of treatment, by setting documentation standards which support the appropriateness of the treatment; by requiring additional documentation for treatment falling outside the guideline's parameter; and by providing that treatments for the spine are subject to the Commission's separate rule requiring insurance carrier preauthorization for certain treatments as a prerequisite to payment for the services.

The guideline allows for prospective, concurrent, and retrospective review of treatment by: setting standards for eligibility and treatment and setting documentation standards. These standards are to be used by health care providers as a basis for prospective review of possible treatment. The guideline and the documentation requirements should also provide the health care provider with a means to justify treatments when questioned concurrently or retrospectively by an insurance carrier.

The guideline and documentation also provide a starting point for insurance carriers in conducting prospective, concurrent, or retrospective review of treatment. The Medical Review Division and the Compliance and Practices Division will use the guideline and documentation as a tool for prospective, concurrent, and retrospective review of treatment, including use in conducting audits of health care providers and insurance carriers, use in the establishment of a program for systematic monitoring of the necessity of treatments administered, and use in medical dispute resolution.

The guideline also promotes quality health care, injury specific treatment and appropriateness of care, by facilitating communication between all parties in order to achieve rapid recovery from the effects of an injury. This communication will also promote a timely return to modified or full duty work that takes into account the job demands and the functional capabilities of the injured employee.

The rule will promote quality health care and injury specific treatment for injured employees by identifying clinically acceptable courses of care for specific spine injuries. Another benefit will be that the rule will provide a mechanism to monitor the necessity of treatment administered and establish treatment parameters, thus providing greater efficiency in the provision of treatment to the injured employee for spine injuries.

The clinical and diagnostic treatment guidelines contained in this proposed amendment have been developed in conjunction with health care providers and other parties in the employees' compensation system. The Commission's Medical Review Division began its review of the STG by conducting a focus group with insurance carriers in 1997. The Commission invited eight different insurance carriers to participate in this focus group. The purpose of the meeting was to collect feedback on the STG from the insurance carriers' perspective. The following insurance carriers were represented at this focus group, Forte, Intracorp, Cigna, Corvel Corporation, Kemper National Services, Liberty Mutual, Texas Association of School Boards and the Texas Workers' Compensation Insurance Fund.

The Medical Review Division also contacted the Spine Treatment Guideline Workgroup members, who assisted in drafting the guideline in 1994, composed of members from the following areas of medical practice and business: chiropractic, neurosurgery, orthopaedic surgery, physical medicine and rehabilitation, family practice, physical therapy, occupational therapy, osteopathic medicine and insurance. Workgroup members were asked to review the guideline, recommend changes, and give feedback on the guideline's use and effectiveness since it was adopted. The Medical Review Division also conducted separate focus groups with medical doctors and chiropractors in Austin, Dallas, El Paso, Houston and San Antonio. These focus groups gave feedback on the guidelines' use and recommended changes.

The Commission formed a Spine Treatment Guideline Revision Workgroup (STGRW) to review the recommendations from all these different groups and consider new treatments for inclusion in the STG. The STGRW was composed of members from the following areas of medical practice and business: chiropractic, neurosurgery, orthopaedic surgery, physical medicine and rehabilitation, occupational medicine, physical therapy, occupational therapy, osteopathic medicine and insurance. The workgroup met in January, February, March and April of 1999 and reviewed treatments currently in the STG to determine if they were still reasonable and medically necessary. The workgroup recommended adding parameters to some of the treatments to clarify when these treatments are reasonable and medically necessary.

The workgroup also reviewed 10 new treatments identified through the feedback collected. Out of the 10 reviewed, only acupuncture is recommended for addition to the STG. The workgroup used reports of scientific research as well as their own expertise and practice experience in developing their recommendations. Intradiscal electrothermal annuloplasty was not recommended for inclusion in the STG because of insufficient data at the time of their review to warrant inclusion. The STGRW also considered the following treatments but found there was little or no scientific literature to support their inclusion in the STG: magnet therapy, vitamin therapy and prolo therapy. In addition, the following treatments were reviewed, but were found to have contradictory results in the medical literature and insufficient support to warrant inclusion in the STG: vertebral axial decompression and botox.

The STGRW also discussed current perception threshold, a type of sensory conductive test, and agreed that there was supporting literature for its effectiveness in some medical conditions but that there was little evidence to warrant its use for musculoskeletal conditions. Therefore the STGRW recommended that this treatment not be included in the STG. The STGRW also discussed nerve conduction velocity studies and somatosensory evoked potentials. The STGRW concluded that somatosensory evoked potentials were appropriate only for intraoperative monitoring and that repeated studies have extremely limited application. The STGRW did not recommend that these studies be included in the STG.

The STGRW considered recommendations made by the Texas Workers' Compensation Commission's Medical Advisory Committee. By statute, the MAC advises the division in developing and administering the medical policies, fee guidelines, and utilization guidelines established under the Texas Labor Code, §413.011. The MAC is composed of members from the following fields, appointed by the Commission: public health care facility, private health care facility, a doctor of medicine, a doctor of osteopathic medicine, a chiropractor, a dentist, a physical therapist, a pharmacist, a podiatrist, an occupational therapist, a medical equipment supplier, a registered nurse, a representative of employers, a representative of employees, and two representatives of the general public. The Medical Advisory Committee formed the Guideline Standardization Subcommittee (GSS) to review all treatment guidelines and recommend changes which make all treatment guidelines consistent. The STGRW considered recommendations made by the GSS and recommendations made by the focus groups and the original STG workgroup. The MAC reviewed and endorsed recommendations made by the GSS and the STGRW as well as making some additional recommendations.

The Texas Register published text shows words proposed to be added to or deleted from the current text, and should be read to determine all proposed changes.

A number of changes are proposed to make the text portion of the STG consistent with the recently adopted Upper Extremities Treatment Guideline (UETG) and the Lower Extremities Treatment Guideline (LETG). Because musculoskeletal injuries are similar in the workers' compensation system and involve similar treatments, consistency between all treatment guidelines will minimize confusion and ensure that the guidelines address similar issues in the same way.

Proposed subsection (a) corrects references to other subsections of the rule in the table of contents.

In addition, a number of changes are proposed for grammatical and form consistency between the STG and the UETG and the LETG and do not substantively alter the guideline.

The term "Primary Gatekeeper" has been changed to "Treating Doctor" in proposed subsections (a)(2) and (c) to make them consistent with the UETG and the LETG and with terms used generally in the workers' compensation system.

Proposed subsection (b)(1) and (2) change the Purpose and Goals statements to make them consistent with the UETG and the LETG. A new proposed phrase in subsection (b)(1) clarifies the purpose by stating that treatments and services will not be automatically deemed as reasonable and necessary because the treatment or service is listed in the guideline.

Subsection (b)(2)(C) has been reworded to clarify that the guideline addresses treatment for a compensable injury and to make it consistent with the UETG and the LETG.

Proposed changes to subsections (c)(3) and (5), and (d)(1) make the wording in the STG consistent with the UETG and the LETG.

Proposed changes to subsection (d)(1)(E) make it consistent with the UETG and the LETG and also cross-reference other sections of the guideline that refer to the same subject. This cross-referencing helps the reader access related sections of the guideline with ease.

Proposed changes to subsection (d)(1)(F) clarify return to work options (either full or modified duties) for the injured employee.

In a number of places throughout the guideline, terms such as "will" and "should" have been changed to "shall." Also passive language has been replaced with active tense. These changes make the STG more consistent with the UETG and the LETG and also provide additional clarity. Such language changes were placed in proposed subsections (d)(2), (d)(2)(A), (d)(3), (e)(1), (e)(2)(H) and (e)(3)(B).

Proposed subsection (d)(2)(D) and (E) have been changed to make the STG consistent with the UETG and the LETG. Proposed subsection (d)(2)(F) has been added to the STG to make it consistent with the UETG and the LETG.

Proposed subsection (d)(4), (5), and (6) have been changed to make them consistent with the UETG and the LETG. In addition, subsection (d)(2), the Application Tables in the current guideline, have been deleted as a result of a recommendation made by the workgroup and the MAC. The tables describe the process and the documentation requirements needed for health care providers and insurance carriers during the treatment of the injured employee. The workgroup considered that this information gave needed guidance to the parties in the system when the STG was first adopted but is now outdated and should be deleted unless public comment indicates a need for these tables.

Proposed subsection (e)(1) and (2) have been changed to make them consistent with the UETG and the LETG. In addition, the workgroup and the MAC recommended adding the term "most appropriate" in subsection (e)(2)(A)(iii) to describe "least intensive setting." This addition would clarify that appropriateness is also a consideration in choosing a treatment setting.

In proposed subsection (e)(2)(B) and in other sections throughout the rule, the term "plan of treatment" has been replaced with "treatment plan" for consistency with the UETG and the LETG.

Proposed subsection (e)(2)(C) includes changes that are proposed both to make this section consistent with the UETG and the LETG as well as changes recommended by the workgroup and the MAC. The workgroup and MAC recommended that the term "patient" be replaced with "injured employee" to keep it consistent with language used throughout the guideline. They also recommended replacing the term "must" with "should" because the health care provider cannot control whether the injured employee fully understands his/her role in the recovery process. This subsection also contains a cross-reference to other sections of the guideline that address the same subject. The cross-referencing helps the reader access related sections of the guideline with ease.

The workgroup reviewed treatments currently in the STG to determine if they were reasonable and medically necessary. The workgroup recommended adding parameters to some of the treatments to clarify when these treatments are reasonable and medically necessary. Proposed subsection (e)(2)(D), (E), (F), (G), (L), (S), and (T) were added to clarify when these treatments are reasonable and necessary. The treatments listed in these subsections appear in the treatment tables sections of the guideline and include: outpatient evaluation and therapies, manipulation, chronic pain management programs, TENS units, rehabilitation programs (work conditioning, work hardening and outpatient medical rehabilitation), spinal injections, and trigger point injections. This new language adds clarity regarding the appropriateness and purpose of the treatments.

Proposed subsection (e)(2)(H) includes new language that the STGRW and the MAC recommended to emphasize that return to work planning should commence as early as possible for severe injuries. The STGRW and the MAC recommended this change because early planning for severe injuries allows for comprehensive rehabilitation before the injured employee reaches statutory MMI.

Proposed subsection (e)(2)(J) is changed to make it consistent with the UETG and the LETG.

Proposed subsection (e)(2)(K) is changed to make it consistent with the UETG and the LETG and to reflect recommended terminology changes made by the Guideline Standardization Subcommittee (GSS) and the MAC. These recommendations included changing "levels of care" to "phases of care" and are reflected throughout the guideline. The GSS recommended this change because the term "phase" more accurately captured the medical process. This change also appears in subsections (e)(3)(B), (g), (g)(2), (g)(3), (g)(5), (g)(7), (g)(7)(A), (g)(7)(B), and (g)(7)(C), (j)(2)(A), and deletion of the term "level of service" in the glossary. Deletion of current subsection (e)(2)(I) is proposed as recommended by the STGRW and the MAC. This recommendation was made because the content of subsection (e)(2)(I) is now included in the 1996 Medical Fee Guideline. This section addresses mental health evaluations when used exclusively to assess the injured employee's readiness for work hardening and describes which mental health services are independent or inclusive of multidisciplinary programs such as work hardening. These issues are well addressed in the MFG and thus are no longer needed in the STG.

Proposed subsection (e)(2)(M) changes the term "secondary" to "intermediate" to reflect recommendations by the GSS and the MAC. The GSS recommended this change because the term "intermediate" more accurately describes the healing phase than the term "secondary." This change also appears in subsections (g)(3), (g)(7)(B), (C), (D), and (i)(7).

Proposed subsection (e)(2)(N) and (O) are changed to make them consistent with the UETG and the LETG.

Proposed subsection (e)(2)(Q) reflects changes recommended by the STGRW and the MAC. These changes update the indications for the use of bone growth stimulators.

Proposed subsection (e)(2)(R) was reworded and reorganized by the STGRW and supported by the MAC. The rewording makes the subsection clearer. Current subsection (e)(2)(R)(ii) was deleted because the workgroup felt it was an inappropriate objective for interventional pain procedures.

Proposed subsection (e)(2)(U) adds acupuncture to the services used for the care of the spine. The STGRW and the MAC recommended this addition and added this subsection to give indications for the appropriate use of acupuncture. The STGRW reviewed literature regarding the results of scientific research on acupuncture treatment and used their experience in treating patients who benefitted from the treatment of acupuncture to make their recommendation. The STGRW and the MAC recommended adding acupuncture because it has been successfully used for the treatment of spine injuries within the parameters set forth in subsection (e)(2)(U).

Proposed subsection (e)(2)(Y) is added for consistency with the UETG and the LETG.

Proposed subsection (e)(3)(A) and (B) are changed in part for consistency with the UETG and the LETG.

Proposed subsection (e)(3)(B)-(F) include new language that corresponds with proposed subsection in the ground rules for outpatient evaluation and therapies, rehabilitation programs (work conditioning, work hardening, and outpatient rehabilitation), manipulation, and TENS units. This new language is added based on recommendations from the STGRW and the MAC and sets out guidelines for objective documentation of the need to continue these treatments.

Proposed subsection (e)(3)(G), (H) and (4) are changed to make them consistent with the UETG and the LETG.

Proposed subsection (f)(2)(J) is moved to subsection (f)(2)(N) because the time line recommendation for the performance of discography is no longer as listed in the current STG. Proposed new subsection (f)(2)(N) places discography towards the end of the list of diagnostics which is more appropriate with the new indications recommended by the STGRW and the MAC and gives a description of a discogram. Proposed subsection (f)(3)(C) provides time recommendations for the performance of discography, gives guidance for their use, and lists specific indicators that must occur for discography to be appropriate. These changes are made to improve the quality of care the injured employee receives by allowing for this diagnostic test to be done when it is most appropriate. In addition, the indications for discography also appear as part of the surgical algorithms in subsection (i)(8).

Proposed subsection (f)(2)(L) and (M) cross-reference selective nerve root injections and facet injections to new subsection (e)(2)(S)(ii) and (iv) because these new subsections list indications for these injections. Subsection (f)(2)(L) changes the wording which requires fluoroscopy to make it consistent with the wording requiring fluoroscopy in subsection (f)(2)(M).

It is proposed that current subsection (f)(2)(O) listing "physical capacity evaluation" be deleted because this procedure is now rarely performed alone and is usually part of a functional capacity evaluation which is already listed. This recommendation has also resulted in changes to subsections: (f)(3)(D), (g)(7)(A), (g)(7)(C), (h)(2) and deletion of subsection (h)(2)(C).

Proposed subsection (f)(3)(A), (B), and (C) change the term "treatment" to "diagnostics" to reflect that these are diagnostic interventions rather than treatments.

Proposed subsection (g)(1) deletes the current introduction section and replaces it with new language that clarifies the content of this subsection and makes it consistent with the UETG and the LETG.

Proposed subsection (g)(2) changes the term "primary" to "initial" as recommended by the GSS and the MAC. The GSS recommended this change to all treatment guidelines because the term "initial" more accurately describes the healing phase than "primary." Other changes to this subsection make it consistent with the UETG and the LETG. This change also appears in subsections (g)(7)(A), (C), (D), and (i)(7).

Proposed subsections (g)(4) and (g)(5) change the language to make it consistent with the UETG and the LETG.

Proposed new subsection (g)(6) adds language to describe treatment for all treatment guidelines beyond the tertiary phase. This subsection was added as a recommendation from the GSS. The MAC reviewed the new language and recommended it be included in the STG revision. This new subsection would clarify that there are some cases where the injured employee requires treatment after reaching MMI or after completing the tertiary phase of treatment. This new subsection describes the treatment typically provided. The section also repeats the responsibilities for the health care providers and insurance carriers that are listed in other sections of the guideline to ensure these responsibilities are adhered to when evaluating post-tertiary care.

Proposed changes to the Initial, Intermediate and Tertiary Phases of Care treatment tables include the following. The heading "Types of Intervention" has been changed to "Treatment Intervention" to make the STG consistent with the UETG and the LETG and because the term treatment more accurately represents the items included in this section. The heading "Clinical or Behavioral Indicators" has been changed to "Clinical Indicators" to make the STG consistent with the UETG and the LETG. "Attended Procedures," "Concurrent Home Program," and "Unattended Modalities," have been replaced with "Outpatient Evaluation and Therapy" which is subdivided into "Attended Modalities and Procedures", "Unattended Modalities" and "Concurrent Home Programs." These changes make the treatment tables consistent with the UETG and the LETG and help clarify related services by listing them under one heading. "Job Site Analysis" and "Functional Capacity Evaluations" have been moved from the Treatment Intervention section to the Return To Work Issues section. These changes are made to make the STG consistent with the UETG and the LETG and because these evaluations are not treatments and are therefore more appropriately listed under the Return To Work Issues section.

Proposed changes to the Initial Phase of Care treatment table include the following. The sentence listed in the Goal of Initial Intervention section has been changed to make it consistent with the wording that appears in subsection (g)(2) which describes the initial phase of care. "Biofeedback" was deleted based on a recommendation from the STGRW and the MAC, that "Biofeedback" is not appropriate for this phase of care.

The STGRW and the MAC recommended that the term "Mental Health Intervention" be replaced with "Mental Health Evaluation." Although the UETG and the LETG do not include this treatment at the initial phase, the STGRW recommended it be included in the STG because the need for a mental health evaluation for spine injuries is more likely than for extremity injuries.

It is proposed that the term "Pharmaceutical Treatment" be replaced with the term "Medication" to make it consistent with the UETG and the LETG.

In the proposed phases of care tables the following treatments have a cross-reference added to refer the reader to new ground rules which describe the appropriate use of the treatment: acupuncture, diagnostic testing, injections, outpatient evaluation and treatment, and TENS units. The term "pain/symptom control" has been deleted from the treatment intervention section because it is already covered under other treatments listed.

Proposed changes to the Intermediate Phase of Care Treatment Table are as follows. The Description section would be changed to make this section consistent with the description that appears in subsection (g)(3). In the Goal of Intermediate Intervention section "work return" has been replaced with "return to work" to reflect the terms more commonly used in the field. Under the Treatment Intervention section "Biofeedback" is deleted based on the STGRW's recommendation because "Biofeedback" is covered under "Behavioral Pain Management" which is already listed. "Conditioning" is deleted because it falls under the newly listed "Outpatient Evaluation and Therapy" heading. The term "Diagnostic" is deleted from "Diagnostic Injections" because these injections can be both diagnostic and therapeutic. "Behavioral Pain Management/Relaxation Training" is removed from under the heading "Education" and listed separately as "Behavioral Pain Management." "Relaxation Training" is not listed because it falls within the scope of "Behavioral Pain Management" and does not need to be listed separately. "Chronic Pain Management" has been deleted from under the heading "Single or Interdisciplinary Programs" because the STGRW believed these programs are appropriate only after 6 months of chronic pain. Therefore such programs are not appropriate for the Intermediate Phase of Care which is typically only 0 to 8 weeks long. The term "Limited program activity with access to health care providers as referrals and/or consultants" is deleted because it is not a treatment intervention and is dealt with elsewhere in the guideline. The term "Limited Unattended Modalities only in conjunction with Attended Procedures" is deleted because this is covered under the heading "Outpatient Evaluation and Therapy". The term "Medication Modification" has been changed to "Medication" to make it consistent with UETG and the LETG. The terms "Post-op Phase as limited rehabilitation" and "Rule in/rule out surgery" are deleted because these are not treatment interventions. The term "Single" is added to the term "Interdisciplinary Programs" to accurately describe the programs listed under this heading. "Work Conditioning" is added under this heading because it is a program which is appropriate at this phase of care. The following treatments have a cross-reference added to refer the reader to the new ground rules which describe the appropriate use of the treatments: Injections, Diagnostic Testing, and Outpatient Evaluation and Therapy.

Proposed changes to the Tertiary Phase of Care Treatment Table include the following. The term "claimant" is replaced with "injured employee" for consistency throughout the guideline. The word "final" is replaced with"tertiary" in the Goal of Tertiary Intervention section, since the tertiary phase is not always the final phase of care for injured employees. In the Treatment Intervention section "Relaxation Training" is deleted because it falls within the scope of "Behavioral Pain Management" and does not need to be listed separately. The term "Single" is added to the term "Interdisciplinary Programs" to accurately describe the programs listed under this heading. "Work Conditioning" is added under the heading of "Single or Interdisciplinary Programs" because it is a program appropriate for this phase of care. The term "Medication" is added in this section because it is an appropriate treatment intervention for this phase of care and to make the STG consistent with the UETG and the LETG. The following treatments have a cross-reference added to refer the reader to the new ground rules which describe the appropriate use of the treatments: Diagnostic Testing, Chronic Pain Management, and Outpatient Evaluation and Therapy.

A sentence is added to the "Return To Work Issues" section of the Tertiary Phase of Care table to include the possibility of vocational rehabilitation services by the Texas Rehabilitation Commission for injured employees who are unable to return to work after the tertiary phase of care. This is added to reflect procedures that are currently in place. "Assessments" is replaced with the word "evaluations" in proposed subsection (h)(3)(B) because this is the more commonly used term in the medical community.

Proposed subsection (i)(2) has been updated to list 1999 Current Procedural Terminology (CPT) codes as published in the Physician's Current Procedural Terminology, 1999, (American Medical Association, copyright 1998). Similarly subsection (i)(7)(A), (B) and (C) have been updated to use 1999 CPT codes.

Proposed subsection (i)(7) changes "intercostal" to "radiating chest wall" to clarify the meaning of this chart.

Changes to the glossary, subsection (j), are proposed for clarification and to make the STG consistent with the UETG and the LETG. These changes are made as a result of a recommendation by the GSS and the MAC to make the glossaries of all treatment guidelines consistent. The following terms were added to the glossary: acceptable standards of care, acute, aggravation, algorithm, assessment/evaluation, chronic, compensable injury, decomposition, diagnosis, diagnostic module, diagnostic test, exacerbation, examination, first, first doctor, focus review, frequency of intervention, functional capacity evaluation, health care, initial phase of care, intermediate phase of care, intermediate treatment, medical necessity, module, objective findings, phases of care, proper clinical documentation, reason for denial, referral, screening criteria, single point of contact, standard, static, subacute, subjective complaints, tertiary phase of care, tertiary treatment, time limited, and treatment module. In addition, the following terms include other changes: in subsection (j)(11)(A) the word "change" is replaced with "objective improvement" to clarify the definition; and in subsection (j)(11)(B) the word "objective" is also added to clarify the definition.

Proposed subsection (j)(35) is amended to update the definition of MMI so that it is consistent with changes to the Texas Labor Code and to make the STG consistent with the UETG and the LETG.

Proposed subsections (j)(31), (49), (58), and (59) are changed to make the definitions consistent with the UETG and the LETG.

Proposed subsection (j)(47) and (52) are changed to incorporate changes recommended by the GSS and the MAC to the definitions of "Significant Neurological Deficit" and "Strain."

A proposed new section titled "Revised Bibliography" has been added to reflect the additional references used by the STGRW.

Other changes to subsections (b), (c), (d), (e), and (f) are proposed for clarity of language, consistency with the UETG and the LETG, and/or grammatical improvement.

Victor Rodriguez, Finance Manager, has determined that for the first five-year period the proposed amendment is in effect there will be no fiscal implications for state or local governments as a result of enforcing or administering the rule.

For the first five years the proposed amendment is in effect, local government as a regulating entity is expected to have no additional or reduced costs and no loss or increase in revenue because it does not regulate under this rule. Because the Guideline is currently in effect, state government is expected to have no additional or reduced costs and no loss or increase in revenue as a result of enforcing or administering the proposed amendments to the rule. Local government and state government as covered regulated entities will be impacted in the same manner as described later in this preamble for persons required to comply with the rule as proposed.

Mr. Rodriguez has also determined that for each year of the first five years the rule as proposed is in effect the public benefits anticipated as a result of enforcing the rule will be the promotion of quality health care and injury specific treatment for injured employees by identifying clinically acceptable courses of care for spine injuries. The rule will provide a mechanism to monitor the necessity of treatment administered and establish treatment parameters, and guidelines relevant to prospective, concurrent, and retrospective review of treatment, thus providing greater efficiency in the provision of spine treatment to the injured employee.

There are no anticipated economic costs to persons required to comply with the rule as proposed because the Guideline is currently in effect and the proposed amendments would not result in economic costs. There will be no adverse economic impact on small businesses. There will be no difference in cost of compliance for small business compared to larger businesses.

Comments on the proposal or requests for public hearing must be submitted to Donna Davila by 5:00 p.m. July 26, 1999, at Office of the General Counsel, Mailstop #4-D, Texas Workers' Compensation Commission, Southfield Building, 4000 South IH-35, Austin, Texas 78704-7491. A public hearing on this proposed rule is tentatively scheduled for August 4, 1999, at the Austin office of the Commission (Southfield Building, 4000 South IH-35, Austin, Texas). Those persons interested in attending the public hearing should contact the Commission's Office of Executive Communication at (512) 440-5690 to confirm the date, time, and location of the public hearing. The rule as adopted may be revised from the rule as proposed. Persons in support of the rules as proposed, in whole or part, may wish to comment to that effect.

The amendment is proposed under the Texas Labor Code, §402.061, which authorizes the Commission to adopt rules necessary to administer the Act, and the Texas Labor Code, §413.011, which authorizes the Commission to establish by rule medical policies and guidelines relating to necessary treatments for injuries, and the Texas Labor Code, §413.013, which authorizes the Commission to establish by rule a program for prospective, concurrent, and retrospective review and resolution of a dispute regarding health care treatments and services; and to establish by rule a program for the systematic monitoring of the necessity of treatments administered and fees charged and paid for medical treatments or services, including the authorization of prospective, concurrent, or retrospective review under the medical policies of the Commission to ensure that the medical policies or guidelines are not exceeded. These statutory provisions clearly authorize the Commission to adopt a rule such as §134.1001 which includes guidelines relating to necessary treatments.

The rule affects the Texas Labor Code, §§402.061, 413.011, 413.013.

§134.1001.Spine Treatment Guideline.

(a)

Table of Contents. The following headings and their corresponding subdivisions comprise a table of contents for this section.

(1)

(No change.)

(2)

Role of Treating Doctor [ Primary Gatekeeper ] - subsection (c).

(A)

Statutory Requirements - subsection (c)(1).

(B)

Treating Doctor [ Primary Gatekeeper ] Responsibilities - subsection (c)(2).

(C)

Referrals - subsection (c)(3).

(D)

Diagnostics - subsection (c)(4).

(E)

Expectation and Compliance - subsection (c)(5).

(3)

Application Instructions for Involved Parties - subsection (d).

(A)

Health Care Provider [ Concepts and Governing Principles ] - subsection (d)(1).

(B)

Insurance Carriers [ Application Matrix Table ] - subsection (d)(2).

(C)

Medical Review Division - subsection (d)(3).

(D)

Consulting or Peer Review Health Care Provider - subsection (d)(4).

(E)

Injured Employee - subsection (d)(5).

(F)

Employer - subsection (d)(6).

(4)

(No change.)

(5)

Diagnostic Procedures - subsection (f).

(A)

Introduction - subsection (f)(1).

(B)

List of Diagnostic Interventions - subsection (f)(2).

(C)

Time Recommendations for Listed Diagnostic Interventions [ Procedures ] - subsection (f)(3).

(6)

Phases [ Levels ] of Nonoperative Care - subsection (g).

(A)

Introduction to Nonoperative Treatment Tables - subsection (g)(1).

(B)

Initial [ Criteria in Primary Intervention ] Phase [ Primary Level ] of Care - subsection(g)(2).

(C)

Intermediate [ Referral Criteria in Secondary Intervention ] Phase [ Secondary Level ] of Care - subsection (g)(3).

(D)

[ Referral Criteria in Tertiary Intervention Phase ] Tertiary Phase [ Level ] of Care - subsection (g)(4).

(E)

Criteria to Distinguish between Intermediate [ Secondary ] and Tertiary Phases of Care - subsection (g)(5).

(F)

Post-tertiary Treatment - subsection (g)(6).

(G)

Phase [ Levels ] of Care Tables - subsection (g)(7) [ (g)(6) ].

(7)

Assessments/Evaluations - subsection (h).

(A)

Interdisciplinary Assessment - subsection (h)(1).

(B)

[ Physical Capacity and ] Functional Capacity Evaluations [ Assessments ] - subsection (h)(2).

(C)

Appropriate and Inappropriate Testing - subsection (h)(3).

(8)

Treatment Algorithms - subsection (i).

(A)

Introduction to Algorithms - subsection (i)[ (1) ].

(B)

Surgical Treatment Code Legend - subsection (i) (1) [ (2) ].

(C)

Initial Approach to Treatment of Spinal Injury Chart 1 - subsection (i) (2) [ (3) ].

(D)

Fracture and/or Dislocation Chart 2 - subsection (i) (3) [ (4) ].

(E)

Soft Tissue Injury Chart 3 - subsection (i) (4) [ (5) ].

(F)

Peri-Operative Algorithm Chart 4 - subsection (i) (5) [ (6) ].

(G)

Surgical Treatment Chart 5 - subsection (i) (6) [ (7) ].

(H)

Surgical Treatment Subchart Chart 5A - subsection (i) (6) [ (7) ](A).

(I)

Surgical Treatment Subchart Chart 5B - subsection (i) (6) [ (7) ](B).

(J)

Surgical Treatment Subchart Chart 5C - subsection (i) (6) [ (7) ](C).

(K)

Treatment Continuation Chart 6 - subsection (i) (7) [ (8) ].

(9)

Glossary - subsection (j).

(10)

Bibliography - subsection (k).

(11)

Revision Bibliography - subsection (l).

(b)

Introduction.

(1)

Purpose. The purpose of this guideline is to clarify those services that are reasonable and medically necessary for operative and nonoperative care of [ to ] the spine for the injured employees [ workers ] of Texas. This guideline identifies a normal course of treatment. There may be injured employees who will require more or less treatment than is recommended in this guideline. [ It is anticipated that there will be injured workers who will require less treatment than the average and other injured workers who will require more treatment. ] This is a guideline and shall not be used as the sole reason for denial [ of treatments and services. ] when a treatment or service is not listed in the guideline. Similarly the guideline shall not be used as the sole reason for accepting the treatment or service as reasonable and medically necessary simply because the treatment or service is listed in the guideline.

(2)

Goals. The[ following subparagraphs outline the ] primary goals of this guideline are :

(A)

to assist all parties with regard to the appropriate treatment and management of disorders of the spine;

(B)

to establish elements against which aspects of care can be compared;

(C)

to establish a guideline to identify services that are reasonable and medically necessary for [ clinically acceptable courses of ] treatment of the compensable injury ;

(D)

to establish documentation standards which support the appropriateness of the level of service; and

(E)

to provide a mechanism of prospective, concurrent, retrospective review for efficient and effective health care utilization.

(3)

(No change.)

(4)

Philosophy of Care. The health care of the injured employee [ worker ] is a coordinated team effort. All parties including employees, employers, health care providers, insurance carriers and the Texas Workers' Compensation Commission should promote quality health care, injury specific treatment and appropriateness of care. Communication between all parties must remain open in order to achieve rapid recovery from the effects of the injury. This communication should promote a timely return to modified or full duty work that takes into account the job demands and the functional capabilities of the injured employee [ worker ].

(c)

Role of Treating Doctor (Primary Doctor/Gatekeeper) [ Primary Gatekeeper ].

(1)

(No change.)

(2)

Treating Doctor [ Primary Gatekeeper ] Responsibilities.

(A)

The role of the treating doctor is an important role which requires the treating doctor to monitor all health care services being provided for the injured employee [ worker ]. These responsibilities of the treating doctor are vital aspects of the goal to ensure that the injured employee [ worker ] receives quality health care. This monitoring extends to ensure:

(i)-(viii)

(No change.)

(B)

Refer to §126.9 of this title [ and §133.3 of this title ] (relating to Choice of Treating Doctor and Liability) for Payment ; and §133.3 of this title (relating to Responsibilities of Treating Doctor) ,[ respectively ] for responsibilities of the treating doctor.

(3)

Referrals. The treating doctor is responsible for recommending timely and appropriate referrals. The treating doctor must clearly delineate the clinical rationale for all referrals. The documentation contained in the TWCC required reports [ 64 ] should clearly outline whether the purpose of the referral is to corroborate the diagnosis and/or proposed course of treatment or to initiate ongoing treatment. [ It is appropriate for the treating doctor to document and explain the referral in the TWCC 61 or TWCC 64. ] Once a consultation or referral has occurred, the consulting or referral doctor should submit a summary report or initiate a case management phone call back to the treating doctor. [ This communication by the consulting or referral doctor is necessary to enable the treating doctor to meet his responsibility to submit a TWCC 64 every (60) days. ]

(4)

Diagnostics. Diagnostic work should be performed in accordance with the recommended testing and timeframes contained in this guideline. If the need arises to deviate from the guideline, then a clinical rationale must be provided which adequately substantiates the need for this deviation. The need to repeat previously completed diagnostic procedures due to the quality of the study may trigger a review. All health care providers involved in the treatment of an injured employee [ worker ] must share copies of all diagnostic studies, film and reports in order to avoid unnecessary duplication of procedures. Section 133.2 of this title (relating to Sharing Medical Reports and Test Results) addresses the need to share medical records, including diagnostic studies, to avoid duplication. Section 133.106 of this title (relating to Fair and Reasonable Fees for Required Reports and Records) addresses reimbursement for copies of records.

(5)

Expectation and Compliance.

(A)

All health care providers must encourage injured employees [ workers ] to be active participants in their health care treatment regimens and must communicate to the injured employee [ worker ] realistic expectations regarding the potential outcome of this treatment regimen as it relates to his/her physical functioning and/or ability to return to work. Therefore, documenting the injured employees' compliance with his/her treatment regimen is important [ it is important to document the injured worker's compliance with his/her treatment regimen ] when reporting the progress of his/her recovery.

(B)

Health care providers must explain to the injured employee [ worker ] in clear terms the extent and severity of the injury and the treatment needed. Health care providers must define the symptomatology that is directly and/or indirectly related to the injury and specify treatment not covered under workers' compensation.

(d)

Application Instructions for Involved Parties.

[ (1)

Concepts and Governing Principles.]

(1)

[ (A) ] Health Care Provider. This guideline shall [ is to ] be used as a tool by the health care provider to establish the required elements to initiate and continue treatment. If, for example, a health care provider's treatment deviates from this [ the ] guideline, documentation of the medical condition that specifically requires treatment outside the guideline parameters would be required to clearly delineate the need for the treatment [ a clearly delineated rationale for the need for this treatment would be required ].

(A)

[ (i) ] This guideline identifies typical treatment based on normal tissue healing responses for the average injured employees [ workers ].

(B)

[ (ii) ] This guideline recognizes that a subset of injured employees will be found to be outside the parameters of this guideline. If a health care provider's treatment deviates from this guideline, documentation would be required to clearly delineate the need for the treatment. [ It is expected that a subset of injured workers will be found to be outside the parameters of these guidelines. ]

(C)

[ (iii) ] This guideline should be used as a tool which identifies the recommended treatment parameters for treatment of injured employees [ workers ] within the workers' compensation system.

(D)

[ (iv) ] This guideline identifies the need to provide documentation which clearly explains the reason for the treatment, the relatedness to the workers' compensation injury and alternative treatment.

(E)

[ (v) ] The health care provider is responsible for [ also becomes aware of the need to ] educating [ educate ] the injured employee [ worker ] about [ of ] health care treatment appropriate for [ in ] the workers' compensation injury (refer to subsections (d)(1)(E) and (e)(2)(C)) .

(F)

[ (vi) ] This guideline recommends timely [ early ] return to work of either full or modified job duties based upon the injured employee's [ worker's ] functional capacity which includes ability, clinical status, and either full or modified job requirements.

(2)

[ (B) ] Insurance Carriers. The insurance carrier shall [ should ] use this guideline to compare treatment prospectively, concurrently and retrospectively with the predetermined elements contained in this guideline [ the guides ].

(A)

[ (i) ] This document and its parameters serve only as a guideline and shall [ are ] not to be used as the sole reason for denial of treatments and services.

(B)

[ (ii) ] This guideline provides a tool by which to monitor the injured employee's [ worker's ] recovery process.

(C)

[ (iii) ] This guideline serves as a tool to assist the insurance carrier [ carriers ] in the medical audit process.

(D)

[ (iv) ] This guideline is not to be used to direct care toward a specific health care discipline or to a specific type of treatment. The insurance carrier is responsible for providing their [ It is the responsibility of the insurance carrier to provide ] specific documentation and rationale if treatment is denied. This rationale may include elements of the guideline. Additional information regarding the rationale for denial of treatment may also be derived from the injured employee's [ worker's ]medical records and from the professional opinion of a peer review, if utilized. In addition, this treatment guideline is a part of the screening criteria required by the Texas Department of Insurance to be used by Utilization Review Agents to determine preauthorization and retrospective review for medical necessity. Please refer to Title 28 of the Texas Administrative Code, Subchapter U, 28 TAC §§19.2000 - 19.2021, relating to Utilization Reviews for Health Care Provided Under Workers' Compensation Insurance Coverage.

(E)

[ (v) ] A [ It is expected that a ] subset of injured employees [ workers ] will be found to be outside the parameters of this guideline. If a health care provider's treatment deviates from this guideline, documentation would be required to clearly delineate the need for the treatment.

(F)

The insurance carrier is responsible for performing a focus review of the injury. This focus review shall primarily consist of case management. The focus review must clarify and attempt to reach agreement that the proposed treatment is appropriate as early as possible. Concurrent case management and bill review activities should address and focus on:

(i)

adherence to treatment plans;

(ii)

clinical progress;

(iii)

return to work issues;

(iv)

medical necessity;

(v)

injured employee compliance with the treatment;

(vi)

services provided consistent with treatment plan;

(vii)

response to treatment;

(viii)

improvement in injured employees' progress;

(ix)

recommendations for changes in treatment in situations where there is no compliance, plateau, and/or there is minimal or no progress; and

(x)

achievement of goals, improvement sooner than treatment plan indicated.

(3)

[ (C) ] Medical Review Division. The Medical Review Division shall [ will ] use the guideline as a tool for the basis of their administrative review of prospective, concurrent and retrospective treatment. This guideline shall [ It will ] also be used as a tool in conducting on-site audits and desk audits for both health care providers and insurance carriers.

(4)

[ (D) ] Consulting or Peer Review Health Care Provider. This guideline should be used as a reference in advising the Medical Review Division and to determine when the need for an unbiased medical opinion is indicated. The peer reviewer should use his/her clinical expertise in conjunction with the clinical intent of the guideline to address issues.

(5)

[ (E) ] Injured Employee [ Worker. It is essential ] The [ the ] injured employee should understand [ worker understands ] his/her role in complying with recommended treatment. The recovery [ and return to work ] process requires active cooperation of the injured employee [ worker ]. The health care provider is responsible for educating the injured employee about health care treatment appropriate to the workers' compensation injury (refer to subsections (d)(1)(A)(v) and (e)(2)(C)).

(6)

[ (F) ] Employer. [ It is the responsibility of ] The [ the ] employer shall be responsible for reporting [ to report ] the compensable injury in a timely fashion to ensure that there is no delay in the treatment of the compensable injury. The employer should, when appropriate, be responsible for working [ It is also the responsibility of the employer to work ] with the insurance carrier and health care providers to ensure that the injured employee [ worker ]is afforded the opportunity to return to work in either a modified or full employment capacity as rapidly as possible within the medical limitations of his/her injury.

[ (2)

Application Tables. See Figures (1)-(3) published in the Tables and Graphics Section of this issue of the Texas Register. ]

[ (A)

Initiation of Treatment.]

[ Figure: 28 TAC §134.1001(d)(2)(A)]

[ (B)

Ongoing Treatment. ]

[ Figure: 28 TAC §134.1001(d)(2)(B) ]

[ (C)

Ongoing Treatment (For other parties involved).]

[ Figure: 28 TAC §134.1001(d)(2)(C) ]

(e)

Ground Rules.

(1)

Introduction. The Texas Workers' Compensation Commission treatment guidelines are not to be used as fixed treatment protocols. The guidelines reflect services that are reasonable and medically necessary for treatment of spine injuries. The guidelines recognize that a subset of injured employees will be found to be outside the guidelines' parameters. [ typical courses of intervention. It is acknowledged that, in atypical cases, treatment may fall outside these guidelines. ] However, [ those ]cases exceeding [ that exceed ]the guidelines' level of treatment shall [ will ] be subject to more careful scrutiny and review and shall [ will ] require documentation of the special circumstances justifying that treatment. The guideline should not be seen as prescribing the type, frequency or duration of treatment. Treatment must be based on the injured employee's [ worker's ] need and the doctor's professional judgment.

(2)

Ground Rules.

(A)

Not withstanding any other provision of this section, treatment of a work related injury must be:

(i)

adequately documented;

(ii)

evaluated for effectiveness and modified based on clinical changes;

(iii)

provided in the most appropriate, least intensive setting;

(iv)

cost effective;

(v)

consistent with this guideline which may include providing [ or contain ] a documented clinical rationale for deviation from this guideline;

(vi)

objectively measured and demonstrated [ demonstrate ] functional gains; and

(vii)

consistent in demonstrating ongoing progress in the recovery process by appropriate re-evaluation of the treatment.

(B)

Communication between all health care providers involved in treating the injured employee [ worker ] must ensure that all previous treatment and diagnostic tests are considered when developing a [ plan of ] treatment plan . All reports and records shall [ should ] be made available to all health care providers to prevent unnecessary duplication of tests and examinations ( refer to [ as provided ]in subsection (c)(2) and (3) of this section).

(C)

Education [ Patient education ] is an essential component in ensuring the injured employees' [ patient ] compliance to all treatment. Education is essential for the active cooperation of the injured employee [ patient ] in all aspects of health care and as a means to prevent re-injury. The injured employee should understand his/her role in the recovery and return to work processes. The health care provider is responsible for providing education to the injured employee about health care treatment appropriate to the workers' compensation injury (refer to subsections (d)(1)(A)(v) and (e)(2)(C) of this section). [ It is essential that the patient understand his/her role in the recovery and return to work process. ]

(D)

Outpatient evaluation and therapy is required to meet the definitions/criteria set forth in the current Medical Fee Guideline. Treatment in this area should include activation as early as possible but no later than two weeks after treatment begins unless there is medical justification for delay. Early activation may include but is not limited to bilaterally symmetrical activities such as walking, swimming, bicycling and self-stretching. The activities should be goal directed - either timed intervals or numbered repetitions and may be performed at home or under supervision. Documentation of the injured employee's compliance and substantive and continued improvement over time of treatment should be included in reports already being submitted. This documentation should justify the continuation of therapy. For examples of types of documentation refer to paragraph (3)(C) of this subsection.

(E)

Manipulation should be performed for the minimum appropriate duration. Minimum appropriate duration can be defined as that duration of time from the initiation of treatment which will result in continued improvement, and where additional treatment will not further benefit the injured employee. The frequency of such treatment should be consistent with the phase of the injured employee's disease or dysfunctional process as determined by on-going evaluation and management of the injured employee's conditioning. Substantive and continued improvement over time from the treatment should be objectively documented. For examples of objective documentation refer to paragraph (3)(E) of this subsection. Additional treatment or further evaluation may be necessary if repeated efforts to withdraw from treatment results in documented significant deterioration of clinical status and the doctor has taken steps to determine that the patient is not physician/system dependent (i.e. behavioral consultation).

(F)

[ (D) ] Although preoperative educational programs and chronic pain management programs are not specifically outlined, the intent of this guideline is not to eliminate or prohibit their use. When deemed medically necessary, these programs may be considered appropriate types of intervention to be utilized. Chronic pain management programs may be appropriate for injured employees with chronic pain for which all conventional treatments have failed, surgical and non-surgical, and who are not immediately returning to any conventional treatment. Chronic pain is pain that has lasted without abatement for six months, A primary goal of the chronic pain management program should be the independent self-directed management of chronic pain by the injured employee. Chronic pain management programs should include the following components: usual duration of four to six weeks; identified endpoint which coincides with the determination of Maximum Medical Improvement (MMI); and notification to the injured employee that non-compliance will result in a determination of MMI. The chronic pain management program should also provide coordinated, goal-oriented, interdisciplinary team services to reduce pain, improve functioning, and decrease the dependence on the health care system of persons with chronic pain syndrome. After completion of a full chronic pain management program, re-enrollment or repetition of another full chronic pain management program would not be medically warranted. For additional ground rules on the use of interventional measures for pain, refer to paragraph (2)(R) of this subsection.

(G)

TENS (transcutaneous electric nerve stimulation) units and other transcutaneous stimulators should be used for acute pain and usually for no longer than four to six weeks. If stimulators are needed beyond the acute phase, objective documentation should be provided for the continued rental/purchase. For examples of objective documentation refer to paragraph (3)(F) of this subsection.

(H)

[ (E) ] All parties in the workers' compensation system should work together to ensure that the injured employee [ worker ] returns to work at the earliest medically appropriate time. Return-to-work is an important therapeutic approach which benefits the injured employee [ worker ]. The health care provider shall [ should ]communicate with the injured employee [ worker, ] employer and the insurance carrier to coordinate a successful return to work. Return to work planning efforts should commence as early as possible in cases where the injury is severe and the provider expects obstacles in returning the injured employee to the workplace.

(I)

[ (F) ] The level of service should be the same as the health care provider's usual and customary level of service regardless of the payor system.

(J)

[ (G) ] Although not the typical course of treatment, there may be circumstances in which the [ The ] injured employee [ worker ] may move between phases [ levels ] of care or utilize interventions in more than one phase [ level ] of care simultaneously, depending on clinical indicators.

(K)

[ (H) ] Treatment durations are cumulative; it may [ however, it should ] not always be necessary to use full durations for any given phase [ level ] of care.

(L)

Rehabilitation programs such as work hardening, work conditioning and outpatient medical rehabilitation are required to meet the definitions/criteria set forth in the current Medical Fee Guideline. Work conditioning and work hardening program goals should be tailored to physical demands required by job specificity. When the injured employee does not have a specific job that he/she is returning to, the goal of these programs should be to restore a reasonable level of physical functioning. Work conditioning programs at the job site or a combination of work conditioning/work hardening and modified duty as part of a progressive return to work program can also be utilized to meet these goals when the employer has these programs in place.

[ (I)

An initial mental health evaluation to determine the injured worker's readiness for the Work Hardening program may be performed prior to entrance into the program. This evaluation is not considered part of the Work Hardening program. Group therapy, provided by a Qualified Mental Health Provider, is considered to be part of the Work Hardening program. Individual therapy (i.e., one-to-one therapy with a Qualified Mental Health Provider) is not considered to be part of the Work Hardening program. Referral for this evaluation must come from the treating doctor.]

(M)

[ (J) ] The highest quality of patient care and clinical outcomes should be the standards by which referrals to intermediate [ secondary ] and tertiary care programs are determined. Documentation should be provided by the treating doctor which demonstrates the clinical progress of the injured employee's [ worker's ] condition and evidence of the doctor's supervision. With this documentation present, both intermediate [ secondary ]and tertiary nonoperative care may be provided sequentially within the same facility or in facilities with linked ownership if self-referral or conflict of interest elements do not exist.

(N)

[ (K) ] All health care providers treating [ providing services to ]an injured employee [ worker ] are responsible for substantiating [ have the responsibility to substantiate ] in their documentation the level of service for which they request reimbursement . All payors have the responsibility to review all documentation submitted as the basis for the treatment and services provided.

(O)

[ (L) ] Any new treatment must meet acceptable standards of care (as defined in the Glossary) and may be subject to review by the Texas Workers' Compensation Commission.

(P)

[ (M) ] Documentation of significant neurological deficit may support early intervention (0 - 6 weeks) of MRI's and CT scans, which would better direct the course of treatment.

(Q)

[ (N) ] Indications for bone growth stimulators[ (internal and external) (CPT codes 20974 and 20975) ] include:

(i)

revision spinal fusion;

(ii)

history of spinal fusion with prior [ or ] delayed union at different level;

(iii)

multiple level spinal fusion;

[ (iv)

use of allograft;]

[ (v)

spondylolisthesis greater than grade two; and ]

(iv)

[ (vi) ] nonassociated high risk problems: e.g. [ metabolic bone disease, ] smokers,[ diabetics, obesity. ] and pseudoarthroses.

(R)

[ (O) ] Interventional pain procedures may include spinal cord or peripheral nerve stimulation and/or implantable infusion pumps and [ CPT codes for these procedures include 64555, 63650, 63655, 63685, ] 62351, 62360, 62361, 62362, [ 63750, ] 62350, [ 63780, 64575, and 64590. These procedures ] are performed to achieve one or more of the following objectives:

(i)

to establish a diagnosis by identifying an anatomical source of pain (e.g., nerve sleeve injections and facet injections); [ lesion specific delivery of medications to damaged nerve roots; ]

[ (ii)

release of entrapped nerve roots from scars;]

(ii)

[ (iii) ] to complete therapeutic neurodestructive procedures to an anatomic source of pain identified by an appropriate response to diagnostic injections (e.g., injection of neurolytic substances, cryoneurolysis, and radiofrequency thermocoagulation);

(iii)

to deliver specific medications (e.g. steroids and narcotics) to potential sources of pain.

[ (iv)

establish diagnosis using only diagnostic procedures (e.g., nerve sleeve injections and facet injections)]

(S)

Spinal injection techniques are interventional pain procedures that can be diagnostic as well as therapeutic and may also facilitate other treatment options such as rehabilitation or manipulation. Interventional pain procedures should be performed methodically based on reproducible clinical examination findings. Consideration should be given to the destructive properties of corticosteroids and care taken in their appropriate use.

(i)

Epidural Steroid Injections - Indications for epidural steroid injections include radicular symptoms that prove unresponsive to noninvasive treatments including non-steroidal anti-inflammatories (NSAIDS), appropriate active rehabilitation or manipulation, and/or oral corticosteroids. Epidural injections should be performed under fluoroscopic control. Relief for less than seven to 10 days to the initial injection precludes the need for additional injections. The frequency of injections should be limited to one to three injections spaced minimally seven to 14 days apart as determined by clinical response and not to exceed six injections in a 12 month period. Repeat series of injections after the initial injection series would be precluded if initial series did not provide at least one month of good relief.

(ii)

Zygapophyseal (Facet) and Costovertebral Joint Injections - Indications for intra-articular injections are limited to axial and referred pain in patients who are neurologically intact with pain for at least four weeks unresponsive to noninvasive treatments including NSAIDS, appropriate active rehabilitation or manipulation and/or oral corticosteroids. These injections must be performed under fluoroscopic control. Relief for less than seven to 10 days to the initial injection precludes the need for additional injections. Furthermore, injections should be limited to three to four joints not to exceed three injections in a 12 month period.

(iii)

Sacroiliac Joint (SI) Injections - Indications for SI injections are a strong clinical suspicion of SI joint dysfunction in a patient who has experienced pain for at least four weeks and failed to improve with noninvasive treatments including NSAIDS, appropriate active rehabilitation or manipulation and/or oral corticosteroids. SI injections must be performed under fluoroscopic control. Relief for less than seven to 10 days to the initial inejctions precludes the need for additional injections. The frequency of injections should be limited to one to three injections spaced minimally seven to 14 days apart as determined by clinical response and not to exceed four injections in a 12 month period. Repeat series of injections after the initial injection series would be precluded if initial series did not provide at least one month of good relief.

(iv)

Selective Diagnostic Nerve Root Blocks - Indications for selective nerve root blocks exist in that patient in whom clinical findings of nerve root irritation and radiculopathy persists with negative or equivocal imaging studies and in spite of appropriate treatment including NSAIDS, appropriate active rehabilitation or manipulation, and/or oral corticosteroids. These diagnostic blocks must be performed under fluoroscopic control. Relief of less than seven to 10 days to initial injection precludes the need for additional injections at the same levels. Frequency of injections should be limited to three injections spaced minimally 14 days apart as determined by clinical response and should not exceed six injections in a 12 month period. Levels injected should not exceed three per given spinal segment-cervical, thoracic or lumbar.

(v)

Medial Branch and Dorsal Ramus Blocks - Indications for medial branch and dorsal ramus blocks exists in those patients with at least four weeks of axial or referred pain that has persisted in spite of appropriate treatment including NSAIDS, appropriate active rehabilitation or manipulation, and/or oral corticosteroids. These diagnostic blocks must be performed under fluoroscopic control. Repeat blockade should only be performed for confirmation of equivocal results in patients for whom ablative block is to be considered and should not exceed two additional injections in a 12 month period.

(vi)

Ablative Dorsal Median Branch Blocks (radiofrequency thermocoagulation, cryoneurolysis, chemical neurolysis) - Indications for these techniques exist in that patient with at least eight weeks of axial or referred pain that has a confirmed facet pain source limited to no more than two joints by prior diagnostic facet or select dorsal median branch blockade. Repeat ablation may be performed for recurrent pain not sooner than four months after initial ablative blockade and should not exceed two times in a 12 month period.

(T)

Trigger point injections - Indications include reproducible and palpable paraspinal muscle spasticity of at least two weeks duration nonresponsive to appropriate treatment including NSAIDS and rehabilitation or manipulation. Less than five days of relief with initial injection would preclude additional injections. Frequency of injections should be limited to three injection sessions spaced minimally seven days apart and should not exceed four injection sessions in a 12 month period. No more than four injections should be given at any session. Failure to obtain at least three months of improvement with a set of three injection sessions would preclude additional injections.

(U)

Acupuncture - Acupuncture when indicated may be used for acute musculoskeletal pain and usually for no longer than four to six weeks. If treatment is needed beyond the acute phase, objective documentation should be provided for the continued treatment.

(V)

[ (P) ] Preauthorization of any treatments or services will be as required in the Commission's preauthorization rule.

(W)

[ (Q) ] When it becomes necessary for an injured employee [ worker ] to travel in order to obtain appropriate and necessary medical care for a compensable injury, reimbursement for travel expenses is governed by §134.6 of this title.

(X)

[ (R) ] The CPT codes in the current Medical Fee Guideline should be used. The CPT codes listed should not be used until they are adopted into a current Medical Fee Guideline.

(Y)

When the injured employee displays signs and symptoms which may require further evaluation by a Qualified Mental Health Provider, refer to §134.1000 of this title (relating to the Mental Health Treatment Guideline) for parameters regarding documentation, evaluation and treatment.

(3)

General Documentation Requirements.

(A)

The health care provider's documentation is vital as an information source regarding the injured employee's [ worker's ] injury and treatment and [ . It ]also provides information which impacts income benefits. For these reasons, many of the Commission's rules have set time requirements for submission of required reports. For more information, refer to Chapter 133, Subchapter B of this title (relating to Required Reports). [ For example, the TWCC 61 could be the first report submitted which informs the insurance carrier of the injury. The TWCC 64 provides medical information regarding the injured worker's clinical progress and the need for continuation of any income benefits. The TWCC 69 provides the determination of MMI and an impairment rating which may result in a change in income benefits. ]

(B)

Documentation shall [ should ] be provided by the health care provider to determine the phase [ level ] of care to be provided and the necessity for that care. The elements of that documentation may include:

(i)

a [ A ]description of the injury, including the events surrounding that injury and the extent and severity of that injury;

(ii)

a [ A ] description of any pre-existing condition(s), complicating conditions, and/or any non-related conditions;

(iii)

a [ A plan of ] treatment plan, including proposed methods of treatment, expected outcomes, and probable duration of treatment;

(iv)

updates [ Updates ] to the [ plan of ] treatment plan as needed, including the clinical progress of the injured employee [ worker, ] and any revisions needed to the treatment plan based on [ in light ] of the injured employee's [ worker's ] response to treatment;

(v)

education [ Education/ ]information provided to the injured employee [ worker ] regarding his or her injury and [ plan of ] treatment plan, and the injured employee's [ worker's ] compliance with this [ plan of ] treatment plan ; and

(vi)

documentation [ Documentation ] substantiating the need for deviation from the guideline, if necessary.

(C)

Documentation of acceptable outpatient evaluation and therapies should be objective and illustrate compliance and substantive and continued improvement over time. Examples of this documentation may include but are not limited to :

(i)

patient diaries documenting home program;

(ii)

description of patient's capabilities and progress made;

(iii)

notes describing quantified changes in pain behavior using tools such as pain drawings;

(iv)

notes describing the patient's demonstrated independent performance of provider instructed exercise;

(v)

notes describing patient's exercise such as "patient is walking 45 minutes";

(vi)

notes indicating increased ability in activities of daily living;

(vii)

notes indicating increase in walking distance;

(viii)

notes indicating increase in sitting time tolerance;

(ix)

notes indicating increase in standing time tolerance;

(x)

neck disability index results; and

(xi)

back disability index results.

(D)

Documentation for rehabilitation programs such as work conditioning, work hardening or outpatient medical rehabilitation should show objective substantive and continued improvement over time that correlates to the job description the injured employee will most likely enter upon completion of the program. The examples listed in paragraph (3)(C) of this subsection may also be used to appropriately document progress made in rehabilitation programs.

(E)

Documentation for manipulation should show objective/quantified substantive and continued measures of improvement over time. The examples listed in paragraph (3)(C) of this subsection may be used to appropriately document progress.

(F)

Documentation for the continued use of TENS units and other transcutaneous stimulators beyond four to six weeks should show objective/quantified measures of substantive and continued improvement over time which may include but are not limited to:

(i)

decreased use of medication;

(ii)

increased function due to reduction in pain; and

(iii)

return to work.

(G)

[ (C) ] Permanent impairment for compensable injuries in workers' compensation shall [ should ]be limited to these injuries and illnesses for which doctors [ physicians ]are able to demonstrate objective findings.

(H)

[ (D) ] The need for emergency treatment must be based on the doctor's professional judgment. This documentation must provide a clear explanation of the nature of the emergency, the injured employee's [ worker's ]medical condition, complications which could occur as well as any irreversible conditions which occurred or could occur as a result of the emergency [ this event ].

(4)

Documentation Requirements for Unrelated or Intercurrent Illness. Situations may arise where certain medical conditions need to be delineated or clarified prior to intervention. Treatment administered to other body areas (not a part of the original injury) or for a pre-existing medical condition(s) must be identified and the relation of this treatment to the compensable injury must be documented by the health care provider. If this treatment [ it ] appears [ that this treatment is ] not to be related to the compensable injury, then the health care provider should inform the injured employee that this treatment may not be covered by the insurance carrier [ the injured worker should be informed by the health care provider that this treatment may not be covered by the insurance carrier ]. The health care provider should clearly document the [ The ] rationale for such treatment and its relation to the compensable injury [ should also be clearly documented for the insurance carrier by the health care provider. ]

(f)

Diagnostic Procedures.

(1)

Introduction. This subsection provides an average timeline in which to utilize certain listed diagnostic studies. The actual need for the diagnostic studies will be dependent on both the amount of time that has passed since the date of injury and on the injured employee's [ worker's ] documented clinical condition. If the clinical condition of the injured employee [ worker ] is more severe, certain tests may be required sooner than is proposed in this guideline.

(2)

List of Diagnostic Interventions. The following subdivisions of this paragraph comprise a list of diagnostic interventions:

(A)-(I)

(No change.)

(J)

[ discography +/- CT scan; ]

[ (K) ]

radionucleotide bone scan:

(i)

nucleotide;

(ii)

dual photon; or

(iii)

P.E.T.;

(K)

[ (L) ] EMG/evoked potential;

(L)

[ (M) ] diagnostic selective nerve root injection -[ must be ] done under fluoroscopy control ; (refer to subsection (e)(2)(S)(iv) of this section);

(M)

[ (N) ] diagnostic facet injection - done under fluoroscopy control both diagnostic and therapeutic (refer to subsection (e)(2)(S)(ii) of this section) ;

(N)

discography - discography involves the injection of a water-soluble imaging material directly into the nucleus pulposus of the disc. Information is then recorded about the amount of dye accepted, the pressure necessary to inject the material, the configuration of the opaque material, and the reproduction of the patient's pain. Discography is useful in select situations.

[ (O)

physical capacity evaluation;]

(O)

[ (P) ] functional capacity evaluation; or

(P)

[ (Q) ] mental health evaluation.

(3)

Time Recommendations for Listed Diagnostic Interventions.

(A)

Recommended diagnostics [ treatment ] at zero to six weeks include [ includes ] the diagnostic interventions listed in paragraph (2)(A),(B), and (C) of this subsection.

(B)

Recommended diagnostics [ treatment ] at six weeks to four months includes the diagnostic interventions listed in paragraph (2)(D) - (L) [ (I) and (K) ,- (M) ] of this subsection.

(C)

Recommended diagnostics [ treatment ]at greater than four months includes the diagnostic interventions listed in paragraph (2) (M) [ (J) and (N) ] of this subsection.

(D)

Discography should not be performed before six months from date of injury and only after appropriate imaging studies such as an MRI or CT/myelogram has been performed with questionable/suggestive/abnormal findings. Discography should not be the sole determining factor or justification for a surgical intervention. A positive discogram correlates the reproduction of the patient's pain with an imaging study and a control. The following indicators (which also appear in chart 6 of the surgical algorithms) must occur for discography to be appropriate:

(i)

the patient has had unremitting lower back pain resistant to conservative care for more than six months; and

(ii)

significant psychosocial issues are not dominant or have been addressed; and

(iii)

suspect degenerated discs and one normal disc by MRI are injected; and

(iv)

results of appropriately and carefully performed provocative and imaging tests are combined

(E)

[ (D) ] The diagnostic interventions listed in paragraph (2)(O) - (P) [ (Q) ] of this subsection may occur at any time after the initial date of injury. Once the injured employee [ worker ] has sufficiently recovered, a[ Physical Capacity Evaluation and/or ] Functional Capacity Evaluation is usually performed to determine whether or not the injured employee [ worker ] is considered a candidate for a work hardening or work conditioning program. These tests are usually performed just prior to entry into the program and at the end of the program to determine the injured employee's [ worker's ] level of physical ability and his capability to return to work.

(g)

Phases [ Levels ] of Nonoperative Care.

(1)

Introduction to Nonoperative Treatment Tables. The treatments, set out in the following tables, represent treatment that is reasonable and medically necessary for a given period of time according to the diagnosis(es). The "Treatment Interventions" sections of the Treatment Tables are in alphabetical order and do not infer numerical sequence. There will be some injured employees who require less treatment, and other injured employees who require more treatment than is outlined. This document serves as a guideline and should not be used as the sole reason for denial or requirement of treatment. The provision of specific services to an injured employee is dependent on the injured employee's diagnosis, and response to treatment. [ Introduction. The following subsection defines the criteria for referral to primary, secondary and tertiary levels of care that are reasonable and necessary for care to the spine. Primary, secondary and tertiary levels of nonoperative care are illustrated in Tables I, II and III in paragraph (6) of this subsection. The tables define duration and specific components of each level of care. The clinical condition of the injured worker, as documented by the treating doctor, will be the determining factor for placing the injured worker in the most appropriate level of care. The injured worker may move between these levels of care dependent upon his condition and the treatment preceding the move between levels. The duration of treatment at any one level of care may be less than or greater than the recommended duration dependent upon the documented condition of the injured worker. If the treatment provided exceeds the recommended duration at that level of care, additional documentation needs to be provided regarding the need for extended care. Treatment durations are considered cumulative and it should not always be necessary to use full durations for any given level of care (see subsection (e)(2)(G)of this section). ]

(2)

Initial Phase [ Primary Level ] of Care. This phase [ level ] of care is generally considered to be appropriate for injured employees [ workers ] immediately following the compensable injury; however, the injured employee [ worker ] in this phase [ level ] of care may also be an early postoperative patient or may be experiencing an acute exacerbation of his/her chronic condition [ back pain ]. Since [ bedrest and ] partial or total cessation of work over a brief period of time [ (i.e., two to three days maximum) ] is also considered to be part of the initial phase [ primary level ] of care, further treatment by a health care provider may not be considered necessary at this phase [ level ] of care. Little or no deconditioning has occurred due to the injury, immobilization or decreased activity. The goals [ goal ] for this phase [ level ] of care are [ is ] to prevent disease, alleviate or minimize the effects of the illness or injury and to maintain function [ symptom control to facilitate rapid recovery and return to work before deconditioning or psychosocial barriers occur. The usual duration for this level of care is eight weeks ].

(3)

Intermediate Phase [ Secondary Level ] of Care. This phase [ level ] of care is [ the first stage of rehabilitation ] for those injured employees [ workers ] who have not returned to productivity after [ through ] the normal healing process. This phase of care [ It ] is designed to facilitate return to productivity , including return to work in either full or modified duty, before the onset of a chronic condition [ disability ]. This phase of care may also be indicated for the injured employee whose physical capacity to work still does not meet the job requirements for heavy physical labor after adequate treatment, thereby causing an inability to return to full duty. It is individualized, time limited and of limited intensity. The injured employee [ worker ] has a history of a limited-to-good response to early primary treatment with persistent symptoms limiting activities of daily living. The objective physical examination demonstrates findings suggestive of early deconditioning including loss of range of motion and/or strength with limitation of activities of daily living. Evidence of mental health or psychosocial barriers may be present which impede the injured employee's [ worker's ]clinical progress. [ Duration of this level of care is generally up to eight weeks. In addition to the normative duration listed, an additional two weeks is added to secondary level for less intensive care if necessary at the termination of the tertiary level of care. Documentation of necessity must be included with the request for the additional two weeks. ]

(4)

Tertiary Phase [ Level ] of Care. This phase [ level ] of care is interdisciplinary, individualized, coordinated and intensive . [ , ] It is designed for the injured employee [ worker ] who demonstrates physical and psychological changes consistent with a chronic condition [ disability ]. [ There is a documented history of persistent failure to respond to nonoperative or operative treatment which surpasses the usual healing period of four to six months post-injury or post-surgery or special cases with severe mental health issues lasting more than two months without response to primary or secondary treatment. ] Psychosocial issues such as substance abuse, affective disorders, and other psychological disorders may be present. There is a documented inhibition of physical functioning evidenced by pain sensitivity, and nonorganic signs such as fear which produce a physical inhibition or limited response to reactivation treatment. This phase [ level ] of care may also be indicated for the injured employee [ worker ] whose physical capacity to work still does not meet the job requirements for heavy physical labor after adequate treatment, thereby causing an inability to return to full duty. This situation would be evidenced by an excessive transitional period of light duty or significant episodes of lost work time due to the need for continued medical treatment. This phase [ level ] of care is also indicated for those injured employees [ workers ] who cannot tolerate either initial [ primary ]or intermediate phases [ secondary levels ] of care. The usual duration for this phase [ level ] of care is generally up to six weeks.

(5)

Criteria to Distinguish between Intermediate [ Secondary ] and Tertiary Phases [ Level ] of Care. Many factors may determine the choice between intermediate [ secondary ] and tertiary phases [ levels ] of care. In general, if lower cost intermediate [ secondary ] treatment can be effective, this phase [ level ] of care is preferred over the more expensive tertiary care. However, if the documented condition of the injured employee indicates [ worker is indicative of ] the need for more intensive treatment, the tertiary phase [ level ] of care may be more appropriate. Key factors in determining the need for intermediate [ secondary ] versus tertiary care include:

(A)

(No change.)

(B)

the presence of psychosocial barriers to recovery such as but not limited to depression, substance abuse, personality disorder, etc., and the severity of these barriers;

(C)-(F)

(No change.)

(6)

Post-tertiary treatment. Injured employees are entitled to the reasonable and necessary medical benefits for the duration of the injury. In some cases injured employees will require treatment after they have reached MMI or after they have completed the tertiary phase of treatment. Treatment should be provided to control pain or other symptomology, maintain function and/or to help the injured employee remain at work. Treatment provided post MMI or after the tertiary phase of care is typically aimed towards one or more of these three goals. Interventions for these injured employee are generally provided at a lower frequency than in the three phases of care outlined in the treatment tables. Examples of interventions that might be utilized include office visits, manipulations, home exercise, injections, and medications. Preauthorization is applicable to any services listed in the preauthorization rule. Other services are subject to retrospective bill review for medically reasonable and necessary treatment and/or payment amount. Health care providers who provide services to injured employees after the tertiary phase of care or after MMI, who are not paid for their services may apply to Commission's Medical Dispute Resolution section, for resolution of the issue of medical necessity or bill payment amount. To receive payment for services, a treatment must be related to the compensable injury and be reasonable and necessary treatment for that injury. Health care providers are responsible for appropriate utilization of medical services. Health care providers may be sanctioned or removed from the Approved Doctor List for over utilization of health care services. Insurance carriers must review treatments in accordance with the standards set forth by the Texas Department of Insurance Utilization Review Rules. An insurance carrier operating outside the parameters of these rules may be subject to regulatory sanctions and/or criminal charges by the Texas Department of Insurance. An insurance carrier who unreasonably denies medical benefits may be subject to sanctions by the Texas Workers' Compensation Commission.

(7)

[ (6) ] Phase [ Level ] of Care Tables. See Figures in subparagraphs (A)-(D) of this paragraph [ 4 - 7 published in the Tables and Graphics Section in this issue of the Texas Register. ]

(A)

Table I. Initial Phase of Care. [ Levels of Care Tables. ]

Figure: 28 TAC §134.1001(g) (7) [ (6) ](A).

(B)

Table II. Intermediate Phase of Care. [ Table II. Secondary Level of Care ].

Figure: 28 TAC §134.1001(g) (7) [ (6) ](B)

(C)

Table III. Tertiary [ Level ] Phase of Care.

Figure: 28 TAC §134.1001(g) (7) [ (6) ](C).

(D)

Table IV. Surgical Intervention.

Figure: 28 TAC §134.1001(g) (7) [ (6) ](D).

(h)

Assessments/Evaluations

(1)

Interdisciplinary Assessment. In certain cases involving either surgical or nonoperative treatment, an interdisciplinary assessment may be needed. This assessment may include:

(A)

Sequelae of Injury. Injuries may produce a variety of unanticipated nonoperative or postoperative sequelae, including problems with other joints/regions due to deconditioning, chronic or progressive neurological conditions, urological problems, or a variety of mental health disturbances. Any or all of these may result in the need for an interdisciplinary assessment to determine what treatment options are needed to bring the injured employee [ worker ] to the highest functional level.

(B)

Intercurrent Illness. Injured employees [ workers ] suffering from a variety of intercurrent illnesses (e.g., hypertension, cardiac disease, diabetes, etc.) may require medical management beyond the scope of the treating doctor. An interdisciplinary assessment may be needed to determine the treatment options required to bring the injured employee [ worker ] to the highest functional level, given the limitations of the intercurrent illness. Treatment for the intercurrent illness may not be related to the compensable injury and therefore, may not be the responsibility of the workers' compensation insurance carrier.

(C)

Risk Factors for Complications. Some injured employees [ workers ] may have risk factors in their personal or family history which may affect the delivery of care. In particular, injured employees [ workers ] expecting to undergo surgery or to undergo an exercise program may demonstrate a variety of cardiovascular risk factors necessitating additional evaluations and modification to the treatment plan.

(2)

[ Physical Capacity and ]Functional Capacity Evaluations [ Assessments ]. This paragraph specifically discusses the issues of [ physical and ] functional capacity evaluations [ assessments ]. These measurements have been used to monitor the injured employee's [ workers's ] clinical progress; to guide the doctors and/or therapists in determining an exercise program and to provide objective data to determine a permanent physical impairment.

(A)

Physical Examination vs. Human Performance Measurement: A physical examination usually consists of a qualitative estimate of the injured employee's [ worker's ] physical or functional ability. A human performance measurement, by contrast, involves the use of accurate devices and specific skills to quantitatively determine the performance parameters that provide an objective measurement of the injured employee's [ worker's ] ability as it relates to the compensable injury.

(B)

(No change.)

[ (C)

A physical capacity evaluation of the injured area may include the following:]

[ (i)

range of motion: quantitative measurements (using appropriate devices) of the injured joint or region (i.e., knee, shoulder, lumbar spine, cervical spine, etc.); and ]

[ (ii)

strength/endurance: quantitative measures of the injured area or region using accurate devices (isometric, isoinertial and/or isokinetic devices in one or more planes), with comparison to contralateral side and/or normative database.]

(C)

[ (D) ] A functional capacity evaluation of the whole person or multiple areas of the body may include the following:

(i)

isometric lifting: NIOSH standard leg lift, torso lift, arm lift or extremity isometric test using measurement device;

(ii)

isokinetic lifting: controlled speed floor-to-knuckle, knuckle-to-shoulder lifts using measurement devices and standardized protocols;

(iii)

isoinertial lifting: standardized free weight lifting tests;

(iv)

activities of daily living tests: standardized tests (but often observational) of generic functional tasks (i.e. pushing, pulling, kneeling, squatting, carrying, climbing, etc.)

(v)

hand function tests: measurement of fine/gross motor coordination, grip strength, pinch strength, manipulation tests, etc., using measurement devices;

(vi)

submaximal cardiovascular endurance tests: measurement of aerobic capacity using bicycle or treadmill; and

(vii)

static positional tolerance: observational for tolerance of sitting or standing tolerance.

(3)

Appropriate and Inappropriate Testing.

(A)

Evaluations Appropriate to Phase [ Level ] of Care. The actual need for diagnostic studies is dependent on both the amount of time that has passed since the date of injury and on the injured employee's [ worker's ] documented clinical condition. To determine the level of testing appropriate for the injured employee [ worker ], please refer to subsection (f) (relating to Diagnostic Procedures) of this section.

(B)

Inappropriate Testing. Certain tests and procedures are inappropriate for the assessment of work-related injuries. Some examples include tests performed only to assess the injured employees' [ workers' ] efforts, physical capacity evaluations [ assessments ] for a joint or body region not related to the compensable injury or invalid or scientifically unjustifiable techniques.

(i)

Treatment Algorithms. Paragraphs (1) - (7) of this subsection present commonly pursued courses of treatment for spinal injuries depending on presenting conditions and associated factors. Algorithms are provided for progressive decisions relating to treatment approaches as well as commonly recognized treatment procedures. The treatment algorithms presented in this guideline offer greater potential for agreement between health care providers and payors on medical utilization for specific conditions than use of ICD-9 codes alone. Health care providers who pursue treatment at variance with the guideline are subject to greater documentation requirements as provided in subsection (e)(4) of this section.

(1)

Surgical Treatment Code Legend.

Figure: 28 TAC §134.1001(i)(1).

(2)

Initial Approach to Treatment of Spinal Injury Chart 1.

Figure: 28 TAC §134.1001(i)(2).

(3)

Fracture and/or Dislocation Chart 2.

Figure: 28 TAC §134.1001(i)(3).

(4)

Soft Tissue Injury Chart 3.

Figure: 28 TAC §134.1001(i)(4).

(5)

Peri-Operative Algorithm Chart 4.

Figure: 28 TAC §134.1001(i)(5).

(6)

Surgical Treatment Chart 5.

Figure: 28 TAC §134.1001(i)(6).

(A)

Surgical Treatment Subchart 5A.

Figure: 28 TAC §134.1001(i)(6)(A).

(B)

Surgical Treatment Subchart 5B.

Figure: 28 TAC §134.1001(i)(6)(B).

(C)

Surgical Treatment Subchart 5C.

Figure: 28 TAC §134.1001(i)(6)(C).

(7)

Treatment Continuation Chart 6.

Figure: 28 TAC §134.1001(i)(7).

(j)

Glossary.

(1)

Acceptable Standards of Care - outlines some of the types of tests and treatments which are generally accepted by the professional organizations.

(2)

[ (1) ]Active Care vs. Passive Care.

(A)

Active care - modes of treatment or care requiring that the injured employee [ worker ] participate in and be responsible for the phase [ level ] of care received.

(B)

Passive care - modes of treatment or care which do not require the injured employee [ worker ] to participate in his/her care; i.e., the care is "done to" or "applied to" the injured employee [ worker ] (e.g., hot packs or cold packs)

(3)

Acute - medical condition having rapid onset, severe symptoms, and usually a short course.

(4)

Aggravation - an act or circumstance that intensifies or makes worse a pre-existing condition.

(5)

Algorithm - a suggested step-by-step procedural pathway for solving a problem or accomplishing some end.

(6)

Assessment/Evaluation -the act or process of inspecting or testing for evidence of injury, disease or abnormality.

(7)

Chronic - medical condition with recurrent symptoms of long duration

(8)

[ (2) ] Chronic Pain Management - a program which provides coordinated, goal-oriented, interdisciplinary team services to reduce pain, improve functioning, and decrease the dependence on the health care system of persons with chronic pain syndrome.

(9)

Compensable Injury - is defined as an injury that arises out of and in the course and scope of employment for which compensation is payable under this subtitle.

(10)

[ (3) ] Clinical Plateau - a period of time of relative stability in which the injured employee [ worker ] displays minimal or minor changes in his/her condition.

(11)

[ (4) ] Clinical Progress vs. Lack of Clinical Progress.

(A)

Clinical progress - documented objective improvement [ change ] in the condition of the injured employee [ worker, ] in response to the injured employee's [ worker's ] current treatment program.

(B)

Lack of clinical progress - documented objective absence of change in the condition of the injured employee [ worker ] over a period of time of no less than one month, requiring re-evaluation of the injured employee's [ worker's ] condition and re-evaluation of the current treatment program.

(12)

[ (5) ] Consulting Doctor - a doctor who provides an opinion or advice regarding the evaluation and/or management of a specific problem, as requested by the treating doctor, the Commission, or the insurance carrier. A consulting doctor may only initiate diagnostic and/or therapeutic services with approval from the treating doctor. (See the definition of referral doctor in paragraph 44 of this subsection).

(13)

Decompensation - the inability of the body to maintain adequate functioning in the presence of an injured, abnormal, or nonfunctioning body system.

(14)

Diagnosis - the art or act of identifying a disease or injury from evaluation of its signs and symptoms

(15)

Diagnostic Module - a standard which establishes normal parameters or boundaries of time within which to perform studies to assist in identifying a disease, injury or abnormality.

(16)

Diagnostic Test - objective studies performed to assist in identifying a disease, injury, or abnormality.

(17)

[ (6) ] Doctor - a doctor of medicine, osteopathic medicine, optometry, dentistry, podiatry, or chiropractic who is licensed and authorized to practice.

(18)

Exacerbation - an increase in the seriousness of a previously diagnosed disease or disorder as marked by greater intensity in the signs or symptoms of the patient being treated.

(19)

Examination - the act or process of inspecting or testing for evidence of disease, injury, or abnormality.

(20)

First - preceding all others in time.

(21)

First Doctor - the initial doctor who evaluates and treats the injured employee, and who may or may not ultimately become the treating doctor.

(22)

Focus Review - to critically examine the prospective, concurrent, and retrospective care received by the injured employee as related to the compensable injury.

(23)

Frequency of Intervention - the number of occurrences in a specified time in which the health care provider acts to treat the injured employee.

(24)

Functional Capacity Evaluation - a battery of tests administered and evaluated to determine the injured employee's ability to perform tasks related to both his or her daily activities and his or her job performance. This evaluation consists of the following elements:

(A)

a physical examination and neurological evaluation which includes an assessment of the physical appearance of the injured employee, flexibility of the extremity joint or spinal region, posture and deformities, vascular integrity, the presence or absence of sensory deficit, muscle strength and reflex symmetry:

(B)

a physical capacity evaluation which includes quantitative measurement of range of motion and muscular strength and endurance; and

(C)

a dynamic functional abilities test which includes activities of daily living, hand function tests, cardiovascular endurance tests, and static/dynamic positional tolerance.

(25)

Health Care - all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services. The term does not include vocational rehabilitation. The term includes:

(A)

medical, surgical, chiropractic, podiatric, optometric, dental, nursing, and physical therapy services provided by or at the direction of a doctor;

(B)

physical rehabilitation services performed by a licensed occupational therapist provided by or at the direction of a doctor;

(C)

psychological services prescribed by a doctor;

(D)

the services of a hospital or other health care facility;

(E)

prescription drugs, medicines, or other remedy; and

(F)

a medical or surgical supply, appliance, brace, artificial member or prosthesis, including training in the use of the appliance, brace, member or prosthesis.

(26)

[ (7) ] Health Care Facility - means a hospital, emergency clinic, outpatient clinic, or other facility providing health care.

(27)

[ (8) ] Health Care Practitioner.

(A)

an individual who is licensed to provide or render and provides or renders health care; or

(B)

a nonlicensed individual who provides or renders health care under the direction or supervision of a doctor.

(28)

[ (9) ] Health Care Provider - a health care facility or health care practitioner

(29)

[ (10) ] Impairment - any anatomic or functional abnormality or loss existing after maximum medical improvement that results from a compensable injury and is reasonably presumed to be permanent.

(30)

Initial Phase of Care - this phase of care is generally considered to be appropriate for injured employees immediately following the compensable injury; however, the injured employee in this phase of care may also be an early postoperative patient or may be experiencing an acute exacerbation of his or her chronic condition. Since partial or total cessation of work over a brief period of time is also considered to be part of the initial phase of care, further treatment by a health care provider may not be considered necessary at this phase of care. Little or no deconditioning has occurred due to the injury, immobilization or decreased activity. Duration of this phase of care is 0-8 weeks. (The goals are to prevent disease, alleviate or minimize the effects of the illness or injury and to maintain function.)

(31)

[ (11) ] Interdisciplinary Programs - programs in which the delivery of services is provided by more than one type of health care service (e.g., occupational therapy, physical therapy, counseling services, medical services) and in which there is [ Examples of ] a coordination between the disciplines regarding the care plan and the delivery of care to the injured employee. This [ this ] type of program includes [ include ] work hardening, outpatient [ medical ] rehabilitation, and chronic pain management.

(32)

Intermediate Phase of Care - This phase of care is for those injured employees who have not returned to productivity after the normal healing process. This phase of care is designed to facilitate return to productivity, including return to work in either full or modified duty, before the onset of a chronic condition. This phase of care may also be indicated for the injured employee whose physical capacity to work still does not meet the job requirements for heavy physical labor after adequate treatment, thereby causing an inability to return to full duty. It is individualized, time limited and of limited intensity. The injured employee has a history of a limited-to-good response to early initial treatment with persistent symptoms limiting activities of daily living. The objective physical examination demonstrates findings suggestive of early deconditioning including loss of range of motion and/or strength with limitation of activities of daily living. Evidence of mental health or psychosocial barriers may be present which impede the injured employee's clinical progress. Duration of this phase of care is 0-8 weeks.

(33)

Intermediate Treatment - refer to paragraph (32) of the subsection regarding intermediate phase of care.

(34)

[ (12) ] Intervention - the act or fact of interfering with a condition to modify it or with a process to change its course

[ (13)

Level of service - refers to primary, secondary, or tertiary care.]

(35)

[ (14) ] Maximum Medical Improvement (MMI) - the earlier of the following [ two ] items:

(A)

the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated; [ or ]

(B)

the expiration of 104 weeks from the date on which income benefits begin to accrue or [ . ]

(C)

the date determined as provided by §408.104 of the Texas Labor Code.

(36)

Medical Necessity - the determination that the tests or treatment provided is required based on the presenting signs and symptoms.

(37)

Module - a standard or unit of measurement

(38)

Objective Findings - signs, or test results that can be measured or quantified or are otherwise perceptible to persons other than the affected individual. A medical finding of impairment resulting from a compensable injury, based on competent medical evidence, that is independently confirmable by a doctor, including a designated doctor, without reliance on the subjective symptoms perceived by the employee.

(39)

[ (15) ] Outpatient Medical Rehabilitation - a program of coordinated and integrated services, evaluation, and/or treatment with emphasis on improving the functional levels of the persons served. The program is interdisciplinary in nature and is applicable to those persons who have severe functional limitations of recent onset or recent regression or progression or those persons who have not had prior exposure to rehabilitation. Services may be directed toward the development and/or maintenance of the optimal level of functioning and community integration of the persons served.

(40)

Phases of Care - the stages in the treatment of an injury or illness (initial, intermediate, and tertiary phases of care).

(41)

Proper Clinical Documentation - written records which meet the requirements outlined by statute and rule and which convey the following information to the required parties:

(A)

a description of the injury, including the extent, severity and events surrounding that injury;

(B)

a description of any pre-existing, complicating and/or any non-related conditions;

(C)

a treatment plan, including proposed method, frequency, and probable duration of treatment, with expected outcomes;

(D)

updates to the treatment plan as needed, including the clinical progress of the injured employee, and any revisions needed to the treatment plan in light of the injured employee's response to treatment;

(E)

education/information provided to the injured employee regarding his or her injury and treatment plan, and the injured employee's compliance with this treatment plan; and

(F)

the need for deviation from the guideline, if necessary.

(42)

Reason for Denial - refer to paragraph (45) of this subsection on screening criteria.

(43)

Referral - the process of directing or redirecting a medical case or a patient to an appropriate specialist or agency for definitive treatment.

(44)

[ (16) ] Referral Doctor - a consulting doctor who initiates health care treatments at the request or with the consent of the treating doctor.

(45)

Screening Criteria - a set of established elements or boundaries beyond which testing or treatment may be denied.

(46)

[ (17) ] Self-referral - the direction of a patient to another doctor, institution or facility whereby the referring doctor has a financial or conflict of interest element.

(47)

[ (18) ] Significant Neurological Deficit - signs of sensory impairment, progressive numbness, or [ rapidly progressing symptoms of ] increased physiological impairment such as severe weakness, bowel or bladder dysfunction directly related to the spinal injury ; [ , or severe sensory impairment. ]

(48)

Single Point of Contact - one person whom the doctor/health care provider(s) may contact for all questions regarding a specific injured employee.

(49)

[ (19) ] Sprain - an injury to a ligament

(A)

Mild (Grade 1) - only a few fibers are torn; ligament is mostly intact and the joint is stable;

(B)

Moderate (Grade 2) - more fibers are torn, resulting in some instability with abnormal joint motion and some functional loss ;

(C)

Severe (Grade 3) - ligaments are completely disrupted and instability may be severe (synonymous with marked).

(50)

Standard - established by authority, custom, or general consent as a model or example; the generally accepted norm for quality and quantity.

(51)

Static - characterized by a lack of movement or change.

(52)

[ (20) ] Strain - an injury to a muscle and/or tendon .

(A)

Mild (Grade 1) - only a few fibers are torn; muscle /tendon unit is mostly intact and functional;

(B)

Moderate (Grade 2) - more muscle fibers are torn resulting in muscle pain with contraction;

(C)

Severe (Grade 3) - muscle fibers or tendons are completely disrupted, extreme pain and loss of use of muscle.

(53)

Subacute - medical condition between acute and chronic but with some acute features.

(54)

Subjective Complaints - report of symptoms, perceivable only by the injured employee, relating to the injury and which cannot be independently verified or confirmed by recognized laboratory or diagnostic tests or observable by physical examination.

(55)

Tertiary Phase of Care - this phase of care is interdisciplinary, individualized, coordinated, and intensive. It is designed for the injured employee who demonstrates physical and psychological changes consistent with a chronic condition disability. In general, differentiation from intermediate treatment includes medical direction, intensity of services, severity of injury, individualized programmatic protocols with integration of physician, mental health, and disability or pain management services and specificity of physical/psychosocial assessment. This phase includes a documented history of persistent failure to respond to nonoperative or operative treatment which surpasses the usual healing period for that injury. Psychosocial issues such as substance abuse, affective disorders, and other psychological disorders may be present. This phase of care is indicated by a documented inhibition of physical functioning evidenced by pain sensitivity, loss of sensation, and nonorganic signs such as fear which produce a physical inhibition or limited response to reactivation treatment. This phase of care may also be indicated for the injured employee whose physical capacity to work still does not meet the job requirements for heavy physical labor after adequate treatment, thereby causing an inability to return to full duty. This situation would be evidenced by an excessive transitional period of light duty or significant episodes of lost work time due to the need for continued medical treatment. This phase of care is also indicated for those injured employees who cannot tolerate either initial or intermediate phases of care.

(56)

Tertiary Treatment - health care rendered during the tertiary phase of care.

(57)

Time Limited - a specific duration of clock or calendar time which is not exceeded on a routine basis.

(58)

[ (21) ] Treating Doctor - the doctor primarily responsible for [ coordinating ] the employee's health care for an injury. [ (synonymous with Primary Gatekeeper) ]

(59)

[ (22) ] Treatment Duration - calendar time allowed for treatment for a specific phase [ level ] of care.

(60)

Treatment Module - a standard which establishes routine parameters of time within which to provide therapy for the illness or injury.

(61)

[ (23) ] Treatment Plan - [ this is ] a written document which must contain the following components:

(A)

type of intervention/treatment modality

(B)

frequency of treatment;

(C)

expected duration of treatment;

(D)

expected clinical response to treatment; and

(E)

specification of a re-evaluation timeframe.

(62)

[ (24) ] Work Conditioning - a highly structured, goal-oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks. Work conditioning is a single disciplinary approach.

(63)

[ (25) ] Work Hardening - a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured employee [ worker ]. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of the persons served.

(k)

(No change.)

(l)

Revision Bibliography:

(1)

American College of Occupational and Environmental Medicine, Practice Guidelines Committee, (1997) OCCUPATIONAL MEDICINE PRACTICE GUIDELINES, Chapter 14, Low Back Pain Complaints, OEM Press.

(2)

American osteopathic Association, (1998) PROTOCOLS FOR OSTEOPATHIC MANIPULATIVE TREATMENT, Chicago.

(3)

Block, A.R., Kramer, E.F., Fernandez, E. Eds. HANDBOOK OF PAIN SYNDROMES, Chapter 5, Clinical Outcome and Economic Evaluation of Multidisciplinary Pain Centers by Okifui, A., Turk, D.C. and Kalauokalani, D.; Lawrence Earlbaum & Associates Publishers, Mahwah, NJ 1999

(4)

Connor, Patrick M., Darden, Bruce V., (1993). Cervical Discography Complications and Clinical Efficacy. SPINE, Vol. 18, no. 14, 2035-2038.

(5)

Coulter, Ian D., et. al., (1996). The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Rand.

(6)

Cutler, Robert B., et. al., (1994). Does Nonsurgical Pain Center Treatment of Chronic Pain Return Patients to Work? A Review and Meta-analysis of the Literature, SPINE, Vol. 19, no. 6, 643-652.

(7)

Flor, Herta, Fydrich, Thomas, Turk, Dennis C., (1992). Efficacy of Multidisciplinary Pain Treatment Centers: a Meta-Analytic Review, PAIN, Vol. 49, 221-230.

(8)

Guyer, Richard D., Ohnmeiss, Donna D. (1995). Contemporary Concepts in Spine Care Lumbar Discography, Position Statement from the North American Spine Society Diagnostic and Therapeutic Committee. SPINE, Vol. 20, no. 18, 2048-2059.

(9)

Holt, Earl P., (1975). Further Reflections on Cervical Discography, JAMA, Vol. 231, no. 6, 613-614.

(10)

Jarvis, Kelly b., Phillips, Reed B., Morris, Elliot K. (1991). Cost per Case Comparison of Back Injury Claims of Chiropractic versus Medical Management for Conditions with Identical Diagnostic Codes. JOURNAL OF OCCUPATIONAL MEDICINE, Vol. 33, no. 8. 847-852.

(11)

Kikuchi, Shinichi, MacNab, Ian, Moreau, Paul, (1981). Localisation of the Level of Symptomatic Cervical Disc Degeneration, THE JOURNAL OF BONE AND JOINT SURGERY, Vol. 63-B, no. 2, 272-277.

(12)

Mayer, Tom, et.al., (1995). Contemporary Concepts in Spine Care Spine Rehabilitation, Secondary and Tertiary Nonoperative Care, SPINE, Vol. 20, no. 18, 2060-2066.

(13)

Merriam, W.F. Stockdale, H.R., (1983). Is Cervical Discography of Any Value? EUROPEAN JOURNAL OF RADIOLOGY Vol. 3, 183-141.

(14)

North American Spine Society Task Force on Clinical Guideline, Phase III Herniated Disc Clinical Guideline 10/13/98 Draft.

(15)

Osler, G.E., (1987). Cervical Analgesic Discography, A test for diagnosis of the painful disc syndrome. SOUTH AFRICAN MEDICAL JOURNAL, Vol. 71 no. 363.

(16)

Pauza, Kevin, Proposed Guidelines for the Performance of Spinal Injection Procedures April 1999 Draft.

(17)

Parfenchuck, Thomas A., Janssen, Michael E. (1994). A Correlation of Cervical Magnetic Resonance Imaging and Discography/Computed Tomographic Discograms, SPINE, Vol. 19, no. 24, 2819-2825.

(18)

Polatin, Peter B. et. al. (1993). Psychiatric Illness and Chronic Low-Back Pain, The Mind and the Spine-Which Goes First? SPINE, Vol. 18, no. 1, 66-71.

(19)

Roth, David A. (1976). Cervical Analgesic Discography, A new Test for the Definitive Diagnosis of the Painful Disk Syndrome. JAMA, Vol. 235, no. 16, 1713-1714.

(20)

Schellhas, Kurt P., et. al. (1996). Cervical Discogenic Pain, Prospective Correlation of Magnetic Resonance Imaging and Discography in Asymptomatic Subjects and Pain Sufferers. SPINE, Vol. 21, no. 3, 300-312.

(21)

Shekelle, Paul G., et.al. (1992). Spinal Manipulation for Low-Back Pain, ANNALS OF INTERNAL MEDICINE, Vol. 117, no. 7, 590-653.

(22)

Siebenrock, K.A., Aebi, M. (1994). Cervical Discography in Discogenic Pain Syndrome and Its Predictive Value for Cervical Fusion, ARCH ORTHOP TRAUM SURGERY, Vol. 113, 199-203.

(23)

Simmons, Edward H., Segil, Clive M., (1975). An Evaluation of Discography in the Localization of Symptomatic levels in Discogenic Disease of the Spine, CLINICAL ORTHOPAEDICS AND RELATED RESEARCH, Vol. 108, 57-69.

(24)

Stano, Miron, Smith, Monica, (1996). Chiropractic and Medical Costs of Low Back Care. MEDICAL CARE, Vol. 34, No. 3, 191-204.

(25)

Turk, Dennis C., Gatchel, Robert J. Multidisciplinary Programs for Rehabilitation of Chronic Low Back Pain Patients; prepublication manuscript accepted for publication.

(26)

U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, CLINICAL PRACTICE GUIDELINE, ACUTE LOW BACK PROBLEMS IN ADULTS, AHCPR Publication No. 95-0642, Decmeber 1994

(27)

Van Tulder, Maurits, Koes, Bart W., Bouter, Lex M., (1997). Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain, A Systematic Review of Randomized Controlled Trials of the Most Common Interventions. SPINE. Vol. 22, no. 18. 2128-2156.

(28)

Wheeler, Anthony H., Goolkasian, Paula, Gretz, Stephanie (1998). A Randomized, Double-Blind, Prospective Pilot Study of Botulinum Toxin Injection for Refractory, Unilateral, Cervicothoracic, Paraspinal, Myofascial Pain Syndrome, SPINE, Vol. 23, no. 15, 1662-1667.

(29)

Whitecloud, Thomas S. III, Seago, Randall A. (1987). Cervical Discogenic Syndrome, Results of Operative Intervention in Patients with Positive Discography, SPINE, Vol. 12, no. 4, 313-316.

(30)

Zeidman, Seth M., Thompson, Kerry, Ducker, Thomas B. (1995). Complications of Cervical Discography: Analysis of 4400 Diagnostic Disc Injections, NEUROSURGERY, Vol. 37, no. 3, 414-417.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on June 14, 1999.

TRD-9903484

Craig Smith

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: July 25, 1999

For further information, please call: (512) 707-5829