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
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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,
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(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
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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
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(21)
Shekelle, Paul G., et.al. (1992). Spinal
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(22)
Siebenrock, K.A., Aebi, M. (1994). Cervical
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(24)
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(29)
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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