ODG: Medical Treatment For Back

And Neck Injuries - 2008

Matthew Lewis
(972) 644-1111 Telephone
matt@mattlewislaw.com
 Rule 137.100
Treatment Guidelines
• HCP’s shall provide treatment in accordance
with the current edition of the Official
Disability Guidelines – Treatment in Workers’
Comp unless the treatment requires
preauthorization under Rule 134.600
• Services provided in accordance with the
Guidelines is presumed reasonable and
reasonably required (medically
necessary).
• Carrier is not liable for services that
exceed the Guidelines unless provided in
an emergency or preauthorized under
Rule 134.600
 § 408.021(a). ENTITLEMENT TO MEDICAL
BENEFITS
• An employee who sustains a compensable
injury is entitled to all health care reasonably
required by the nature of the injury as and
when needed.
• The employee is specifically entitled to health
care that:
• (1) cures or relieves the effects naturally
resulting from the compensable injury;
• (2) promotes recovery; or
• (3) enhances the ability of the employee to
return to or retain employment.
 Low Back
• “The focus of treatment should not be
symptom reduction, but improving function
with a goal of return to work”
• Not necessarily about healing
• Tape’m up, shoot’em up, and get’em back in
the game
 Low Back
• X-Rays are generally not recommended until
the third visit, and only then if the patient is
still disabled.
• X-Rays may be performed on the first visit if
there is evidence of significant trauma.
Reimbursement may be denied if there is a
question about the "significance" of any
trauma.
• ODG parenthetically provides an example of
significant trauma as a fall.
 Low Back
• ODG Chiropractic Guidelines:
Therapeutic care –
Mild: up to 6 visits over 2 weeks
Severe: Trial of 6 visits over 2 weeks
Severe: With evidence of objective functional improvement,
total of up to 18 visits over 6-8 weeks, if acute, avoid
chronicity
Elective/maintenance care – Not medically necessary
Recurrences/flare-ups – Need to re-evaluate treatment
success, if RTW achieved then 1-2 visits every 4-6 months
 Low Back
• ODG Physical Therapy Guidelines –
Allow for fading of treatment frequency (from up to 3
or more visits per week to 1 or less), plus active self-
directed home PT.
• Lumbar sprains and strains (ICD9 847.2):
10 visits over 8 weeks
• Sprains and strains of unspecified parts of back (ICD9
847):
10 visits over 5 weeks
• Sprains and strains of sacroiliac region (ICD9 846):
Medical treatment: 10 visits over 8 weeks
• Lumbago; Backache, unspecified (ICD9 724.2; 724.5):
9 visits over 8 weeks
 Low Back
• Intervertebral disc disorders without myelopathy (ICD9
722.1; 722.2; 722.5; 722.6; 722.8):
Medical treatment: 10 visits over 8 weeks
Post-injection treatment: 1-2 visits over 1 week
Post-surgical treatment (discectomy/laminectomy): 16 visits
over 8 weeks
Post-surgical treatment (arthroplasty): 26 visits over 16 weeks
Post-surgical treatment (fusion): 34 visits over 16 weeks
• Intervertebral disc disorder with myelopathy (ICD9 722.7)
Medical treatment: 10 visits over 8 weeks
Post-surgical treatment: 48 visits over 18 weeks
• Spinal stenosis (ICD9 724.0):
10 visits over 8 weeks
 Low Back

• Sciatica; Thoracic/lumbosacral
neuritis/radiculitis, unspecified (ICD9 724.3;
724.4):
10-12 visits over 8 weeks
See 722.1 for post-surgical visits
• Work conditioning
10 visits over 8 weeks
 Low Back

• No referral consults are recommended in the

absence of radiculopathy. If radiculopathy is
clinically indicated, a referral to a nonsurgical
musculoskeletal physician is recommended
following the second visit.
• Surgical consult with fellowship trained spine
surgeon (orthopedist or neurologist)
recommended after three months
 Low Back
• MRI, EMG, ESI & Psych Testing are all
recommended after the fourth visit, if
radicular symptoms are present.

• MRI or CT not indicated without obvious

clinical level of nerve root dysfunction, clear
radicular findings, or before 3-4 weeks
 Low Back

• The purpose of ESI is to reduce pain and

inflammation, restoring range of motion and
thereby facilitating progress in more active
treatment programs, but this treatment alone
offers no significant long-term functional
benefit
• May be a way to obtain preauthorization for
additional active therapy
 Low Back
• Criteria for admission to a Work Hardening Program:
(1) Work related musculoskeletal condition with functional
limitations precluding ability to safely achieve current job
demands, which are in the medium or higher demand level (i.e.,
not clerical/sedentary work). An FCE may be required showing
consistent results with maximal effort, demonstrating capacities
below an employer verified physical demands analysis (PDA).

(2) After treatment with an adequate trial of physical or

occupational therapy with improvement followed by plateau,
but not likely to benefit from continued physical or occupational
therapy, or general conditioning.

(3) Not a candidate where surgery or other treatments would

clearly be warranted to improve function.
 Low Back
(4) Physical and medical recovery sufficient to
allow for progressive reactivation and
participation for a minimum of 4 hours a day for
three to five days a week.

(5) A defined return to work goal agreed to by the

employer & employee:
(a) A documented specific job to return to with
job demands that exceed abilities, OR
(b) Documented on-the-job training
 Low Back
(6) The worker must be able to benefit from the
program (functional and psychological limitations
that are likely to improve with the program).
Approval of these programs should require a
screening process that includes file review,
interview and testing to determine likelihood of
success in the program.

(7) The worker must be no more than 2 years

past date of injury. Workers that have not
returned to work by two years post injury may
not benefit.
 Low Back
(8) Program timelines: Work Hardening
Programs should be completed in 4 weeks
consecutively or less.

(9) Treatment is not supported for longer than

1-2 weeks without evidence of patient
compliance and demonstrated significant
gains as documented by subjective and
objective gains and measurable improvement
in functional abilities.
 Low Back

(10) Upon completion of a rehabilitation

program (e.g. work hardening, work
conditioning, outpatient medical
rehabilitation) neither re-enrollment in nor
repetition of the same or similar rehabilitation
program is medically warranted for the same
condition or injury.
 Low Back
• Criteria for the general use of multidisciplinary
pain management programs:
• Outpatient pain rehabilitation programs may be
considered medically necessary when all of the
following criteria are met:
• (1) An adequate and thorough evaluation has
been made, including baseline functional testing
so follow-up with the same test can note
functional improvement;
• (2) Previous methods of treating the chronic pain
have been unsuccessful and there is an absence
of other options likely to result in significant
clinical improvement;
 Low Back

• (3) The patient has a significant loss of ability

to function independently resulting from the
chronic pain;
• (4) The patient is not a candidate where
surgery or other treatments would clearly be
warranted;
 Low Back

• (5) The patient exhibits motivation to change,

and is willing to forgo secondary gains,
including disability payments to effect this
change; &
• (6) Negative predictors of success above have
been addressed.
 Neck & Upper Back
• X-Rays are necessary on the first visit if there
is any possibility of a fracture.

• A history of direct trauma, blow to the head,

any significant whiplash type injury, or any
significant fall. These patients should have an
x-ray of the cervical spine.
 Neck & Upper Back
• On first visit, if there is an acute injury with
positive neurological findings, referral to a
spine surgeon or musculoskeletal physician is
recommended.
• Otherwise, a referral to a spine surgeon is not
recommended until the fourth visit if there is
no improvement in neurological complaints.
 Neck & Upper Back
Indications for MRI of the cervical spine include the following:
• Any suggestion of abnormal neurologic findings below the
level of injury.
• Progressive neurologic deficit.
• Persistent unremitting pain with or without positive
neurologic findings.
• Previous herniated disk within the last two years and
radicular pain with positive neurologic findings.
• Patients with significant neurologic findings and failure to
respond to conservative therapy despite compliance with
the therapeutic regimen.
• Recommended after three to four weeks of no response to
conservative care.
 Neck & Upper Back
ODG Chiropractic Guidelines –
• Regional Neck Pain:
• 9 visits over 8 weeks
• Cervical Strain (WAD):
• Mild (grade I - Quebec Task Force grades): up to 6 visits over
2-3 weeks
• Moderate (grade II): Trial of 6 visits over 2-3 weeks
• Moderate (grade II): With evidence of objective functional
improvement, total of up to 18 visits over 6-8 weeks, avoid
chronicity
• Severe (grade III & auto trauma): Trial of 10 visits over 4-6
weeks
• Severe (grade III & auto trauma): With evidence of objective
functional improvement, total of up to 25 visits over 6
months, avoid chronicity
 Neck & Upper Back
• Cervical Nerve Root Compression with
Radiculopathy:
• Patient selection based on previous chiropractic
success --
• Trial of 6 visits over 2-3 weeks
• With evidence of objective functional
improvement, total of up to 18 visits over 6-8
weeks, if acute, avoid chronicity and gradually
fade the patient into active self-directed care
• Post Laminectomy Syndrome:
• 14-16 visits over 12 weeks
 Neck & Upper Back
• ODG Physical Therapy Guidelines –

Cervicalgia (neck pain); Cervical spondylosis

(ICD9 723.1; 721.0):
• 9 visits over 8 weeks
Sprains and strains of neck (ICD9 847.0):
• 10 visits over 8 weeks
 Neck & Upper Back

Displacement of cervical intervertebral disc (ICD9

722.0):
• Medical treatment: 10 visits over 8 weeks
• Post-injection treatment: 1-2 visits over 1 week
• Post-surgical treatment
(discetomy/laminectomy): 16 visits over 8 weeks
• Post-surgical treatment (fusion): 24 visits over 16
weeks
 Neck & Upper Back

Degeneration of cervical intervertebral disc

(ICD9 722.4):
• 10-12 visits over 8 weeks

Brachia neuritis or radiculitis NOS (ICD9 723.4):

• 12 visits over 10 weeks