Embed Size (px)
Citation preview
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 1
Maximal Medical Improvement
What It Is
And One Method in
How To Achieve It
James W Butler MD MPH FACOEM
533 W. Columbia, Evansville, In 47710 800-264-1208
Unfortunately, I have nothing to disclose.
This talk is not implied to be the opinion of my employers past, present or
future
Permission has been granted by Work Loss Data Institute to use the ODG examples, and by The Reed Group to briefly discuss their ACOEM
Guideline products. IAIABC gave permission for the handout at the back listing all state laws. Finally, I have to thank AADEP and the Texas Department of Insurance, Work Comp Division for enlightening me to this system of determining
MMI.
1. MMI Definitions
2. Methods to help find MMI
3. Case Scenarios for discussion
4. A List of Take home references
533 W. Columbia, Evansville, In 47710 800-264-1208
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 2
What is it?
The goal in work comp cases
Most stakeholders want MMI.
Adjusters can close cases,
Injured workers and lawyers get to settle.
Defined many different but similar ways by many states and organizations
AMA 5th Guides to The Evaluation of Permanent Impairment
An examinee has reached MMI when further recovery and restoration of function can no longer be anticipated to a reasonable degree of certainty
It implies that the claimant’s condition is medically
permanent and stable in the sense that further treatment will probably not result in appreciable prolonged improvement
It also implies that an individual may or may not have
completely recovered from the injury or illness, i.e. not necessarily reached pre-injury functional status.
AMA 6th Guides to
The Evaluation of Permanent Impairment
Maximum medical improvement (MMI) is defined in the glossary of the AMA Guides, Sixth Edition as the "point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment" (6th ed, 612).
IT DOES NOT MEAN FUTURE MEDICAL TREATMENT
IS OVER!
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 3
2 States have no formal designation
The rest use MMI or:
Maximum Cure Medical Stability Medically Stationary
Permanent & Stationary
Medical Stabilization
Maximal Medical Healing
Stability Stable and Ratable Fixed and Stable
Ascertainable loss Medical End Result
Maximum Degree of Medical Improvement
Remember
MMI does not imply that further treatment is not needed
Nor does it imply that the person has returned to full function.
Who defines MMI?
The Treating Physician
an IME
or statute (i.e. Texas Law – normally 104 weeks from when benefits begin to accrue, i.e. TTD payments)
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 4
What happens if:
New procedures developed?
Later development of dysfunction?
Some states allow a case to be reopened
Other continue medical treatment
For example, a knee sprain, lumbar sprain and surgery is recommended 10 – 20 years later, some states and jurisdictions allow this
Later developments are what keep lawyers in business.
BUT Remember MMI is defined as at that moment in time, “unlikely to change (improve or worsen) substantially in the next year, with or without treatment”
It allows an injured worker to be rated for any permanent impairments, possibly resulting in some extra compensation
It allows insurance companies to correct the reserves they have put aside for the case costs.
It allows a company to determine if any restrictions/Limitations the injured worker has, can be permanently accommodated
It ends the payment, if any is being received, of Temporary Total Disability monies
It allows the lawyer to work at settling the case, or going to trial.
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 5
Sometimes easy – a simple injury is resolved, the worker is
at full duty without need for any further medication or treatment
The Patient declares that they want no further treatment, i.e. declines surgery or other treatments.
All your treatment is aimed at maintaining the patient’s status without any honest expectation of improvement, and may be Palliative only
There is no further medically proven treatment
Most appropriate method is to use guidelines that are also a part of the UR system.
Texas uses the ODG,
California uses the MTUS (which incorporates the ACOEM Guidelines),
Other states use the ACOEM Guidelines that are now part of the MD Guidelines
A complete list copied from IAIABC is attached
Other State That have Guidelines are linked in
MD Guidelines.com
California Mississippi
Colorado Montana
Connecticut New York
Delaware Rhode Island
Kentucky South Dakota
Louisiana VA/DOD
Maine Washington
Massachusetts West Virginia
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 6
Controversies of Guidelines
1. Not always scientific based (process of moving from consensus based to evidence based is a long and tedious process)
Most Guidelines are being continually updated now
2. Does not allow for “outliers”
Some such as the ODG’s have an appendix for outliers
3. Does not allow for new procedures and techniques
True…but remember IDET. That is why you try to get evidence based treatment plans
58 yo female miner.
Slips in the mine, breaks her ankle requiring surgery. The injury heals and she is ready to return to full duty. Requires an occasional Aleve for discomfort.
AT MMI?
58 yo female miner.
Slips in the mine, breaks her ankle requiring surgery. The injury heals and she is ready to return to full duty. Requires an occasional Aleve for discomfort.
Returns to full duty…complains of intolerable back pain. Her treating doc takes her off work permanently and says her back pain is secondary to her ankle problem.
Back pain not deemed compensable by the court
AT MMI?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 7
35 yo male welder in Kentucky
Lifting a 350 pound heater, felt pain in low back at belt line.
Exam shows it is axial only with no abnormal neurological findings.
Treated with NSAIDS, Ice, Work restrictions, and given a home exercise program
4 weeks later no change
AT MMI?
Kentucky has their own acute low back pain Guideline
The doctor ordered Chiropractic treatment
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 8
Now 4 weeks of chiropractic and physical therapy - No change.
Exam is unchanged…axial low back pain only
Doctor wants acupuncture?
At MMI?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 9
Kentucky defines Acute low Back pain as less than 3 months. So yes – at MMI!
But What about a Texas doctor asking for acupuncture? After 8 weeks of treatment
At MMI?
Kentucky defines Acute low Back pain as less than 3 months. So yes!
But What about a Texas doctor asking for acupuncture? After 8 weeks of treatment
Or California?
At MMI?
Official Disability Guidelines (ODG)
TEXAS is a NO
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 10
Official Disability Guidelines (ODG)
TEXAS is a NO
Acupuncture:
Not recommended for acute low back pain. (Tulder-Cochrane, 2000)
(Furlan-Cochrane, 2005)
Recommended as an option for chronic low back pain using a short course
of treatment in conjunction with other interventions. (See the Pain
Chapter.) Acupuncture has been found to be more effective than no
treatment for short-term pain relief in chronic low back pain, but the
evidence for acute back pain does not support its use. (Furlan-Cochrane,
2005) (Manheimer, 2005) (van Tulder, 2005) (Thomas, 2005) (Ratcliffe,
2006) (Thomas, 2006) (Haake, 2007) (Santaguida, 2009)
Low Back Pain [Chronic] - Recommended - Limited Evidence (C) Acupuncture is recommended for select use in chronic LBP as an adjunct to more efficacious treatments.
2008 ACOEM Practice Guidelines - pp. 822
Low Back Pain [Acute, Sub Acute] - Not Recommended - Insufficient Evidence
(I) Although it is not high cost and its use is not associated with high potential for patient harm, routine use of acupuncture i s not recommended for acute or subacute LBP.
Citations 2008 ACOEM Practice Guidelines - pp. 822
2004 ACOEM Practice Guidelines
Radicular Pain Syndromes (including Sciatica) [Acute, Sub Acute] - Not Recommended -
Insufficient Evidence (I) Although it is not high cost and its use is not associated with high potential for patient harm, routine use of acupuncture i s not recommended for radicular pain.
Citations 2008 ACOEM Practice Guidelines - pp. 822
Acupuncture - California
Looks like not authorized…so at MMI?
California MTUS
§ 9792. 23.5. Low Back Complaints
(a) The Administrative Director adopts and incorporates by reference the Low Back
Complaints (ACOEM Practice Guidelines, 2nd Edition (2004), Chapter 12) into the MTUS
from the ACOEM Practice Guidelines.
(b) In the course of treatment for low back complaints where
acupuncture or acupuncture with electrical stimulation is being
considered, the acupuncture medical treatment guidelines in
section 9792.24.1 shall apply and supersede the text in the ACOEM
chapter referenced in subdivision (a) above relating to acupuncture.
California is a YES for acupuncture, so not at MMI
Remember, the rules are state specific
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 11
Now 16 weeks out. Has completed PT. Doctor wants an MRI
Doesn’t fit criteria
Had a negative Xray, had an MRI (despite not
fulfilling the criteria) without any specific findings and
an exam that is positive only for Axial tenderness.
Being given opoids for his pain
He has requested full duty because he said he could
not survive on TTD payments because his company
could not accommodate his restrictions
at MMI?
Some controversies:
1. A recent AMA 6th Guides newsletter suggests that you can never put anyone at MMI who is on opioids..others disagree because you are providing palliative treatment
2. There is growing literature that using opioids in the face of “benign non-cancer pain” may cause OIH (Opioid induced hyperalgesia), i.e. you may be putting them at a worse condition.
3. Is there really anything left to do?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 12
But Wait, this is a Rhode Island Case. The Spine surgeon wants to do a fusion!
Does that change whether he is at MMI or not? Indications for Lumbar Fusion
1. Unstable vertebral fracture
2. Fusion may be indicated after second or third surgery with documented
MRI, CT Scan, or myelogram showing re-extrusion of previously unsuccessfully
operated disc at the same level, with or without intractable back pain and clear clinical
evidence of new lumbar radiculopathy with EMG evidence, if felt needed.
3. Traumatic (acquired or congenital ) spinal deformity, history of
compression wedge fractures with demonstrated acquired kyphosis-scoliosis.
4. Intractable low back pain for longer than three months and six-week trial with a rigid back brace or body cast producing significant pain relief associated with one of the following conditions involving the lower lumbar segments below L3. a. For first surgery only, degenerative disc disease with pre-operative
documentation of instability (motion on flexion/extension or fixed spondylolisthesis)
b. Pseudoarthrosis
c. For second or third time disc surgery
ANSWER = No, He is at MMI
This is one of those cases that can cause much heartburn and indecision.
But remember that if there is no further evidence based treatment then the worker is most likely at MMI
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 13
44 yo male factory worker.
Developed Carpal Tunnel Syndrome
He had been undergoing physical therapy, followed by a cortisone injection.
Still Symptomatic after 6 - 8 weeks.
At MMI?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 14
EMG diagnoses severe CTS. He undergoes surgery.
Returns to restricted duty.
4 months later symptoms have not abated
At MMI?
2nd surgery by Fellowship trained hand Surgeon
Still symptomatic.
Redo EMG. Confirms permanent damage to median nerve
At MMI?
48 yo male insurance salesman, S/P back strain in 1998. Lives by himself in a house in the woods. Has to get own firewood, do own home repairs
Receiving pain meds monthly and his family physician has him unable to work, since 1999.
AT MMI?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 15
Probably…BUT he has had no real treatment…So How about work Hardening?
Per ODG: Chronic pain programs (functional restoration programs). There has been some suggestion that WH should be aimed at individuals who have been out of work for 2-3 months, or who have failed to transition back to full-duty after a more extended period of time, and that have evidence of more complex psychosocial problems in addition to physical and vocational barriers to successful return to work.
PER ODG WORK HARDENING MAY BE REASONABLE.
AT MMI?
Hard to Answer.
Remember MMI does not guarantee a return to full function.
But in care of Injured Workers our Goal is always to try to get a return to function as good as possible
So, support from Guidelines, would suggest approval of the request
AT MMI?
Official Disability Guidelines says: •"These publications are guidelines, not inflexible proscriptions, and
they should not be used as sole evidence for an absolute standard of care. Guidelines can assist clinicians in making decisions for specific conditions and also help payors make reimbursement determinations, but they cannot take into account the uniqueness of each patient's clinical circumstances."
http://www.odg-twc.com/preface.htm#COPYRIGHTPAGE
•Appendix D, Documenting Exceptions to the Guidelines defines a process for health care providers and insurance carriers to follow to help ensure that appropriate medical treatment is provided in light of consideration of exceptional factors in individual cases.
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 16
Documenting and Considering Exceptions to ODG - Appendix D
Situations Not addressed in the Guidelines Conditions not commonly seen in workers’ compensation
Facial Injuries requiring dental treatment
Plastic surgery for burn patients
Documenting functional improvement & patient co-morbidities In those
situations where the treatment at issue is not addressed in ODG, the health care provider should demonstrate how functional improvement would be the expected result of the treatment. Providers should also document any relevant co-morbidities (if applicable) that may increase the likelihood that this treatment would be appropriate for their patient.
Conditions commonly seen in workers’ compensation, but in unusual presentations
Knee fractured so severely it requires a Total Knee replacement in a 30 year old
Documenting and Considering Exceptions to ODG - Appendix D Treatments that are covered but not recommended
When a treatment and condition are already covered in ODG, but specifically not recommended in ODG (or ODG has a patient selection criteria that would not include the case under consideration), the health care provider requesting the treatment should provide documentation specific to his or her case to support the use of the treatment outside of the guidelines. This is because the highest quality scientific evidence for this situation should already be in the guidelines, so it would not be likely to find evidence that could trump the evidence already in the guidelines. Patients with co-morbidities and/or documented functional improvement warrant additional consideration and the health care provider should adequately document these factors if present.
?
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 17
1. MMI is the goal in Work Comp
2. MMI does not imply no further treatment or full functionality
3. We have some good references to help determine MMI in difficult cases – the UR guidance
4. BUT…the Guidance is ultimately only that…guidance not law.
1. Maximum Medical Improvement, Brooks & Brigham, AMA Guides Newsletter, Jan/Feb 2014., pp8-10
2. Official Disability Guidelines
for treatment in Worker’s Comp requires a subscription
http://www.odg-twc.com/
3. MD Guidelines requires a subscription
(Includes a link to most state guidelines
AND ACOEM Guidelines)
http://www.mdguidelines.com
State Guidelines in the MD Guidelines
require a subscription:
California Mississippi
Colorado Montana
Connecticut New York
Delaware Rhode Island
Kentucky South Dakota
Louisiana VA/DOD
Maine Washington
Massachusetts West Virginia
Minnesota Wisconsin
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 18
ODG Example – Low Back Pain
Without Radiculopathy (90% of cases) [ICD9 724.2, 724.5, 724.8, 724.9, 846.0, 847.2, 847.9]
· Also first visit (day 1):
o Prescribe activity modifications, if necessary, based on severity and difficulty of job, while encouraging return to activity as much as possible; limited passive therapy with heat/ice (3-4 times/day), stretching/exercise (training by physical therapist OK), appropriate analgesia (i.e., acetaminophen) and/or anti-inflammatory (i.e., ibuprofen) [Benchmark cost: $14]; back to work except for severe cases in 72 hours, possibly modified duty; AVOID bed rest
o REASSURE PATIENT: Patient education - common problem, usually a self-limiting and benign disease that tends to improve spontaneously over time (See Return to work for studies on recovery time)
o No X-Rays unless significant trauma (e.g., a fall)
o If muscle spasms, then consider muscle relaxant with limited sedative side effects [Benchmark cost: $44] (Note: The purpose of muscle relaxants is to facilitate return to activity, but muscle relaxants have not been shown to be more effective than NSAIDs.)
ODG Return-To-Work Pathways (847.2 lumbar sprain & 724.2 lumbago)
Modified Duty --
Mild (Grade I)1, clerical/modified work: 0 days
Severe (Grade II-III) 1, clerical/modified work: 3 days
(See ODG Capabilities & Activity Modifications for Restricted Work under “Work” in Procedure Summary for Ergonomic accommodations)
ODG Example – Low Back Pain
Second visit (day 3-10 – about 1 week after first visit, or sooner, because delayed treatment is not recommended)
o Document progress (flexibility, areas of tenderness, motor strength, straight leg raise – sitting & supine)
o If still 50% disabled (i.e., cannot return to work) then consider referral for exercise/instruction/manual therapy [Benchmark cost: $250]: Options are physical therapist, chiropractor, massage therapist, or occupational therapist (3 visits in first week), or by treating DO/MD. (Choose providers supporting active therapy and not just passive modalities. The focus of treatment should not be symptom reduction, but improving function with a goal of return to work.) Consider screening for psychosocial symptoms in cases with expectations of delayed recovery.
o Discontinue muscle relaxant
ODG Return-To-Work Pathways (847.2 lumbar sprain & 724.2 lumbago)
Manual Work --
Mild, manual work: 7-10 days
Severe, manual work: 14-17 days
·
Third visit (day 10-17 – about 1 week after second visit)
o Document progress
o Prescribe muscle-conditioning exercises
o At this point 66%-75% should be back to regular work
o While not indicated in the absence of red flags, if still disabled, then consider imaging study (AP/Lateral 2-view X-Ray of lumbar) [Benchmark cost: $150] to rule out tumor, fracture, osteoporosis, myelopathy [ICD9 721.3, 721.4, 724.02]
o Maintain therapy, continue focus on active therapy and not passive modalities, 2 visits in next week, teach home exercises
o End manual therapy at 4 weeks (1 visit in last week)
ODG Return-To-Work Pathways (847.2 lumbar sprain & 724.2 lumbago)
Manual & Heavy Manual Work --
Severe, manual work: 14-17 days
Severe, heavy manual work: 35 days
IAIABC Reference for State Guidelines The whole PDF is included in Handout
With hyperlinks to each state
Session 408
MMI “When and How to Call It a day“
5/6/2015
JWB 19
For those who can stick around…
Q and A
IAIABC State Index on Medical Treatment Guidelines
February 2015
Injections and pain management services
Acute cauda equina syndrome
Ankle/foot surgery
Antiepileptic drugs guideline for chronic pain
Carpal tunnel syndrome
Cervical Radiculopathy and Myelopathy
Complex Regional Pain Syndrome
Facet Neurotomy
Knee surgery
Low back pain (hospitalization)
Lumbar Fusion (Arthrodesis)
Lumbar nerve root (single Lumbar
Laminectomy)
Porphyria conditions
Prescribing opioids to treat pain
Proximal median nerve entrapment
Psychiatric conditions
Radial nerve entrapment (diagnosis and
treatment)
Shoulder conditions (diagnosis and treatment)
Thoracic Outlet Syndrome (neurogenic)
Thoracic Outlet Syndrome (vascular)
Ulnar neuropathy at the elbow (diagnosis and
treatment)
Post-concussion syndrome
Organ transplants
Corneal abrasion
Corneal foreign body
Canalicular laceration
Eyelid laceration
Orbital contusion/fracture
Corneoscleral lacerations
Chemical ocular injuries
Experimental procedures
Coverage medication check
Medication/injections
Dental services
Hyphema
Psychiatric compensability treatment
Functional capacity evaluations
Work hardening rehabilitation
Work conditioning
Interventional management of chronic pain
Head & neck Pain
OP cases
Herniated lumbar disc
Acute herniated cervical disc
Meniscal injuries
Injury to knee
Medical imaging
Low back pain
Neck pain
Thoracic back pain
Upper extremity disorders
Complex regional pain syndrome (upper and
lower extremities)
Surgical procedures
Chronic management
Artificial discs
MRI
Knee
Shoulder
Spinal fusion
Carpal tunnel syndrome
Impairment rating
Pain treatment
Narcotic monitoring
Spinal cord stimulator
Laser spine surgery
Joint revision procedures
CT scan
Hylagan injections
Causality ratings for AC joint resection or distal
clavicle excision
Off label medications
Staged spinal injections
Anulex Xclose
Intradiscular Methylene Blue
Pre-surgical psychological evaluations
New
technology/procedure/therapy/treatment
request for medical review
Optimesh
Calmare therapy
Hypnotherapy
Bone growth stimulation
Bone morphogenetic protein
Compound creams
Compound medications
Discography
Platelet-rich plasma
SI fusion
Viagra, Cialis, Levitra
