Justification Care Chronic

JUSTIFICATION OF CARE VIA the Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy"):

The patients condition is well into the chronic phase (past 90 days duration) and the "presumed correct" American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines (second edition), ACOEM herein, are silence with respect to specific treatment recommendation for such chronic pain. More explicitly, Chapter 12, page 287 of ACOEM states: Recommendations on assessing and treating adults with potentially work-related low back problems (i.e., activity limitations due to symptoms in the low back of less than three months duration) are presented in this clinical practice guideline…. this chapters master algorithm schematizes how primary care and occupational medicine practitioners generally can manage acute or subacute low back complaints. Therefore, ACOEM is not applicable for this patient. In situations were ACOEM is silent regarding requested medical treatment, Labor Code section 4604.5 (e) states in relevant part, “For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines… authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.” Therefore, I shall present the Guidelines for Chiropractic Quality Assurance and Practice Parameters (“Mercy Guidelines”) to justify the treatment of this patient, who has just suffered an exacerbation of pain: The Mercy Conference Guidelines are both nationally recognized and based upon scientific medical evidence. In fact, Chapter 8 alone was developed using 67 peer-review quality investigations, text book citations and/or other state treatment guidelines. With regard to reasonable chiropractic treatment frequency for acute injuries, page 125; chapter 8, subsection "E" of said Mercy Conference Guideline, entitled “Acute Episode,” allows the following treatment frequency for an "exacerbation of a chronic condition":

(1) "three to five treatments per week" during the first "10-14 days,"

(2) “up to three treatments per week” for “six to eight weeks.”

Thus a maximum of 34 chiropractic treatments are allowed, per Mercy, for acute exacerbations of a chronic condition.

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Support of manipulative care for exacerbations of chronic pain:

The patient’s condition, which is now chronic (over 90 days in duration), has responded well to an occasional manipulation with physiotherapy for exacerbations of his pain. Since ACOEM is silent regarding patients with chronic pain ( Hamilton v. State Compensation Insurance Fund (2004) 32 CWCR 249 WCAB Panel Decision & Los Angeles Times v. WCAB (2005) (Herbinger) 70 CCC 504 WCAB Writ Denied Decision), Labor Code § 4604.5(e) mandates that “authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based."

Therefore, I shall use the Guidelines for Chiropractic Quality Assurance and Practice parameters (“Mercy”) to support the continued use of manipulation for exacerbations of chronic pain:

The Mercy Conference Guidelines are both nationally recognized and based upon scientific medical evidence. In fact, Chapter 8 alone was developed using 67 peer-review quality investigations, text book citations and/or other state treatment guidelines. With regard to reasonable chiropractic treatment frequency for acute injuries, page 125; chapter 8, subsection "E" of said Mercy Conference Guideline, entitled “Acute Episode,” allows the following treatment frequency for an "exacerbation of a chronic condition":

(1) "three to five treatments per week" during the first "10-14 days,"

(2) “up to three treatments per week” for “six to eight weeks.”

Thus, my one or two treatments per flare-up is well with said guidelines.

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JUSTIFICATION OF CARE:

In Hamilton (supra), WCJ Alvin R. Webber ruled that the ACOEM guidelines were only applicable “during the first 90 days following the industrial injury” and were erroneously used by the insurer to deny requested medical treatment. More explicitly, the WCJ stated, “the ACOEM guidelines themselves, in the opinion of this WCJ, clearly provide for applicability only during the first 90 days following the industrial injury." (Bold added.) (2) Los Angeles Times v. WCAB (Herbinger) (2005) 70 CCC 504: In Herbinger (supra), the second district court of appeals upheld a WCJ and WCAB’s decision to award medical care that was not incompliance with the ACOEM guidelines on the basis that said guidelines were not applicable to patients “who sought treatment for chronic pain.” The courts agreed that the ACOEM guidelines for not applicable for chronic pain patients. More explicitly, the courts up-held the forthcoming WCJ opinion:

…the WCJ stated that those guidelines related to acute medical treatment within the first few days to the first four to six weeks following the injury, that Applicant's injury had occurred 14 years prior to the hearing, that Applicant sought treatment for chronic pain, not acute care, and that the ACOEM Guidelines were accordingly inapplicable. (Bold added.)

In situations were ACOEM is silent regarding requested medical treatment, Labor Code section 4604.5 (e) states in relevant part: For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines… authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based. Therefore, in order to justify treatment to this patient, I shall present the forthcoming

OTHER MEDICAL TREATMENT GUIDELINES:

The Guidelines for Chiropractic Quality Assurance and Practice Parameters, Mercy herein, are both nationally recognized, evidence based, and scientifically based. In fact, Chapter 8 alone was built using 67 endnotes (all of which were peer-review quality investigations, text books or other treatment guidelines) used to support the authors recommendations.

On page 125; chapter 8, subsection "E" Mercy, the following recommendations for treatment frequency are given for patients who had suffered an “exacerbation of a chronic condition”: "three to five treatments per week" during the first "10-14 days" following an "exacerbation of a chronic condition." In order for the patient to return to "pre-episode status," the guidelines allow for "up to three treatments per week" for "six to eight weeks." Thus 34 treatments are recommended for such an exacerbation. Noteworthy is the fact that a recent WCAB panel decision (Casillas vs. The County of San Luis Obispo (2005) 33 CWCR 217 WCAB Panel decision) used these same Mercy guidelines, “arguendo” to successfully rebut the presumption that ACOEM carries.

Furthermore, Randomized controlled of peer review quality that support chiropractic manipulation for the treatment of chronic pain may also be used to establish rebut the ACOEM guidelines. I shall now offer these investigations to help establish a variance from ACOEM exists for this patient:

1) Aure OF, Nilsen JH, Vasseljen O. - Spine 2003 28(6):525-31; discussion 531-532.

2) Triano JJ, McGregor M, Hondras MA, Brennan PC. - Spine. 1995 Apr 15;20(8):948-55.

3) Giles LGF, Muller R. - Spine 2003;28(14):1490-1503