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MAXIMUS FEDERAL SERVICES, INC.
Notice of Independent Medical Review Determination

Dated: 9/26/2013
1) MAXIMUS Federal Services, Inc. has determined the request for a 28 day functional restoration program is not medically necessary and appropriate.
2) MAXIMUS Federal Services, Inc. has determined the request for a 6 month follow-up aftercare program is not medically necessary and appropriate.
INDEPENDENT MEDICAL REVIEW DECISION AND RATIONALE
An application for Independent Medical Review was filed on 9/6/2013 disputing the Utilization Review Denial dated 8/30/2013. A Notice of Assignment and Request for Information was provided to the above parties on 9/23/2013. A decision has been made for each of the treatment and/or services that were in dispute: 1) MAXIMUS Federal Services, Inc. has determined the request for a 28 day functional restoration program is not medically necessary and appropriate.
2) MAXIMUS Federal Services, Inc. has determined the request for a 6 month follow-up aftercare program is not medically necessary and appropriate.

Medical Qualifications of the Expert Reviewer:
The independent Medical Doctor who made the decision has no affiliation with the employer, employee, providers or the claims administrator. The physician reviewer is Board Certified in Occupational Medicine and is licensed to practice in California. He/she has been in active clinical practice for more than five years and is currently working at least 24 hours a week in active practice. The Expert Reviewer was selected based on his/her clinical experience, education, background, and expertise in the same or similar specialties that evaluate and/or treat the medical condition and treatments
Case Summary:
Disclaimer: The following case summary was taken directly from the utilization review denial/modification dated August 30, 2013. “The patient is a 44 year-old female with a date of Injury of 8/28/2001. The provider submitted a request for 28 days of residential functional restoration program (FRP), and. 6 months follow-up aftercare program.”
Documents Reviewed for Determination:
The following relevant documents received from the interested parties and the documents provided with the application were reviewed and considered. These  Application for Independent Medical Review  Utilization Review Determination by Claims Administrator  California Medical Treatment Utilization Schedule  Medical Records submitted by Claims Administrator 1) Regarding the request for a 28 day functional restoration program:

Medical Treatment Guideline(s) Relied Upon by the Expert Reviewer to Make
The Claims Administrator based its decision on the Chronic Pain Medical Treatment Guidelines (2009), Functional Restoration Programs section, Aquatic Therapy section, and Psychological Treatment section, which are part of the Final Letter of Determination Form Effective 5.16.13 P a g e | 2
California Medical Treatment Utilization Schedule (MTUS). The provider did not dispute the guidelines used by the Claims Administrator. The Expert Reviewer relied on the Chronic Pain Medical Treatment Guidelines (2009), page 32, which The employee was injured on 8/28/2011 and has experienced chronic pain, depression, weight gain, and has developed a recurrent suicidal ideation. Treatment has included a functional restoration program four years prior, psychotropic medications, apparent removal from the workplace, and medications (Lyrica, Cymbalta, Abilify, Lidoderm, insulin, ramipril, glipizide, metformin, Zocor, Prilosec, Motrin, and aspirin). The employee has previously had an opioid addiction and has apparently regressed. A request was submitted for a 28 day functional restoration program. The Chronic Pain Guidelines indicate inpatient pain rehabilitation programs may be appropriate for patients who: (1) don’t have the minimal functional capacity to participate effectively in an outpatient program; (2) have medical conditions that require more intensive oversight; (3) are receiving large amounts of medications necessitating medication weaning or detoxification; or (4) have complex medical or psychological diagnosis that benefit from more intensive observation and/or additional consultation during the rehabilitation process. In this case, there is no evidence that any of the aforementioned criteria have been met. It is not clearly stated why the employee cannot be rehabilitated through conventional outpatient office visits and/or an outpatient functional restoration program. It is not clearly stated what medications (if any) the provider intends to wean or detox the employee off of. The employee is apparently no longer using opioids or marijuana, but is using a number of psychotropic and diabetic mediations. There is no evidence that the employee intends to discontinue or self-wean off of these agents, which have seemingly been deemed necessary for continuation. There is no evidence that the employee requires daily observation and the provider has acknowledged that the employee is not in imminent danger of committing suicide or self-harm. The MTUS Chronic Pain Guideline criteria has not been met. The request for a 28 day functional restoration program is not medically necessary 2) Regarding the request for a 6 month follow-up aftercare program:

Medical Treatment Guideline(s) Relied Upon by the Expert Reviewer to Make
The Claims Administrator based its decision on the Chronic Pain Medical Treatment Guidelines (2009), Functional Restoration Programs section, Aquatic Therapy section, and Psychological Treatment section, which are part of the California Medical Treatment Utilization Schedule (MTUS). The provider did not dispute the guidelines used by the Claims Administrator. The Expert Reviewer relied on the Chronic Pain Medical Treatment Guidelines (2009), page 32, which Final Letter of Determination Form Effective 5.16.13 P a g e | 3
The employee was injured on 8/28/2011 and has experienced chronic pain, depression, weight gain, and has developed a recurrent suicidal ideation. Treatment has included a functional restoration program four years prior, psychotropic medications, apparent removal from the workplace, and medications (Lyrica, Cymbalta, Abilify, Lidoderm, insulin, ramipril, glipizide, metformin, Zocor, Prilosec, Motrin, and aspirin). The employee has previously had an opioid addiction and has apparently regressed. A request was submitted for a 6 month follow-up aftercare program. As noted in the previous section, the request for a 28-day inpatient functional restoration program is not medically necessary and appropriate. By definition, there is no need for a six month “aftercare” program. It is unknown what the employee’s mental state and/or medical state wil be at that point in time. As noted in page 32 of the MTUS Chronic Pain Guidelines, criteria for follow up programs include an absence of other options likely to result in significant clinical improvement. In this case, there is no clear evidence that would support the proposition that the employee cannot be rehabilitated through conventional home outpatient office visits. The request for a 6 month fol ow-up aftercare program. Final Letter of Determination Form Effective 5.16.13 P a g e | 4
Effect of the Decision:
The determination of MAXIMUS Federal Services and its physician reviewer is deemed to be the final determination of the Administrative Director, Division of Workers’ Compensation. With respect to the medical necessity of the treatment in dispute, this In accordance with California Labor Code Section 4610.6(h), a determination of the administrative director may be reviewed only if a verified appeal is filed with the appeals board for hearing and served on all interested parties within 30 days of the date of mailing of the determination to the employee or the employer. The determination of the administrative director shall be presumed to be correct and shall be set aside only upon proof by clear and convincing evidence of one or more of the grounds for appeal listed in Labor Code Section 4610.6(h)(1) through (5).

Sincerely;
Disclaimer: MAXIMUS is providing an independent review service under contract with the California Department of Industrial Relations. MAXIMUS is not engaged in the practice of law or medicine. Decisions about the use or nonuse of health care services and treatments are the sole responsibility of the patient and the patient’s physician. MAXIMUS is not liable for any consequences arising from these decisions. Final Letter of Determination Form Effective 5.16.13 P a g e | 5

Source: http://www.workcompliens.com/files/IMR-13-21321-10272013-Functional-restoration.pdf

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