Medical treatment guidelines for L&I claims
L&I has published medical treatment guidelines which are used administratively to determine medical treatment authorization for certain conditions. The conditions for which medical treatment guidelines have been published include: Acute Cauda Equina Syndrome, Ankle and Foot Surgery, Beryllium Sensitization and Chronic Beryllium Disease, Carpal Tunnel Syndrome, Cervical Radiculopathy and Myelopathy. In addition, they include Complex Regional Pain Syndrome, Facet neuropathy, Knee Surgery, Hospitalization Related to Low Back pain, Lumbar Fusion, Lumbar Single Nerve Root Radiculopathy, Porphyria Conditions, Opioid Pain Prescriptions, Proximal Median nerve Entrapment, Radial nerve Entrapment, Shoulder Conditions, Neurogenic and Vascular Thoracic Outlet Syndrome, Ulnar Neuropathy at the Elbow, and an interim guideline on Sacroiliac conditions.
When a utilization review is conducted regarding proposed treatment for any one of these conditions, the facts of the case are compared against the guidelines in order to reach a decision regarding whether the proposed treatment will be authorized. Today, lets take a closer look at the treatment guidelines for Acute Cauda Equina Syndrome.
Lower back pain as symptom
Cauda Equina Syndrome is a condition that occurs when nerves at the end of the spinal cord called the cauda equina are damaged. Work and non-work-related conditions known to cause cauda equina include disc herniation, trauma, infection, degenerative conditions, metastatic or primary tumor, postsurgical complications, vascular malformations, intradiscal electrothermal annuloplasty, and spinal manipulation. Symptoms of this cauda equina nerve damage can include acute low back pain or bilateral sciatica, pain radiating into the lower extremities, numbness around the anus, and loss of bowel and bladder control, sexual dysfunction, impaired sensation in the lower extremities, leg weakness, hyporeflexia or areflexia in the legs, and gait disturbance.
According to the L&I medical treatment guideline, a lumbar decompression surgery to treat acute cauda equina syndrome may be appropriate when:
1) The medical provider documents subjective complaints including any or all of the following: partial or complete loss of bladder and/or bowel function, acute low back pain, bilateral or unilateral sciatica, and/or sexual dysfunction; AND
2) The medical provider documents objective clinical examination findings including any or all of the following: diminished or absent anal sphincter tone, saddle anesthesia, numbness and/or weakness involving both legs or multiple nerve roots in a leg, urinary retention, incontinence and/or patulous anus, reduced or absent bulbo cavernous reflex, and/or gait disturbances; AND
3) The medical provider has obtained imaging that demonstrates a lesion with mass effect on the cauda equina in the spinal canal compressing multiple lumbro-sacral nerve roots as documented on lumbar MRI or CT or CT myelography.
It should be noted that MRI is the preferred imaging test but CT/CT Myleography, plain x-rays, ultrasound or urodynamic tests may also add diagnostic value in cauda equina cases. Finally, it is noted that conservative treatment alone is rarely indicated because cauda equina syndrome is an emergent condition. Assuming the treatment guideline criteria are met, surgical decompression is the preferred treatment option and should be performed urgently to prevent further neurological deterioration.
Given the emergent nature of this condition, it is critical that medical reports and records submitted to the Department in support of a surgical recommendation clearly document the clinical and diagnostic findings that support immediate surgical authorization without delay.