It has been certified by the Texas Department of Insurance as an Independent Review Organization. The Texas Worker's Compensation Commission has assigned this case to ___ for independent review in accordance with TWCC Rule 133.308 which allows for medical dispute resolution by an IRO.

___ has performed an independent review of the care rendered to determine if the adverse determination was appropriate. In performing this review, all relevant medical records and documentation utilized to make the adverse determination, along with any documentation and written information submitted, was reviewed.

The independent review was performed by a matched peer with the treating doctor. This case was reviewed by a licensed Medical Doctor who is board certified in orthopedic surgery. The ___ health care professional has signed a certification statement stating that no known conflicts of interest exist between the reviewer and any of the treating doctors or providers or any of the doctors or providers who reviewed the case for a determination prior to the referral to ___ for independent review. In addition, the reviewer has certified that the review was performed without bias for or against any party to the dispute.

CLINICAL HISTORY
This patient is a 60-year-old gentleman who injured his low back on ___ while employed for ___. It was noted that the patient was trying to catch a 55-gallon drum when he felt pain in his lower back. He had low back pain and left leg pain. The patient had an MRI of the lumbar spine in May 2000 that demonstrated multi-level degenerative disc disease most prevalent at L4/5 and L5/S1. He has undergone extensive conservative treatment to include PT (physical therapy), lumbar epidural steroid injections, facet joint injections and radiofrequency rhizotomy. He has stopped smoking for the past two years and has lost twenty pounds through diet efforts. A discogram has been recommended but refused by the carrier. Currently he is on Vioxx, Prozac, OxyContin, Kadian and Zanaflex for chronic pain.

Physical examination documents demonstrate tenderness over the lumbosacral region with decreased motion and pain with forward flexion. He has lost his normal lordosis and he cannot fully straighten his lower back. He has positive long track signs on the left leg. Weakness has been documented in the left leg to 4/5 muscle strength.

DISPUTED SERVICES
The carrier has denied the medical necessity of a lumbar laminectomy/discectomy PLIF, pedicle screws, cages and DynaGraft.

DECISION
The reviewer disagrees with the prior adverse determination.

BASIS FOR THE DECISION
This patient has a clear documentation of lumbar degenerative joint disease at those levels with documented left leg pain consistent with L5 and L1 radiculitis. The patient has failed all conservative methods. He is dependent on high levels of narcotic analgesic to control his pain. This patient has no other alternative other than to have surgery in attempts to decrease the 'pain generators' in his lumbar region. The patient has successfully lost a fair amount of weight and has stopped smoking, both of which will give him a better chance of obtaining fusion if surgery is performed.

___ has performed an independent review solely to determine the medical necessity of the health services that are the subject of the review. ___ has made no determinations regarding benefits available under the injured employee's policy.

As an officer of ___, I certify that there is no known conflict between the reviewer, ___ and/or any officer/employee of the IRO with any person or entity that is a party to the dispute. ___ is forwarding this finding by US Postal Service to the TWCC.

Sincerely,