Meeting Minutes

November 4, 2025 via Teams

Tennessee Room, 220 French Landing Drive, Nashville, TN 37243

Members

• Rob Behnke, Cracker Barrel
• Carina Sloat, RN, CCM, Travelers
• John Brophy, MD, Neurosurgery
• Jeff Hazlewood, MD, PM&R, Pain Management
• Lisa Bellner, MD, PM&R Pain Management
• Cerisia Cummings, DO, Bridgestone
• Lisa Hartman, RN, AFL-CIO
• Tim Jones, MD
• Dan Headrick, PT CEAS III, ASTYM, BS
• Ginny Howard, Arch Insurance
• Amy Moses, McKee Foods
• Veatrice Storey, Zurich
• J. Wills Oglesby, MD—Proxy to Dr. Snyder

Staff

• Robert Snyder, MD, Medical Director, BWC 
• James Talmage, MD, Asst. Medical Director, BWC 
• Amanda Terry, BWC 
• Jay Blaisdell, BWC 
• Suzy Douglas, RN, BWC 
• Lacy Conner, BWC 
• Marshay Jones, BWC 
• Maria Trotter, BWC 
• Kyle Jones, BWC 
• Suzanne Gaines, BWC 
• Mark Finks, BWC 

Guests

• Adam Fowler, My Matrixx
• Yarnell Beatty, TMA
• Sarah Herbert, Erie Insurance
• Pauline Williams, Fair Health
• Larry Brinton, Accuro Solutions
• Lee Hunter, MD,TOA
• Brian Allen, Enlyte

In Person

• John Brophy, MD, Neurosurgery
• Cerisia Cummings, DO, Bridgestone

By Telephone

• Veatrice Storey, Zurich

Virtual Option

The meeting will be held in the BWC Large Conference Room with telephone and virtual options available. The use of the virtual platform is a benefit to the public, allowing participation of out-of-state stakeholders and others interested in the subjects of this meeting.   It is necessary for establishment of a quorum that the members have the virtual option available.  The committee rules provide for the members to be counted as present for the determination of a quorum (see rule 0800-02-23-.04 (2-3)). 

Call to Order

The meeting was called to order at 1:05 PM by the Chair, Ms. Sloat. 

Introductions were made.

Quorum

Mr. Finks took role, and a quorum was confirmed as present (1/3 of the members needed, 14/18 members present).

Ms. Conner said that all the Conflict-of-Interest forms had been turned in.

Approval of Minutes

Ms. Sloat called for approval of the minutes for the September 23, 2025, meeting.   

Dr. Brophy motioned and Mr. Behnke seconded.   

The minutes were approved as written.

Old Business 

ODG Updates:

Changes became effective on October 3rd, which included about 100 different changes of topic and updates.

Dr. Snyder highlighted some of the significant changes.

There was a set of updates that included spinal cord stimulators on a recommendation statement, and lumbar and sacroiliac fusions.

Dr. Brophy commented that the lumbar fusion section addresses a lot of issues that are not pertinent to Tennessee since Tennessee does not cover aggravation of pre-existing conditions, meaning degenerative changes.  This would eliminate degenerative spondylolisthesis and other issues that are listed but doesn’t cover the issue that would be most likely in the state of Tennessee, which is a second disc recurrence, generally quite painful.  All the other fusion criteria should require psychological evaluation.  They need to address it specifically; under the 6-week criteria of lumbar radiculopathy, no psychological evaluation should be required.

Dr. Talmage recalled that the committee approved the ODG guidelines prior to the July 2024 update.   The July 2024, November 2024, April 2025, July 2025 and October 2025 updates have not been approved by the committee.  The lumbar fusion criteria for spondylolisthesis require imaging that’s supposed to demonstrate spondylolisthesis.   The words dynamic instability are in parentheses.   They don’t clearly state that you can do a fusion for spondylolisthesis with proven instability or without proven instability.  Their method of documenting instability is standing flexion-extension lateral radiographs.  Many people with bad backs when standing for those flexion-extension films move very little into flexion and very little into extension, and don’t demonstrate the instability that’s there.   Many spine surgeons compare supine radiographs to standing neutral position radiographs that have a better yield at demonstrating true instability.  

In this spinal fusion for lumbar stenosis section there is no comment about doing a fusion for stenosis as opposed to doing a simple decompression.  Published multiple randomized control trials say outcomes are not better with fusion.  There are more complications and slower recovery with fusion.   Simple decompression should be the recommended treatment, not fusion or stenosis.  

The criterion for having fusion frequently involves having a favorable psychological evaluation.  This issue was raised previously but they still haven’t addressed it.

The psychological evaluation states no uncontrolled mental health or substance use disorder but doesn’t define “uncontrolled”.  There is abundant literature that says major depressive disorder forecasts poor outcomes with lumbar fusion.  In appeals, are seen psychological evaluations that diagnose major depressive disorder on a questionnaire like the PHQ-9.  You get a maximum possible score of severe depression, and a psychologist says, “On an antidepressant”, so it is okay to do the surgery.   “Uncontrolled” should be defined.

The psychological report is also supposed to assess “personality style” and “coping ability”.   There is no literature support for “personality style” affecting outcome. “Personality style” and “coping ability” are undefined terms.  Therefore, UR reviewers can say “not certified” and on appeal, we must try to define what ODG means by “personality style” and “coping ability”.  

There are still major problems with the ODG. 

Sacroiliac joint fusion requires imaging that shows pathology but the older you are, the more degenerative changes you have.  That’s been well established.   So, if undefined, degenerative changes are all that’s needed, anybody over 40 probably qualifies.  The older you are, the higher the incidence of spontaneous fusion of the SI joint.  

There is no requirement that spontaneous fusion be excluded by CT scan.  Theoretically, you can fuse surgically the SI joint that’s already fused spontaneously.

They use response to injection of the SI joint as a criterion with no comment on the volume of injectate administered or whether you used X-ray dye and watch to see if it extravasates.  Forton, who’s well known for SI joint issues, published in 1999 that if you inject more than 3cc’s in the SI joint it extravasates on to the lumbosacral plexus L5 nerve root and the S1 nerve root. So, it’s possible to extravasate the local anesthetic with the injection and get a false positive result.

 For SI disease, there is one published randomized control trial that is not manufacturer sponsored and it found no benefit.  All the manufacturer sponsored randomized trials found benefits, so it is a confusing area.   Washington State says we don’t cover it.  There are improvements, but still a lot of issues.  

Dr. Brophy spoke of the ongoing discussion from the past year of the problem with 3 months of conservative management for radiculopathy.   During the last meeting, Mr. Prevot implied that this was going to be solved, and it was agreed that 6 weeks was reasonable.  They changed it in the lumbar radiculopathy section but not in the cervical radiculopathy section.  In addition, there are minor issues with their therapies.   For all these reasons, approval of this version of the spine section should be delayed until the next meeting to see what ODG changes.

Dr. Hazlewood asked if the ACOEM guidelines address all the issues that Dr. Brophy just listed.  

Dr. Brophy said there are frustrations with Washington State and ACOEM, especially with ACOEM in terms of how to read it as it is written for medical practitioners.  Mr. Prevot could bring the committee into agreement with ODG with some straightforward changes to their guidelines.  It is as if they did not have a surgeon or physician who does the cases read their literature because they would see the problems.  

Dr. Snyder said there was a motion to approve the ODG changes except for the spine section.  Dr. Talmage seconded.   The committee voted to approve without dissent.  

Dr. Snyder will write up the comments and send them to Mr. Prevot.

Dr. Talmage suggested that whoever is head of the spine section should speak with him and Dr. Brophy.  Dr. Snyder will make that suggestion.

Drug Formulary:

The drug formulary updates became effective for ODG® on October 3rd  and then become effective for the state of Tennessee on November 1st .

Dr. Snyder said that for a long time, ODG had not approved cold compression therapy or continuous flow.  They finally updated the “continuous-flow cryotherapy” and the problem lies in the lay and physician understanding that there is no distinction between “cold compression therapy” and “continuous flow cryotherapy”.  

ODG only makes an evaluation for cold compression therapy of the Game Ready® unit and not of any other cold compression units.   Dr. Snyder has written to them and told them that they need to cross reference the cold compression with the continuous flow cryotherapy to try to clear up this distinction without a difference.

Most physicians when they write an order or most individuals when they receive a unit do not understand whether it is cold compression or continuous flow cryotherapy.There is limited literature about the significant difference.  One of the problems is with the individual denials when they include the DVT prophylaxis sequential compression devices (SCDs) in the same order.  There are confusion and denials from utilization review for sequential compression devices which are standard of care for shoulder surgery and for the opposite knee in knee surgery.  They deny those because they confuse them with the cold compression units.   Both problems have been identified and sent to ODG for clarification.

Ms. Sloat agreed that insurance was dealing with the same things; with the same things being put on the orders and causing confusion.  SCDs should be considered within the cold compression but there needs to be a distinction between these devices or more explanation within ODG to make it clear to utilization review companies.

Dr. Snyder stated that ODG should cross reference between the cold compression therapy and the continuous flow cryotherapy.  There’s only 1 article on the shoulder for cold compression and it is not persuasive that it’s any better than continuous-flow cryotherapy.  The other problem has to do with the length of time that they are recommended.  Clinical experience shows that after about 10 to 14 days, most quit using it anyway (the recommendation under cold compression therapy is 2 weeks).  A lot of reviewers will eliminate it even though it is recommended for 30 days.  It would have to be very rare circumstances in which somebody would continue to use it for 30 days in the absence of other complications.  The committee is trying to get clarification about this problem from ODG.

AMA Guidelines®:

Approximately 3 weeks ago, the AMA sent out a letter.  Dr. Snyder read 1paragraph from this letter because it impacts where the committee is with the AMA guides update.  

From the Vice President of the AMA,

“We believe this is the right moment to make a strategic pivot to protect and strengthen the value of the AMA guides by investing in the long-term support and accessibility of existing content.   For example, initiatives such as implementing an FAQ section and earmarking the year when each chapter was updated are underway.  By focusing resources where they will have the most impact, we can ensure that the current edition remains usable, relevant and well supported for all stakeholders.”

It appears that the content released this year, (AMA 6th 2025®) is going to be the stable content for a significant period going forward.  This includes all 3 of the musculoskeletal chapters which represent probably 90% of permanent impairment evaluations.  It included the 2023 update to the neurology section, and it included the 2025 update to the pulmonary and ENT sections.  All of these will be stable content and be published on the AMA site.  The AMA is not going to publish a book; it will be a digital version.  

Where does the committee go from here?  Do we need to re-evaluate these sections since the content is stable?  Is the effort to change to a separate edition so overwhelming?

The Medical Advisory Committee is the first to review these changes and make a recommendation.  If the recommendation is positive, then it would go to the administrator for evaluation.  The administrator would then call together a meeting of stakeholders.  The stakeholders would then make another recommendation to the administrator.  The administrator would then have to make that recommendation to the Governor’s Office for the governor to put it in a legislative package.

There will be a new governor in 2026, so it would be in the legislative term for 2027.  This will be at a minimum, a 3-year process, even if comments and suggestions to the administrator are positive.  

The floor was opened to comments on the process.

Dr. Talmage said that he had not heard any Tennessee physician advocate that the 2008 book should be switched off.

The AMA did not answer Dr. Snyder’s question about what jurisdictions by law adopted the Guide’s 2025 digital so we could see if they had a positive experience with it.   The states Wyoming, New Mexico, and Montana have adopted the Guides 2025®.  Dr. Snyder can contact a physician that works in Montana to see what their experience has been so far.

Dr. Talmage remarked that if the committee is not familiar with the digital product, the AMA took a 600-page book published in 2008 and turned it into 1,500 pages of digital content by revising some but not all the chapters.  

There is a good revision of the 2022 psych chapter.  They have not revised the skin, the GI, the GU and several chapters that are potentially in need of revision, and the sheer number of pages is a detractor.  In addition, you can buy the 2008 book on Amazon for less than $200.00, or you can subscribe to and access digital content but only for a year for considerably more money.  Dr. Talmage has not spoken with any physicians who are particularly happy with the subscription fee.

Dr. Hazlewood prefers the book so that he can make notes in the book tag and refer to it.   The old book is still misinterpreted all the time on the correct impairment ratings.  The cost is also a very important point.  It will be a deterrent for a lot of doctors to invest.  Many doctors do not understand how to appropriately apply the Guides®.   It would take an significant investment of time, taking courses, paying for courses, etc., to learn all the new information. 

 

According to some committee members, Texas, Alabama, and Arkansas are using the 4th Edition of the AMA Guides from the 1990’s. Colorado and Oregon use the 3rd Edition, revised, published in 1988.

Dr. Hazlewood motioned to table the evaluation, wait for more information and discuss it at the next meeting.  Give it time to settle and see how the other 3 states that are doing it respond.  Why is there a rush to change it when we’re still having trouble (inaccurate results) with the old one?

Dr. Bellner seconded the motion.  

Dr. Talmage amended the motion to wait until WCRI publishes a cost analysis of what happened in the states that switch compared to their experience before they switched.

Dr. Snyder requested that Dr. Talmage remove “WCRI” from the motion and replace it with “until a cost analysis is available”.   Dr. Talmage agreed.

Dr. Hazlewood seconded the amended motion.

The committee voted to approve the amended motion with no dissent: “Table an assessment of the revisions to the AMA Guides® until further information is available including a cost analysis”.

Medical Fee Schedule:

Dr. Snyder reported that the Medical Fee Schedule has been released by the Attorney General’s office and is published on the Secretary of State’s website.

The fee schedule goes before the Government Operations Committee in December.  The effective date of the new fee schedule rules is January 19, 2026.

There is a provision in the new rules that all the changes to the rules become effective with the publication of the rate tables on April 1, 2026.   Therefore, the fee schedule changes will become fully effective April 1, 2026. 

There are several clarifications and simplications in the fee schedule reducing the number of separate professional payment levels from 6 to 3.

The other major change is to code the Certified Physician Program with its own modifier.

Ms. Conner provided a link to the fee schedule. In January, there will be town hall meetings for the medical fee schedule as part of the rules roll-out.

Case Management:   

New rules for case management will become effective November 10th.  Ms. Conner and Ms. Jones have given 5 town hall meetings with the 6th scheduled for tomorrow.

The major changes to the case management rules have to do with clarifications of certain roles.  The other change is the identification of face to face and virtual meetings.  

During COVID, face to face meetings were not allowed so penalties that had to do with violation of face-to-face meetings were suspended and virtual meetings were allowed.  The virtual meetings are two-way audiovisual that are satisfactory to the injured worker.  This has been added so that it is clear what an acceptable virtual meeting is.  At this time, it is still recommended that the information gained by face-to-face interaction and communication with the injured worker benefits the system in identifying problems and motivation and secondary issues.

Contact Dr. Snyder if there are any questions.

Claims Handling Standards:

The claims handling standards have new rules, 800-02-14, that will become effective on November 10th.  The changes have to do with the adjuster responsibilities in responding to requests and adjuster responsibility to identify the adjuster correctly when adjusters change.  The adjusters must notify the injured worker and providers of record.  The new rules will be on the website. 

UR Report:

Penalties:

A utilization review advisory medical practitioner failed to properly apply the medical treatment guidelines.  The patient had a left shoulder injury which was a dislocation and required a special operation called a Bankart procedure or Bankart lesion, Bankart repair for the shoulder.  The reviewer used the wrong section.  It is called a labral tear, which is not appropriate to the type of surgery that the individual had.  As a result, the denied treatment was overturned.  

In 2016, the Medical Advisory Committee approved the following recommendation which was to notify the administrator when the utilization review physician had improperly applied the guidelines by clearly using the wrong diagnosis, citing the wrong procedure or section, or citing an inconsequential variation and failure to identify the major facts.  

In this circumstance, Dr. Snyder asked the Medical Advisory Committee to authorize him to recommend to the administrator that a penalty be sent to the advisory medical practitioner that he clearly used the wrong diagnosis in citing the wrong section.

Dr. Snyder motioned for the committee to send the penalty. Dr. Cummings seconded the motion.  The committee voted to accept with no dissent.

The peer-to-peer has become a problem for physicians trying to get treatment approved.   The system does not work smoothly.

There was a meeting regarding the announcement Sedgwick makes when they deny treatment.   It has to do with the wording that Sedgwick uses in identifying the time frames involved in the peer-to-peer which are not in line with the time frames in the Bureau rules.  There was discussion about revising how they word the length of time they are going to allow a physician to contact Sedgwick about a peer-to-peer meeting.

The second problem identified was leaving messages at physicians’ offices.

In the UR review denial, the reviewer will list that they called a certain telephone number at the physician’s office and left a message with a certain person at some date or time.  The problem is they do not leave a telephone number so that an individual physician could call back and get an answer from the peer reviewer or their organization.   It is suggested that the reviewers leave a return telephone number that can be called back because it is not clear whether they are giving the correct telephone number or a number that is other than the general phone number or mailbox for the review organization.

This will be addressed going forward, but at this time there is no good answer for it.  It has been identified as a problem with peer-to-peer.

Dr. Bellner said that printed at the bottom of the denials is notification that the physician has either 24 or 48 hours to reopen that appeal.   The telephone number provided might be incorrect because the denial is being handled by another company.   The carrier needs to put the correct telephone number on the request so that the physician can reopen the case without spending hours trying to track down the correct telephone number.

Dr. Snyder said that one of the problems with Sedgwick is that they use more than 1 physician review company.  It creates a second level of complication and that’s why they said they didn’t handle that.  The committee will continue to work on this communication problem and try to straighten it out.

Ms. Sloat asked for comments or any other problems to discuss.

New Business

WCRI Reports:

WCRI has issued several reports since August.   The first one had to do with the high-cost claims, and these were limited to back and shoulder.  The high-cost claims, the back claims, included neurologic complications, soft tissue and disc complications, and why they went wrong.  The shoulder had to do with rotator cuff and arthritis.

The back groups had 5 times more cost on an average claim with $120,000.00 in medical expenses, twice the number of temporary disability weeks.  Ninety percent of the individuals with high-cost claims had significant co-morbidities.  Obesity, pain syndromes, mental health issues, and sleep disorders were identified in more of these claims than on any of the average or normal expenditure claims.

There was a lot of overlaps with neurologic back disorders that included disc disorders and stenosis so usually there was more than one diagnosis that led to the treatment.  Both shoulders and backs had higher utilization use, often with multiple providers after the index procedure.  Once these claims went wrong, they continued to go wrong and expended a significant number of resources long after the index injury and the index procedure.

Cases that had surgery were 8 times more likely to lead to high-cost claims than cases that did not have surgery.

Obviously, those who had surgery may have more severe injuries.  In the soft tissue disorders, those who had surgery for only a listed soft tissue diagnosis still had high-cost claims that could not be justified based upon the index injury.  It appears that there’s long resource utilization in these cases and be careful who you operate on.

WCRI also had a report on AI.  They identified things that AI should do first.  It should reduce administrative burdens including more consistent processing of structured and unstructured data.  Automation of routine tasks and prediction potential for outcomes and early interventions.  It should also enhance speed, consistency and accuracy of communication.  It should prevent accidents with data loss and correspondence.  Finally, it should improve personalized care and transparency.  

Advisory Council of Workers’ Compensation Report:

Ms. Terry addressed the committee.  The Advisory Council of Workers’ Compensation will not decide anything until tomorrow.  

Dr. Snyder added that the NCCI recommended a 2% reduction in lost cost analysis.  Both consultants for the committee recommended a larger decrease, and so the committee will vote tomorrow on whether to recommend to the insurance commissioner a reduction of 2% or greater.

Overdose Report:

The Office of Overdose Surveillance Program released a report on October 3rd.  In 2024, 2,473 Tennesseans died of drug overdose.  This was a 31% decrease from the year before.  Most of the overdose deaths were related to contaminants in expected pills, including fentanyl.   The biggest issue is contaminants in the cocaine and in opioids.  There are cocaine, heroin, and opioids coming into Tennessee.

The American College of Surgeons released a research report on the 6-year analysis of 1 Ohio County that showed that 40% of deceased drivers in motor vehicle accidents tested positive for THC.  

The high rate of the THC positivity remained consistent over the 6 years of the analysis and was unaffected by the state’s legalization of recreational marijuana during the study period. Even before they authorized recreational marijuana, the significant numbers of patients and significant numbers of deceased drivers were positive for THC.  It doesn’t appear to have anything to do with whether or not there’s recreational marijuana approved in a state.

Ms. Sloat asked for questions or comments.

Regarding the overdose deaths on opioids, Dr. Hazlewood asked how many occurred with people taking them at the dosages they were supposed to take with no aberrant behavior or misuse.  It was simply from the morphine equivalent dose. Dr. Snyder did not think that it was broken down.  There were a lot of combinations of people that were taking cocaine and opioids.  

Mr. Headrick asked that the multiple studies showing the reduction in opioids, the reduction in testing, the reduction in sticks and reductions in surgery and the relative functional outcome that is equal to certain kinds of surgical procedures would be positively influential with ODG?  Regarding the 6 weeks, 8 weeks, 10 weeks or visit guidelines that are arbitrary and not taking into account functional outcomes with regard to work or with regard to the reduction in the use of opioids and in the use of surgery with physical therapy, unsure how to proceed on that because it takes a lot of research, but it seems linked.  

Dr. Snyder said that it has been identified in the ODG in the past and will do so again.

Mr. Headrick offered to provide additional studies.

Announcements:

Dr. Snyder asked the committee if there were other subjects that they would like to have investigated.

• Next Meeting: 2/10/2026
• Second Meeting: 5/5/2026

Dr. Snyder thanked the committee members and wished everyone happy holidays.

Adjournment: 

2:10 PM