Treatment Supplement to ODG by MCG®

for Utilization Review in Tennessee Workers' Compensation Claims

Purpose and Scope

The Tennessee Bureau of Workers’ Compensation uses ODG by MCG treatment guidelines in the utilization review of medical treatment provided to injured workers. These supplemental spine treatment recommendations address specific areas in which the Bureau’s Medical Advisory Committee identified a need for additional or updated guidance.

The Medical Advisory Committee approved these supplemental recommendations on August 25, 2026, following review and discussion of the proposed changes. For the treatment of spinal conditions addressed in this document, these recommendations supersede the corresponding ODG by MCG treatment guidelines for utilization review under Tennessee Workers’ Compensation Law.

These recommendations are intended to provide clear, consistent guidance to treating providers, utilization review physicians, adjusting entities, and other parties involved in the review and authorization of medical treatment for Tennessee workers’ compensation claims.

Spine Treatment Recommendations

These supplemental recommendations supersede ODG by MCG® treatment guidelines for the treatment of injured workers covered under the Tennessee Workers’ Compensation Law.

  1. Incapacitating acute radicular pain from spinal disc pathology may be considered a valid reason to accelerate surgical intervention if the diagnostic studies and the [objective radicular] nerve root physical examination deficits correlate. Although not commonly seen, incapacitating pain may include an inability to perform sedentary and/or personal care activities without assistance, inability to stand for over 5 minutes, or interference with minimal functional activities. This applies to cervical and lumbar radiculopathy.
  2. Cervical or lumbar radiculopathy related to nerve root compression can be considered for surgical treatment after 6 weeks of conservative care including activity modification, NSAIDs, physical therapy or steroid injections.
  3. Acute cervical myelopathy (multiple nerve roots or central stenosis with significant weakness or gait/balance disturbances) or cauda equina syndrome (lumbar nerve roots with significant weakness or bowel/bladder incontinence or loss of control), although uncommon, requires immediate surgical treatment. Utilization review for these conditions should be conducted retrospectively. When the pre-operative medical records document either condition, prospective utilization review should not be required.
  4. Stable lumbar spondylolisthesis at the level of radiculopathy due to spinal stenosis or disc herniation typically needs only decompression, and not a decompression combined with fusion. In the cervical and lumbar spine, instability should be defined by a radiology report documenting instability on flexion-extension standing lateral radiographs. If limited spinal motion is present, supine lateral radiographs should be compared with standing lateral radiographs. Laminectomy alone does not produce spinal instability.
  5. Spinal fusion in the lumbar spine may be indicated at the time of spinal stenosis decompression for ≥ 20 degrees of scoliosis (coronal plane deformity). Lesser degrees of coronal plane deformity are usually adequately treated with decompression alone.
  6. Lumbar fusion is not recommended for degenerative disc disease or for the initial or first recurrence of a lumbar disc herniation at any level.
  7. When lumbar fusion is indicated, the choice of surgical approach, grafts, implants, and method of stabilization should be the choice of the surgeon, and not the UR physician.
  8. Cervical disc replacement (ADR) yields a result comparable to anterior cervical discectomy and fusion (ACDF) and may be recommended for radiculopathy or myelopathy.
  9. Lumbar disc replacement is not recommended.
  10. The decision regarding a multilevel cervical fusion is multifactorial involving the distribution of pain, which could include more than one nerve root, as well as the severity/significance of the radiographic findings at adjacent levels. If the radiographic findings demonstrate compression of cervical nerves or the spinal cord at an adjacent level, the decision concerning a one- versus a two-level procedure should be left to the discretion of the operative surgeon.
  11. Diagnostic [radiculopathy] criteria for C-4 (no motor weakness or reflex available) and C-8 (no reflex) are limited. After appropriate conservative treatment, surgical indications will primarily be related to correlation with the radicular pain distribution in a clear corresponding dermatomal distribution and the appropriate imaging findings. When nerve root deficit on exam is one vertebral disc level different from imaging showing nerve root or spinal cord compression (level, but not side of neurologic deficit), anomalous innervation may explain the discrepancy from “anatomy textbook” neurology. The neurological deficit, if new, should be used to justify the indication for surgery, and the imaging should determine the level at which the surgery occurs.
  12. Lumbar fusion is recommended for chronic pain and/or instability after spinal fracture. A psychological evaluation is not necessary for these indications. For other indications, a psychological evaluation is required. Lumbar fusion is not recommended for degenerative disc disease, discogenic pain, or annular “tear” (annular fissure is the preferred term).
  13. Sacroiliac joint fusion is not recommended for any of the following:
    • Inflammatory (rheumatologic) sacroiliac joint disease.
    • Sacroiliac joint pain syndromes not due to pelvic fracture/dislocations.
  14. Psychosocial factors are known to affect the outcome of pain procedures. Outcomes should be judged by “hard” outcomes, and not subjective “visual analog pain scales”. The Oswestry Disability Index for lumbar disorders and the Neck Disability Index have been validated in multiple cultures and document self-reported symptoms and functions. Better metrics would be “hard outcomes” like return-to-work rate after the procedure, or major reduction in medication use after the procedure. When a pre-procedure psychological or psychiatric assessment is indicated, the Bureau suggests the documentation recommended:
    • Mental health diagnoses, including depressive disorders, anxiety disorders, and personality disorders, should each be assessed. “Cut points” for depressive disorders would be a PHQ-8 or a Beck Depression Scale ≥ 10; a Beck Anxiety scale of ≥8 or a Generalized Anxiety Disorder 7 score ≥10.
    • Catastrophizing should be assessed with the Pain Catastrophizing Scale “cut point” ≥30.
    • Kinesiophobia should be assessed and the cut point for the Tampa Kinesiophobia Scale would be ≥40.
    • Somatization as an ego defense should be assessed by the PAI or MMPI. A “cut point” ≥ 2 standard deviations above the mean is significant (T Score ≥70). An alternative is the PHQ15 with a somatic symptom score ≥15.
    • Central sensitization should have been assessed on physical exam by the requesting physician. Psychologists or psychiatrists can assess this by the Central Sensitization Inventory with a “cut point” ≥40.
    • If only 1 of these self-report instruments is above the cut point, no caution is advised, but the more of these that score above the cut point, the less likely a procedure is to be successful if the outcome is to be judged by subjective pain relief.
    • The mental health professional should include a statement, after assessing responses from the patient, as to their expectation of improvement (ideally in percentage terms) so that reviewers and others can assess whether the patient has reasonable or unreasonable expectations for improvement from the recommended treatment.

This Page Last Updated: September 4, 2026 at 2:50 PM