The employee appeals from the compensation judge’s denial of certain treatment on grounds that it was closed out under terms of the parties’ stipulation for settlement.  We reverse the judge’s finding in that regard, and we vacate and remand the judge’s denial of the benefits at issue, pending the judge’s findings and determination regarding certain issues not yet addressed.

On January 9, 2004, Barbara Griffin sustained a work-related injury to her low back, neck, and left shoulder while lifting a patient in the course of her work as a respiratory therapist with Kindred Hospitals.  Ms. Griffin [the employee] was forty-nine years old on that date and was earning a weekly wage of $936.72.  Kindred Hospitals [the employer] and its insurer acknowledged liability for the injury and commenced payment of benefits.  Subsequent to her injury, on January 29, 2004, the employee saw Dr. Gary Johnson, who, regarding the low back injury, diagnosed ongoing regional low back pain, with symptoms that suggested a possible mild radiculopathy from L4-5 on the right, and he referred the employee to Dr. Blake Johnson, who administered a steroid injection at L4-5 of her lumbar spine on February 4, 2004.  Immediately following the injection, the employee reported a thirty percent reduction in her pain, but by February 12, 2004, she was no longer feeling any relief from the injection.

On June 30, 2004, the employee was examined at the request of her attorney by orthopedic surgeon Dr. Robert Wengler.  It was Dr. Wengler’s opinion that the employee had sustained, related to her work injury, a 13% whole body impairment related to her neck, a 2% whole body impairment related to her shoulder, and a 7% whole body impairment related to her low back.  Regarding the low back impairment, Dr. Wengler diagnosed degenerative disc disease at multiple levels, with an intra-foraminal annular tear at L4-5 on the right.  In addition to these physical injuries, the doctor also diagnosed probable emotional decompensation, with reactive depression secondary to recent trauma.  The employee eventually underwent rotator cuff surgery to repair her left shoulder injury and a fusion from C4 to C7 of her cervical spine to repair her neck injury, neither of which injuries is here at issue.

On February 1, 2006, the employee commenced treatment with anesthesiologist Dr. Long Vu, in Winter Haven, Florida, chiefly for low back pain that radiated into her right buttock and hip.  Dr. Vu prescribed medications and, on February 6, 2006, administered a steroid injection at L4-5 of the employee’s spine, which the employee reported on February 24, 2006, to have resulted in a thirty percent reduction in her pain.  On March 6, 2006, Dr. Vu administered another injection at the same level, which the employee reported on March 29, 2006, to have resulted in a fifty percent reduction in her pain.

In May of 2006, the parties stipulated to a full, final, and complete settlement of all potential remaining consequences of the employee’s work injury, aside from most future medical expenses.  Medical expenses that were closed out under the stipulation included “multi dimensional in-patient and out-patient chronic pain treatment programs.”  An award on this stipulation was issued and filed on June 5, 2006.

On May 26, 2006, the employee had reported to Dr. Vu that her pain had gradually returned since her last injection, and Dr. Vu scheduled her for another, which he administered on June 26, 2006, following which, on July 12, 2006, the employee reported “significant pain relief, at least 50%.”  Dr. Vu continued the employee’s medications and referred her to orthopedic surgeon Dr. Thomas Porter, to whom the employee reported on August 4, 2006, that she had realized significant pain relief for a period of between four and six weeks after previous steroid injections but that pain had recurred thereafter.  On November 3, 2006, Dr. Porter performed a lumbar discography at levels L3 through S1 of the employee’s spine, which was read to reveal a disc protrusion/herniation at the L4-5 level.  On the basis of this study, and because of the employee’s persistent pain, Dr. Porter recommended that the employee undergo, for further treatment, an intradiscal electrothermal therapy [IDET] procedure at the L4-5 and L5-S1 disc levels.

Five months later, on April 4, 2007, the employee underwent another steroid injection, which she reported on May 30, 2007, to have resulted in seventy-five percent pain relief for about four weeks.  Seven months later, on November 2, 2007, the employee underwent yet another injection, which evidently resulted in relief of fifty percent of the pain in her left lower extremity, and two weeks later, on November 17, 2007, Dr. Porter ordered a repeat injection, which evidently resulted in relief of forty-five percent of her pain.  A month later, on December 14, 2007, the employee underwent yet another injection, which evidently left her with only minimal benefit after five weeks.  A year and a half later, on July 8, 2009, the employee saw Dr. Porter again, with continuing complaints of low back pain.  Dr. Porter concluded that she had failed conservative treatment, and he apparently recommended that she consult a spine surgeon, but she evidently declined the referral.

In October of 2009, the employee moved back to Minnesota, where, on October 19, 2009, she saw Dr. Mark Schmidt, who referred her for a consultation at Midway Pain Center [MPC], a facility that is affiliated with HealthEast St. John’s Hospital and that specializes in the treatment of chronic pain.  The employee was evaluated at MPC on November 5, 2009, by Certified Nurse Practitioner [C.N.P.] Nancy Schmidt, who, regarding the employee’s low back, diagnosed lumbar degenerative disc disease, status post work-related injury of January 9, 2004.  C.N.P Schmidt noted that the treatment goal for the employee was “to maintain adequate pain relief for the [employee] with low-dose opioid medications, physical therapy and possible injections.”  C.N.P. Schmidt noted also that the employee was to “consider medial branch blocks,” that she had been “educated extensively regarding our chronic pain program,” and that she was to “follow up in 1 to 2 months.”

The employee was evidently referred for consultation with physiatrist Dr. Mark Agre at Impact Physical Medicine & Aquatic Center, who recommended that she be given occupational or physical therapy, including pool therapy, and use of a TENS unit.  When she returned to MPC in follow-up on January 7, 2010, the employee was evaluated by C.N.P. Collin Dolecheck, who noted in part that a “[p]lan of care was developed within the collaborative practice agreement between myself and Dr. David Nelson” pertaining to the employee’s treatment at MPC.  The employee was seen again by C.N.P. Dolecheck three weeks later, on January 28, 2010, who indicated that the employee was to continue with her medications, to pursue physical therapy at Impact Physical Medicine & Aquatic Center, “to consider injection therapy in the future,” and “to follow up with [MPC] in 1 or 2 months.”

On February 11, 2010, the employee saw her surgeon, Dr. James Schwender, for the first time since August of 2008, to whom she complained of continuing neck pain and stiffness and now, chiefly, of low back pain with radiation into her lower extremities.  Dr. Schwender found the employee’s cervical fusion solid and well healed, and he concluded that it was “reasonable to do epidural injections at the L4-5 level, up to three per year, for treatment of her low back and leg symptoms.”  On March 11, 2010, a month later, the employee saw C.N.P. Dolecheck again, to whom she reported constant, throbbing, level-seven pain in her neck and back.  C.N.P. Dolecheck noted that a “[p]lan of care [had been] developed within the collaborative practice agreement between myself and Dr. Hazmer Cassim,” which included medication, epidural steroid injections, physical therapy, and education in the elements and treatment of the employee’s disease, with a return to the clinic in a month scheduled for ongoing evaluation.  On March 31, 2010, Dr. Cassim, at MPC, performed an epidural steroid injection at L4-5 of the employee’s back, which resulted immediately in a ten percent reduction in the employee’s pain.  In follow-up with C.N.P. Dolecheck on April 8, 2010, the employee reported greater pain to palpation on the right than on the left, and on April 14, 2010, Dr. Cassim performed a repeat injection at L4-5, this time distributing the medication so as to effect immediately a forty percent pain reduction particularly on the right side.

On January 26 and February 18, 2010, respectively, the employee had filed a medical request and an amended medical request, claiming entitlement to a consultation and treatment at MPC, as recommended by Dr. Schmidt, and payment for three epidural injections, as recommended by Dr. Schwender.  On March 12 and March 19, 2010, respectively, the employer and insurer filed medical responses, denying the requests on grounds that (1) the parties’ stipulation for settlement precluded pain clinic treatment, (2) Dr. Schwender’s recommendation offered no explanation of the causation or necessity for the injections or of their specific type, and (3) the indefinite and prospective nature of the treatment requested exceeded the parameters of Minnesota Rules 5221.6200, subparts 5.A.(1) to 5.A.(5).  The matter was considered at an administrative conference on April 23, 2010.  Pursuant to a decision and order filed May 3, 2010, it was determined that, while not all treatment at MPC was precluded by the parties’ stipulation for settlement, the employee’s requests lacked sufficient specificity and limitation to be granted.  On May 11, 2010, the employee filed a request for formal hearing.

On May 13, 2010, the employee reported to C.N.P. Dolecheck that her pain relief from the April 14 injection had lasted about two weeks.  The employee was apparently last seen at MPC about a month after that, on June 10, 2010, when she reported to C.N.P. Dolecheck that she continued to have a constant, electrical, pulsating pain in her neck, low back, and legs, at a level 6 on a scale of 0 to 10.  C.N.P. Dolecheck continued her medications and encouraged her to continue exercise and activity, to schedule repeat injections as needed, to obtain a TENS unit if she could get it approved by the insurer, and to return to MPC in six or eight weeks for ongoing evaluation.

On July 9, 2010, the employee was examined for the employer and insurer by pain specialist Dr. Matthew Monsein, who noted that the employee reported, and her records indicated, that each of her epidural injections to her low back had resulted in relief for only a couple of weeks, after which there was either minimal or no continuing relief.  Dr. Monsein’s diagnoses included chronic pain syndrome, underlying multilevel degenerative disc disease, obesity, and chronic opioid use.  He opined further that the employee’s history of injections had been excessive and not within Minnesota workers’ compensation guidelines, had not been reasonable and necessary, in particular those on March 31 and April 14, 2010, and had ultimately been of no material effect.  It was his further opinion that the employee’s treatment at MPC constituted a chronic pain treatment plan.  Dr. Monsein did support trial use of a TENS unit and involvement in a continued home exercise program, but he did not think that any further physical therapy or any more epidural injections would be reasonable or necessary.

On July 20, 2010, Dr. Cassim issued a narrative report to the employee’s attorney, in which he indicated that the employee had affirmatively not been enrolled in MPC’s comprehensive multidimensional out-patient pain program, that that treatment had been reasonable and necessary and causally related to her work injury, that it had not exceeded the Minnesota Workers’ Compensation Treatment Parameters, specifically Minn. Rule 5221.6200, subp. 5.(A), and that, were it deemed to be outside those parameters, a departure would certainly be appropriate in this case, based up the employee’s dramatic pain reduction and increased function.

The matter came on for formal hearing before a compensation judge on July 21, 2010.  Issues presented to the judge included whether or not the employee’s treatment at MPC was reasonable and necessary, whether that treatment exceeded the parameters established in Minnesota Rules 5221.6050 to 5221.6600, and whether that treatment was precluded by the parties’ March 2006 stipulation for settlement.  Evidence admitted at hearing included the testimony of the employee, in part that, while she was made aware of various treatment options at MPC, including physical therapy, medial branch blocks, medication management, and the chronic pain program, she was never enrolled in the chronic pain program itself.  Nor, she testified, did she see a psychologist or physical therapist at MPC or get any bio-feedback training in the context of her treatment there, her treatment there being limited to injections and medication management.  She testified that two injections, medication monitoring, and a referral to Impact Physical Medicine for a physical therapy evaluation were all that she received at MPC and that there was nothing really different between the treatment that she had been getting there and the treatment that she had gotten previously, in Florida.  The employee testified also, however, that she neither received nor expected long-term relief from her lumbar steroid injections, often scheduling them to be performed just prior to important family events and the like.

By findings and order filed August 23, 2010, the compensation judge concluded in part that the employee’s treatment at MPC consisted of a multi-dimensional out-patient treatment plan for the employee’s chronic pain, including medical evaluation, medication management, injection therapy, physical therapy, exercise, and education, and that compensability for that treatment was therefore precluded by the parties’ 2006 stipulation for settlement.  Given his conclusion that payment for the treatment at issue was precluded by terms of the parties’ stipulation for settlement, the compensation judge did not address the issues of the reasonableness and necessity of that treatment or whether or not it exceeded the treatment parameters.  The employee appeals.

“[A] decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which [the Workers’ Compensation Court of Appeals] may consider de novo.”  Krovchuk v. Koch Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993).

The compensation judge concluded at Finding 6 that MPC had “developed a multi-dimensional out-patient treatment plan for the employee’s chronic pain [that] included medical evaluation, medication management, injection therapy, physical therapy, exercise, and education.”  Compensability for such a plan, the judge concluded, is precluded by the parties’ March 2006 stipulated close-out of all “multi dimensional in-patient and out-patient chronic pain treatment programs.”  The parties apparently agree that the close-out in the stipulation here at issue is in direct reference to the sort of multidisciplinary chronic pain management program that is defined in Minnesota Rules 5221.6600, subpart 2.E.  The employee contends that the definition and requirements contained in that rule do not describe or apply to her treatment at MPC.  We agree.

Minnesota 5221.6600, subpart 2.E., defines multidisciplinary chronic pain management programs as follows:

We note that the provisions of Minnesota Rules 5221.6600, subpart 2.E., are mandatory, and we conclude that the employee’s treatment at MPC has not been described by those provisions.  That treatment does not appear, for instance, to have been provided by any clearly constituted multidisciplinary “team” that provided “coordinated, goal-oriented” services.  Nor is there much evidence that that treatment included the physical rehabilitation, education, relaxation training, and psychosocial counseling that are mandatory under Rule 5221.6600, subpart 2.E.  Although the treatment does appear to have been individualized, admission for it does not appear to have involved evaluation by both a doctor and a licensed mental health professional, and there is no evidence that it was based on “an organized evaluative process for screening and selecting patients.”  Nor does there appear to have been “a specific set of prescribed activities and treatments,” certainly not one laid out with any “specific timetable of progression in those activities” or any “set frequency and hours of attendance,” with “documentation of attendance” for any “set duration.”

We conclude that the compensation judge erred in finding that the treatment received by the employee at MPC was treatment closed out under the parties’ 2006 stipulation for settlement, and therefore we reverse that finding.  Because, however, the judge failed to address the employer and insurer’s other defenses to the employee’s claims - - i.e., whether the treatment at issue was reasonable and necessary and whether any of it exceeded the treatment parameters - - we vacate and remand rather than reverse the judge’s denial of payment for the treatment at issue, pending the judge’s findings and determination as to those thus-far unaddressed issues.