DECISION AND ORDER

I. STATEMENT OF CASE

East Texas Chiropractic (ETC) challenges the decision of the State Office of Risk Management (SORM) to deny reimbursement for a lumbar MRI provided to an injured worker (Claimant) sixteen days after her injury.

A hearing at the State Office of Administrative Hearings convened and closed December 2, 2003, before Administrative Law Judge (ALJ) Gary Elkins. Michael T. Fleck, D.C., appeared via telephone on behalf of ETC. SORM appeared and was represented by Attorney Stephen Vollbrecht. Neither jurisdiction nor notice were contested.

II. DISCUSSION

Claimant suffered a compensable lumbar back injury on ____. Sixteen days later, on ________, an MRI was performed on Claimant’s lumbar spine. The MRI was ordered and provided by East Texas Chiropractic (ETC). It revealed tearing in a lumbar disk, for which Claimant ultimately underwent surgery.

In support of its opinion that the MRI was medically necessary, ETC argued the following:

• Claimant was experiencing radicular pain at the site of her injury.
• Claimant reported that she had previously undergone back surgery.
• An X-ray revealed a “vacuum” phenomena at the injury site, which suggested the existence of air inside a disk.

ETC’s representative, Michael Fleck, D.C., testified that based on these factors his colleague and the treating doctor, R. Keith Calda, D.C., made the clinical determination that an MRI was needed to determine whether a more serious injury might be present.

SORM’s conclusion that the MRI was not medically necessary was based on the following conclusions:

• According to “InterQual” Guidelines,^[1] MRIs are not supported until one-to-two months post-injury. Consequently, the MRI was not medically necessary two weeks post-injury regardless of any injury it revealed.
• Claimant had responded favorably to conservative treatment during the days
• preceding the MRI. Her reported pain levels were decreasing.
• Dr. Calda’s conclusion that Claimant had previously undergone back surgery was based solely on Claimant’s representations. There is no independent evidence verifying the existence of a prior surgery.

SORM also pointed out that the MRI was performed at ETC’s facility more than 90 miles from Claimant’s home and was billed at twice the maximum allowable reimbursement (MAR) rate.

Notwithstanding the applicability of the InterQual guidelines to this case, which was not demonstrated by SORM, the ALJ concludes the MRI was not medically necessary at the time it was performed. Claimant’s medical condition was improving while she was receiving conservative chiropractic care during the brief period between her injury and the MRI. The decision to proceed with the MRI only sixteen days after her injury, therefore, was neither a medically necessary diagnostic tool at the time it was administered nor a cost-effective approach to providing the medical

care to which Claimant was entitled under Section 408.021 of the Texas Workers’ Compensation Act, TEX. LAB. CODE ANN. § 401.001et seq. (Act). ^[2] Consequently, reimbursement is denied.

III. FINDINGS OF FACT

1. Claimant suffered a compensable lumbar back injury on ____.
2. At the time she was injured, Claimant’s employer maintained workers’ compensation insurance coverage with the State Office of Risk Management (SORM).
3. On ________, sixteen days after Claimant’s injury, an MRI was performed on Claimant’s lumbar spine. The MRI was ordered and provided at an East Texas Chiropractic (ETC) facility ninety miles from Claimant’s home.
4. Based on its conclusion that the MRI was not medically necessary, SORM refused to reimburse ETC for the procedure.
5. In response to SORM’s denial of reimbursement, ETC requested a hearing before the State Office of Administrative Hearings (SOAH).
6. Notice of the hearing was mailed to the parties October 20, 2003. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
7. The hearing convened and closed December 2, 2003, before Administrative Law Judge Gary Elkins. Michael T. Fleck, D.C., an employee of ETC, appeared via telephone on behalf of ETC. SORM appeared and was represented by Attorney Stephen Vollbrecht.
8. Before undergoing chiropractic treatment during her initial visit to ETC on February 17, 2003, Claimant reported the pain level of her compensable injury at eight on a scale of one-to-ten.
9. Before undergoing chiropractic treatment on February 21, 2003, Claimant reported the pain level of her compensable injury at seven on a scale of one-to-ten.
10. After undergoing chiropractic treatment on February 21, 2003, Claimant reported the pain level of her compensable injury at five on a scale of one-to-ten.
11. ETC measured Claimant’s range of motion on her initial visit but did not do so during either her February 19 or February 21 visits.
12. Claimant’s medical condition relating to her compensable injury was improving in the days before the MRI.
13. Based on Claimant’s subjective reports of pain, her representation that she had previously undergone back surgery, and an X-ray, the treating doctor at ETC, R. Keith Calda, D.C., concluded a lumbar MRI was appropriate.
14. Dr. Calda’s specific findings relating to the X-ray are unknown.
15. Claimant received conservative chiropractic care only three times before undergoing the MRI.

IV. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. chapter 401 et seq.
2. SOAH has jurisdiction over this proceeding pursuant to Section 413.031(d) of the Act and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§2001.051 and 2001.052.
4. ETC has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
5. ETC failed to prove that the MRI provided on February 22, 2003, was medically necessary to treat Claimant’s compensable injury, as contemplated in § 408.021 of the Act.
6. The MRI was neither reasonably required nor medically necessary at the time it was provided.

ORDER

IT IS ORDERED that ETC’s requested reimbursement for the February 22, 2003, MRI performed on Claimant is denied.

Signed January 29, 2004.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. SORM explained that the InterQual guidelines, created by the private company InterQual, were created for use by carriers in the absence of the Treatment Guidelines, which were abolished effective January 1, 2002.↑
2. Pursuant to Section 408.021(a) of the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.↑