DECISION AND ORDER

I. DISCUSSION

American Home Assurance Company (Petitioner) filed a request for a hearing following issuance of the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through Texas Medical Foundation, an Independent Review Organization (IRO). The IRO disagreed with the Petitioner’s decision to deny preauthorization of the proposed MRI of the thoracic spine of the claimant, ___ The basis of the IRO’s denial was that the original MRI was a technically poor scan and that a repeat MRI without contrast was justified and necessary.

In this decision, the Administrative Law Judge (ALJ) concludes that the MRI is not medically necessary and grants the relief sought by Petitioner.

A hearing convened on August 2, 2004, at 1:30 p.m. before ALJ Paul D. Keeper. Jim Korioth, an attorney, made an appearance on behalf of Petitioner. No one made an appearance for Respondent, and no motion to appear by telephone had been filed on behalf of any representative of Respondent.

Without objection by counsel for Petitioner, the ALJ attempted to contact Respondent by telephone at his office. Respondent was not available at the time of the call. The ALJ was able to reach Cheryl Owen, Respondent’s receptionist, and James Miller, physician’s assistant to Respondent. Ms. Owen and Mr. Miller informed the ALJ that: (1) Respondent had received notice of the hearing, (2) had expected the hearing to be convened at this date and time, (3) had not hired counsel to represent Respondent, (4) had not filed a request to appear by telephone, (5) had not prefiled any documentary evidence, and (6) had authorized Mr. Miller to represent Respondent in this proceeding. Counsel for Petitioner had no objection to Mr. Miller’s serving as the representative for Respondent.

The IRO’s decision reflects that the claimant sustained a work-related injury on ___, as he was stacking boxes and cat litter bags for ___. He experienced pain, was treated at the emergency room of a hospital, and was treated at a pain center. He was administered an MRI on June 4, 2002, but the quality of the MRI was technically poor. Respondent requested a repeat MRI of the thoracic spine without contrast. The IRO issued its decision on June 17, 2004, and Petitioner filed its request for a hearing on June 18, 2004. Written notice was issued to the parties by the Commission on July 9, 2004, regarding the hearing to be held on August 2, 2004, at 1:30 p.m. before the State Office of Administrative Hearings (SOAH). On July 22, 2004, Petitioner filed a written request for its witness, Dr. Melissa D. Tonn, M.D., to appear by telephone, and the request was automatically granted.

Petitioner called as its witness Dr. Tonn, a board-certified occupational medicine physician, an ADL level II physician for the Commission, with a private practice in Dallas, Texas. Dr. Tonn is an adjunct professor for the University of Texas Health Science Center. Dr. Tonn reviewed the medical records of Respondent to perform an MRI on the claimant and concluded that the preauthorization of the MRI was not medically necessary. Dr. Tonn reached her conclusion because the claimant had a prior MRI, and the claimant had a history of non-employment related injuries that

arose from his having served as a paratrooper. Dr. Tonn found no medical evidence showing that the claimant required further diagnostic studies for medical treatment for any employment-related injuries. Respondent’s representative had no cross-examination for the witness.

Petitioner introduced into the record without objection Petitioner’s Exhibit 1, consisting of 165 pages of medical records and IRO-related documents. Petitioner introduced into the record without objection Petitioner’s Exhibit 2, a copy of a financial disclosure summary reflecting Respondent’s ownership interests in a series of health care facilities, including hospitals, imaging centers, pain clinics, pharmacies, and surgical supply companies.

Respondent’s representative gave an opening statement relating to the non-testifying Respondent’s opinion about the need for an additional MRI for the claimant. Respondent’s representative called no witnesses and offered no evidence into the record. The administrative record was then closed.

Because the preponderance of the evidence in the record indicates that an MRI is not medically necessary for any effects from the claimant’s work-related injury more than two years ago, the ALJ concludes that preauthorization should be denied.

II. FINDINGS OF FACT

1. The claimant, ___, sustained a work-related injury on ___, as he was stacking boxes and cat litter bags for ___.
2. The claimant experienced pain, was treated at the emergency room of a hospital, and was treated at a pain center.
3. The claimant was administered an MRI on June 4, 2002.
4. In 2004, two years after the claimant’s initial injury, Jacob Rosenstein, M.D., Respondent, requested a repeat MRI of the thoracic spine without contrast, and Petitioner denied the request for preauthorization as medically unnecessary.
5. The IRO issued its decision on June 17, 2004, in favor of Respondent on the grounds that the original MRI is over two years old and is of extremely low resolution.
6. American Home Assurance Company, Petitioner, filed its request for a hearing on June 18, 2004.
7. Written notice was issued to the parties by the Texas Workers’ Compensation Commission (Commission) on July 9, 2004, regarding the hearing to be held on August 2, 2004, at 1:30 p.m. before the State Office of Administrative Hearings (SOAH).
8. On July 22, 2004, Petitioner filed its request for its witness, Dr. Melissa D. Tonn, M.D., to appear by telephone, and the request was automatically granted. Dr. Tonn is also a board- certified occupational medicine physician, an ADL level II physician for the Commission, and maintains a private practice in Dallas, Texas.
9. Dr. Tonn is an adjunct professor for the University of Texas Health Science Center.
10. Dr. Tonn reviewed the medical records of Respondent to perform an MRI on the claimant and concluded that the preauthorization of the MRI was not medically necessary.
11. The claimant had a history of non-employment related injuries, including injuries sustained as a paratrooper over a several year period prior to his employment.
12. Claimant’s injury from 2002 has been treated, and there is no evidence indicating that any effects he is current suffering are the result of his compensable injury or that would justify an MRI.
13. Although Respondent’s representative gave an opening statement relating to the need for an additional MRI for the claimant, Respondent’s representative called no witnesses and offered no evidence into the record.
14. There were no contested issues of notice or jurisdiction.
15. The record closed following adjournment of the hearing.

III. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 413.031.
2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(k) and Tex. Gov’t. Code Ann. ch. 2003.
3. Petitioner timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) §§ 102.7 and 148.3.
4. Notice of the hearing was proper and complied with the requirements of Tex. Gov’t. Code Ann. ch. 2001.
5. 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. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. Code Ann. § 408.021(a).
6. Petitioner had the burden of proof by a preponderance of evidence in this matter. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41(b).
7. Petitioner proved by a preponderance of the evidence that the preauthorization of an MRI of the claimant was not medically necessary.

ORDER

IT IS ORDERED that Petitioner American Home Assurance Company’s request for relief is GRANTED and the preauthorization of an MRI for claimant ___ is DENIED.

Signed August 5, 2004.

PAUL D. KEEPER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS