DECISION AND ORDER

Irving Imaging (Provider) appealed the decision of the Texas Workers’ Compensation Commission (Commission) designee, an Independent Review Organization (IRO), which denied its request for reimbursement for an MRI of the lumbar spine and an MRI of the brain as not medically necessary. The Administrative Law Judge (ALJ) finds that Provider did not prove that the MRIs of the lumbar spine and the brain were medically necessary; therefore, American Home Assurance Company (Carrier) shall not be required to reimburse Provider for the MRIs.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

On January 31, 2005, ALJ Michael J. O’Malley convened the hearing on the merits at the William P. Clements Building, 300 West 15^th Street, Austin, Texas. Carrier appeared through its attorney, Jeffrey Federspiel. Provider appeared and through its attorney, Peter N. Rogers. After the evidence was presented, the record of the hearing closed the same day. There were no contested issues regarding notice or jurisdiction; therefore, those issues are presented in the findings of fact and conclusions of law without further discussion.

II. BACKGROUND, EVIDENCE, AND DISCUSSION

Background

On ___, Claimant ___ (a 33 year-old male) sustained a compensable work-related injury when he fell from a ladder and landed on his back and hit his head while employed at ___. Dr. Hong Wang Davis, M.D., ___’s physician, evaluated Claimant, including taking x-rays of the lumbar spine, and the x-rays were negative. Dr. Davis instructed Claimant to begin pain medications and return to work the next day with no restrictions. Claimant’s condition worsened and, on June 13, 2003, Claimant began treatment with Samuela Stankovic, D.C. Based on the mechanism of injury, her initial exam, and Claimant’s level of pain, Dr. Stankovic referred Claimant to Provider for an MRI of the lumbar spine and an MRI of the brain. On June 20, 2003, Provider performed the MRIs.

Legal Standards

Provider has the burden of proof in this proceeding. 28 Tex. Admin Code § 148.21(h). 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. Labor Code Ann. § 408.021(a).

1. Parties’ Positions and Evidence
2. Provider’s Position and Evidence

After submitting documents in evidence, Mark Laning, D.C., an associate of Dr. Stankovic, testified on the medical necessity of the MRIs of the lumbar spine and the brain. He testified that positive results from the various tests indicated possible disc herniation (and radiating pain), warranting an MRI of the lumbar spine. Specifically, the initial exam showed positive test results on the Formina Compression, the Adson Sign, the Kemps, the Psoas, the Lasegue Sign, the Braggard Test, the Fabere-Patrick Test, the Leg Drop Test, and the Sacral-Apex Prone.^[1] With regard to the brain MRI, Dr. Laning stated that Claimant’s dizziness and confusion warranted the brain MRI.^[2]

Carrier’s Position and Evidence

After submitting its documents in evidence, Carrier called Bobby Enkvetchakul, M.D., to testify. Dr. Enkvetchakul testified that an MRI of the lumbar spine is not routine eight days after the injury. In fact, he stated this type of an MRI would rarely be performed within four weeks of the injury unless objective findings showed a severe back injury. He also indicated that there were no red flag indicators, such as fracture or fever, requiring an MRI. He further testified that because the x-rays were negative and there was no serious pathology, it was not medically necessary to perform an MRI of the lumbar spine. Again, with regard to the brain MRI, Dr. Enkvetchakul stated that there were no red flag indicators, such as neurological deficit, justifying an MRI.

ALJ’s Analysis

The ALJ finds Provider did not prove by a preponderance of evidence that the MRIs of the lumbar spine and brain were medically necessary. Although the initial exam performed by Dr. Stankovic may have shown possible signs of disc herniation, these preliminary findings would not justify an MRI of the lumbar spine eight days after the injury.^[3] Furthermore, because the x-rays of

the lumbar spine were negative, there was no urgency to conduct an MRI. When Dr. Stankovic performed her initial exam, she noted Claimant’s back pain (although not acute back pain), which would be normal one day after the injury in which Claimant fell on his back. She did not, however, note any serious pathology, such as a fracture or severe, localized back pain. Absent a severe back injury that might require surgery, an MRI of the lumbar spine would not typically be required within four weeks of an injury.^[4]

With regard to the MRI of the brain, Dr. Stankovic noted Claimant had headaches and had dizziness that was clearing up, but she did not indicate a closed head injury that would warrant an MRI of the brain. Although some dizziness may have existed, this seemed to be clearing up and would not have been abnormal a day after the injury. Furthermore, at the time Dr. Stankovic referred Claimant for the brain MRI, Claimant had no sign of a neurological deficit, no blurred vision, and no abnormal pupil size.^[5] With limited objective findings justifying an MRI one day after the injury, Dr. Stankovic should have proceeded with a course of conservative care, monitored Claimant’s progress, and then determined whether MRIs were necessary. Thus, the ALJ concludes that the MRIs were not medically necessary.

III. FINDINGS OF FACT

1. On ___, Claimant ___ (Claimant) sustained a compensable work-related injury when he fell from a ladder and landed on his back and hit his head while employed at ___.
2. At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance with American Home Assurance Company (Carrier).
3. Claimant’s company doctor, Hong Wang Davis, M.D., treated Claimant the day of the injury, prescribed pain medication for him, and informed him that he could return to work the next day without restrictions.
4. Dr. Davis performed x-rays of the lumbar spine and hip, which were negative.
5. Dr. Davis diagnosed Claimant with a contusion of the back but did not find any serious pathology.
6. On June 13, 2003, Claimant’s condition worsened and he sought treatment with Samuela Stankovic, D.C., who became Claimant’s treating doctor.
7. Based on the mechanism of injury, Dr. Stankovic’s initial exam, and Claimant’s level pain, Dr. Stankovic referred Claimant for MRIs of the lumbar spine and brain.
8. On June 20, 2003, Irving Imaging (Provider) performed the MRIs.
9. Although certain tests (Formina Compression, the Adson Sign, the Kemps, the Psoas, the Lasegue Sign, the Braggard Test, the Fabere-Patrick Test, the Leg Drop Test, and the Sacral-Apex Prone) conducted by Dr. Stankovic resulted in positive findings, indicating possible disc herniation, these preliminary findings do not justify an MRI of the lumbar spine one day after injury.
10. An MRI of the lumbar spine would typically not be performed within four weeks of the injury without objective findings indicating a severe back injury that may warrant surgery.
11. Without more objective findings indicating radicular pain, nerve compression, fracture, or more serious back condition, it was not medically necessary to perform a lumbar spine MRI eight days after Claimant’s injury.
12. Without more objective findings indicating neurological deficit, change in consciousness, blurred vision, or severe head injury, it was not medically necessary to perform a brain MRI eight days after Claimant’s injury.
13. Because neither Dr. Davis nor Dr. Stankovic noted any serious pathology of the lumbar spine or brain, there was no urgency to perform MRIs of the lumbar spine without further treatment, evaluation, and objective findings.
14. Carrier denied payment for the MRIs of the lumbar spine and brain as not medically necessary.
15. On May 19, 2004, an Independent Review Organization (IRO) upheld Carrier’s decision to deny reimbursement for the MRIs.
16. On June 24, 2004, Provider appealed the IRO’s decision.
17. The Texas Workers’ Compensation Commission (Commission) sent notice of the hearing to the parties on July 21, 2004. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
18. The hearing was held on January 31, 2005. Carrier appeared through its attorney, Jeffrey Federspiel. Provider appeared through its attorney, Peter N. Rogers.
19. At the hearing, the only contested issue involved the medical necessity of the MRIs of the lumbar spine and brain.

IV. CONCLUSIONS OF LAW

1. 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. §§ 402.073 and 413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Proper and timely notice of the hearing was provided to the parties in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
3. 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 relives 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).
4. Pursuant to 28 Tex. Admin. Code § 148.21(h), Provider has the burden of proving by a preponderance of the evidence that the MRIs of the lumbar spine and brain were medically necessary.
5. Provider did not prove by a preponderance of the evidence that the MRIs of the lumbar spine and brain were medically necessary.
6. Based on the Findings of Fact and Conclusions of Law, the MRIs of the lumbar spine and brain should not be reimbursed.

ORDER

IT IS HEREBY ORDERED that American Home Assurance Company shall not reimburse Irving Imaging for the MRIs of the lumbar spine and brain performed on June 20, 2003.

Signed March 18, 2005.

MICHAEL J. O’MALLEY
Administrative Law Judge
State Office of Administrative Hearing

1. Provider Ex. 6 at 21-22.↑
2. Provider Ex. 6 at 23.↑
3. Although the MRIs were performed eight days after the injury, Dr. Stankovic referred Claimant for the MRIs the day after the injury with limited objective findings.↑
4. Carrier Ex. 1 at 2.↑
5. Provider Ex. 6 at 21-23.↑