DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUES

A contested case hearing was held on April 23, 2009 to decide the following disputed issue:

1. Is the preponderance of the evidence contrary to the decision of the IRO that the claimant is not entitled to lumbar myelogram with CT to follow for the compensable injury of ______________?

PARTIES PRESENT

Petitioner/Claimant appeared and was represented by RP Jr., attorney. Respondent/Self-Insured appeared and was represented by TW, attorney.

BACKGROUND INFORMATION

Claimant sustained a compensable injury to his back on ______________. He has had numerous diagnostic studies including discogram, myelogram, MRI, and EMG. He was found to have significant degenerative changes with disc protrusions and herniations, but multiple examiners found no neurological abnormalities. Dr. C made a request for CT myelography. Pre-authorization was denied by the Self-Insured. The IRO doctor, board certified in physical medicine and rehabilitation, pain management, and electrodiagnostic medicine, upheld the denial of the requested procedure.

Texas Labor Code Section 408.021 provides that an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. Health care reasonably required is further defined in Texas Labor Code Section 401.011 (22a) as health care that is clinically appropriate and considered effective for the injured employee’s injury and provided in accordance with best practices consistent with evidence based medicine or, if evidence based medicine is not available, then generally accepted standards of medical practice recognized in the medical community. Health care under the Texas Workers’ Compensation system must be consistent with evidence based medicine if that evidence is available. Evidence based medicine is further defined in Texas Labor Code Section 401.011 (18a) to be the use of the current best quality scientific and medical evidence formulated from credible scientific studies, including peer-reviewed medical literature and other current scientifically based texts and treatment and practice guidelines.

In accordance with the above statutory guidance, the Division of Workers’ Compensation has adopted treatment guidelines by Division Rule 137.100. This rule directs health care providers to provide treatment in accordance with the current edition of the Official Disability Guidelines (ODG), and such treatment is presumed to be health care reasonably required as defined in the Texas Labor Code. Thus, the focus of any health care dispute starts with the health care set out in the Official Disability Guidelines (ODG).

The ODG entry for CT & CT Myelography (computed tomography) provides:

Not recommended except for indications below for CT. CT Myelography OK if MRI unavailable, contraindicated (e.g. metallic foreign body), or inconclusive. (Slebus, 1988) (Bigos, 1999) (ACR, 2000) (Airaksinen, 2006) (Chou, 2007) Magnetic resonance imaging has largely replaced computed tomography scanning in the noninvasive evaluation of patients with painful myelopathy because of superior soft tissue resolution and multiplanar capability. Invasive evaluation by means of myelography and computed tomography myelography may be supplemental when visualization of neural structures is required for surgical planning or other specific problem solving. (Seidenwurm, 2000) The new ACP/APS guideline as compared to the old AHCPR guideline is more forceful about the need to avoid specialized diagnostic imaging such as computed tomography (CT) without a clear rationale for doing so. (Shekelle, 2008) A new meta-analysis of randomized trials finds no benefit to routine lumbar imaging (radiography, MRI, or CT) for low back pain without indications of serious underlying conditions, and recommends that clinicians should refrain from routine, immediate lumbar imaging in these patients. (Chou-Lancet, 2009)

Indications for imaging — Computed tomography:

– Thoracic spine trauma: equivocal or positive plain films, no neurological deficit

– Thoracic spine trauma: with neurological deficit

– Lumbar spine trauma: trauma, neurological deficit

– Lumbar spine trauma: seat belt (chance) fracture

– Myelopathy (neurological deficit related to the spinal cord), traumatic

– Myelopathy, infectious disease patient

– Evaluate pars defect not identified on plain x-rays

– Evaluate successful fusion if plain x-rays do not confirm fusion (Laasonen, 1989)

The IRO doctor noted that Claimant has had an MRI, and that there was no need to visualize neural structures because no neurological abnormality had been identified. The IRO doctor determined that Claimant did not meet the ODG criteria.

There was no testimony at the hearing. There was a letter from Dr. C, however he did not contend Claimant met the ODG criteria, and there was no showing of evidence based medical evidence to overcome the IRO decision.

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

1. The parties stipulated to the following facts:

A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B. On ______________ Claimant was the employee of (SELF-INSURED EMPLOYER).

C.On ______________ Claimant sustained a compensable injury.

D.The Independent Review Organization determined Claimant should not have the requested procedure.

Self-Insured delivered to Claimant a single document stating the true corporate name of Self-Insured, and the name and street address of Self-Insured’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.

Claimant did not meet the ODG criteria for the requested procedure.

There was no showing of evidence based medical evidence to overcome the IRO decision.

Lumbar myelogram with CT to follow is not health care reasonably required for the compensable injury of ______________.

CONCLUSIONS OF LAW

1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
2. Venue is proper in the (City) Field Office.
3. The preponderance of the evidence is not contrary to the decision of the IRO that lumbar myelogram with CT to follow is not health care reasonably required for the compensable injury of ______________.

DECISION

Claimant is not entitled to lumbar myelogram with CT to follow for the compensable injury of ______________.

ORDER

Self-Insured is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021 of the Act.

The true corporate name of the insurance Self-Insured is (SELF-INSURED EMPLOYER), and the name and address of its registered agent for service of process is

CC, COUNTY CLERK

(STREET ADDRESS)

(CITY), TEXAS (ZIP CODE)

Signed this 23rd day of June, 2009.

Thomas Hight
Hearing Officer