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At a Glance:
Title:
10092
Date:
December 30, 2009
Status:
Concurrent Medical Necessity

10092

December 30, 2009

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 December 30, 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 MRI lumbar without contrast long train fast spin echo for the compensable injury of ________?

PARTIES PRESENT

Petitioner/Claimant appeared and was represented by DC, attorney. Respondent/Carrier appeared and was represented by RJ, attorney.

BACKGROUND INFORMATION

Claimant sustained a compensable low back injury on ________. She had a fusion at L4-5 in 1992 with revision surgery in 1995. She has been diagnosed with post laminectomy syndrome and complains of continuing low back pain and pain into her legs. A lumbar MRI was recommended to identify a neuro occlusive lesion. The IRO doctor, a board certified orthopedic surgeon, upheld the denial of the requested MRI.

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. The Commissioner of the Division of Workers' compensation is required to adopt treatment guidelines that are evidence-based, scientifically valid, outcome-focused and designed to reduce excessive or inappropriate medical care while safeguarding necessary medical care. Texas Labor Code Section 413.011(e). Medical services consistent with the medical policies and fee guidelines adopted by the commissioner are presumed reasonable in accordance with Texas Labor Code Section 413.017(1).

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 ODG. Also, in accordance with Division Rule 133.308 (t), "A decision issued by an IRO is not considered an agency decision and neither the Department nor the Division are considered parties to an appeal. In a Contested Case Hearing (CCH), the party appealing the IRO decision has the burden of overcoming the decision issued by an IRO by a preponderance of evidence-based medical evidence."

The ODG provides in pertinent part concerning MRIs:

Recommended for indications below. MRI’s are test of choice for patients with prior back surgery. Repeat MRI’s are indicated only if there has been progression of neurologic deficit. (Bigos, 1999) (Mullin, 2000) (ACR, 2000) (AAN, 1994) (Aetna, 2004) (Airaksinen, 2006) (Chou, 2007)

Claimant had a lumbar MRI in October 2007. The requested procedure was a repeat MRI. The IRO doctor could not confirm progression of a neurological deficit and was unable to recommend the proposed study as medically necessary. Claimant presented reports and a letter from the requesting physician in which he expressed his opinion that the ODG guidelines for the MRI were met. He opined that there was a neurological deficit, although he never explicitly stated there was progression of the deficit. Claimant has not had an EMG/NCV. Findings on clinical examinations varied. The greater weight of credible evidence did not support progression of a neurological deficit. Claimant failed to overcome the IRO decision by the preponderance of evidence.

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 Dallas Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

B. On ________ Claimant was the employee of (Employer).

C.On ________ Claimant sustained a compensable injury.

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

  • Carrier delivered to Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • MRI lumbar without contrast long train fast spin echo 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 Dallas Field Office.
    3. The preponderance of the evidence is not contrary to the decision of the IRO that MRI lumbar without contrast long train fast spin echo is not health care reasonably required for the compensable injury of ________.

    DECISION

    Claimant is not entitled to MRI lumbar without contrast long train fast spin echo for the compensable injury of ________.

    ORDER

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

    The true corporate name of the insurance carrier is EMPLOYERS INSURANCE COMPANY OF WAUSAU, and the name and address of its registered agent for service of process is

    CORPORATION SERVICE COMPANY

    701 BRAZOS STREET, SUITE 1050

    AUSTIN, TEXAS 78701

    Signed this 30th day of December, 2009.

    Thomas Hight
    Hearing Officer

    End of Document
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