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 March 4, 2010, to decide the following disputed issue:
Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that Claimant is not entitled to lumbar MRI without contrast for the compensable injury of ____________?
PARTIES PRESENT
Petitioner/Claimant appeared and was assisted by AC, ombudsman.
Respondent/Carrier was represented by GM, attorney.
BACKGROUND INFORMATION
The Claimant sustained a compensable lumbar injury on ____________. As a result of the compensable injury, Claimant had surgery to his lumbar spine and has had a total of four MRIs to his lumbar spine. Claimant testified that in September of 2009, he sought medical attention because his pain had increased. Claimant stated that an MRI of the lumbar spine was recommended so that an epidural injection could be requested.
The IRO reviewer, a board certified orthopedic surgeon, determined that the requested services did not meet the Official Disability Guidelines (ODG). The IRO reviewer noted that Claimant had a previous repeat MRI study which revealed epidural fibrosis. The reviewer was aware that Claimant had been complaining of an increase of pain to his lower back and numbness to the soles of his feet. He further noted that the physical examination did not show any focal weakness, nerve tension signs, or radiculopathy. He also commented that the Claimant’s diabetes was of concern.
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 recognizes the use of MRI’s and states:
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) Magnetic resonance imaging has also become the mainstay in the evaluation of myelopathy. An important limitation of magnetic resonance imaging in the diagnosis of myelopathy is its high sensitivity. The ease with which the study depicts expansion and compression of the spinal cord in the myelopathic patient may lead to false positive examinations and inappropriately aggressive therapy if findings are interpreted incorrectly. (Seidenwurm, 2000) There is controversy over whether they result in higher costs compared to X-rays including all the treatment that continues after the more sensitive MRI reveals the usual insignificant disc bulges and herniations. (Jarvik-JAMA, 2003) In addition, the sensitivities of the only significant MRI parameters, disc height narrowing and annular tears, are poor, and these findings alone are of limited clinical importance. (Videman, 2003) Imaging studies are used most practically as confirmation studies once a working diagnosis is determined. MRI, although excellent at defining tumor, infection, and nerve compression, can be too sensitive with regard to degenerative disease findings and commonly displays pathology that is not responsible for the patient’s symptoms. With low back pain, clinical judgment begins and ends with an understanding of a patient’s life and circumstances as much as with their specific spinal pathology. (Carragee, 2004) Diagnostic imaging of the spine is associated with a high rate of abnormal findings in asymptomatic individuals. Herniated disk is found on magnetic resonance imaging in 9% to 76% of asymptomatic patients; bulging disks, in 20% to 81%; and degenerative disks, in 46% to 93%. (Kinkade, 2007) Baseline MRI findings do not predict future low back pain. (Borenstein, 2001) MRI findings may be preexisting. Many MRI findings (loss of disc signal, facet arthrosis, and end plate signal changes) may represent progressive age changes not associated with acute events. (Carragee, 2006) MRI abnormalities do not predict poor outcomes after conservative care for chronic low back pain patients. (Kleinstück, 2006) 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 magnetic resonance imaging (MRI) 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) Despite guidelines recommending parsimonious imaging, use of lumbar MRI increased by 307% during a recent 12-year interval. When judged against guidelines, one-third to two-thirds of spinal computed tomography imaging and MRI may be inappropriate. (Deyo, 2009) As an alternative to MRI, a pain assessment tool named Standardized Evaluation of Pain (StEP), with six interview questions and ten physical tests, identified patients with radicular pain with high sensitivity (92%) and specificity (97%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. (Scholz, 2009) Clinical quality-based incentives are associated with less advanced imaging, whereas satisfaction measures are associated with more rapid and advanced imaging, leading Richard Deyo, in the Archives of Internal Medicine to call the fascination with lumbar spine imaging an idolatry. (Pham, 2009) There is support for MRI, depending on symptoms and signs, to rule out serious pathology such as tumor, infection, fracture, and cauda equina syndrome. Patients with severe or progressive neurologic deficits from lumbar disc herniation, or subjects with lumbar radiculopathy who do not respond to initial appropriate conservative care, are also candidates for lumbar MRI to evaluate potential for spinal interventions including injections or surgery. See also ACR Appropriateness Criteria™. See also Standing MRI.
Indications for imaging — Magnetic resonance imaging:
– Thoracic spine trauma: with neurological deficit
– Lumbar spine trauma: trauma, neurological deficit
– Lumbar spine trauma: seat belt (chance) fracture (If focal, radicular findings or other neurologic deficit)
– Uncomplicated low back pain, suspicion of cancer, infection, other “red flags”
– Uncomplicated low back pain, with radiculopathy, after at least 1 month conservative therapy, sooner if severe or progressive neurologic deficit. (For unequivocal evidence of radiculopathy, see AMA Guides, 5th Edition, page 382-383.) (Andersson, 2000)
– Uncomplicated low back pain, prior lumbar surgery
– Uncomplicated low back pain, cauda equina syndrome
– Myelopathy (neurological deficit related to the spinal cord), traumatic
– Myelopathy, painful
– Myelopathy, sudden onset
– Myelopathy, stepwise progressive
– Myelopathy, slowly progressive
– Myelopathy, infectious disease patient
– Myelopathy, oncology patient
Pursuant to the ODG recommendations, repeat MRI’s are indicated only if there has been progression of neurologic deficit. The Claimant testified that his lumbar symptoms have worsened and on October 28, 2009, the treating physician noted “the patient has new onset of radiculopathy which means the nerve roots in his back are being compromised probably S1 nerve roots bilaterally, and he needs an MRI to evaluate this. This MRI is essential so that he can get an injection.” However, the treating doctor provided no explanation regarding his basis for the requested repeat MRI nor has he addressed the concerns raised by the IRO or the recommendations in the ODG for repeat MRI’s, specifically the lack of any neurological deficits as a result of this injury. Based on the evidence presented, Claimant failed to provide evidence based medicine sufficient to contradict the determination of the IRO and the preponderance of the evidence is not contrary to the decision of the IRO.
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
- 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 the (Self-Insured) and sustained a compensable injury.
C.The IRO determined that the requested services were not reasonable and necessary health care services for the compensable injury of ____________.
CONCLUSIONS OF LAW
- The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
- Venue is proper in the (City) Field Office.
- The preponderance of the evidence is not contrary to the decision of the IRO that a lumbar MRI without contrast is not health care reasonably required for the compensable injury of ____________.
DECISION
Claimant is not entitled to a lumbar MRI without contrast 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 §408.021.
The true corporate name of the insurance carrier is CITY OF (CITY) (SELF-INSURED) and the name and address of its registered agent for service of process is:
MAYOR OF THE CITY OF (CITY)
(STREET ADDRESS)
(CITY), TX (ZIP CODE)
Signed this 10th day of March, 2010.
Teresa G. Hartley
Hearing Officer