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.
A contested case hearing was held on June 01, 2010, to decide the following issue:
Is the preponderance of the evidence contrary to the Medical Fee Dispute Resolution decision that Petitioner is not entitled to additional reimbursement in the amount of $848.64 plus applicable accrued interest per Section 408.027(a)?
Petitioner appeared and was represented by GB, lay representative. Carrier/Respondent appeared and was represented by attorney RJ. The record was held open until June 07, 2010, for the parties to submit written briefs on their respective positions.
Petitioner received a referral from Claimant’s doctor requesting an MR arthrogram of the left knee. On April 08, 2009, Petitioner received an authorization from (Company) The requested service was “Radiologic examination, knee, arthrography, radiological supervision and interpretation.” A service date was given, the setting was “outpatient” and under additional information was noted “MR Arthrogram of the left knee.” The arthrogram injection was performed on April 24, 2009, and, on that same date, Claimant was then transferred for the MRI, which was also performed. The MRI knee with contrast post arthrogram-left was then performed. On June 15, 2009, the CMS-1500 was billed to Carrier using the procedure code 73722 LT. As noted in the Official Disability Guidelines, the CPT code 73722is listed as “MRI joint of lwr extr w/dye Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)”. (Italics in the original.) In Box 23 of the CMS-1500 is the authorization code number 090860373S001002, as noted on the pre-authorization letter dated April 08, 2009.
The Carrier paid for the arthrogram but not for the post-arthrogram MRI. At dispute is the payment for the post-arthrogram MRI in the amount of $848.64. The Petitioner is relying upon the letter dated April 08, 2009, wherein the Carrier authorizes the MR arthrogram. The Petitioner contends the arthrogram and post-arthrogram MRI are inclusive procedures. The Petitioner argues one cannot do an arthrogram and not do the post-arthrogram MRI and the procedures, when done together, are billed together under the code 73722. (Incidentally, the CPT code for only an arthrography of the knee is 73580. It does not include an MRI. The CPT code for an MRI without contrast is 73718. The term "MR arthrogram" specifically means the performance of an MRI scan after the injection of contrast.) The Petitioner argues by authorizing the MR arthrogram, the Carrier by definition authorized the post-arthrogram MRI. The Carrier relies upon two pre-authorization requests, dated April 01, 2009, and April 08, 2009, stating unequivocally it was not authorizing an MRI but it was authorizing the MR arthrogram. The explanation code given on the Explanation of Procedure (EOP) was, “X388 Pre-authorization was requested but denied for this service per DWC Rule 134.600.”
The Medical Fee Dispute officer made findings that a repeated individual diagnostic study with a reimbursement rate greater than $350 required pre-authorization. She also found the Carrier denied the MRI of the left knee but approved the MR arthrogram of the left knee. Her Conclusion was the Requestor/Petitioner failed to establish reimbursement was due.
At the beginning it should first be noted exactly what an MR arthrogram procedure entails:
Intraarticular contrast material was injected by one of four radiologists: two staff physicians (M.Z., J.H.), a 2nd-year fellow in musculoskeletal imaging (C.A.B.), or a 1st-year fellow. One milliliter of mepivacaine hydrochloride (Scandicain 2%; AstraZeneca, Södertälje, Sweden) was used to anesthetize the skin, the joint capsule, and the intraarticular space. With use of fluoroscopic control, a 20-gauge needle was advanced to the medial aspect of the upper third of the humeral head (Fig 2). The intraarticular position of the needle tip was confirmed with injection of 1 mL of iopamidol (Iopamiro 200; Bracco, Milan, Italy) followed by 10 mL of 2 mmol/L gadoteridol (ProHance; Bracco).
MR imaging was performed by using a 1.0-T unit (Siemens Expert; Siemens Medical Systems, Erlangen, Germany) with a dedicated receive-only shoulder coil. The MR imaging protocol included T1-weighted transverse imaging (580/20 [repetition time msec/echo time msec], 4-mm-thick sections, a 140 × 160-mm field of view, and a 224 × 512 matrix), T1-weighted parasagittal imaging (700/12, 5-mm-thick sections, a 160 × 160-mm field of view, and a 192 × 256 matrix), angled coronal dual-echo spin-echo imaging (3,500/14, 85; 4-mm-thick sections; a 184 × 210-mm field of view; and a 230 × 512 matrix), and T1-weighted fat-suppressed imaging (800/20, 4-mm-thick sections, a 160 × 160-mm field of view, and a 192 × 256 matrix).
Robbins MI, Anzilotti KF, Katz LD, et al. Patient perception of magnetic resonance arthrography. Skeletal Radiol 2000; 29:265–269.
The medical literature above is taken as a source relied upon by the Official Disability Guidelines. It supports the Petitioner’s position that an MR arthrogram by definition is an arthrogram with an MRI.
On April 01, 2009, Carrier did its initial utilization review for the requested procedure. The treatment/service requested as indicated is MRI, any joint of lower extremity, with contrast materials. Under the listed item “Discussion” the requested service indicates two diagnostic tests: “MRI of the left knee, MR Arthrogram of the left knee”. For this initial utilization review it is noted there was no peer discussion with the doctor, despite being requested many times. “Without the benefit of a peer discussion…the MRI of the left knee and the MR arthrogram cannot be recommended…” (R4p1.) The reviewer based his/her opinion on the Official Disability Guidelines.
On April 07, 2010, a Physician Review Recommendation (PRR) was completed by the Carrier’s doctor. (R4p3.) The reason for the referral is noted as: 1. MRI of the knee, 2. MR arthrogram of the left knee. The “Recommendation” noted was the following: 1. Adverse determination – MRI of the left knee; 2. Approval – MR Arthrogram of the left knee.
The PRR noted, “Dr. C recommended a left knee MRI, Celebrex and continuation of physical therapy. Dr. C saw the claimant on 03/25/09 and examination was unchanged. The requested MRI arthrogram of the knee may be reasonable given the medical records provided.” (Emphasis added.) The PRR continued by stating, “The claimant had previous meniscal surgery and would fulfill typical Official Disability Guidelines criteria for MR arthrogram….The left knee MRI would not be medically necessary in light of the fact the MR arthrogram is recommended.”
Based upon the PRR, Carrier wrote its response to the request for review in two letters dated April 08, 2009. In one of its letters it denied the MRI where it quoted from the PRR, “The claimant had previous meniscal surgery and would fulfill typical Official Disability Guidelines criteria for an MR arthrogram…. The left knee MRI would not be medically necessary in light of the fact the MR arthrogram is recommended.” (R4p5) Also based upon the PRR, Carrier wrote a separate letter/response to (Healthcare Provider) on April 08, 2009. (Petitioner’s one page exhibit.) It notes the non-authorization had been overturned. It notes the Treatment/Service request: Radiologic examination, knee, arthrography, radiological supervision and interpretation. Under that it also notes “Additional information: MR arthrogram of the left knee.”
Based upon one of the April 08, 2009, authorization letters from Carrier, (Healthcare Provider) performed an MR arthrogram of Claimant’s left knee. (Healthcare Provider) did not do a lone MRI of the left knee. That was not authorized, as written in the second letter from Carrier, and Carrier would be correct in not paying for a procedure that was not authorized. However, that is not what (Healthcare Provider) did. (Healthcare Provider) performed an MR arthrogram. This is a two-part procedure consisting of an arthrogram with a follow-up post-arthrogram MRI -- a special type of MRI in which a dye is injected into the knee to see more detail of the joint. (See Magee T, Shapiro M, Rodriguez J, Williams D. MR arthrography of postoperative knee: for which patients is it useful? Radiology. 2003 Oct; 229(1):159-63, 160. This is the study the Official Disability Guidelines uses to support the use of MR arthrograms.) On R4p3, Dr. W wrote, “The requested MRI arthrogram of the knee may be reasonable given the medical records provided.” (Emphasis added.) He later writes, “The left knee MRI would not be medically necessary in light of the fact the MR arthrogram is recommended.”
The Official Disability Guidelines, which the URA and Dr. W rely upon, separates MR arthrogram from a basic MRI; just as Dr. W did on the PRR when he denied the MRI of the left knee and approved the MR arthrogram of the left knee. Based upon Dr. W’s approval, the Carrier authorized the MR arthrogram. Based upon the Official Disability Guidelines, this was the correct procedure of the two requested. “MR arthrogram” is the abbreviation for magnetic resonance arthrogram. By definition, this will include the MRI after the arthrogram study is performed, as Dr. W opines is reasonable, and Magee (2003) describes.
In the instant case, Petitioner properly performed and billed for an MR arthrogram for services rendered on April 24, 2009, and provided evidence Carrier authorized this procedure, which is inclusive of the arthrogram and post-arthrogram MRI, per Dr. W and the authorization letter dated April 08, 2009. Petitioner met its burden of proof by a preponderance of the evidence and is entitled to be reimbursed for an MR arthrogram for the amount of $848.64 it seeks.
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.
- On ________________, Claimant was an employee of (Self-Insured), and sustained a compensable injury.
- C.Medical Fee Dispute Resolution officer found Petitioner was not entitled to reimbursement in the amount of $848.64 for services rendered on April 24, 2009, coded as 73722.
2.Carrier delivered to Petitioner 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.
- Petitioner performed an MR arthrogram on Claimant on April 24, 2009, under the coding 73722 “MRI joint of lower extremity with dye” that consists of an arthrogram and the post-arthrogram MRI.
- Petitioner’s claim for the withheld $848.64 was submitted with a pre-authorization letter identifying approval of the MR arthrogram (which includes an arthrogram and a post-arthrogram MRI) as required in accordance with Rule 134.600.
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 Health Care Provider is entitled to reimbursement in the amount of $848.64, plus accrued interest for services rendered on April 24, 2009.
The preponderance of the evidence is contrary to the Medical Fee Dispute resolution. The Health Care Provider is entitled to reimbursement in the amount of $848.64, plus accrued interest for services rendered on April 24, 2009.
Carrier/Respondent is liable for the reimbursement 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 (SELF-INSURED) and the name and address of its registered agent for the service of process is:
(CITY), TX (ZIP CODE)
Signed this 15th day of June, 2010.