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At a Glance:
Title:
11009
Date:
September 23, 2010
Status:
Concurrent Medical Necessity

11009

September 23, 2010

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.

ISSUE

A contested case hearing was held on September 22, 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 a repeat cervical MRI study, without contrast, for the compensable injury of ______________?

PARTIES PRESENT

Claimant appeared, and was assisted by Ombudsman BO; Carrier appeared, and was represented by Attorney DP.

BACKGROUND INFORMATION

Claimant, a flight attendant, sustained the injury made the basis of this case when the aircraft encountered unexpected turbulence, causing her to fall.

Dr. S, Claimant’s treating doctor, testified, acknowledging that Claimant does not meet the criteria set forth in the Official Disability Guidelines (ODG) for the proposed repeat MRI study. However, he noted that the contents of the ODG are simply guidelines, and that it is medically advisable for Claimant to undergo another MRI study in order to ensure her ability to return to work safely.

DISCUSSION

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(22-a) 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(18-a) 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, and 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. 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."

With regard to a cervical MRI study, the ODG states as follows:

Not recommended except for indications list below. Patients who are alert, have never lost consciousness, are not under the influence of alcohol and/or drugs, have no distracting injuries, have no cervical tenderness, and have no neurologic findings, do not need imaging. Patients who do not fall into this category should have a three-view cervical radiographic series followed by computed tomography (CT). In determining whether or not the patient has ligamentous instability, magnetic resonance imaging (MRI) is the procedure of choice, but MRI should be reserved for patients who have clear-cut neurologic findings and those suspected of ligamentous instability. (Anderson, 2000) (ACR, 2002) See also ACR Appropriateness Criteria™. MRI imaging studies are valuable when physiologic evidence indicates tissue insult or nerve impairment or potentially serious conditions are suspected like tumor, infection, and fracture, or for clarification of anatomy prior to surgery. MRI is the test of choice for patients who have had prior back surgery. (Bigos, 1999) (Bey, 1998) (Volle, 2001) (Singh, 2001) (Colorado, 2001) For the evaluation of the patient with chronic neck pain, plain radiographs (3-view: anteroposterior, lateral, open mouth) should be the initial study performed. Patients with normal radiographs and neurologic signs or symptoms should undergo magnetic resonance imaging. If there is a contraindication to the magnetic resonance examination such as a cardiac pacemaker or severe claustrophobia, computed tomography myelography, preferably using spiral technology and multiplanar reconstruction is recommended. (Daffner, 2000) (Bono, 2007)

Indications for imaging -- MRI (magnetic resonance imaging):

- Chronic neck pain (= after 3 months conservative treatment), radiographs normal, neurologic signs or symptoms present

- Neck pain with radiculopathy if severe or progressive neurologic deficit

- Chronic neck pain, radiographs show spondylosis, neurologic signs or symptoms present

- Chronic neck pain, radiographs show old trauma, neurologic signs or symptoms present

- Chronic neck pain, radiographs show bone or disc margin destruction

- Suspected cervical spine trauma, neck pain, clinical findings suggest ligamentous injury (sprain), radiographs and/or CT "normal"

- Known cervical spine trauma: equivocal or positive plain films with neurological deficit

As noted above, Claimant, as the party appealing the IRO decision, bears the burden of overcoming that decision by the preponderance of evidence-based medical evidence; the terms “medical evidence” and “evidence-based medicine” are not synonymous, and must remain carefully distinguished from one another.

Dr. S’s testimony in support of Claimant’s position consisted solely of his professional opinion, which is medical evidence, but is not evidence-based medicine. Since Claimant has not presented evidence-based medical evidence in support of her position, it must be determined that Claimant has not met her burden of proof to overturn the IRO’s decision, and a decision in Carrier’s favor therefore must be entered as to the sole issue presented for resolution herein.

Even though all the evidence presented may not have been discussed in detail, it was considered; the Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

  1. On ______________, Claimant was employed by (Employer).
  2. On ______________, Employer subscribed to a policy of workers' compensation insurance issued by the American Home Assurance Company, Carrier.
  3. On ______________, Claimant's residence was located within seventy-five miles of the (City) office of the Texas Department of Insurance, Division of Workers' Compensation.
  4. 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.
  5. On ______________, Claimant sustained damage or harm to the physical structure of her body while she was within the course and scope of her employment with Employer.
  6. The injury referenced in the previous Finding of Fact arose out of Claimant's employment with Employer.
  7. A repeat cervical MRI, without contrast, is not health care reasonably required for Claimant’s 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-based medicine is not contrary to the decision of the Independent Review Organization that a repeat cervical MRI, without contrast, is not health care reasonably required for Claimant’s compensable injury of ______________.

DECISION

Claimant is not entitled to a repeat cervical MRI, without contrast, for her 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 AMERICAN HOME ASSURANCE COMPANY, and the name and address of its registered agent for service of process is

CORPORATION SERVICE COMPANY

211 EAST 7TH STREET, SUITE 620

AUSTIN, TEXAS 78701-3232

Signed this 23rd day of September, 2010.

Ellen Vannah
Hearing Officer

End of Document
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