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At a Glance:
February 2, 2012


February 2, 2012


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 January 19, 2012, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that the claimant is not entitled to an MRI of the lumbar spine for the compensable injury on (Date of Injury)?


The petitioner/claimant appeared and was assisted by LS, ombudsman. The carrier/respondent appeared and was represented by PB, attorney.


The claimant sustained her low back injury in September, 2005 when, as a kindergarten teacher, she attempted to pick up an unruly child. She had a hemilaminectomy with a partial facetectomy approximately a year later at the L5-S1 level of her lumbar spine. According to the information provided to the IRO for review, the claimant has already had three lumbar MRIs. One pre-surgery in January, 2007, one immediately post-surgery in September, 2007, and a third in March, 2008. In or about July, 2011, Dr. F, M.D., the claimant's treating doctor, requested a new lumbar MRI due to the ongoing pain the claimant has experienced since Dr. F performed the surgery in 2007.

The first utilization review doctor denied Dr. F’s request on the basis that there was an “absence of neurologic deficits” reflected in the medical records presented for his review. The utilization review doctor who reviewed the request on reconsideration, an orthopedic surgeon, upheld the denial in August, 2011. He noted that the last documented physical exam of the claimant by Dr. F was in April, 2008. He opined that a thorough physical examination should be documented prior to the request for a significant diagnostic study, such as an MRI, in order to document objectified clinical findings of neurologic deficits.

An IRO reviewer, identified as an orthopedic surgeon, upheld the carrier’s denial of a repeat lumbar MRI. As did the two utilization review doctors, the IRO reviewer based his decision on the absence of medical evidence that would support a finding that the claimant had a progressive neurologic deficit, as well as the absence of a recent physical examination to correlate clinical findings with the claimant's subjective complaints.


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."

On the date of this medical contested case hearing, the ODG provides the following with regard to MRIs:

Recommended for indications below. MRI’s are test of choice for patients with prior back surgery. Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology (e.g., tumor, infection, fracture, neurocompression, recurrent disc herniation). (Bigos, 1999) (Mullin, 2000) (ACR, 2000) -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) Primary care physicians are making a significant amount of inappropriate referrals for CT and MRI, according to new research published in the Journal of the American College of Radiology. There were high rates of inappropriate examinations for spinal CTs (53%), and for spinal MRIs (35%), including lumbar spine MRI for acute back pain without conservative therapy. (Lehnert, 2010) Degenerative changes in the thoracic spine on MRI were observed in approximately half of the subjects with no symptoms in this study. (Matsumoto, 2010) This large case series concluded that iatrogenic effects of early MRI are worse disability and increased medical costs and surgery, unrelated to severity. (Webster, 2010) Routine imaging for low back pain is not beneficial and may even be harmful, according to new guidelines from the American College of Physicians. Imaging is indicated only if they have severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition, or if they are candidates for invasive interventions. Immediate imaging is recommended for patients with major risk factors for cancer, spinal infection, cauda equina syndrome, or severe or progressive neurologic deficits. Imaging after a trial of treatment is recommended for patients who have minor risk factors for cancer, inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. Subsequent imaging should be based on new symptoms or changes in current symptoms. (Chou, 2011) The National Physicians Alliance compiled a "top 5" list of procedures in primary care that do little if anything to improve outcomes but excel at wasting limited healthcare dollars, and the list included routinely ordering diagnostic imaging for patients with low back pain, but with no warning flags, such as severe or progressive neurologic deficits, within the first 6 weeks. (Aguilar, 2011) Owning MRI equipment is a strongly correlated with patients receiving MRI scans, and having an MRI scan increases the probability of having surgery by 34%. (Shreibati, 2011) A considerable proportion of patients may be classified incorrectly by MRI for lumbar disc herniation, or for spinal stenosis. Pooled analysis resulted in a summary estimate of sensitivity of 75% and specificity of 77% for disc herniation. (Wassenaar, 2011) (Sigmundsson, 2011) 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. For unequivocal evidence of radiculopathy, see AMA Guides. (Andersson, 2000) See also ACRAppropriateness Criteria™. See also Standing MRI.

Indications for imaging -- Magnetic resonance imaging:

  • - horacic 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.
  • -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

Both parties testified that they had experienced difficulties obtaining records from Dr. F’s office. In light of the primary basis for the utilization reviewers’ and the IRO reviewer’s decision, the record was held open for a week following the hearing to allow the claimant the opportunity she requested to obtain any records from Dr. F that were not in the exhibits offered at the hearing. No further records were presented and the record was closed on January 27, 2012.

Based on a careful review of the evidence presented in the hearing, the claimant failed to meet her burden of overcoming the IRO decision by a preponderance of the evidence-based medicine. The IRO decision in this case is based on the ODG and the evidence revealed that the claimant failed to meet all of the necessary criteria for an MRI of the lumbar spine prescribed in the ODG. The preponderance of the evidence-based medicine is not contrary to the decision of the IRO and, consequently, the claimant is not entitled to the proposed MRI of the lumbar spine.

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.


  1. The parties stipulated to the following facts:
    1. Venue is proper in the (City) Field Office of the Workers’ Compensation Division of the Texas Department of Insurance.
    2. On (Date of Injury), the claimant was the employee of (Employer), Employer.
    3. On (Date of Injury), the employer provided workers’ compensation insurance as a Self-Insurer.
    4. On (Date of Injury), the claimant sustained a compensable injury to her lumbar spine.
    5. The IRO determined that the claimant is not entitled to an MRI of the lumbar spine.

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

  • An MRI of the lumbar spine is not health care reasonably required for the compensable injury of (Date of Injury).

    1. The Workers’ Compensation Division of the Texas Department of Insurance 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 an MRI of the lumbar spine is not health care reasonably required for the compensable injury of (Date of Injury).


    The claimant is not entitled to an MRI of the lumbar spine.


    The carrier is not liable for the benefits at issue in this hearing. The claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

    The true corporate name of the insurance carrier is WORKERS COMPENSATION SOLUTIONS, and the name and address of its registered agent for service of process is:


    4531 US HIGHWAY 271 SOUTH

    BOGATA, TX 75417

    Signed this 2nd day of February, 2012.

    William M. Routon, II
    Hearing Officer

    End of Document