DECISION AND ORDER
This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and the Rules of the Texas Department of Insurance, Division of Workers’ Compensation. For the reasons discussed herein, the Hearing Officer determines that the preponderance of the evidence is not contrary to the decision of the Independent Review Organization (IRO) that claimant is not entitled to cervical spine x-rays.
STATEMENT OF THE CASE
On October 1, 2015, Britt Clark, a Division hearing officer, held a contested case hearing to decide the following disputed issue:
Is the preponderance of the evidence contrary to the decision of the IRO that claimant is not entitled to cervical spine x-rays?
Claimant appeared and was assisted by ED, ombudsman. Carrier appeared and was represented by TL, adjuster.
No witnesses testified.
The following exhibits were admitted into evidence:
Hearing Officer’s Exhibits HO-1 and HO-2.
Claimant’s Exhibits C-1 through C-4.
Carrier’s Exhibits CR-A through CR-F.
It is undisputed that Claimant sustained a compensable injury to her cervical spine on (Date of Injury) Claimant’s neurosurgeon, Dr. JR, requested preauthorization for cervical spine x-rays. Carrier’s utilization review agent (URA) doctors denied the request. The IRO doctor agreed with the denial. Claimant is disputing the IRO decision and relied on the opinion of Dr. R to establish that the preponderance of the evidence is contrary to the decision of the IRO.
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(s), "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 Official Disability Guidelines provides the following with regard to the radiography (x-rays) of the cervical spine:
Not recommended except for indications 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™. Initial studies may be warranted only when potentially serious underlying conditions are suspected like fracture or neurologic deficit, cancer, infection or tumor. (Bigos, 1999) (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) There is little evidence that diagnostic procedures for neck pain without severe trauma or radicular symptoms have validity and utility. (Haldeman, 2008)
Indications for imaging -- X-rays (AP, lateral, etc.):
- -Cervical spine trauma, unconscious
- -Cervical spine trauma, impaired sensorium (including alcohol and/or drugs)
- -Cervical spine trauma, multiple trauma and/or impaired sensorium
- -Cervical spine trauma (a serious bodily injury), neck pain, no neurological deficit
- -Cervical spine trauma, alert, cervical tenderness, paresthesias in hands or feet
- -Cervical spine trauma, alert, cervical tenderness
- -Chronic neck pain (= after 3 months conservative treatment), patient younger than 40, no history of trauma, first study
- -Chronic neck pain, patient younger than 40, history of remote trauma, first study
- -Chronic neck pain, patient older than 40, no history of trauma, first study
- -Chronic neck pain, patient older than 40, history of remote trauma, first study
- -Chronic neck pain, patients of any age, history of previous malignancy, first study
- -Chronic neck pain, patients of any age, history of previous remote neck surgery, first study
- -Post-surgery: evaluate status of fusion
The IRO doctor went through the ODG and explained why Claimant did not meet the requirements for this treatment. Two utilization review doctors on behalf of the Carrier had the same opinion. To rebut the IRO, Claimant provided several letters from requesting cervical spine x-rays. Dr. R opined that claimant had neurological findings which justify the need for cervical spine x-rays. He states an x-ray should be performed before a more invasive objective test. Although he indicates that the proposed treatment is consistent with the ODG, it appears he is basing that opinion on his own opinion regarding the best course of treatment and not citation to the ODG itself. There was no other evidence-based medical studies cited by Dr. R.
The most persuasive evidence came from Dr. RA, M.D., one of the Carrier’s URA doctors, who explained that it was unclear as to why x-rays were being requested as opposed to a more detailed imaging study or a nerve conduction study if the Claimant was having changing or worsened neurological symptoms. Dr. A’s analysis is supported by the ODG. Dr. R does not provide a persuasive explanation to rebut Dr. A’s concern, and his letters as a whole do not show that the requested treatment is in conformity with the ODG, or that evidence-based medicine supports that request. After review of the evidence, the preponderance of the evidence is not contrary to the opinion of the IRO. Therefore, Claimant is not entitled the requested cervical spine x-rays.
The Hearing Officer considered all of the evidence admitted. The Findings of Fact and Conclusions of Law are based on an assessment of all of the evidence whether or not the evidence is specifically discussed in this Decision and Order.
FINDINGS OF FACT
- The parties stipulated to the following facts:
- Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
- On June 24, 2003, June 24, 2003, Claimant was the employee of the (Employer) Employer.
- On (Date of Injury), Employer provided workers compensation insurance through merged Royal Insurance Company of America Into ARR, Carrier.
- On (Date of Injury), Claimant sustained a compensable injury.
- 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.
- Cervical spine x-rays are not health care reasonably required for the compensable injury of (Date of Injury).
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 claimant is not entitled to cervical spine x-rays.
The preponderance of the evidence is not contrary to the decision of the IRO that claimant is not entitled to claimant is not entitled to cervical spine x-rays.
Carrier is not liable for the benefits at issue in this hearing, and it is so ordered. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.
The true corporate name of the insurance carrier is MERGED ROYAL INSURANCE CO. OF AMERICA INTO ARR, and the name and address of its registered agent for service of process is
9300 ARROWPOINT BLVD.
CHARLOTTE, NC 78232-2029
Signed this 7th day of October, 2015.