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. For the reasons discussed herein, the Hearing Officer determines that the preponderance of the evidence-based medical evidence is not contrary to the decision of the Independent Review Organization (IRO) that the Claimant is not entitled to an MRI of the lumbar spine without contrast for the compensable injury of (Date of Injury).
STATEMENT OF THE CASE
A contested case hearing was held on June 13, 2016 by Patrice Fleming-Squirewell, hearing officer, to decide the following disputed issue:
- Is the preponderance of the evidence contrary to the decision of the IRO that the claimant is not entitled to an MRI of the lumbar spine without contrast for the compensable injury of (Date of Injury)?
Petitioner/Claimant appeared and was assisted by SG, ombudsman. Respondent/Carrier appeared and was represented by JL, attorney.
The following witnesses testified:
The following exhibits were admitted into evidence:
Hearing Officer’s Exhibit HO-1
Petitioner/Claimant’s Exhibits C-1 through C-6
Respondent/Carrier’s Exhibits CR-A through CR-F
It was undisputed that the Claimant sustained a compensable lumbar injury on (Date of Injury) while working for (Employer). In 2007, the Claimant underwent an L5-S1 posterior spinal fusion with instrumentation and decompression performed by Dr. VK. On January 21, 2014, the Claimant underwent a lumbar MRI ordered by Dr. VK that was performed by Dr. HH. The only abnormality reflected in the January 21, 2014 MRI report was post-operative changes at L5-S1. Dr. VK states his opinion in an undated letter that the January 21, 2014 MRI was grossly under-read. See Claimant’s Exhibit C-3. On March 11, 2014, Dr. HH re-reviewed the MRI and issued an addendum, maintaining his initial opinion regarding the findings reflected by the test. On May 12, 2014, the Claimant underwent another surgery at L5-S1, including hardware removal, revision laminectomy, facetectomy, foraminotomy, decompression of the L5 and sacral nerve roots, and revision posterior spinal fusion. On July 1, 2015, Dr. VK noted that x-rays showed the fusion to be stable, and that there were sclerotic changes in the S1 joints. Thereafter, on September 29, 2015 and November 24, 2015, Dr. VK noted that the Claimant had worsening back pain.
In December 2015, Dr. VK requested pre-authorization for the Claimant to undergo another lumbar MRI, and this request was denied by two Carrier utilization review agents (URAs). The Carrier denials were upheld by an IRO. The IRO physician reviewer, who is an orthopedic surgeon, reasoned that the Claimant does not meet the Official Disability Guidelines (ODG) for a repeat lumbar MRI since the documentation provided did not show a “…significant change in symptoms and/or findings suggestive of significant pathology after the failure of recommended conservative therapies.” See Petitioner’s Exhibit C-2, p. 4; Respondent’s Exhibit CR-F, p. 4. The IRO physician reviewer based the decision on medical judgment and the recommendations set forth in the ODG.
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 in making decisions about the care of individual patients. 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 the ODG as its treatment guidelines by Division Rule 137.100. This rule directs health care providers to provide treatment in accordance with the current edition of the 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.
The ODG addresses the medical necessity of lumbar MRIs as follows:
Recommended for indications below. MRI’s are test of choice for patients with prior back surgery, but for uncomplicated low back pain, with radiculopathy, not recommended until after at least one month conservative therapy, sooner if severe or progressive neurologic deficit. 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) (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) 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 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) Accurate terms are particularly important for classification of lumbar disc pathology from imaging. (Fardon, 2001) (Fardon, 2014) Among workers with LBP, early MRI is not associated with better health outcomes and is associated with increased likelihood of disability and its duration. (Graves, 2012) 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) MRI with and without contrast is best test for prior back surgery. (Davis, 2011) See also ACR Appropriateness Criteria™. See also Standing MRI.
Recent research: More than half of requests for MRI of the lumbar spine are ordered for indications considered inappropriate or of uncertain value, pointing to evidence of substantial overuse of lumbar spine MRI scans. For family physicians, only 34% of their MRI scans were considered appropriate vs 58% of those ordered by other specialties. On the other hand, the vast majority of MRIs ordered for headaches, 83%, were deemed appropriate. (Emery, 2013) This study casts doubt on the value of post-op spinal imaging for patients with sciatica, because it could not distinguish those with a favorable clinical outcome from those with persistent symptoms. Disk herniation was visible in 35% of patients with a favorable outcome and in 33% with an unfavorable outcome, and nerve root compression was present in 24% of those with a favorable outcome and in 26% of those with an unfavorable outcome. They concluded that the MRI scan does not have any discriminatory power at all. Irrelevant findings have the potential to frighten patients and initiate cascades of unnecessary testing or intervention, with occasional risks. The study showed that neither a herniated disk nor the presence of scar tissue on MRI was associated with patient outcome, but these findings may lead to unnecessary further imaging and surgery. (el Barzouhi, 2013) A JAMA article on worsening trends for low back treatment found that there was an escalation in the use of MRI or CT, from 7.2% in 1999 to 11.3% in 2010, while imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain. The general feeling among physicians was that patients may equate getting MRIs with being synonymous with good medical care, which could drive doctors to try to improve patient satisfaction. (Mafi, 2013) Clinicians should be aware of the diagnostic limitations of MRI as there is significant variability in the interrater and intrarater agreements of MRI in assessing different degenerative conditions of the lumbar spine. (Fu, 2014) The impact of nonadherent early MRI includes a wide variety of expensive and potentially unnecessary services, and occurs relatively soon post-MRI, with early MRI having as much as 55 times the likelihood of advanced imaging, injections, and surgery within six months post-MR. (Webster, 2014)
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.
- 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
- Repeat MRI: When there is significant change in symptoms and/or findings suggestive of significant pathology (eg, tumor, infection, fracture, neurocompression, recurrent disc herniation)
Under the ODG, a repeat lumbar MRI is medically necessary when there is a significant change in symptoms and/or findings suggestive of significant pathology. The record does not establish that this criterion is met. In addition, the IRO physician reviewer noted that no recent (relative to the time frame of the review) clinical documentation was submitted to show that the Claimant’s condition, aside from his complaints of low back pain, warranted another MRI, and that no information was provided to show that the Claimant had undergone recent conservative treatment regarding his low back pain. Such documentation also was not offered into evidence. For these reasons, and after a careful review of the entire record, it is determined that the evidence does not establish that the preponderance of the evidence-based medical evidence is contrary to the IRO decision. It is, therefore, determined that the record does not establish that the requested MRI is health care reasonably required for the Claimant’s compensable (Date of Injury) injury.
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:
A.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
B.On (Date of Injury), Claimant was the employee of (Employer), Employer.
C.On (Date of Injury), Employer had workers' compensation insurance coverage with (Carrier), Carrier.
D.On (Date of Injury), the Claimant sustained a compensable lumbar injury while in the course and scope of his employment with (Employer).
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 the Claimant is not entitled to an MRI of the lumbar spine without contrast for the compensable injury of (Date of Injury).
The Claimant is not entitled to an MRI of the lumbar spine without contrast for the compensable injury of (Date of Injury).
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 Section 408.021 of the Act.
The true corporate name of the insurance carrier is (Carrier), and the name and address of its registered agent for service of process is
C T CORPORATION SYSTEM
1999 BRYAN STREET, STE. 900
DALLAS, TX 75201
Signed this 28th day of June, 2016.