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At a Glance:
Title:
16031-nr
Date:
June 28, 2016
Type:

16031-nr

June 28, 2016

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 determined that Claimant/Petitioner timely appealed the IRO decision. The Hearing Officer also determined that Claimant/Petitioner is not entitled to a CT Myelogram for the lumbar spine for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

On June 28, 2016, Gerri Thomas, a Division hearing officer, held a contested case hearing to decide the following disputed issues:

  1. Is the preponderance of the evidence contrary to the decision of the IRO that the Claimant is not entitled to a CT Myelogram for the lumbar spine?
  2. Did the Claimant/Petitioner timely appeal the IRO decision?

PARTIES PRESENT

Claimant/Petitioner appeared and was assisted by RB, ombudsman. Carrier/Respondent appeared and was represented by BJ, attorney.

DISCUSSION

Medical Necessity

Evidence Based Medicine (EBM)

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 lumbar CT Myelograms:

Not recommended except for selected indications below, when MR imaging cannot be performed, or in addition to MRI. Myelography and CT Myelography OK if MRI unavailable, contraindicated (e.g. metallic foreign body), or inconclusive. (Mukherji, 2009)

ODG Criteria for Myelography and CT Myelography:

  1. Demonstration of the site of a cerebrospinal fluid leak (postlumbar puncture headache, postspinal surgery headache, rhinorrhea, or otorrhea).
  2. Surgical planning, especially in regard to the nerve roots; a myelogram can show whether surgical treatment is promising in a given case and, if it is, can help in planning surgery.
  3. Radiation therapy planning, for tumors involving the bony spine, meninges, nerve roots or spinal cord.
  4. Diagnostic evaluation of spinal or basal cisternal disease, and infection involving the bony spine, intervertebral discs, meninges and surrounding soft tissues, or inflammation of the arachnoid membrane that covers the spinal cord.
  5. Poor correlation of physical findings with MRI studies.
  6. Use of MRI precluded because of:

a.Claustrophobia

b.Technical issues, e.g., patient size

c.Safety reasons, e.g., pacemaker

d.Surgical hardware

The parties stipulated that Claimant’s compensable injury of (Date of Injury), extends to include a low back sprain/strain and L4-L5 disc herniation/extrusion. Claimant/Petitioner testified that he sustained a compensable injury to his lower back on (Date of Injury), when he slipped and fell backwards while carrying a heavy box. Claimant underwent a lumbar discectomy surgery in January of 2012. On May 13, 2014, Claimant underwent a lumbar fusion surgery at L4/L5. Claimant testified that his lower back pain continued despite surgical intervention.

Pre-authorization was requested for a CT Myelogram of Claimant’s lumbar spine. On February 15, 2016, a reviewing physician advisor, VD, D.O., recommended non-certification of the requested CT Myelogram. On March 16, 2016, another utilization review physician, LK, M.D., also recommended non-certification of the requested CT Myelogram for Claimant’s lumbar spine.

In an IRO dated April 20, 2016, the IRO Reviewer upheld the previous denials. Specifically, the IRO reviewer noted the following:

… there was lack of clinical documentation submitted for review indicating a rationale at the requested juncture. There was also lack of clinical documentation indicating the patient had clinical findings of cerebrospinal fluid leak, would be undergoing surgical or radiation therapy planning, or required evaluation for spinal basal or cisternal disease and infection. In addition, there was lack of clinical documentation indicating the patient would be undergoing surgical intervention. Based on the above, the request is not supported at this time. Therefore, the denial for a CT myelogram is upheld.

As such, the IRO Reviewer recommended that the previous adverse determinations be upheld.

Claimant/Petitioner relied on his testimony and the totality of his medical to support his position regarding the issues in dispute. Carrier offered testimony BS, M.D., to support its position that the IRO decision should be upheld in this case. Dr. BS testified that he agreed with the prior denials in this case.

The evidence offered did not provide a persuasive explanation through the use of evidence-based medical evidence as to how Claimant/Petitioner met the requirements of ODG for the requested CT Myelogram for the lumbar spine. Claimant/Petitioner also did not establish the necessity of the requested CT Myelogram for the lumbar spine at issue through other evidence-based medical evidence. As such, insufficient evidence-based medical evidence existed to explain that the requested CT Myelogram for the lumbar spine was medically reasonable and necessary. Therefore, the preponderance of the evidence is not contrary to the decision of the IRO that Claimant/Petitioner is not entitled to a CT Myelogram for the lumbar spine.

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

  1. The parties stipulated to the following facts:

A.The Texas Department of Insurance, Division of Workers’ Compensation has jurisdiction to hear this matter.

B.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.

C. On (Date of Injury), Claimant/Petitioner was the employee of (Employer), Employer.

D.On (Date of Injury), Employer provided workers’ compensation insurance with (Carrier), Carrier/Respondent.

E.On (Date of Injury), Claimant/Petitioner sustained a compensable injury.

F.The compensable injury of (Date of Injury), extends to include a low back sprain/strain and L4-L5 disc herniation/extrusion.

G.The Independent Review Organization determined that Claimant/Petitioner should not have the requested treatment of a CT Myelogram for the lumbar spine.

H.Claimant/Petitioner filed his appeal of the decision of the IRO on April 29, 2016, which was timely.

  • Carrier/Respondent delivered to Claimant/Petitioner a single document stating the true corporate name of Carrie/Respondent, and the name and street address of Carrier/Respondent’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.
  • Based on the evidence offered, a CT Myelogram for the lumbar spine is not health care reasonably required for the compensable injury of (Date of Injury).
  • 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. Claimant/Petitioner timely appealed the IRO decision.
    4. The preponderance of the evidence is not contrary to the decision of the IRO that Claimant is not entitled to a CT Myelogram for the lumbar spine.

    DECISION

    Claimant/Petitioner timely appealed the IRO decision. Claimant/Petitioner is not entitled to a CT Myelogram for the lumbar spine for the compensable injury of (Date of Injury).

    ORDER

    Carrier/Respondent is not liable for the benefits at issue in this hearing. Claimant/Petitioner remains entitled to medical benefits for the compensable injury in accordance with § 408.021.

    The true corporate name of the insurance carrier is (Carrier), and the name and address of its registered agent for service of process is:

    RICHARD J. GERGASKO

    TEXAS MUTUAL INSURANCE COMPANY

    6210 EAST HIGHWAY 290

    AUSTIN, TEXAS 78723

    Signed this 28th day of June, 2016.

    Gerri Thomas
    Hearing Officer

    End of Document
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