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At a Glance:
Title:
17014-nnr
Date:
November 13, 2017

17014-nnr

November 13, 2017

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. For the reasons discussed herein, the Administrative Law Judge determines that an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast is not health care reasonably required for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

A contested case hearing was held on November 6, 2017 by a Division administrative law judge, Francisca Okonkwo, 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 an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Claimant appeared and was represented by FC, attorney. Carrier appeared and was represented by MA, attorney.

EVIDENCE PRESENTED

No witness testified.

The following exhibits were admitted into evidence:

Administrative Law Judge’s Exhibits ALJ-1 through ALJ-3.

Claimant’s Exhibits C-1 through C-5.

Carrier’s Exhibits CR-A through CR-C.

DISCUSSION

The record reflects that Claimant worked as a flight attendant and sustained injury to her lumbar and cervical spine when she fell down some stairs while exiting a crew bus on (Date of Injury). Claimant received conservative treatment in the form of prescription medications, physical therapy and a work hardening program. She was evaluated by an orthopedic specialist and spine surgery has not been recommended. The record shows that Claimant underwent one cervical epidural steroid injection (ESI) and three lumbar ESIs with minimal pain relief. The record also shows that Claimant continued to complain of pain and radicular symptoms.

On May 15, 2017, JB, MD, ordered an MRI of Claimant’s cervical and lumbar spine to evaluate for any underlying pathology. Carrier denied the request and Specialty Independent Review Organization (IRO) performed an independent review of the proposed care to determine if the adverse determination was appropriate. The reviewer, a Medical Doctor, reviewed the medical records and documentation provided and upheld the denial. The IRO reviewer relied on the Official Disability Guidelines (ODG), the AMA Guides to the Evaluation of Permanent Impairment, and on the reviewer's medical judgment, clinical experience and expertise in accordance with accepted medical standards. The reviewer found that there was no documentation of any lumbar symptoms beyond local tenderness of the thoracolumbar junction, no documentation of any restrictions in lumbar range of motion, no documentation of any neurological deficit, functional limitations or any objective finding beyond painful cervical flexion. Claimant disagrees with the IRO decision that upheld Carrier's denial of an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast.

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.”

With regard to an MRI of the lumbar spine without contrast, the ODG lists the following criteria:

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 of 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 (e.g., tumor, infection, fracture, neurocompression, recurrent disc herniation)

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 disc is found on magnetic resonance imaging in 9% to 76% of asymptomatic patients; bulging discs, in 20% to 81%; and degenerative discs, 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 meta-analysis of randomized trials found no benefit to routine lumbar imaging (radiography, MRI, or CT) for low back pain without indications of serious underlying conditions, and the researchers recommended 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 to competing demands for physicians. (Pham, 2009) Primary care physicians are making a significant number 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 severe progressive neurologic impairments or signs or symptoms indicating a serious or specific underlying condition are present, or if the patient is a candidate 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) 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. (Roudsari, 2010) For unequivocal evidence of radiculopathy, see AMA Guides. (Andersson, 2000) MRI with and without contrast is best test for prior back surgery. (Davis, 2011)

With regard to an MRI of the cervical spine without contrast, the ODG lists the following criteria:

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

  • -Chronic neck pain (after 3 months of 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
  • -Upper back/thoracic spine trauma with neurological deficit

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)

Based on the outlined criteria, the IRO found that an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast are not indicated. After a careful review of all of the evidence presented, Claimant has not shown that the preponderance of the evidence based medical evidence is contrary to the IRO decision.

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.

FINDINGS OF FACT

  1. The parties stipulated to the following facts:
    1. The Texas Department of Insurance, Division of Workers’ Compensation has jurisdiction in this matter.
    2. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
    3. On (Date of Injury), Claimant was the employee of (Employer), Employer.
    4. On (Date of Injury), Employer provided worker’s compensation insurance through New Hampshire Insurance Company, Carrier.
    5. Claimant sustained a compensable injury on (Date of Injury).
    6. The Independent Review Organization determined that claimant should not have an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast.
  2. 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 Administrative Law Judge’s Exhibit Number 2.
  3. The preponderance of the evidence is not contrary to the decision of the IRO that an MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast 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 has not shown that the preponderance of the evidence based medical evidence is contrary to the IRO decision.
  4. An MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast is not health care reasonably required for the compensable injury of (Date of Injury).

DECISION

An MRI of the lumbar spine without contrast and an MRI of the cervical spine without contrast is not health care reasonably required for the compensable injury of (Date of Injury).

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 NEW HAMPSHIRE INSURANCE 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

Signed this 13th day of November, 2017.

FRANCISCA OKONKWO
Administrative Law Judge

End of Document
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