The claimant appealed the decision of the Independent Review Organization in Case Number ________.
The hearing for this appeal was held on November 30, 2020. For the reasons discussed below, the administrative law judge decides the claimant is not entitled to magnetic resonance imaging (MRI) for the right knee with out contrast for the compensable injury sustained on (Date of Injury).
At the hearing, Teresa G. Hartley, an administrative law judge, considered the following unresolved issue:
Is the claimant entitled to magnetic resonance imaging (MRI) for the right knee without contrast for the compensable injury of (Date of Injury)?
The claimant appeared and was represented by JS, attorney. The insurance carrier was represented by TH, attorney. Due to the COVID-19 pandemic, the parties appeared by videoconference.
The following witnesses testified:
For the claimant: None
For the insurance carrier: None
The following exhibits were admitted into evidence:
Administrative Law Judge’s Exhibit: ALJ-1
Claimant’s Exhibits: C-1 through C-9
Insurance Carrier’s Exhibits: CR-A through CR-R
It is undisputed that on (Date of Injury), the claimant sustained a compensable injury, and as a result of the compensable injury, the parties stipulated the injury is a right knee sprain and right knee medial meniscus tear. There are no disputes surrounding the extent of the compensable injury. The claimant had two surgeries to his right knee: May 3, 2019, and November 7, 2019.
The claimant’s treating physician recommended an MRI of the right knee. Preauthorization from the insurance carrier’s utilization review agent was requested and denied. The claimant then requested an independent review organization (IRO) review of the denials. In the decision letter dated July 22, 2020, the IRO upheld the insurance carrier’s denials. The claimant is now appealing the IRO decision.
The IRO reviewer, a physician board certified in orthopedic surgery, stated in part “[t]here is no evidence of postoperative x-rays since the most recent surgery. Given the lack of mechanical symptoms consistent with recurrent internal derangement and the lack of postoperative x-rays, MRI is not supported.”
To determine if treatment is medically necessary, Texas law requires the Division of Workers’ Compensation (DWC) to use treatment guidelines. These guidelines must be evidence-based, scientifically valid, and outcome-focused. Use of these guidelines ensures that an injured employee will receive reasonable and necessary health care. (See Texas Labor Code §413.011(e) and 413.017(1).) DWC uses the current edition of the Official Disability Guidelines (ODG). If the ODG does not address the requested treatment, then other guidelines or generally accepted standards of practice recognized in the medical community are used.
In this dispute, the claimant has the burden of showing by a preponderance of the medical evidence that the IRO decision is wrong. The claimant relied on his testimony, the medical records in evidence, and the opinion from his treating doctor to support his position of entitlement to the disputed treatment. The treating physician explained that to determine the diagnosis and the type of treatment necessary for the claimant, the MRI of the right knee would assist him in this decision. He explained that “[i]f the patient has patellar tendinitis, the treatment is different from the treatment of a meniscal tear.” He further stated “I am ordering the MRI, to assess the status of the meniscus, partial meniscectomy and I agree that the patient does not have any mechanical symptoms. The patient has symptoms and signs of patellar tendinitis. This cannot be confirmed with an x-ray in which the denial letter suggests.”
In our case, the ODG addresses the requested disputed procedure and states that an MRI is used “post-surgical only to assess knee cartilage repair tissue when symptomatic, not post-meniscectomy. Routine use of MRI for follow-up of asymptomatic patients following knee arthroplasty is not recommended.” Although the claimant relies on the medical records from the treating physician, the treating physician did not persuasively provide evidence-based medical establishing why the requested procedure is medically and necessary. Therefore, the preponderance of the evidence is not contrary to the decision of the IRO that the claimant is not entitled to magnetic resonance imaging (MRI) for the right knee without contrast for the compensable injury sustained on (Date of Injury).
The Administrative Law Judge considered all the evidence admitted. The Findings of Fact and Conclusions of Law are based on an assessment of all the evidence, whether or not the evidence is specifically discussed in this Decision.
Findings of Fact
1. 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), the claimant was the employee of (Employer).
C. On (Date of Injury), the employer provided workers’ compensation insurance with Starr Indemnity and Liability Company.
D. On (Date of Injury), the claimant sustained a compensable injury in the form of a right knee sprain and right knee medial meniscus tear.
2. The insurance carrier delivered to the claimant a document stating the insurance carrier’s true corporate name and the registered agent’s name. This document was admitted into evidence.
3. The Independent Review Organization determined that the requested service is not reasonable and necessary health care for the compensable injury of (Date of Injury).
4. The claimant did not present evidence-based medical evidence contrary to the Independent Review Organization’s decision.
5. The preponderance of the evidence is not contrary to the decision of the Independent Review Organization that the magnetic resonance imaging of the right knee is not health care reasonably required for the compensable injury.
Conclusions of Law
1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
2. The claimant is not entitled to magnetic resonance imaging of the right knee (MRI) without contrast for the compensable injury of (Date of Injury).
The insurance carrier is not liable for the benefits in dispute in this hearing. The claimant remains entitled to medical benefits for the compensable injury in accordance with Texas Labor Code §408.021.
The true corporate name of the insurance carrier is STARR INDEMNITY AND LIABILITY COMPANY, and the name and address of its registered agent for service of process is:
CT CORPORATION SYSTEM
1999 BRYAN STREET, SUITE 900
DALLAS, TX 75201-3136
Signed on December 3, 2020.
Teresa G. Hartley
Administrative Law Judge