DECISION AND ORDER
Travelers Indemnity Company of Connecticut (Carrier) has appealed a decision of the Texas Workers Compensation Commission (TWCC) Medical Review Division Officer (MRD). MRD ordered the Carrier to pay the reasonable and necessary costs for outpatient bilateral facet joint injections and bilateral sacroiliac joint injections, first right side, then left (the injections), that S. Ali Mohamad, M.D. (Provider) had prescribed for____ (Claimant). The only dispute is whether those injections are medically necessary.
It is uncontroverted that the Claimant continues to have pain resulting from a compensable injury. However, the Carrier introduced documentary evidence indicating that the Claimant has reached maximum medical improvement and does not require further care. The Provider introduced documentary evidence indicating that the likely sources of the Claimant’s pain are his facet and sacroiliac joints and that the proposed injections would confirm that hypothesis and, if the hypothesis is correct, relieve that pain. Moreover, the Commission’s Spine Treatment Guideline provides for the proposed injections, either for treatment or diagnosis, when there is a strong suspicion of joint disfunction, pain for more than four weeks, and failure to improve with noninvasive treatments. The Carrier’s documentary evidence does not clearly refute the Provider’s hypothesis and was not explained or supplemented so as to allow the Administrative Law Judge (ALJ) to conclude that the hypothesis is unreasonable.
Given the above, the ALJ concludes that Carrier has failed to show that the proposed injections are not reasonably medically necessary. Since Carrier has the burden of proof, the ALJ preauthorizes and orders Carrier to pay for the injections.
II. FINDINGS of Fact
- The Claimant sustained a compensable work-related injury on_______, while his employer was______ and its workers compensation insurance carrier was the Carrier.
- As a result of the compensable injury, the Claimant suffers from pain in his lumbar area, which radiates to the bilateral paravertebral areas and bilateral inguinal areas, thoracic area, left rib cage and cervical area.
- The Claimant has experienced the above-described pain for more than four weeks and has failed to improve with non-invasive treatments.
- The Claimant has no neurological problems.
- The Claimant’s pain seems to come from the facet and sacroiliac joints, since there is pain when they are palpitated and pain upon hyperextension of the lumbar spine.
- The Claimant’s treating doctor, the Provider, has prescribed injections to the Claimant’s bilateral lumbar facet joint and bilateral sacroiliac (SI) joint to diagnose whether they are the sources of the Claimant’s pain and to relive that pain if they are.
- The Provider has sought preauthorization from the Carrier for those injections.
- The Carrier has denied preauthorization, maintaining that the Provider has failed to submit adequate supporting documentation showing that the injections were medically necessary.
- An MRD officer reviewed the dispute, found that the injections were medically necessary, and ordered the Carrier to pay for them.
- The Carrier appealed the decision of the MRD Officer to the State Office of Administrative Hearings (SOAH).
- Notice of a January 17, 2002 hearing in this case was mailed to the Carrier, the Provider, and the Claimant on November 30, 2001. In that notice, the TWCC staff indicated that it would not participate in the hearing.
- On January 17, 2002, the Provider requested a continuance of the hearing, which the ALJ granted until January 31, 2002.
- On January 31, 2002, William G. Newchurch, an ALJ with SOAH held a hearing on the Carrier’s appeal at the Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas. Representatives of the Carrier and the Provider attended the hearing, either in person or by telephone.
- The hearing concluded on January 31, 2002, but the record was left open until the end of the business day January 31, 2002, to allow the Provider to fax to the ALJ an additional exhibit that he sought to introduce. No such exhibit was ever received by the ALJ, and the record closed at the end of the business day on January 31, 2002.
III. CONCLUSIONS of Law
- The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to TEX. LABOR CODE ANN. §413.031(d) and TEX. GOV’T CODE ANN. ch. 2003. (Vernon 2001).
- Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T. CODE ANN. §2001.052 (Vernon 2001).
- The Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
- Under Tex. Labor Code § 408.021 (a), 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.
- The Commission’s Spine Treatment Guideline provides for facet joint injections, either for diagnosis or treatment, when a neurologically intact patient has had pain for at least four weeks that is unresponsive to noninvasive treatments. 28 Tex. Admin. Code §§ 134.1001(e)(2)(T)(ii).
- The Commission’s Spine Treatment Guideline provides for SI joint injections, either for diagnosis or treatment, when there is a strong suspicion of SI joint disfunction in a patient who has experienced pain for at least four weeks and failed to improve with noninvasive treatments. 28 Tex. Admin. Code §§ 134.1001(e)(2)(T)(iii).
- Based on the above Findings of Fact and Conclusions of Law, the Carrier has failed to show that the prescribed bilateral lumbar facet joint and bilateral SI joint injections are not in accordance with the above Spine Treatment Guideline.
- Based on the above Findings of Fact and Conclusions of Law, the Carrier has failed to show that the prescribed bilateral lumbar facet joint and bilateral SI joint injections are not reasonably necessary to relieve the Claimant’s pain or diagnose his condition in accordance with the above Spine Treatment Guideline .
- Based on the above Findings of Fact and Conclusions of Law, the Carrier’s appeal should be denied and the Provider’s request for preauthorization to give the above-described injections to the Claimant should be approved.
IT IS ORDERED THAT the Carrier’s appeal is denied and request for preauthorization to give injections to the Claimant’s bilateral lumbar facet joint and bilateral SI joint is granted.
Signed February 8, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
WILLIAM G. NEWCHURCH
Administrative Law Judge