DECISION AND ORDER
Linden Dillin, M.D., challenges a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) confirming the denial by American Home Assurance Company (AHAC) of his request to perform an arthroscopy on an injured worker. This decision finds the requested procedure is reasonable, is medically necessary, and should be authorized.
I. JURISDICTION, NOTICE AND PROCEDURAL HISTORY
Neither jurisdiction nor notice was contested. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without discussion here.
The hearing convened and closed on May 30, 2002, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Gary Elkins. Dr. Dillin was represented by his attorney, Norman Darwin. Carrier was represented by its attorney, Dan Kelley.
A. Background and Conclusion
Claimant, ___, suffered a compensable injury when she twisted her right ankle in____. After the injury, she saw a number of medical doctors and chiropractors for diagnosis and treatment. She was diagnosed with tenosynovitis. The treatment consisted of non-operative care, including physical therapy and treatment with steroidal, anti-inflammatory medications.
Claimant was referred to Dr. Dillin in May 2001, and he became her treating physician. Based on Claimant’s medical history and persisting symptoms, Dr. Dillin concluded there might be damage to Claimant’s ankle not revealed by an earlier MRI and bone scan. As a result, he sought preauthorization from AHAC to perform arthroscopy, and debridement if needed. Dr. Dillin characterized the proposed procedure as the only fully reliable means of diagnosing and treating Claimant in light of her ongoing ankle pain.
Dr. Dillin suspects the cause of Claimant’s ankle pain could include one of the following: hyaline cartilage tearing, antero-lateral impingement, anterior-inferior tibial fibular ligament adhesions, adhesions in the ankle joint, or meniscoid lesions. Arthroscopy is the best diagnostic tool for determining whether any of these conditions exist, he testified, adding that little risk accompanies the procedure.
AHAC, which disputed the need for arthroscopy, had concluded after reviewing Claimant’s medical records that previous diagnostic tests and evaluations by doctors sufficiently established there was no internal derangement of Claimant’s ankle. Consequently, there was no reason to perform an arthroscopy.
The ALJ concludes the proposed arthroscopy is reasonable based on Dr. Dillin’s testimony relating to the inability of the MRI and bone scan to reveal all possible damage. Consequently, the procedure should be authorized.
B. Evidence and Argument
In support of his position, Dr. Dillin addressed both the imaging tests performed on Claimant and the evaluations of other doctors who had concluded surgical intervention was not supported. He also detailed his education and training as positioning him to make a more informed, educated, and accurate diagnosis.
a. MRI and Bone Scan
In regard to the bone scan that revealed no abnormalities, Dr. Dillin testified that bone scans can miss many injuries, including such things as tears to the anterior cruciate ligament (ACL) located in the knee. Likewise, Dr. Dillin contended, MRIs are not adequate for many problems that can occur in the ankle. They do not show anatomy but, instead, cross-section “slices” of the body part. Furthermore, he added, MRI technology relies on the excitability of sub-atomic particles, and it would be erroneous to conclude that all injured tissue would be revealed by these excited sub-atomic particles.
Dr. Dillin characterized the MRI as helpful in providing adjunctive information in the diagnostic process, but he emphasized it is not always as reliable in revealing the problem. In fact, he contended, the accuracy rate for MRI technology in revealing ACL tears is about 95%, and its accuracy rate drops to 82% for meniscus tears. Ankle maladies such as adhesions, small loose bodies, and some cartilage tears are routinely missed by the MRI. Even when the MRI and bone scan are used together an injury could be overlooked, according to Dr. Dillin. The proposed arthroscopy would simply serve to validate either the absence or existence of an injury. If any damage was revealed by the diagnostic portion of the procedure, it could be corrected at that time. Dr. Dillin emphasized that Claimant’s symptoms and medical history support this proposal.
b. Opinions of Other Doctors
When asked about the opinions of other doctors that arthroscopy was not warranted, Dr. Dillin was equally emphatic in his testimony. He opined that Donald Mauldin, M.D., who was retained by the Commission to provide second surgical opinion relating to the arthroscopy, had a bad attitude toward injured workers shared by the orthopedic community as a whole. This attitude was revealed in Dr. Mauldin’s comment that Claimant experienced non-physiological responses, simply another way of saying Claimant was “faking it,” according to Dr. Dillin. Dr. Dillin added that he had never seen a favorable evaluation of one of his patients by Dr. Mauldin.
Dr. Dillin dismissed the opinion of the other doctor who recommended against arthroscopy, Phillip Osborne, M.D., as having shortcomings that are “reflected in his curriculum vitae.” Dr. Osborne had concluded that all of the positive findings previously revealed by an MRI had resolved, with the exception of minimal findings in the calcaneal area (the heel), and that Claimant appeared to be “basically normal.” Based on these findings, he concluded surgery would not be appropriate.
AHAC argues that the MRI and bone scan were performed over and above the x-ray required by the Lower Extremity Treatment Guideline for a diagnosis of tenosynovitis, and both came back
negative. In addition, AHAC notes, Claimant’s medical records were reviewed by several doctors, and all disagreed with Dr. Dillin that arthroscopy would benefit Claimant. These two facts together prove that Dr. Dillin’s proposal is not supported. Furthermore, AHAC points out, there are risks that accompany a surgical procedure, as evidenced by one doctor’s conclusion that an inappropriate procedure such as the one proposed by Dr. Dillin could cause more damage to the joint.
Notwithstanding the opinions of several doctors that arthroscopy was not indicated for Claimant’s ankle, the ALJ was persuaded by the testimony of Dr. Dillin regarding the limits of MRIs and bone scans in detecting various orthopedic maladies. It is true Section 134.1003(f)(4)(A) of the Lower Extremity Treatment Guideline provides for x-rays as the diagnostic procedure where, as here, tenosynovitis is suspected. However, nothing prohibits a doctor from using more aggressive diagnostic tools where warranted by the circumstances. In fact, Section 134.1003(b)(2) describes the purposes of the Guideline, consistent with the Commission’s other guidelines, as a means of clarifying “those services that are reasonable and medically necessary.” The section goes on to state that more or less treatment than is recommended in the Guideline may be required and that the Guideline shall not be used as the sole reason for denying treatments and services.
The issue, then, is whether the more aggressive and invasive arthroscopy with possible surgical correction was warranted based on the evidence. Dr. Dillin bore the burden of proof, and the evidence presented, while not overwhelmingly supportive of his proposal, preponderated in his favor. Though it is true the proposed procedure would substantially exceed the invasiveness and complexity of an x-ray, the ALJ was persuaded by Dr. Dillin’s unchallenged testimony about the shortcomings of bone scans and MRIs. Combined with the credentials of Dr. Dillin, this evidence established that the proposed arthroscopy would be effective, with minimal associated medical risks, for uncovering any ankle damage that could then be corrected during the same surgery. This conclusion is consistent with the Act’s general language, found at §408.021(a), 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.
Accordingly, Dr. Dillin’s request for the arthroscopy with debridement, if debridement is found to be necessary, is granted.
III. FINDINGS OF FACT
- In______, Claimant, __, suffered a compensable right ankle injury when she inverted her right foot during an accident at work. The injury was compensable under the Texas Workers’ Compensation Act.
- At the time of Claimant’s compensable injury, American Home Assurance Company (AHAC) was the workers’ compensation insurer for Claimant’s employer.
- Since her injury, Claimant has undergone non-operative care, including testing via MRI and bone scan; physical therapy; and treatment with medication, but pain and swelling in her right ankle persists.
- Claimant was diagnosed with tenosynovitis in the right ankle.
- An MRI on Claimant’s right ankle revealed fluid in the tendon sheath and joint.
- For an injury such as the one suffered by Claimant, negative bone scan results do not conclusively establish that no injury exists.
- Ankle maladies such as adhesions, small loose bodies, and some cartilage tears can be missed by an MRI.
- Arthroscopy serves to validate the existence or absence of an injury.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (the Act), TEX. LABOR CODE ANN. § 413.031.
- 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 § 413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003.
- The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV’T CODE ANN. ch. 2001.
- Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§01.051 and 2001.052.
- Arthroscopy with debridement requires pre-authorization.
- Based on the Findings of Fact, Claimant meets all the criteria for arthroscopy with concurrent debridement, if needed, and this conclusion is consistent with the Commission’s Lower Extremity Treatment Guideline, at 28 TAC §34.1003.
- Based on the foregoing, the proposed arthroscopy with possible debridement constitutes reasonable and medically necessary health care under §08.021 of the Act and should be preauthorized.
IT IS ORDERED that preauthorization for the proposed arthroscopy with possible debridement, as requested by Linden Dillin, M.D., is granted.
Signed this 28th day of June 2002.
Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- 1 “Arthroscopy” is defined as “the evaluation of the interior of a joint with an arthroscope.” Dorland’s Illustrated Medical Dictionary, 28th Edition (1994), at 142.↑
- 2 “Debridement” is defined as the removal of foreign material and devitalized or contaminated tissue . . . until healthy tissue is exposed. Dorland’s, at 430.↑
- 3 “Derangement” is defined as “disarrangement of a part or organ.”Dorland's, at 446.↑
- 4 Dr. Dillin testified that in addition to three years of post-graduate work in general surgery, he completed both foot-and-ankle and arthroscopy fellowships, to which he has limited his practice. He likened the fellowships to medical residencies but described them as providing even more intensive training than residencies and in more specific areas of medicine. Dr. Dillin commented that he was unaware of any other doctor who had participated in two fellowships.↑