DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for a thoracic and lumbar MRI examination provided to ___(Claimant). On September 23, 2000, White Rock Open Air MRI (Provider) rendered an MRI examination to Claimant. Texas Mutual Insurance Co., (Carrier) denied reimbursement for this treatment and Provider sought reimbursement in the amount of $3,200.00. Provider appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in MDR Docket No. M5-01-2501-01 which denied reimbursement for the MRI examination. The MRD decision, issued December 14, 2001, upheld Carrier’s denial of reimbursement based on failure to document medical necessity. This decision finds the reimbursement was properly denied.

I. DISCUSSION

Background Facts

On__________, Claimant sustained a compensable injury. On September 6, 2000, Larry Parent, D.C., examined Claimant in relation to his injuries. Following the examination, Dr. Parent referred Claimant to Provider for a thoracic and lumbar MRI examination. Provider administered the MRI to Claimant on September 23, 2000, and billed Carrier for the service. Carrier denied reimbursement as not medically necessary. After the Provider filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). The MRD held Provider was not entitled to reimbursement, Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).

B. Applicable Law

Under the TEX. Lab. Code Ann. § 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 employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.

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The Commission’s Spine Treatment Guideline sets forth its purpose under 28 Tex. Admin. Code §134.1001(b)(1) in that this guideline is to clarify those services that are reasonable and medically necessary for operative and nonoperative care of the spine for the injured employees of Texas. This guideline identifies a normal course of treatment. There may be injured employees who will require more or less treatment than is recommended in this guideline. This is a guideline and shall not be used as the sole reason for denial when a treatment or service is not listed in the guideline. Similarly the guideline shall not be used as the sole reason for accepting the treatment or service as reasonable and medically necessary simply because the treatment or service is listed in the guideline.

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The Commission’s rule under 28 Tex. Admin. Code §134.1001(c)(4) instructs diagnostic work should be performed in accordance with the recommended testing and timeframes contained in this guideline. The rule further states, if the need arises to deviate from the guideline, then a clinical rationale must be provided which adequately substantiates the need for this deviation.

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The Commission’s rule under 28 Tex. Admin. Code §134.1001(e)(2)(Q) allows early intervention of diagnostic testing, such as MRI, so long as there is documentation of a significant neurological deficit.

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The Commission’s rule under 28 Tex. Admin. Code §134.1001(f)(3) recommends an MRI examination be performed six weeks to four months after a compensable injury.

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The Commission’s rule under 28 Tex. Admin. Code §134.1001(j)(53) defines significant neurological deficit as having signs of sensory impairment, progressive numbness, or increased physiological impairment such as severe weakness, bowel or bladder dysfunction directly related to the spinal injury.

Analysis

The issue here is whether or not it was medically necessary for Claimant to undergo a thoracic and lumbar MRI examination less than three weeks after the date of injury. The timing of the MRI examination is crucial because the Spine Treatment Guideline under 28 Tex. Admin. Code §134.1001(f)(3)(B) recommends diagnostic intervention six weeks to four months after the date of injury. Claimant was injured on_______________, and the MRI exam was performed less than three weeks later on September 23, 2000.

In some cases, the Spine Treatment Guideline allows diagnostic intervention such as MRI exams to occur less than six weeks after the injury. Under 28 Tex. Admin. Code §134.1001(e)(2)(Q), diagnostic intervention less than six weeks after an injury is proper if there is a showing of significant neurological deficit. There not only has to be a showing, but the guideline instructs documentation of significant neurological deficit be presented as well.

As mentioned by both parties in the hearing, the Spinal Treatment Guideline is just that, a guideline. The guideline itself stipulates this same position under 28 Tex. Admin. Code §134.1001(b)(1). However, if proposed spinal treatments fall outside the guideline recommendations, it is necessary that a documented explanation be provided in order for a provider to be eligible for payment of medical services. Under 28 Tex. Admin. Code §134.1001(d)(1)(B), if a provider’s treatment plan falls outside the parameters of the guideline, “documentation would be required to clearly delineate the need for the treatment.”

In this case, the record reflects Dr. Parent administered two musculoskeletal examinations on Claimant. The first exam was performed on ___, the day after the injury. The second exam was performed on September 19, 2000. For both of these examinations there are records of Dr. Parent’s findings. There are additionally some notes where Claimant was seen by Dr. Parent on other days. The documentation generated before the MRI examination was not sufficient to show a significant neurological deficit existed.

Dr. Parent administered a series of orthopedic and neurological tests on Claimant on ___. From the record, it appears Claimant suffered from lower and middle back pain as a result of the injury.^[1] Nowhere within the report does the doctor identify a significant neurological deficit present in Claimant. In fact, after the initial consultation, Dr. Parent indicates Claimant did not even suffer from weakness, a distinct characteristic of significant neurological deficit under 28 Tex. Admin. Code §134.1001(j)(53).^[2] Other than back pain, the Claimant complained of fatigue and difficulty sleeping. Dr. Parent additionally made no finding of numbness, another characteristic of significant neurological deficit.^[3] The notes following the initial consultation appear to indicate Claimant suffered from back pain on the days leading up to the MRI examination, but again do not point out any symptoms of a significant neurological deficit.

On September 19, 2000, Dr. Parent administered another musculoskeletal exam on Claimant. This time, Dr. Parent did only half of the orthopedic exams and none of the neurological exams on Claimant.^[4] Thus, no symptoms of significant neurological deficit were detected at this exam either. The report additionally indicates Claimant denied any new complaints. With an impending MRI examination, a more thorough examination of Claimant might have revealed any number of reasons early diagnostic intervention was necessary. Without the benefit of a thorough exam, and the indication of no new complaints, and in light of the statutory guidelines, the finding of medical necessity is not reasonable in this case.

In this case, given the lack of documentation “clearly delineating” the need for an MRI examination, there can not be a finding of medical necessity. Therefore, Provider should not be reimbursed for the MRI examination it performed on Claimant.

II. FINDINGS OF FACT

1. Claimant, ___, suffered a compensable injury on.
2. Texas Mutual Insurance Co., (Carrier) insured Claimant on the date of the injury.
3. Claimant came under the care of Larry Parent, D.C., who became his treating doctor.
4. Dr. Parent examined Claimant on September 6, 2000, and recommended Claimant undergo a lumbar and thoracic MRI examination.
5. Dr. Parent referred Claimant to the White Rock Open Air MRI (Provider) for an MRI examination which was performed on September 23, 2000.
6. Provider billed Texas Mutual Insurance Co., (Carrier) for the cost of the MRI examination.
7. Carrier denied reimbursement as not medically necessary.
8. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission) seeking reimbursement for the MRI examination rendered to Claimant.
9. On December 14, 2001, the Commission’s Medical Review Decision (MRD) found Provider was not entitled to reimbursement.
10. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
11. Notice of the hearing was sent February 20, 2002.
12. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
13. The hearing was held May 15, 2002, with Administrative Law Judge Steven M. Rivas presiding and representatives of the Carrier, and Provider participating. The hearing was adjourned the same day.
14. Following the injury on__________, the Claimant was examined on September 6, 2000, and September 19, 2000. The request for MRI was made sometime before September 23, 2000.
15. At the time of the MRI examination, Claimant was within the early stage of care where a showing of significant neurological deficit would have supported the need for early diagnostic intervention under 28 Tex. Admin. Code §134.1001(e)(2)(Q).
16. Two examinations of Claimant failed to show Claimant had a significant neurological deficit.
17. Provider failed to offer sufficient evidence that it is entitled to reimbursement for the MRI examination performed on Claimant.

III. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann.§ 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
4. The Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code §148.21(h).
5. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is not entitled to reimbursement for the MRI examination rendered to Claimant on September 23, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Provider is not entitled to reimbursement from the Carrier, Texas Mutual Insurance Co., for the MRI examination rendered to Claimant on September 23, 2000.

Signed this 12^th day of July, 2002.

State office of administrative hearings

Steven M. RivasAdministrative Law Judge

1. Initial consultation dated 9/6/2000, pages 29 through 34 of the certified record.↑
2. Page 32 of the certified record. The box for weakness is marked “no.”↑
3. Page 33 of the certified record. Several boxes for numbness are left unmarked.↑
4. Page 96 of the certified record.↑