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At a Glance:
Title:
453-02-2014-m2
Date:
April 16, 2002
Status:
Pre-Authorization

453-02-2014-m2

April 16, 2002

DECISION AND ORDER

I. Introduction

The University of Texas System (Carrier) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD). MRD directed the Carrier to pay the reasonable and necessary costs of a repeat lumbar magnetic resonance image (Repeat MRI) for___ (Claimant). The only disputed issue is whether the Claimant’s current back pain was caused by, hence whether the Repeat MRI is reasonably required by, that compensable injury.

Due to the passage of time and intervening factors, the Administrative Law Judge (ALJ) cannot conclude that the Claimant’s current back pain was caused by the compensable injury, hence he cannot find that the MRI is reasonable required by the nature of that compensable injury. Accordingly, the ALJ finds that the request of Madhavan Pisharodi, M.D. (Treating Physician) for preauthorization of the MRI should be denied.

II. FINDINGS OF FACT

  1. The Claimant sustained a work-related compensable injury to his back on _____, while the Carrier was his employer and its own workers’ compensation insurance carrier.
  2. As a result of the compensable injury, the Claimant had lower-back pain and right-leg numbness.
  3. On October 26, 1994, Madhavan Pisharodi, M.D. (Treating Physician) performed a lumbar L4-5 laminotomy and removed the Claimant’s herniated disc. That procedure was necessitated by the compensable injury and was the definitive procedure for repairing the Claimant’s herniated disc.
  4. The Claimant reached maximum medical improvement (MMI) on January 13, 1997.
  5. The Claimant has not been employed by the Carrier since 1997 and was employed by ______ in early 1998.
  6. The Claimant had some permanent residual numbness due to nerve root damage and a 20 percent impairment disability from the injury, but had otherwise recovered and was doing well by May 21, 1998.
  7. On April 9, 2001, over seven years after the compensable injury, over four years after reaching MMI, and almost three years after doing well, the Claimant returned to the Treating Physician complaining of intermittent lower back and right leg pain.
  8. On May 7, 2001, the Treating Physician diagnosed the Claimant as having lower back pain after lumbar surgery and lumbar sacral radiculopathy.
  9. On May 9, 2001, the Treating Physician prescribed a Repeat MRI of the Claimant’s lumbar spine to aid in the diagnosis of the Claimant’s pain.
  10. On May 31, 2001, the Treating Physician sought preauthorization for the Repeat MRI from the Carrier and gave diagnosis codes for lumbago and lumbosacral spondylosis without myelopathy.
  11. On June 4, 2001, the Carrier denied the requested preauthorization, maintaining that there was inadequate documentation to show that the requested Repeat MRI was related to the compensable injury that had occurred seven years before and that the Claimant had not been employed by the Carrier 1997.
  12. On August 27, 2001, the Treating physician diagnosed the Claimant as having lumbar spondylosis, degenerative disc disease, and lumbago, which are normal diseases of life.
  13. On September 17, 2001, the Treating Physician again requested that the Carrier pre-authorize the Repeat MRI.
  14. On September 20, 2001, the Carrier again denied preauthorization of the Repeat MRI, maintaining that there was no documentation establishing its casual relationship to the compensable injury.
  15. On October 12, 2001, the Treating Physician filed a request for medical dispute resolution with the TWCC concerning the Repeat MRI.
  16. MRD reviewed the dispute and, on December 19, 2001, ordered the Carrier to pay the reasonable and necessary costs for the Repeat MRI of the Claimant.
  17. On December 31, 2001, the Carrier appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
  18. On March 6, 2002, notice of an April 9, 2002, hearing in this case was mailed to the Carrier, the Treating Physician, and the Claimant.
  19. On April 9, 2002, William G. Newchurch, an Administrative Law Judge (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 Treating Physician attended that hearing. The TWCC staff had previously indicated that they would not attend. The hearing concluded and the record closed on that same day.

CONCLUSIONS OF LAW

  1. 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§§ 402.073(b) and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003. (West 2001).
  2. Adequate and timely notice of the hearing was provided in accordance with TexGov’t. Code Ann. §§ 2001.051 and 2001.052 (West 2001).
  3. As the party appealing the MRD’s decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
  4. 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.
  5. Tex. Labor Code Ann. §413.014 requires the Commission by rule to specify which health care treatments and services require express pre-authorization by the insurance carrier. It also provides that the insurance carrier is not liable for those specified treatments and services unless pre-authorization is sought by the claimant or health care provider and either obtained from the insurance carrier or ordered by the commission. Treatments and services for a medical emergency do not require express pre-authorization.
  6. Under 28 TAC § 134.600 (e) and (h)(8), pre-authorization is required for the repeat MRI.
  7. Given that the Claimant received the definitive procedure for the compensable injury, more than seven years have passed since the injury, more than four years have passed since the Claimant reached MMI, the Claimant had at least one intervening employer, and the Claimant’s back pain primarily stems from diseases of life; the Repeat MRI is not reasonably required by the nature of the compensable injury and the Treating Physician’s request for pre-authorization should be denied.

ORDER

IT IS ORDERED THAT the Treating Physician’s request for pre-authorization of the Repeat MRI is denied.

Signed April 16, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

End of Document
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