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At a Glance:
Title:
453-02-2184-m5
Date:
July 19, 2002
Status:
Retrospective Medical Necessity

453-02-2184-m5

July 19, 2002

DECISION AND ORDER

North Texas Open Air MRI (NTOAMRI) appeals the denial of its request for reimbursement for an MRI by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC). MRD found that NTOAMRI performed the MRI on claimant ___earlier than 60 days after the date of injury without a proper showing of medical necessity. NTOAMRI argues that the MRI was medically necessary while Texas Mutual Insurance Company (TMI) argues that it was not. The Administrative Law Judge (ALJ) finds that the early MRI was not medically necessary and denies NTOAMRI’s appeal.

I. Jurisdiction and Procedural History

There were no challenges to notice or jurisdiction and those matters are stated in the findings of fact and conclusions of law without further discussion here. ALJ Thomas H. Walston convened a hearing on the merits on June 20, 2002, at the hearing facilities of the State Office of Administrative Hearings in Austin, Texas. Attorney Doug Pruett represented NTOAMRI and attorney Chris Trickey represented TMI. The hearing concluded and the record closed the same day.

II. Discussion

Background

Claimant ___sustained a compensable injury to her back on_______, when she fell on her buttocks as she was transferring a disabled patient from a commode to a wheel chair. ___ saw a chiropractor named Reza Assadollahi on the day of injury (_____) and reported pain in her lower back. Dr. Assadollahi referred ___to NTOAMRI for an MRI of her lumbar spine. NTOAMRI performed the MRI on ___, which was six days after ___’s date of injury. The MRI was normal, with no bulging or herniated discs and unremarkable soft tissue. NTOAMRI billed TMI $1400.00 for the MRI.

TMI denied reimbursement on the grounds that the MRI was not medically necessary. TMI relied on the Spine Treatment Guideline (STG), which states that an MRI should not be performed earlier than six weeks after injury unless a significant neurological deficit is documented. NTOAMRI requested medical dispute resolution, and on January 3, 2002, the TWCC MRD denied reimbursement.

Evidence

NTOAMRI:

Thomas Rhudy, D.C., testified on behalf of NTOAMRI.[1] Dr. Rhudy reviewed ___’s records but did not treat her. Dr. Rhudy testified that ___sustained a compensable injury to her thoracic and lumbar spine when she transferred a patient from a commode to a wheel chair. While doing this maneuver, the patient fell, ___tried to catch him, and ___fell to the floor and struck her buttocks. Based on ___symptoms, clinical findings, and the mechanics of injury, Dr. Rhudy testified that an MRI was medically necessary for ___, in his opinion.

On the mechanics of injury, Dr. Rhudy stated that a hard fall on the buttocks exerts axial pressure along the spine at transitional areas, such as between the thoracic and lumbar spinal regions. ___also complained of significant pain (8 on a scale of 0-10) in her upper lumbar spine.

Dr. Rhudy agreed that the neurological exam performed by Dr. Assadollahi was normal, but on the orthopedic exam the Valsalva’s test and the Milgram’s test were positive. In the Valsalva’s test, the patient is requested to strain as in a bowel movement and report any resulting pain. On this test, ___reported pain in the lumbar spine region, which Dr. Rhudy said indicates a possible space occupying lesion. For the Milgram’s test the patient lays on her back, raises her legs about six inches, and holds them for a few seconds. Again the patient reports any resulting pain, and on this test ___reported pain in the lumbar spine. Dr. Rhudy stated that this also indicates a possible disc problem. In addition, ___reported back pain on the Fabere test and on the straight-leg-raising test at 55 degrees, but she did not report pain radiating to her legs. ___initial examination report also showed normal thoraco-lumbar range of motion, except for a slight reduction on flexion and extension. It also showed mild to moderate back pain on palpation.

Dr. Rhudy stated that these tests suggest a possible disc injury, but they do not definitively confirm or rule out such an injury. Therefore, in his view, an MRI to ___lumbar spine was medically reasonable to determine the true nature and extent of ___injury. Dr. Rhudy added that the MRI was recommended for ___lumbar spine because she reported pain at a level of 8 (on a scale of 0-10) in the lumbar spine, but an MRI was not ordered for her thoracic spine because she only reported pain at a level of 4 in the thoracic spine.

Finally, Dr. Rhudy noted that X-rays were taken of ___spine on ___, five days before the MRI was performed. The X-ray report stated that disc spaces and body heights were well maintained, although there was mild pelvic and sacral unleveling. Dr. Rhudy stated that this “indicates some problem” and supported an MRI when all other factors are taken into account.

On cross examination, Dr. Rhudy stated that the positive findings on the Valsalva, Milgrams, SLT, and Fabere tests do not establish sensory impairment, in and of themselves. But he argued that when these positive test results are considered in the context of other findings, such as pain, they do support an MRI. Further, Dr. Rhudy testified that he considered pain to be a “sensory impairment” in the context of the STG.

Dr. Rhudy also conceded that the Dr. Assadollahi’s “Received” stamp for the X-ray report was dated March 30, which was two days after the MRI was performed. Nevertheless, Dr. Rhudi suggested that Dr. Assadollahi likely reviewed the X-rays themselves, rather than the report, in deciding to refer ___for an MRI.

TMI:

Clark Watts, M.D., testified on behalf of TMI. Dr. Watts is a medical doctor who has practiced medicine for more than 30 years and who specializes in neurosurgery. For this case he reviewed the available records for ___.

Dr. Watts stated that “sensory impairment” is a disturbance of the sensory system - in particular the peripheral nervous system. But he found no documentation of sensory impairment in the records for ___ He noted that the STG provides that an MRI should not be performed earlier than six weeks after injury without a showing of “significant neurological deficit.” The STG also defines significant neurological impairment as “signs of sensory impairment, progressive numbness, or increased physiological impairment such as severe weakness, bowel or bladder dysfunction directly related to the spinal injury.” Dr. Watts’ stated that none of these conditions were documented for ___, and, in fact, ___neurological examinations were essentially normal.

Dr. Watts also pointed out that Dr. Wood’s records showed an entirely normal neurological exam for ___and did not document any sensory impairment. He also stated that positive findings on orthopedic exams, such as the Valsalva and Milgrams tests, simply show muscle functions and do not indicate sensory impairment.

Dr. Watts testified that the records show no objective findings or statements that suggest any limit on ___activities of daily living. In his view, the only reason ___did not work was because the doctors told her not to. Dr. Watts stated that under the STG an early MRI is not authorized without documentation of a significant neurological deficit. And with ___, there simply were too few objective findings and too many negative findings to conclude that an early MRI was medically necessary. Therefore, Dr. Watts concluded that any early MRI was not medically justified for ___under the requirements of the STG.

III. ALJ’s Analysis and Decision

The Administrative Law Judge (ALJ) finds that NTOAMRI did not establish that an early MRI was medically necessary for ___and, therefore, denies NTOAMRI’s appeal. In particular, the ALJ finds that NTOAMRI failed to establish that ___had a significant neurological deficit or other documented medical condition that warranted an MRI earlier than six weeks (42 days) after injury.

The STG provides guidance for this case. In several sections of the STG, the Commission makes clear that, although the guidelines are not absolute rules, a provider must document and show a bona fide medical necessity to deviate from the guidelines. For example, 28 TAC § 134.1001(d)(1) states:

Health Care Provider. This guideline shall be used as a tool by the health care provider to establish the required elements to initiate and continue treatment. If, for example, a health care provider’s treatment deviates from this guideline, documentation of the medical condition that specifically requires treatment outside the guideline parameters would be required to clearly delineate the need for treatment.

And concerning diagnostic procedures, such as an MRI, 28 TAC § 134.1001(c)(4) states:

Diagnostics. Diagnostic work should be performed in accordance with recommended testing and timeframes contained in this guideline. If the need arises to deviate from the guideline, then a clinical rationale must be provided which adequately substantiates the need for this deviation.

Likewise, 28 TAC § 134.1001(e) acknowledges that a subset of injured employees will need treatment outside the STG’s parameters, but it also states that such treatment will be subject to more careful scrutiny and requires documentation of “special circumstances.” One subsection of this rule also states that an early MRI may be justified by a documented finding of a significant neurological deficit:

(e) Ground Rules.

  1. Introduction: . . . The guidelines recognize that a subset of injured employees will be found to be outside the guidelines’ parameters. However, cases exceeding the guidelines level of treatment shall be subject to more careful scrutiny and review and shall require documentation of the special circumstances justifying that treatment. . . .
  2. Ground Rules.

(A) Not withstanding any other provision of this section, treatment of a work related injury must be

. . .

(v) consistent with this guideline which may include providing a documented clinical rationale for deviation from this guideline;

. . .

(Q) Documentation of significant neurological deficit may support early intervention (0-6 weeks) of MRI’s and CT scans, which would better direct the course of treatment.

Finally, the Glossary contained at 28 TAC § 134.1001(j) defines “significant neurological deficit” as follows:

(53) Significant Neurological Deficit - signs of sensory impairment, progressive numbness, or increased physiological impairment such as severe weakness, bowel or bladder dysfunction directly related to the spinal injury.

In this case, the ALJ finds that NTOAMRI did not establish that ___had a significant neurological deficit or any other medical condition to support the need for an early MRI. For ___, NTOAMRI performed an MRI of her lumbar spine on ___, which was only six days after ___injured her back (_______). Dr. Rhudy attempted to justify an early MRI for ___based on the mechanics of injury, symptoms, and minimally positive orthopedic tests. But the ALJ did not find Dr. Rhudy’s testimony persuasive. First, ___ neurological examinations (including a sensory exam) were entirely normal. And X-rays taken on March , 2001, were normal except for some postural alterations. In particular, the X-rays showed that vertebral bodies and disc heights were maintained. And the ALJ is not persuaded that Dr. Assadollahi’s review of ___X-rays influenced him to order an MRI. The official record shows that Dr. Assadollahi ordered an MRI on______, which was the date ___first went to see Dr. Assadollahi, was the same day as the date of injury, and was the day before the X-rays were even taken.[2] No other records were offered concerning ___, and the ALJ finds that the evidence does not establish that ___had a significant neurological deficit to justify an early MRI.

In summary, the ALJ finds that NTOAMRI performed an MRI on ___earlier than the time parameters in the STG (i.e., earlier than 42 days after injury), but that NTOAMRI did not prove by a preponderance of the evidence that the early MRI was medically necessary as required by the STG. Therefore, the ALJ denies NTOAMRI’s appeal.

IV. FINDINGS OF FACT

  1. On_______, Claimant ___ suffered a compensable in the course and scope of her employment.
  2. ___injury is covered by workers’ compensation insurance written by Texas Mutual Insurance Company (TMI), formerly Texas Workers’ Insurance Fund.
  3. As a result of the compensable injury, ___had back pain.
  4. Dr. Assadollahi, D.C., was ___treating doctor.
  5. North Texas Open Air MRI (NTOAMRI) performed an MRI on ___lumbar spine on_____, which was 6 days after the date of injury.
  6. TMI denied NTOAMRI reimbursement in the amount of $1400.00, and NTOAMRI requested medical dispute resolution.
  7. In a decision issued January 3, 2002, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denied NTOAMRI reimbursement for the MRI.
  8. On January 16, 2002, NTOAMRI appealed MRD’s decision to the State Office of Administrative Hearings (SOAH).
  9. On March 19, 2002, notice of a hearing in this case was mailed to NTOAMRI, TMI, and the Commission’s APA Litigation Division.
  10. On June 20, 2002, a hearing was convened in Austin, Texas, on NTOAMRI’s appeal. Representatives of NTOAMRI and TMI appeared. No one representing the Commission appeared.
  11. Under the Texas Workers’ Compensation Commission’s Spine Treatment Guideline (STG), the time parameter for performing an MRI for a spinal injury is six weeks to four months after injury.
  12. Under the STG, an MRI should not be performed earlier than six weeks from the date of injury unless the injured worker has a significant neurological deficit or other documented medical condition making an early MRI medically necessary.
  13. ___was not experiencing unremitting pain, progressive numbness, signs of sensory impairment or motor weakness, bowel or bladder dysfunction, or severe weakness within six weeks after the date of injury.
  14. An early MRI was not medically necessary for ___

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code (Labor Code) §413.031.
  2. 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 Labor Code §413.031 and Tex. Gov’t Code (Gov’t Code) ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
  4. The MRI performed by North Texas Open Air MRI on ___earlier than six weeks after their dates of injury was not medically necessary.
  5. North Texas Open Air MRI is not entitled to reimbursement for the MRI performed on ___on _________

ORDER

IT IS ORDERED that North Texas Open Air MRI shall have and recover nothing from Texas Mutual Insurance Company for the MRI performed on ___that is the subject of this proceeding.

Signed July 19, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

THOMAS H. WALSTON
Administrative Law Judge

  1. Dr. Rhudy also holds a J.D. degree.
  2. See p. 65 of the certified record, the second hand written note for 3/22/01, which states: “MRI of L-sp requested to R/O HNP.” The ALJ interprets this entry as “MRI of lumbar spine requested to rule out herniated nucleus pulposus.”
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