DECISION AND ORDER

______ (Petitioner) appealed a decision by an independent review organization (IRO), which denied preauthorization for Petitioner to obtain a second Magnetic Resonance Image (MRI) of his lumbo-sacral spine. The IRO concluded that a second MRI was not medically necessary because there had been no change in Petitioner’s orthopedic or neurologic objective findings since his last MRI. This decision also finds that a second MRI is not medically necessary at this time and denies Petitioner’s appeal.

I. JURISDICTION, VENUE, AND NOTICE

No party challenged jurisdiction, venue, or notice. Therefore, those matters are addressed in the findings of fact and conclusions of law without discussion here.

II. STATEMENT OF THE CASE

Administrative Law Judge (ALJ) John H. Beeler convened the hearing in this matter on October 3, 2003, at the State Office of Administrative Hearings, William Clements State Office Building, 300 W. 15th Street, Austin, Texas. Petitioner appeared by telephone and was assisted by

Texas Worker’s Compensation Commission (TWCC) Ombudsman Juan Mireles. Attorney Steve Tipton represented Facility Insurance Corporation (Carrier). The ALJ concluded the hearing and closed the record the same day.

III. DISCUSSION

A. Introduction

Petitioner is a 41-year-old male who sustained a work related injury to his right leg on__________, when he slipped in mud. He was diagnosed with a stress fracture of the right femur and later complained of back pain. He underwent a lumbar spine MRI on May 3, 1997, which revealed no evidence of spinal stenosis or disc herniation.

Petitioner changed professions from construction to teaching and managed fairly well for several years. Recently, however, he has complained of pain in his low back and legs, and in 2002, Dr. Joseph Neustein, M. D., requested a second MRI to determine if there was spinal stenosis. Carrier denied the request and Petitioner appealed to the IRO. The IRO conducted an independent review and on June 18, 2003, issued a decision that an additional MRI is not medically necessary. This appeal followed.

B. Petitioner’s Position

Petitioner argues that he needs the second MRI and offered written documentation from Dr. Neustein. Dr. Neustein writes that the first MRI showed disc desiccation with mild to moderate disc narrowing at the four lumbar levels. The doctor further states that he cannot understand why the IRO reviewer concluded that the disc disorder would not progress.

Carrier’s Position

Respondent contends that a repeat MRI is not medically necessary. It did not present any testimony but instead relied on documentary evidence including a report from the Journal of Bone and Joint Surgery concerning MRIs on the lumbar spine and an article from the journal Spine. The report and article indicate that the accepted medical opinion is that an MRI at this time would show nothing different concerning the injury than the one done four years after the injury occurred.

IV. ALJ ANALYSIS AND DECISION

ALJ ANALYSIS AND DECISIONALJ ANALYSIS AND DECISIONALJ ANALYSIS AND DECISION

The ALJ concludes that a second lumbar MRI is not medically necessary. Therefore, the ALJ declines to order preauthorization.

Medical Necessity: Under the Texas Workers= Compensation Act, Petitioner is entitled to all health care reasonably required by the nature of his injury. He is specifically entitled to health care that is reasonably required to cure or relieve the effects naturally resulting from his compensable injury, to promote recovery, or to enhance his ability to return to or retain employment. Tex. Lab. Code Ann. ‘ 408.021(a). Health care includes all reasonable and necessary medical services, appliances, and supplies. Tex. Lab. Code Ann. ‘ 401.011(19)(A). An MRI is an approved diagnostic procedure, 28 TAC ‘ 134.1001(f)(2)(F), but a repeat MRI requires preauthorization because its cost exceeds $350.00. 28 TAC’ 134.600(h)(6).

The Spine Treatment Guideline does not specifically address when a repeat MRI is warranted. Petitioner contends, based on his doctor’s request, that he needs a repeat MRI, but nothing in the documentation supplied by the doctor relates the need for the MRI to Petitioner’s injury. Instead, Dr. Neustein discusses the possibility of a degenerative condition.

Because Petitioner’s evidence does not establish the basis for the medical necessity for the MRI, and in view of the fact that the documentary evidence provided by the Carrier indicates that it would not be useful in this situation, preauthorization is not warranted.

V. FINDINGS OF FACT

1. Petitioner suffered a compensable injury to his right leg on________.
2. At the time of the compensable injury, Petitioner’s employer was insured by Facility Insurance Corporation for workers= compensation claims.
3. On May 3, 1997, an MRI was performed on Petitioner’s lumbo-sacral spine. The MRI showed no evidence of spinal stenosis or disc herniation.
4. In 2002, Dr. Joseph Neustein requested preauthorization for a second MRI for Petitioner to determine if spinal stenosis was present.
5. Carrier denied preauthorization for the second MRI.
6. The IRO conducted an independent review and on June 18, 2003, issued a decision that an additional MRI is not medically necessary. Petitioner timely appealed the IRO decision.
7. Notice of hearing was sent July 23, 2003. 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.
8. The hearing was held October 3, 2003, with Administrative Law Judge (ALJ) John H. Beeler presiding. Petitioner appeared by telephone and was assisted by TWCC Ombudsman Juan Mireles. Attorney Steve Tipton represented Carrier. The ALJ concluded the hearing and closed the record the same day.

VI. CONCLUSIONS OF LAW

1. The Texas Workers= Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers= Compensation Act, Tex. Lab. Code Ann. ” 402.073 and 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 Tex. Lab. Code Ann. ” 402.073 and 413.031, and Tex. Gov=t Code Ann. Ch. 2003.
3. Petitioner timely requested a hearing pursuant to 28 Tex. Admin. Code ” 133.308(t), 134.600(g), and 148.3.
4. The parties received adequate and timely notice of the hearing pursuant to Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
5. A repeat MRI is not medically necessary for Petitioner.
6. Based on the above Findings of Fact, a repeat MRI of Petitioner’s lumbo-sacral spine is not reasonably required to treat Petitioner’s compensable injury. Tex. Lab. Code Ann. ‘ 408.021; 28 Tex. Admin. Code ‘ 134.600.
7. Based on the above Findings of Fact and Conclusions of Law, preauthorization is denied for a repeat MRI of Petitioners lumbo-sacral spine.

ORDER

IT IS, THEREFORE, ORDERED that preauthorization is hereby denied for a repeat MRI of____’s lumbo-sacral spine, as requested by Dr. Joseph Neustein

Signed, October 30^th 2003.

JOHN H. BEELER

STATE OFFICE OF ADMINISTRATIVE HEARINGS
Administrative Law Judge