DECISION AND ORDER

This is a dispute over reimbursement for a lumbar magnetic resonance imaging test (MRI). The Administrative Law Judge (ALJ) orders reimbursement.

I. HISTORY OF THE CASE

The workers’ compensation claimant, ___ (the Claimant) injured her lower back and left leg on ___, when she stepped into a drainage hole and fell during the course of her employment with the University of Texas System (the U.T. System). She saw Chad Blackwell, D.C., for treatment. On July 8, 2002, Dr. Blackwell referred her for a lumber MRI, which was conducted by Texas Imaging and Diagnostic Center (Texas Imaging) on July 11, 2002, approximately two and a half weeks after the injury.

Texas Imaging sought reimbursement for the lumbar MRI from the U.T. System, which is self-insured for worker’s compensation insurance. The U.T. System denied reimbursement on the basis that the MRI was not medically necessary. After reimbursement was denied again on reconsideration, Texas Imaging filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission). The amount in dispute, which was the maximum allowable reimbursement for the test, was $924.00. The request was referred to an Independent Review Organization (IRO), which found in favor of Texas Imaging.

The U.T. System filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH). The SOAH hearing was convened January 12, 2005, before ALJ Henry D. Card. Representatives of both parties participated in the hearing, which was adjourned, and the record closed, the same day.

II. DISCUSSION

Michael Bhatt, D.C., who conducted a peer review of the Claimant’s file, found the MRI not to have been medically necessary. Dr. Bhatt stated that medical guidelines and practice call for a lumbar spine MRI to be performed, if a patient is not progressing satisfactorily, four to six weeks after the injury. An earlier MRI may be called for if there are certain “red flags,” which include a previous history of cancer, a progressively worsening condition, bowel and bladder dysfunction, history of significant trauma, or progressive neurologic deficit. Dr. Bhatt stated that none of those

indicators were present in this case. He questioned the health care provider’s performance of manipulation and passive treatment interventions, if there were suspicions of a fracture or a large herniated disc. He observed those treatments with be contraindicated in that circumstance.

In defending the MRI request, Dr. Blackwell explained that the Claimant showed decreased range of motion, along with pain and discomfort upon palpation of the paraspinal musculature of the lumbar spine. His notes from July 1, 2002, showed some diminished sensation. Dr. Blackwell stated the MRI was necessary to diagnose and treat the patient properly.

The IRO reviewer agreed with Dr. Blackwell. The reviewer recognized that national treatment guidelines usually indicate the need for an MRI after a month, if the patient does not respond to treatment. The reviewer found the earlier MRI to be necessary in this case, however, “due to the traumatic nature of this patient’s injury, subjective symptoms, positive orthopedic findings, decreased range of motion, muscle weakness and sensation deficits.”^[1]

Under 28 TAC §148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann.§413.031. In this case there is credible evidence

supporting either side. The ALJ finds the IRO’s comparison of the general guidelines with the Claimant’s specific situation, combined with Dr. Blackwell’s recommendation, at least as convincing as Dr. Bhatt’s review. He concludes the U.T. System did not meet its burden of proving the MRI was not medically necessary. Therefore, he orders the U.T. System to reimburse Texas Imaging $924.00 for the lumbar MRI performed on the Claimant on July 11, 2002.

III. FINDINGS OF FACT

1. The workers’ compensation claimant, ___ (the Claimant) injured her lower back and left leg on ___, when she stepped into a drainage hole and fell during the course of her employment with the University of Texas System (the U.T. System).
2. On July 8, 2002, Chad Blackwell, D.C., referred the Claimant for a lumbar magnetic resonance imaging test (MRI), which was conducted by Texas Imaging and Diagnostic Center (Texas Imaging) on July 11, 2002, approximately two and a half weeks after the injury.
3. Texas Imaging sought reimbursement for the lumbar MRI from the U.T. System, which is self-insured for worker’s compensation insurance.
4. The U.T. System denied reimbursement on the basis that the MRI was not medically necessary.
5. After reimbursement was denied again on reconsideration, Texas Imaging filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission).
6. The amount in dispute, which was the maximum allowable reimbursement for the test, was $924.00.
7. The request was referred to an Independent Review Organization (IRO), which found in favor of Texas Imaging.
8. The U.T. System filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
9. Notice of the hearing was sent September 9, 2003.
10. 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.
11. The SOAH hearing was convened January 12, 2005, before ALJ Henry D. Card. Representatives of both parties participated in the hearing, which was adjourned, and the record closed, the same day.
12. National treatment guidelines usually indicate the need for an MRI after a month, if the patient does not respond to treatment.
13. The earlier MRI was medically necessary in this case due to the traumatic nature of this patient’s injury, subjective symptoms, positive orthopedic findings, decreased range of motion, muscle weakness and sensation deficits.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
3. The lumbar MRI was medically necessary pursuant to Tex. Lab. Code Ann. §§ 408.021 and 401.011(19).
4. The U.T. System should reimburse Texas Imaging for the lumbar MRI.

ORDER

It is, therefore, ordered that the University of Texas System reimburse Texas Imaging and Diagnostic Center $924.00, plus interest, for the lumbar MRI performed on the Claimant on July 11, 2002.

Signed March 7, 2005.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. IRO Decision, Carrier Ex. CR-J.↑