DECISION AND ORDER

Ace USA/ESIS (Carrier) appealed the decision of the Independent Review Organization (IRO) approving the preauthorization request of injured worker M.T. (Claimant) for total knee replacement surgery. After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that Carrier has shown by preponderance of the evidence that the requested total knee replacement surgery is not medically necessary treatment for Claimant’s work-related, compensable injury. Accordingly, the ALJ finds that total knee replacement surgery should not be preauthorized.

I. BACKGROUND FACTS AND PROCEDURAL HISTORY

Claimant is a 58-year-old man who suffered a compensable, work-related injury on December 9, 2000, when he tripped and fell at work, injuring his shoulders, arms, and knees. Claimant had no broken bones or open wounds, but did suffer a rotator cuff tear and significant pain in his right shoulder. Claimant began receiving treatment from Robert Urrea, M.D. As part of his treatment, Claimant received steroid injections and had arthroscopic surgery performed on his right shoulder. Claimant continued to see Dr. Urrea for regular examinations and conservative treatment. On December 12, 2002, Claimant underwent arthroscopic surgery to his left knee. Thereafter, on January 30, 2003, Claimant underwent arthroscopic surgery on his right knee. Because he continued to have pain in his right knee, Claimant’s orthopedic surgeon recommended total knee replacement surgery. Carrier denied preauthorization for the surgery and Claimant requested medical dispute resolution by the Texas Workers= Compensation Commission (Commission). The matter was referred to an IRO designated by the Commission for the review process. The IRO determined that total knee replacement surgery was medically necessary and should be authorized. Carrier then requested a hearing before SOAH, resulting in this proceeding.

II. DISCUSSION AND ANALYSIS

The sole issue in this case is whether total knee replacement surgery is medically necessary to treat Claimant’s work-related injury. After considering the evidence presented, the ALJ concludes it is not. Specifically, the ALJ finds that Claimant’s ongoing knee problems are not the result of his compensable injury.

After his injury on December 9, 2000, Claimant’s treating doctor, Dr. Urrea, continued to see him regularly over the next two years. During that time period, Dr. Urrea continually noted that Claimant’s knees were doing fine without any problems. Below are some excerpts from Dr. Urrea’s treatment notes:

• December 15, 2000: Only right shoulder pain noted.
• February 12, 2001: ABoth knees have good range of motion without significant pain.
• Mrch 9, 2001: ABoth knees are not causing him much discomfort; ABoth knees have good range of motion without pain.
• ugust 6, 2001: ABoth knees are not symptomatic; ABilateral knees have good range of motion without pain.
• November 5, 2001: the ptient’s bilateral knees . . . have full range of motion and the patient is entitled to zero percent whole person impairment for both knees. At this point, Dr. Urrea concluded that Claimant was at maximum medical improvement.

It ws only later that Claimant’s knees became a problem. On February 20, 2002, Dr. Urrea noted that Claimant was having pain in his knees when he squatted. Thereafter, Claimant’s knees improved and, on June 10, 2002, Dr. Urrea again noted that Claimant’s Aknees are not giving him much discomfort and that his Aright knee has full range of motion. However, beginning on September 30, 2002, Claimant’s knees began causing him pain on a regular basis. Dr. Urrea then performed the arthroscopic knee surgeries noted previously. On May 19, 2003, Dr. Urrea diagnosed Claimant with having Abilateral knee post-traumatic arthritis.

Two separate peer review doctors, Lewis Nettrour, M.D., and Randy Pollett, M.D., both concluded that Claimant’s knee problems were the result of degenerative arthritis that was not related to the compensable injury. They further noted that degenerative arthritis is a natural, progressive, and degenerative process related to heredity and age. Although the IRO reviewer determined the treatment was medically necessary given Claimant’s condition, the reviewer did not address the specific issue of whether the treatment actually related to the compensable injury of December 2000. Therefore, the IRO decision is of little value to the ALJ’s deliberations in this proceeding.

Ultimately, in considering the evidence discussed above, the ALJ finds it highly unlikely that Claimant’s degenerative arthritis and related knee problems are the result of his injury from December 2000. Well over a year passed from the time of Claimant’s injury until he began experiencing ongoing knee problems. Moreover, the diagnosis of degenerative arthritis (which all doctors, including Claimant’s own treating doctor, agree is the cause of Claimant’s current knee problems) is not consistent with a compensable injury to Claimant’s knee. For these reasons, the ALJ finds that total knee replacement surgery is not medically necessary treatment for Claimant’s compensable injury and should not be preauthorized. In support of this conclusion, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. M.T. (Claimant) is a 58-year-old man who suffered a compensable, work-related injury on December 9, 2000, when he tripped and fell at work, injuring his shoulders, arms, and knees.
2. Claimant had no broken bones or open wounds, but did suffer a rotator cuff tear and significant pain in his right shoulder.
3. Claimant began receiving treatment for his injury from Robert Urrea, M.D.
4. Dr. Urrea cleared Claimant to return to regular work duties on December 15, 2000.
5. As part of his treatment, Claimant received steroid injections and had arthroscopic surgery performed on his right shoulder.
6. In 2001, 2002, and 2003, Claimant continued to see Dr. Urrea for regular examinations and conservative treatment.
7. Throughout 2001, Dr. Urrea’s examinations of Claimant revealed no knee problems, and Claimant did not complain of pain or ongoing knee problems during that time.
8. Claimant began experiencing ongoing knee problems in September 2002, nearly two years after his underlying compensable injury.
9. On December 12, 2002, Claimant underwent arthroscopic surgery to his left knee.
10. On January 30, 2003, Claimant underwent arthroscopic surgery on his right knee.
11. On May 19, 2003, Dr. Urrea diagnosed Claimant with bilateral knee post-traumatic arthritis.
12. Because Claimant continued to have pain to his right knee, Claimant’s orthopedic surgeon recommended total knee replacement surgery and sought preauthorization for such.
13. Ace USA/ESIS (Carrier) denied the request for preauthorization for total knee replacement surgery.
14. Claimant requested medical dispute resolution by the Texas Workers= Compensation Commission’s Medical Review Division (MRD), which referred the matter to an Independent Review Organization (IRO).
15. On November 7, 2003, after conducting medical dispute resolution, the IRO physician reviewer determined that the requested total knee replacement surgery was medically necessary and should be authorized.
16. On November 17, 2003, Carrier requested a hearing on the IRO decision and the case was referred to the State Office of Administrative Hearings (SOAH).
17. The hearing convened and closed on February 17, 2004, with ALJ Craig R. Bennett presiding. Carrier appeared through its representative, F. Javier Gonzalez. Claimant did not appear or participate.
18. No parties have raised challenges to notice or jurisdiction.
19. Claimant has degenerative arthritis in his knees, which is a natural, progressive, and degenerative process related to heredity and age.
20. Claimant’s degenerative arthritis is the cause of Claimant’s knee pain and knee problems and is not the result of Claimant’s underlying compensable injury.
21. Total knee replacement surgery is not medically necessary treatment for Claimant’s work-related, compensable injury of December 2000.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers= Compensation Act (the Act), specifically Tex. Labor Code Ann. ‘413.031(k), and Tex. Gov=t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=t Code Ann. ch. 2001, and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code ‘ 148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
5. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code ” 148.21(h) and 133.308(v).
6. Carrier established, by a preponderance of the evidence, that the requested total knee replacement surgery is not medically necessary for treatment of Claimant’s work-related injury of December 2000.
7. Claimant’s request for preauthorization should be denied.

ORDER

IT IS, THEREFORE, ORDERED that preauthorization for the requested total knee replacement surgery is denied.

Signed February 23, 2004.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS