Texas Workers’ Compensation

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19019
December 12, 2019

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and the Rules of the Texas Department of Insurance, Division of Workers’ Compensation (DWC). For the reasons discussed herein, the Administrative Law Judge (ALJ) determines that:

Claimant is not entitled to a right shoulder MRI without contrast for the compensable injury of (Date of Injury).

STATEMENT OF THE CASE

On December 12, 2019, Warren E. Hancock, Jr., a DWC administrative law judge, held a contested case hearing to decide the following disputed issues:

  1. 1.Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that Claimant is not entitled to an MRI without contrast for the right shoulder for the compensable injury of (Date of Injury)?

PARTIES PRESENT

Claimant appeared and was assisted by EE, ombudsman. Self-Insured appeared and was represented by AS, attorney. The Employer representative was SM.

EVIDENCE PRESENTED

The following witnesses testified:

For Claimant: Claimant.

For Self-Insured: None.

The following exhibits were admitted into evidence:

ALJ’s Exhibits: ALJ-1 and ALJ-2.

Claimant’s Exhibits: None.

Self-Insured’s Exhibits: CR-A through CR-E.

DISCUSSION

Claimant is a (Age)-year-old teacher who was injured on (Date of Injury) when she was holding a door open for a student who jumped up and hit Claimant’s right arm as the student passed underneath. Claimant testified she felt 3 “pops” in her shoulder with onset of excruciating pain. Claimant waited a week to seek medical attention thinking she would improve. She was seen by BD, M.D. who ordered an MR Arthrogram which was done on March 6, 2019. This study was interpreted as showing no evidence of a full-thickness rotator cuff tear but with fluid in the subdeltoid bursa. A right shoulder X-ray on June 12, 2019 showed no fracture or dislocation, and normal alignment of the shoulder. Claimant has had medications, physical therapy and a shoulder injection.

Claimant continued to have right shoulder pain and began treating with DN, M.D., an orthopedic surgeon, on July 15, 2019. Dr. N requested an MRI of the right shoulder without contrast. This treatment was denied by BB, M.D., a physical medicine specialist who reviewed the request as utilization reviewer for Self-Insured on August 1, 2019. He stated that this would be considered a repeat MRI and there was no indication of a significant change in symptoms. A reconsideration review was done by BA, M.D., an orthopedic surgeon on August 15, 2019. He also recommended denial of the requested MRI without contrast, stating that the ODG recommends an MRI where there is suspicion of a rotator cuff disorder with initial radiographs which are normal or inconclusive. He pointed out that a repeat MRI is only indicated according to the Official Disability Guides (ODG) where there are new symptoms or a significant change in symptoms indicative of new pathology. He stated that the repeat MRI was sought in this case due to continued pain despite conservative treatment, but no new symptoms or change in symptoms was shown. On September 25, 2019, the case was reviewed by an orthopedic surgeon as part of an IRO review, who upheld the denial of the requested test. He explained that Claimant has had an MR Arthrogram of the right shoulder which is the definitive study for rotator cuff tear which is more sensitive than an MRI without contrast. For a repeat MRI such as that requested in this case, the ODG requires a substantial change in symptoms and/or clinical findings suggestive of new pathology. He stated that the medical records in this case do not identify any substantial change in symptoms or findings suggestive of new pathology.

With regard to MRI, the ODG states as follows:

Non-contrast magnetic resonance imaging (MRI) is effective for assessing bony morphology and bone loss with traumatic shoulder injuries, and for assessment of most traumatic soft tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries. MR arthrography (MRA) is considered the gold standard for imaging traumatic shoulder pain and while comparable to non-contrast MRI for extra-articular soft tissues, MRA is superior for intra-articular pathology like SLAP tears, labro-ligamentous injuries, and partial rotator cuff tears. MRA is comparable to CT for evaluation of traumatic osseous lesions, such as bony Bankart and Hill-Sachs defects. For non-localized shoulder pain with negative radiographs, MRI without IV contrast is indicated. When Bankart or Hill-Sachs lesions are detected on radiographs, MRI without IV contrast or MRA are both good studies for assessing labro-ligamentous injuries. Either MRI or MRA are also appropriate for a suspected dislocation event or instability when radiographs are normal. For evaluation of labral tears with normal radiographs either MRA, CT arthrography (CTA), or MRI without IV contrast can be used. For suspected rotator cuff tears with normal radiographs, MRI without IV contrast, MRA, or ultrasound (US) are appropriate studies. (ACR, 2017)

Given its excellent depiction of soft-tissue structures, MRI is also considered the gold standard for evaluation of the glenoid labrum and rotator cuff, and MRA further increases diagnostic sensitivity and specificity. MRI is well tolerated and involves no ionizing radiation. Either MRI without IV contrast or US should be performed when rotator cuff abnormalities, bursitis, or biceps tendon abnormalities are suspected and radiographs are normal or inconclusive. Either MRA or MRI without IV contrast should be performed when instability and labral tears are suspected with normal or inconclusive radiographs. Either MRA, MRI without IV contrast, or US should be performed for shoulder pain after rotator cuff repair when radiographs are normal or inconclusive. MRI without IV contrast should be performed when adhesive capsulitis is suspected or for neurogenic shoulder pain (excluding plexopathy) when initial radiographs are normal or inconclusive. (ACR, 2018) MRI has inherently higher tissue-contrast resolution than CT and is superior for assessing soft-tissue abnormalities following shoulder arthroplasty. Evolving MRI methods with improved image quality and metal artifact reduction make it a more feasible technique for evaluation of component loosening, rotator cuff tear, infection, or hemiarthroplasty glenoid cartilage wear. (ACR, 2016)

Ultrasonography and MRI have comparably high accuracy for identifying biceps pathologies and rotator cuff tears, so the choice should be based on the clinical situation, cost, and available imaging experience. (Ardic, 2006) MRI is particularly useful for evaluation of shoulder pain due to subacromial impingement and rotator cuff disease, showing bursal inflammatory changes, structural impingement, and secondary tendinopathy including partial- and full-thickness rotator cuff tears. However, overall prevalence of rotator cuff tears on MRI is 34% in asymptomatic patients of all age groups (15% full-thickness, 20% partial-thickness). (Hambly, 2007) Primary care physicians make a significant number of inappropriate referrals for CT and MRI, as high as 37% for shoulder MRI, mostly for patients with no history of trauma or with documented osteoarthritis on plain-films. (Lehnert, 2010)Non-contrast MRI is sufficient for most conditions including rotator cuff tears, but contrast enhancement is often recommended for SLAP tears. In the past when MRI images and sensitivity were poor, additional injection of contrast into the shoulder joint improved interpretation, but this has become less necessary with modern high field magnets. (Spencer, 2013) (Farshad-Amacker, 2013) (Arnold, 2012) MR arthrography continues to be an option to better detect labral tears and for suspected re-tear of rotator cuff repairs. (Murray, 2009)

Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant new pathology. (Mays, 2008)

Claimant did not present evidence-based medical evidence at the hearing showing either that Claimant meets the requirements of the ODG for the requested MRI without contrast, or that there is other evidence-based medical evidence which outweighs the ODG in this regard. Accordingly, Claimant failed to meet her burden of showing that the preponderance of the evidence is contrary to the determination of the IRO in this case.

The Administrative Law Judge considered all of the evidence admitted. The Findings of Fact and Conclusions of Law are based on an assessment of all of the evidence whether or not the evidence is specifically discussed in this Decision and Order.

FINDINGS OF FACT

  1. 1.The parties stipulated to the following facts:
  2. B.Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
  3. C.On (Date of Injury), Claimant was the employee of (Employer), Employer.
  4. D.On (Date of Injury), Employer provided workers’ compensation coverage through self-insurance.
  5. E.Claimant sustained a compensable injury on (Date of Injury) in the form of at least the Self-Insured-accepted condition of right shoulder sprain.
  6. F.Treatment for Claimant’s compensable injury is not covered by a Workers’ Compensation Healthcare Network.
  7. G.The IRO determined that a right shoulder MRI without contrast is not healthcare reasonably required for the compensable injury of (Date of Injury).
  8. 8.Self-Insured delivered to Claimant a single document stating the true corporate name of Self-Insured, and the name and street address of Self-Insured’s registered agent, which document was admitted into evidence as Administrative Law Judge’s Exhibit Number 2.
  9. 9.A right shoulder MRI without contrast is not healthcare reasonably required for the compensable injury of (Date of Injury).

CONCLUSIONS OF LAW

  1. 1.The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
  2. 2.Venue is proper in the (City) Field Office.
  3. 3.Claimant is not entitled to a right shoulder MRI without contrast for the compensable injury of (Date of Injury).

DECISION

Claimant is not entitled to a right shoulder MRI without contrast for the compensable injury of (Date of Injury).

ORDER

Self-Insured is not liable for the benefits at issue in this hearing, and it is so ordered. Claimant remains entitled to medical benefits for the compensable injury in accordance with Texas Labor Code §408.021.

The true corporate name of the Self-Insured is (EMPLOYER), and the name and address of its registered agent for service of process is

(NAME)

(EMPLOYER)

(ADDRESS)

Signed this 12th day of December, 2019.

Warren E. Hancock, Jr.

Administrative Law Judge

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At a Glance:

Title:

19019

Decision Type:

MCCH Decision

Date:

December 12, 2019

MCCH Type:

Non-Network
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