Austin, TX – On November 20, 2017, The Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC) solicited and received constructive input from workers’ compensation system participants on the proposed Lumbar Spine Magnetic Resonance Imaging (MRI) Plan-Based Audit (Plan-Based Audit). TDI-DWC appreciates the input provided by system participants. All comments were carefully considered and discussed. The Commissioner of Workers’ Compensation W. Ryan Brannan, approved the Plan-Based Audit on January 23, 2018.
All medical quality reviews initiated on or after January 1, 2018, will follow the approved Medical Quality Review Process (Process) in effect.
Scope and Methodology for this Plan-Based Audit include:
- Indications for ordering lumbar spine MRI will be identified by the criteria established in the ODG for treatment (2015-2017), including Appendix D – documenting exceptions to the Guidelines.
- ODG does not recommend MRI for uncomplicated low back pain, with radiculopathy, until after at least one month of conservative therapy unless symptoms of a severe or progressive neurologic deficit were present.
- The request for medical records will offer doctors an opportunity to provide documentation to support the appropriateness for ordering MRI before at least one month of conservative therapy.
Selection Criteria for the Plan-Based Audit will include:
- Time frame to select data: Lumbar spine MRIs (with, without, and without contrast followed by contrast) performed prior to 30 days from the date of injury for the period of July 1, 2015 through June 30, 2017.
- MRIs performed for injured employees identified as having prior back surgery.
- MRIs performed in emergency rooms or inpatient hospital stays.
- Subject Selection:
- Select 10 health care practitioners who ordered the highest number of lumbar spine MRIs prior to 30 days from the date of injury from July 1, 2015 through June 30, 2017.
- In the event of a tie, select the health care practitioner with the highest billed amount.
- Case Selection: Select a random sample of no more than 10 cases for each health care practitioner.
The Process and Plan-Based Audit are posted on the TDI website at: http://www.tdi.texas.gov/wc/hcprovider/medadvisor.html