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W. Va. Delivery Driver’s Bid for 2nd MRI Comes Up Short on Preexisting Injury, MMI Conclusions

22 Sep, 2023 Frank Ferreri

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Charleston, WV (WorkersCompensation.com) -- What happens in West Virginia when a doctor thinks an injured worker needs a second MRI, but the claims administrator disagrees?

If Stewart v. Wolseley Investments Inc., No. 22-0215 (W. Va. 09/14/23) is any indication, the dispute could make its way up to the state's highest court, which will look at preexisting conditions and maximum medical improvement.

A delivery driver injured his back when lifting a cast iron bathtub on the job. The claims administrator held the claim compensable with regard to a lumbar sprain and lumbar radiculopathy and authorized an MRI of the driver's lumbar spine.

Later, the claims administrator issued a corrected claims decision order in which the administrator clarified that radiculopathy was not a compensable condition as it was a symptom rather than an acute injury.

The driver underwent an independent medical evaluation, which diagnosed the driver with a lumbar sprain, but the IME also determined that the driver had preexisting degenerative spondyloarthropathy.

With regard to the compensable injury, the IME physician assessed the driver as being at maximum medical improvement without the need for further treatment except for the continuation of a home exercise program. The physician adjusted the driver's impairment rating from 12 percent to 8 percent.

After a follow-up appointment, a physician requested a second MRI of the driver's lumbar spine, opining that the MR was "warranted" due to the return of "painful symptoms after finishing his course of physical therapy along with findings of some "very small spondylolisthesis."

The claims administrator denied authorization for the second MRI, finding that it was neither medically necessary nor reasonably required to treat the driver's compensable injury.

The Office of Judges affirmed the claims administrator's denial of authorization for a second MRI because:

(1) The driver was at MMI with regard to the compensable injury
(2) The driver had preexisting degenerative changes.

Thus, in the Office of Judge's view, it was more likely than not that the request for an additional MRI was unrelated to the compensable injury. The Board of Review adopted the Office of Judges' findings.

The driver appealed.

Under West Virginia law, the duration of care for a lower back sprain is estimated not to exceed 8 weeks. Co-morbidities such as degenerative disc disease and spondylolisthesis “may be associated with a higher incidence of persistent symptoms but are not compensable conditions.”

Thus, the court upheld the Office of Judges' ruling.

"It was more likely than not that the request for a second MRI of [the driver's] lumbar spine was unrelated to the compensable injury," the court concluded.

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    About The Author

    • Frank Ferreri

      Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law. Frank encourages everyone to consider helping out the Kind Souls Foundation and Kids' Chance of America.

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