Why Was My Workers’ Comp Claim Denied If I Had A Positive MRI?

Workers’ Comp. attorneys often hear the above phrase in many different forms. There are often times when injured workers have diagnostic tests, such as an MRI, which show various injuries to various different body parts. Injured workers will often feel as though a diagnostic test would be the key to proving that an injury is work related. However, this is not always the case. In fact, even a positive MRI could mean very little.

Many clients will be very confused when they suffer a back injury and subsequently get an MRI which shows a herniated disc, only to find out that the insurance company is going to deny the claim. “How could they do that?” Well, diagnostic studies, such as an MRI, an EMG, or an x-ray are not always a direct indicator that there has been a work injury. Many injured workers feel that as soon as they see a positive finding on a diagnostic test it must mean that whatever the test shows was caused by the work injury. However, this is often not the case. Many people may be walking around with various degenerative findings in thier spines, for instance, which may or may not be causing any types of symptoms. Anyone over 40 years old is likely to have various abnormal findings that may show up on an MRI, which may be causing no symptoms whatsoever. Until there is a work injury, or pain rising to the level of needing treatment, most people never get any type of diagnostic scans of their bodies. When they do and there is a finding, it’s often easy to think that it must have been caused by an injury. Thus diagnostic tests, as useful as they can be, can often be misleading to people who have never had them before.

Workers’ Comp insurance carriers will usually hire highly skilled doctors to perform what is called an “independent” medical exam (IME) to perform a thorough examination of the allegedly injured worker, and will frequently report that a diagnostic test is only showing findings that are age-related or degenerative instead of being related to a work injury. This is, in fact, is one of the most frequently litigated issues in Workers’ Comp cases. Are the findings on the MRI new and caused by the work injury, or are they actually age-related and unrelated to the work injury? There are some definitive ways to tell whether a finding on a diagnostic test is a new finding, but even those ways can be questioned. Confusing things even more is that there may be a finding on a diagnostic test that is clearly age related and existed before the work injury, but it may have been made symptomatic by the work injury. Thus, it could be argued that while the diagnostic test is showing perhaps a herniated disc that clearly predated the work injury, the injured worker was never symptomatic until the accident at work. This is known in the Workers’ Comp world as an aggravation of a pre-existing condition – which is, by law and without a doubt, a work injury. The only problem with this argument is that an aggravation injury may be difficult to actually prove. Further, employers and insurance companies often use the existence of a pre-existing herniated disc on an MRI as a way to deny the claim, especially if there is a pre-injury MRI to which to compare the post-injury study.

MRIs are not the only diagnostic test that can be read in multiple ways. An Electromyography (EMG) is a diagnostic test that measures the electrical activity in muscles to assess the health of muscles and nerves. In the Workers’ Comp world, this test can often be used to corroborate a complaint of pain which is radicular in nature (shooting down one’s leg starting from the lower back area, for example). However, the test is notoriously inaccurate, and positive findings can sometimes be caused by other physical issues than a nerve being pinched in an injured worker’s back. However, many injured workers will receive a positive EMG and feel as though that should be definitive evidence that their injury is work related.

And of course, there is the good old x-ray. Many injured workers get an x-ray showing some type of fracture and immediately feel as though they are entitled to benefits related to a work injury. However, a skilled physician can read an x-ray and make a determination that the findings on the x-ray may have predated the work injury. For instance, a fracture in someone’s spine can often show up months or even years after the injury, but when it does, they might feel as though it should be evidence enough to show that they have suffered an earlier work injury.

All the disc levels in the human spine have correlating dermatomal patterns of nerves which go down into the various upper and lower extremities in the human body. For instance, the L1 nerve pattern generally goes into the lower back, hips and groin. Thus, if you were to suffer a herniated disc at that level, you might feel pain in those areas. However, for the injured worker complaining about pain going down the back of the legs, a “positive finding” of a herniated disc at L1-2 would not have any relevance to the complaint of pain going down the back of the legs. This illustrates that positive findings on an MRI are not necessarily going to be definitive evidence of a work injury.

There are also times when an MRI shows almost no findings, but the injured worker nevertheless complains of pain. Specifically, a torn labrum in the shoulder will only usually show up on a MRI if the MRI is performed with contrast. This type of MRI is when a dye is injected into the affected area, which allows the radiologist to see the injured structures in more detail. This type of study is called an MR arthrogram. Sometimes a regular MRI may not show any injury, which can trigger a denial from a Workers’ Compensation carrier. But if the pain persists, a doctor may request an MR arthrogram, which then may reveal the tear that was not visible on the non-contrast MRI.

The reality is that these diagnostic tests are really just a piece of a larger puzzle. They are simply evidence to be used to try to prove that a work injury occurred. These tests are certainly not always the winning chip that many injured workers think that they are. For instance, a diagnostic test showing a herniated disc at L4-5 may not really mean much at all in diagnosing the work injury. A corroboration with a physical exam, together with a thorough history of the mechanism of injury, is really the only way to make this type of finding useful. Injured workers should not be surprised if a diagnostic test is not the definitive way of winning a Workers’ Compensation case.