Comp Claims, Litigation Often Muddied by Preexisting Conditions, MRI Findings

Business Insurance
Full article on: businessinsurance.com

By: Louise Esola

As the workforce ages, the workers compensation industry faces a convergence of pressures that include rising claim severity and litigation pitting injury causation against preexisting conditions, with many disputes fueled by a familiar diagnostic flashpoint: magnetic resonance imaging.

Known as an MRI, the tool is effective at diagnosing musculoskeletal injuries and degenerative conditions, yet experts say the technology also introduces gray areas that can complicate claims, inflate costs, prolong claim duration and trigger legal battles over causation.

“There’s always been back and forth around compensability because degenerative situations have always existed, and there’s always been incidents that can or cannot make that condition worse,” said Leah Sharp, Huntsville, Alabama-based senior vice president of clinical services at Gallagher Bassett. She added that the issues are now “more prevalent as the workforce is aging.”

“This is certainly an area to watch, as (diagnostics) can convolute and muddy claims management,” said Susan Doering, Scottsdale, Arizona-based director of clinical operations for utilization review at Enlyte.

Over the 10 years leading up to 2033, the workforce is projected to see a 22.4% rise in workers 65 to 74 and a 79% increase in those over 75, according to the U.S. Bureau of Labor Statistics. At Sedgwick Claims Management Services, workers 60 and older had the highest increase in overall new claim volume each year from 2020 to 2024.

As with most accepted work-related injuries, the first task for insurers and employers managing a musculoskeletal claim is to review evidence-based guidelines and work with doctors to understand what they are and why they matter, said Dr. Dorian Kenleigh, Phoenix-based national medical director at MedRisk and a section leader with the American College of Occupational and Environmental Medicine, which provides injury guidelines for states such as California. That organization, along with the equally common Official Disability Guidelines, has established guidelines saying that for most injuries, an MRI typically is not needed in the first six weeks, Dr. Kenleigh said.

That hasn’t stopped the medical profession from ordering the test, primarily when a doctor is not used to working within the scope of workers compensation and may not understand the rules on injury causation, experts said. MRIs can be expensive alone and it’s the cost related to prolonging or complicating a claim can add up, they said.

When it comes to diagnostics and musculoskeletal injuries, many of which deal with subjective pain, “we want to avoid that ‘throw everything at the wall and see what sticks’ approach,” Ms. Doering said.

“Guidelines are really the backbone of our decision-making,” she said. “They give us a framework to ensure imaging is being appropriately applied or allocated to an injured worker.”

Evidence-based guidelines generally recommend delaying MRI for soft-tissue and musculoskeletal injuries—such as back, knee or shoulder pain—unless there are clear “red flag” indicators such as progressive neurological deficits, suspected infection, or other “atypical” presentations, Ms. Doering said.

In most cases, however, “conservative treatment” such as physical therapy, chiropractic care and medication should precede imaging, Dr. Kenleigh said, adding that losses of functions after an incident or injury could trigger the need for an MRI or other advanced tests.

“Advanced imaging may be warranted when symptoms persist beyond six weeks despite nonoperative treatment,” Ms. Doering said. “At that point, an MRI can help determine whether invasive interventions like an epidural or surgery are appropriate.”

Even then, the issue of MRIs and injured workers is not so clear-cut, cautioned Dr. Michael Choo, Walnut Creek, California-based chief medical officer of workers compensation at Paradigm.

“Medicine is art and science mixed,” he said. “There’s a lot more gray than we’d like, especially with imaging and aging.”

Degeneration is also widely common (see related story below).

Dr. Choo said guidelines “shouldn’t be applied rigidly.”

“If someone presents with swelling, bruising or clear signs of trauma, imaging is absolutely appropriate,” he said. “But if the person has vague pain and no clinical findings, you have to pause and ask what you’re looking for.”

That nuance is crucial, because refusing imaging outright can delay care and worsen outcomes. “You can’t just say ‘No MRI for six weeks’ across the board,” Dr. Choo said. “Every case has to be assessed individually—mechanism of injury, symptoms, preexisting conditions. It’s not one-size-fits-all.”

Even when imaging is warranted, Dr. Choo warns that the sophistication of new diagnostic technology can pose its own challenges. “A high-field MRI might reveal things a lower-field scan wouldn’t,” he said. “That doesn’t mean the injury is new—it just means the equipment is more powerful.”

Ms. Doering said some diagnostics can trigger “unnecessary procedures—and potentially worse outcomes, carrying financial and legal consequences. “Premature imaging can reveal incidental findings that complicate a claim,” she said. “That can lead to unnecessary procedures, prolonged disability and inflated costs.”

Dr. Choo sees the downstream effects firsthand. “You fix one thing the MRI shows, but the patient still has pain,” he said. “Then they have another surgery, and another. At some point you’re treating the consequences of intervention rather than the original problem.”

As workers comp cases become more medically complex, disputes over causation—what’s new, what’s preexisting and what’s compensable—are rising, according to experts.

“There’s a lot of room for attorneys to add complexity,” Dr. Choo said. “And that’s not always in the patient’s best interest.”

Imaging doesn’t always help a claimant’s case, as more information can help an employer defending a claim, according to Barak Kassutto, a Philadelphia-based workers comp lawyer with Krasno, Krasno & Onwudinjo, which represents injured workers.

“Diagnostic imaging is something a defendant can point a finger at and say, ‘preexisting condition,’” said Mr. Kassutto, who used to work in workers comp defense. “That’s objective data that they can use to argue against subjective complaints.”

Ms. Doering echoes that sentiment from the utilization side. “It’s about ruling things out methodically and adhering to guidelines,” she said.

Experts say improved collaboration among clinicians, payers and claims professionals can prevent unnecessary imaging and reduce the risk of litigation. “We have to guide injured workers through a complex system,” Dr. Choo said. “They just want to get better—but it’s our job to help them do that safely and wisely.”

Claims handlers also should recognize that delaying imaging can delay appropriate care and recovery, according to Ms. Sharp, who highlighted a conundrum for the industry.

“Everyone talks about early intervention…because the earlier you get on to it, the earlier you’re going to be able to see what needs to be done,” she said.

Degeneration blurs lines between work and age

Physiological degeneration is present in almost a third of workers compensation claims—and is likely more widespread outside the comp industry, experts say.

Degeneration is “a natural part of aging,” said Dr. Michael Choo, Walnut Creek, California-based chief medical officer of workers compensation at Paradigm.

“If you’re 50 years old, I guarantee we’ll see some degeneration,” he said. “It’s like tires on your car—the more miles, the more wear.”

That wear and tear complicates workers comp cases, experts said. With older workers, imaging often reveals preexisting degenerative changes that may or may not be related to a workplace injury and can become a point of contention in litigation, they said.

Degenerative disc disease was found in 33% of claims where the primary work-related injury resulted in a neurological back condition, and osteoarthritis was found in 36% of claims where the primary injury was rotator cuff or shoulder impingement, according to data released this year by the Workers Compensation Research Institute.

“Relying on some of these statistics, there’s not really a lot of utility in getting that early MRI unless you have some really strong clinical findings,” said Dr. Dorian Kenleigh, Phoenix-based national medical director at MedRisk.

Yet “just because you see degeneration doesn’t mean it’s symptomatic,” Dr. Choo said. “You can have severe osteoarthritis on imaging and feel no pain.”