DECISION AND ORDER

I. Introduction

Texas Mutual Insurance Company (Carrier)^[1] has appealed the decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) ordering it to reimburse $852 to Metroplex Diagnostics (Provider) for electromyogram (EMG)/nerve conduction studies that Provider performed on (Claimant) on June 15, 2000. The only issues are whether the services were medically necessary and performed in accordance with TWCC’s Spine Treatment Guideline.^[2]

The Administrative Law Judge (ALJ) concludes that the nerve conduction studies were neither medically necessary nor performed in accordance with the Spine Treatment Guideline and denies the Provider’s request for reimbursement.

II. Findings of Fact

1. The Claimant sustained a compensable work-related injury to his back and upper extremities on May 10, 2000, while his employer was RTC Glass and Mirror and its workers’ compensation insurance carrier was the Carrier.
2. On May 10, 2000, the Claimant’s treating physician, Mark Rayshell, D.C., referred the Claimant to the Provider for EMG/nerve conduction studies on his upper extremities to rule out nerve root irritation/radiculopathy.
3. On June 15, 2000, less than six weeks after the Claimant’s injury, the Provider performed the EMG/nerve conduction studies on the Claimant and thereafter timely sought reimbursement of $825 from the Carrier under current procedural terminology (CPT) codes 95900, 95904, and 95935.
4. The treating physician’s initial neurological, motor, sensory, and reflex evaluations of the Claimant on May 10, 2000, did not indicate that anything was wrong with the Claimant’s nerve function.
5. Additionally, magnetic resonance imaging (MRI) of the Claimant’s lumbar spine on May 20, 2000, did not indicate any spine damage or nerve function abnormality due to the compensable injury or that the EMG/nerve conduction studies were medically necessary.
6. A June 5, 2000 examination of the Claimant by James E. Laughlin, D.O. concluded that the Claimant had no nerve compromise or cervical radioculopathy.
7. Prior to the June 15, 2000 EMG/nerve conduction studies that the Provider performed on Claimant, no medical information indicated that such studies were medically necessary.
8. The June 15, 2000 EMG/nerve conduction study of the Claimant did not reveal any nerve-function abnormalities.
9. On July 25, 2000, the Carrier refused to reimburse the Provider for the EMG/nerve conduction study services.
10. The Provider filed a request for medical dispute resolution with the MRD, asking for reimbursement of $825 for those services.
11. On March 14, 2001, the MRD ordered the Carrier to reimburse the Provider $825 for the above-described services.
12. On April 2, 2001, the Carrier appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
13. On May 29, 2001, notice of the hearing in this case was mailed to the Carrier, the Provider, and the TWCC APA Litigation Section.
14. On January 15, 2002, William G. Newchurch, a SOAH ALJ, held a telephone hearing on the Provider’s appeal. Representatives of the Provider, the Carrier, and the TWCC staff attended that hearing. The hearing concluded and the record closed on that same day.

III. Conclusions of Law

1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented in this case, pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. §413.031 (Vernon 2001).
2. SOAH has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2001).
3. Adequate and timely notice of the hearing was provided in accordance with Tex Gov’t. Code Ann. §§ 2001.051 and 2001.052.
4. As the party appealing the MRD decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
5. Under Tex. Labor Code § 408.021 (a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
6. The Commission’s Spine Treatment Guideline recommends EMG/nerve conduction studies only six weeks to four months after the compensable injury and requires a clinical rationale that adequately substantiates the need for any deviation. 28 Tex. Admin. Code §§ 134.1001(b)(1), (c)(4), (d)(1), (e)(2)(A), (f)(2)(K) and (f)(3)(b).
7. Based on the above Findings of Fact and Conclusions of Law, there was no clinical medical rationale for the EMG/nerve conduction studies that the Provider furnished to the Claimant.
8. Based on the above Findings of Fact and Conclusions of Law, the EMG/nerve conduction studies that the Provider furnished to the Claimant were not medically necessary.
9. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for reimbursement of $825 for the June 15, 2000 EMG/nerve conduction studies that it performed on the Claimant under CPT codes 95900, 95904, and 95935 should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request for reimbursement of $825 for the June 15, 2000 EMG/nerve conduction studies that it performed on the Claimant under CPT codes 95900, 95904, and 95935 is denied.

Signed January 28, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

1. Formerly known as Texas Workers’ Compensation Insurance Fund.↑
2. 28 Texas Administrative Code (TAC) §§134.1001↑