DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for a cervical, thoracic, and lumbar MRI examination provided to P.M. (Claimant) on October 5, 2000, by Bexar County MRI (Provider). Via Metropolitan Transit (Carrier) denied reimbursement to Provider in the amount of $4,200.00, on the basis of medical necessity and Provider requested medical dispute resolution. The Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) denied reimbursement on July 12, 2001, in MDR Docket No. M4-01-1700-01, based on failure to document medical necessity. Provider appealed. This decision finds that Carrier should pay for the MRI.

I.

DISCUSSION

Background Facts

On__________, Claimant sustained a compensable injury. On September 22, 2000, Marcus Wilcox, D.C., examined Claimant in relation to his injuries. Following the examination, Dr. Wilcox referred Claimant to Provider for a cervical, thoracic, and lumbar MRI examination. Based on its belief that Carrier had approved the service, Provider administered the MRI to Claimant on October 5, 2000, and billed Carrier $4,200.00. Carrier denied reimbursement as not medically necessary. The Provider filed a request for Medical Dispute Resolution (MDR) with the Medical Review Division (MRD). The MRD first determined the Maximum Allowable Reimbursement rate for this service was $2,889.00, but held Provider was not entitled to any reimbursement. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the Act) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. §408.021 provides in pertinent part:

(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. The employee is specifically entitled to health care that:

1. cures or relieves the effects naturally resulting from the compensable injury;
2. promotes recovery; or
3. enhances the ability of the employee to return to or retain employment.

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The Commission’s rule under 28 Tex. Admin. Code §134.600(a)(5) defines preauthorization as prospective approval obtained from the insurance carrier by the requestor or injured employee prior to providing the health care treatment or services. Within the same rules under ‘134.600(f)(1) the carrier shall approve or deny requests for preauthorization or concurrent review based solely upon the reasonable and necessary medical health care required to treat the injury.

* * *

The Commission’s rule under 28 Tex. Admin. Code §133.301(a) instructs the insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or services for which the health care provider has obtained preauthorization under Chapter 134 of this title.

Analysis

The issue here is whether or not the Carrier preauthorized the requested treatment. If it did, the issue of medical necessity is already decided as provided in rules 134.600(f)(1) and 133.301(a). In this case, the treatment requested was a cervical, thoracic, and lumbar MRI examination.

On October 3, 2000, a Preauthorization Referral Form was filled out by a Carrier representative regarding Claimant and the requested treatment.^[1] The form includes the Claimant’s name, diagnosis, date of injury, and the name, address and phone number of the treating physician. Under the heading of For Office Use Only, there is a checkmark next to the words, Approve as requested. The requested treatment was a cervical, thoracic, and lumbar MRI examination. The form was signed on the same day by the Carrier representative and indicates a preauthorization approval number of 603.

This ALJ finds from a plain reading of the authorization form, that the Carrier gave preauthorization to the Provider for the treatment requested – cervical, thoracic, and lumbar MRI examination. There is too much indicia of approval contained on the form to believe anything other than Carrier preauthorized the MRI examinations.

The Carrier is attempting to deny reimbursement claiming the MRI examinations were not medically necessary. Under these circumstances, it would be inconsistent with the Commission’s rule 133.301(a) to allow Carrier to deny reimbursement for the MRI examinations it had previously given authorization. The Carrier should be ordered to reimburse Provider for the MRI examinations performed on October 5, 2000.

II.

FINDINGS OF FACT

1. Claimant________ suffered a compensable injury on _________
2. Via Metropolitan Transit (Carrier) insured Claimant on the date of the injury.
3. Claimant came under the care of Marcus Wilcox, D.C., who became his treating doctor.
4. Dr. Wilcox examined Claimant on September 22, 2000, and recommended Claimant undergo a cervical, lumbar and thoracic MRI examination.
5. The request for MRI was made on October 3, 2000.
6. On October 3, 2000, Carrier authorized a cervical, thoracic, and lumbar MRI examination to be performed on Claimant.
7. Dr. Wilcox referred Claimant to the Bexar County MRI (Provider) for the MRI examination which was performed on October 5, 2000.
8. Provider billed Carrier a total of $4,200.00 for the cost of the MRI examination.
9. Carrier denied reimbursement as not medically necessary.
10. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission) seeking reimbursement for the MRI examination rendered to Claimant.
11. The total cost of the MRI examinations was reduced to $2,889.00, pursuant to the Commissions’ Maximum Allowable Reimbursement rate.
12. On July 12, 2001, the Commission’s Medical Review Decision (MRD) found Provider was not entitled to reimbursement.
13. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
14. Notice of the hearing was sent August 21, 2001.
15. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
16. The hearing was held June 4, 2002, with Administrative Law Judge Steven M. Rivas presiding and representatives of the Carrier, and Provider participating. The hearing was adjourned the same day.
17. Provider offered sufficient evidence that it is entitled to reimbursement for the MRI examinations performed on Claimant.

III.

CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
4. The Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
5. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is entitled to reimbursement for the MRI examinations rendered to Claimant on October 5, 2000.
6. The Maximum Allowable Reimbursement rate for the MRI examinations is $2,889.00, pursuant to the Commission’s rule under 28 Tex. Admin. Code §134.202(c) and (d).

ORDER

IT IS, THEREFORE, ORDERED that Carrier, Via Metropolitan Transit, pay Provider, Bexar County MRI, $2,889.00, for the MRI examination rendered to Claimant on October 5, 2000.

Signed this 29^th day of July, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

1. Preauthorization Referral Form, page 39 of the Certified Record and attached as Exhibit #1.↑