DECISION AND ORDER

I. Summary

Metroplex Diagnostic (Metroplex or Provider) sought review of a decision by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC or Commission) denying reimbursement of $1,027 to it for four electrodiagnostic tests performed in March 2001, on behalf of ____ (Claimant). Twin City Fire Insurance (Carrier) denied the claims for payment on the basis the tests were medical services unnecessary to treat Claimant. Based on the evidence, Provider failed to carry its burden to show there were medical indications for using electrodiagnostic tests in the primary phase of Claimant’s care, so it should not be reimbursed for the tests.

Administrative Law Judge (ALJ) Cassandra Church convened a hearing on these issues on November 26, 2002, and the record closed on that date. Doug Pruett appeared on behalf of the Provider; John Fundis appeared for the Carrier. The Commission did not participate.

II. Discussion

On ___________, Claimant was injured when a sliding shelf struck Claimant on his right chest and shoulder, knocking him partially off a ladder. (Resp. Exh. 2, p. 2). He was treated for a strained back, and pain in his right shoulder, right elbow, and neck. The diagnosis was strain of the cervical and the thoracic spine and the right shoulder, although the right elbow and wrist also had some compensable injury.^[1] (Pet. Exh. 1, p. 32; Resp. Exh. 2, pp. 2-3). Five weeks after the injury, Claimant’s treating physician, Dr. Larry Parent, D.C., referred Claimant to Provider for the administration of four electrodiagnostic tests. The four tests performed on March 22, 2001, were a somatosensory evoked potential test (SSEP) (CPT Code 95925), a motor nerve conduction test (CPT Code 95900), a sense nerve conduction test (CPT Code 95904), and an “H” or “F” reflex test (CPT Code 95935). (Pet. Exh. 1, pp. 22-24).

The fifth week of treatment is considered within the initial or primary period of care for both the upper spine and the arm and shoulder. The primary care phase varies depending on which body part was injured, but ranges between two or three months after the date of injury.^[2] Generally, EMG or nerve conduction tests are recommended for diagnostic use between six weeks to four months after the injury in the case of spine injuries.^[3] STG (f)(2)-(3). However, if a treating doctor can document an unusual clinical condition or special circumstance that warrants their use, they may be performed at any time. STG (f)(1); UETG (e)(1).

In this case, Provider argued that early employment of these tests was warranted because the treating doctor needed to confirm or rule out peripheral nerve injury or the existence of a “entrapment lesion.” Dr. Parent suspected this possibility since the Claimant had reported radiating pain, that is, pain felt in an area away from the injured portion of his body. (Pet. Exh. 1, pp. 22-23). For its part, Carrier argued that the medical record showed that Claimant was making steady improvement with conservative treatments, and that the symptoms presented were not sufficiently severe to justify the electrodiagnostic tests at the five-week mark.^[4]

Notwithstanding Provider’s assertions, the examination notes fail to document a deterioration or worsening of Claimant’s condition, or other special circumstances, to support early administration of the tests. Treatment notes from throughout that period show that Claimant’s general condition was either unchanged or progressing. (Pet. Exh. 1 pp. 77-108). The musculoskeletal examination on March 22, 2001, showed some limitations on the cervical range of motion, but showed the sensory, motor and reflex behaviors of Claimant’s arm and fingers to be normal. Claimant did not report any radiating pain, although he did report neck pain. Both Claimant’s right and left sides showed similar results. (Pet. Exh. 1, p. 52). Further, this examination showed improvement of some measures over the examination performed about two weeks earlier, on March 3, 2001. For example, the right deltoid motor exam finding improved, and the sensory elements showed more stability. Some neck range of motion measurements improved, although some showed some decline. On March 22, 2001, Claimant no longer reported the radiating neck pain that he had reported on March 5, 2001. (Pet. Exh. 1, p. 92). In neither examination did the examining physician make any notes or observations regarding the potential for an entrapment lesion or note other special conditions of concern.

In short, Provider’s burden in this case was to demonstrate that there special factors concerning Claimant’s condition in the fifth week of treatment that warranted use of electrodiagnostic tests in the primary phase of Claimant’s care. Although Claimant was not yet symptom-free by March 22, 2001, the medical evidence does not support extraordinary usage of electrodiagnostic tests, so it was unnecessary medical treatment.

III. Findings of Fact

1. On_________,___ (Claimant), suffered a compensable injury to his cervical spine, right shoulder, elbow and wrist. Claimant was hit on the right side of his body and neck by a sliding shelf which partially knocked him off a ladder.
2. Twin City Fire Insurance (Carrier) was the responsible insurer on Claimant’s date of injury.
3. Claimant was diagnosed with strain of the cervical and the thoracic spine and the right shoulder, with injury to the right elbow and wrist .
4. On March 22, 2001, Claimant was in the primary care period for upper extremity injuries, and in the initial care phase for spine injuries. Claimant was being treated conservatively for his injuries, and was under the care of Dr. Larry Parent, D.C.
5. In March 2001, Dr. Parent referred Claimant to Metroplex Diagnostic (Provider) for performance of four electrodiagnostic studies on Claimant’s right shoulder and arm.
6. On Mrch 22, 2001, Provider conducted four electrodiagnostic tests on Claimant’s right shoulder and arm: a somatosensory evoked potential test (CPT Code 95925), a motor nerve conduction test (CPT Code 95900), a sense nerve conduction test (CPT Code 95904) and an AH or AF reflex study (CPT Code 95935).
7. Carrier denied reimbursement to Provider for the four tests, on the basis that the tests were not medically necessary to treat or diagnose Claimant’s compensable injury.
8. Provider timely sought review by the Texas Workers’ Compensation Commission (Commission) of the Carrier’s determinations. On February 20, 2002, the Medical Review Division (MRD) of the Commission declined to compel Carrier to reimburse Provider for any of the four tests, an amount of $1,027, on the basis that Provider had not demonstrated the testing was appropriate for a worker within five weeks of the date of injury, hence not necessary.
9. On March 29, 2002, Carrier requested a hearing on the MRD decision.
10. On May 7, 2002, the Commission issued a notice of hearing which included the date, time, and location of the hearing; and the applicable statutes under which the hearing would be conducted, and a statement of matters asserted.
11. Administrative Law Judge Cassandra Church conducted a hearing on the merits of the case on November 26, 2002; the record closed that day.
12. On March 6, 2001, Claimant reported radiating pain in his neck, but did not report this symptom on March 22, 2001. Claimant’s overall levels of reported pain decreased between March 6, 2001, and March 22, 2001.
13. Most elements of Claimant’s neurological testing on March 6 and March 22, 2001, were within normal limits and showed similar results on both the right and left arms and hands.
14. Between March 6, 2001, and March 22, 2001, of the six measures of cervical range of motion, Claimant’s improved on two measures, remained the same on two measures, and declined somewhat on two measures.
15. During the month before the electrodiagnostic tests, treatment summaries for office visits showed Claimant’s overall condition to be unchanged or progressing.

IV. Conclusions of Law

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code § 413.031.
2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a Decision and Order, pursuant to Tex. Labor Code § 413.031 and Tex. Gov’t Code ch. 2003.
3. Carrier timely requested a hearing, as specified in 28 Tex. Admin Code (TAC) § 148.3.
4. Proper and timely notice of the hearing was effected on the parties in accordance with Tex. Gov’t Code ch. 2001 and 28 TAC § 148.4(b).
5. Provider has the burden of proving by a preponderance of the evidence that it should prevail in this matter, pursuant to 28 TAC § 148.21(h) and (i).
6. Provider failed to prove by a preponderance of the evidence that there were any unusual clinical conditions or special circumstances justifying the use of electrodiagnostic testing within the initial or primary care stage of Claimant’s treatment, within the meaning of the Upper Extremities Treatment Guideline (UETG) (f)(1), 28 Tex. Admin Code (TAC) § 134.1002, and the Spine Treatment Guideline (STG), (e)(1), 28 TAC § 134.1001.
7. Provider failed to prove by a preponderance of the evidence that the electrodiagnostic tests administered by Provider on March 22, 2001, were medically necessary services to treat or diagnose Claimant’s compensable injury, within the meaning of Tex. Labor Code Ann. §§ 408.021 and 401.011(19).

ORDER

IT IS HEREBY ORDERED that Metroplex Diagnostics is not entitled to reimbursement from Twin City Fire Insurance Company for any of the four electrodiagnostic tests conducted on March 22, 2001 (CPT Codes 95925, 95900, 95904, and 95935).

Signed January 9, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CASSANDRA J. CHURCH
Administrative Law Judge

1. The specific treatment tables in both the UETG and the STG are broken down by specific diagnosis codes. However, the ALJ was unable to discern in the record the final diagnosis codes that applied to Claimant. Thus, the ALJ matched the narrative descriptions of the injury as closely as possible to the descriptions appearing in the UETG and the STG, in analyzing the evidence. Upper Extremities Treatment Guideline (UETG) (f)(1), 28 Tex. Admin Code (TAC) § 134.1002, and the Spine Treatment Guideline (STG), (e)(1), 28 TAC § 134.1001.↑
2. In regard to a sprain/strain of the shoulder and upper arm, or elbow, the primary care period lasts up to three months after the date of injury. UETG, Treatment tables (f)(2)(K) and (f)(3)(B), 28 TAC § 134.1002. For cervical or thoracic pain without nerve root pressure, the ‘initial phase of care” is up to 8-12 weeks after the date of injury. STG, 28 TAC§ 134.1001(g), Phase of Care Table I, and (i) Charts (1) – (6).↑
3. The UETG does not reference the use of nerve conduction studies at any phase of treatment for strain/sprains of the any part of the arm, including the shoulder or elbow. (Diagnosis codes 840, 841 and 842). (UETG, amended, eff. February 14, 1997) However, as the specific diagnosis used regarding Claimant’s arm is not in evidence, and since the parties did not argue that electro diagnostic testing would never be appropriate for treatment of an shoulder or arm, the ALJ will assume that the only matter at issue is the timing of the tests-in the same manner the timing of the tests in regard to the injury to the spine was argued.↑
4. The Carrier also seemed to argue that the lack of finding of nerve injury or impingement from the shoulder or spine injuries was in and of itself evidence against the appropriate medical use of the tests. This argument implies that a physician should only order a diagnostic test when he or she is convinced they will get an affirmative result. Diagnostic tests should not be administered or ordered to no purpose, but to argue there is no valid medical purpose to use a test to rule out certain causes for presenting symptoms lacks even surface credibility.↑