DECISION AND ORDER

This case is an appeal by Mobile Diagnostics of Texas (“Petitioner”) from the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (“MRD”) in a medical payment dispute. The insurance carrier and, subsequently, the MRD denied Petitioner reimbursement for medical services (i.e., synaptic nerve blocks) previously provided to an injured claimant, based upon the rationale that the medical necessity for such services had not been adequately documented.

This decision finds that the disputed services were medically necessary and that Petitioner should receive reimbursement as sought.

I. JURISDICTION AND VENUE

The Texas Workers’ Compensation Commission (“the Commission”) has jurisdiction to consider appeals from decisions of its Medical Review Division pursuant to § 413.031 of the Texas Workers’ Compensation Act, Tex. Labor Code Ann. ch. 401 et seq. (“the Act”). The State Office of Administrative Hearings (ASOAH) has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(k) of the Act and Tex. Gov’t. Code Ann. ch. 2003.

II. STATEMENT OF THE CASE

The hearing in this docket was convened on August 14, 2002, at SOAH facilities in the William P. Clements Building, 300 W. 15 St., Austin, Texas. Administrative Law Judge (“ALJ”) Lilo Pomerleau presided over the hearing. Petitioner was represented by Peter Rogers, attorney, who appeared via telephone.^[1] Travelers Indemnity Company (“Respondent”) was represented by Dan Flanagan, attorney. After presentation of evidence and argument, the hearing was adjourned on August 14, 2002, and the record closed on that date.

The record developed at the hearing revealed that the claimant sustained a compensable injury to the lower back, left knee, and left ankle on_______. Thereafter, she experienced persistent pain and was referred to Petitioner for alleviating treatment. On May 8, 2001, Petitioner administered electrical synaptic nerve blocks to the claimant. Respondent, the insurance carrier for claimant’s former employer, subsequently denied Petitioner’s request for reimbursement of $500.00 for these services, asserting that they had not been demonstrated to be “diagnostically appropriate” for the claimant’s treatment. Petitioner then sought medical dispute resolution with respect to this issue from the Commission’s MRD.

The MRD issued a decision on May 10, 2002, finding that Petitioner was not entitled to reimbursement, because no documentation submitted on Petitioner’s behalf demonstrated the medical necessity of the disputed services. The decision noted that the only documentation provided-a physician’s report- “indicates no improvement in flexion or extension as a result of the treatment and offers only the subjective opinion of the patient that pain is reduced.” Accordingly, the MRD concluded that Petitioner had failed to satisfy the requirements of the Commission’s Spine Treatment Guideline (“STG”)^[2]-particularly §134.1001(e)(2)(A)(i-iii), (c)(2)(A)(ii), and (c)(2)(A)(v). Petitioner effected a timely appeal from the MRD’s decision and requested a hearing before SOAH.

EVIDENCE, ARGUMENT, AND BASIS FOR DECISION

At the hearing, Petitioner presented the testimony of Charles Marable, M.D., a board-certified neurologist who was the medical director for the facility at which the disputed treatment was provided. Dr. Marable noted that the claimant was about six months pregnant at the time of the disputed treatment for pain. Since most pain-relieving medications are contra-indicated for a patient in that condition, electrical stimulation of the type provided by Petitioner represented the only reliable method of relief available to the claimant, in Dr. Marable’s view. Such stimulation blocks pain impulses without injecting foreign substances into the patient’s body and stimulates the body’s own natural production of pain-reducing endorphins.

Petitioner submitted into evidence medical records in addition to those contained in the certified record from the MRD review of this case. The additional records generally corroborated Dr. Marable’s testimony and indicated that the claimant experienced some relief from pain (by both subjective and objective measurements) subsequent to the disputed treatment.

Respondent submitted no additional evidence at the hearing but argued that the adequacy of documentation in this case should be judged on the basis of only the material that was presented to the MRD for evaluation prior to its decision on May 10, 2002.

In the ALJ’s view, the overall record-as supplemented by the testimony and other documents offered by Petitioner at the hearing-demonstrates the medical necessity of the treatment at issue. Because the claimant’s pregnancy was well advanced by the time of her injury, she clearly needed to be able to obtain regular rest and marshal her strength. The only feasible method of relief for the pain that undermined these objectives was, according to uncontroverted evidence, the synaptic nerve blocks provided by Petitioner. Although documentation of the claimant’s pregnancy was not provided to the Carrier and to the MRD, this evidence, presented at the hearing, clearly supports a finding of medical necessity. The ALJ concludes that Petitioner has satisfied relevant documentation requirements of the STG in documenting that the treatment in dispute is medically reasonable and necessary.

IV. CONCLUSION

The ALJ finds that, under the evidence provided in this case, reimbursement sought by Petitioner for medical services performed on May 8, 2001, in the amount of $500.00, should be approved based upon documentation that such treatment was medically necessary within the meaning of §§ 408.021 and 401.011(19) of the Act.

V. FINDINGS OF FACT

1. On_____, the claimant suffered an injury to the lower back, left knee, and left ankle that was a compensable injury under the Texas Workers’ Compensation Act (“the Act”), Tex. Labor Code Ann. §401.001et seq. Subsequent to the injury, the claimant suffered persistent pain.
2. For treatment of the claimant’s pain, she was referred to Mobile Diagnostics of Texas (“Petitioner”). On May 8, 2001, Petitioner administered electrical synaptic nerve blocks to the claimant (CPT Codes 64999 and A4556).
3. Petitioner sought reimbursement of $500.00 from Respondent Travelers Indemnity Company (“Respondent”), the insurance carrier for the claimant’s employer at the time of her injury, for the services noted in Finding of Fact No. 2.
4. Respondent denied the request for reimbursement on the grounds that the treatment in question had not been demonstrated to be “diagnostically appropriate” for the claimant’s treatment.
5. Petitioner made a timely request to the Medical Review Division (“MRD”) of the Texas Workers’ Compensation Commission (“Commission”) for medical dispute resolution with respect to the requested reimbursement.
6. The MRD declined to order reimbursement in a decision dated May 10, 2002, in dispute-resolution docket No. M5-02-1247-01. The MRD determined that the medical services and associated medical goods provided by Petitioner (CPT Codes 64999 and A4556) were ineligible for reimbursement because Petitioner failed to document the medical necessity of those services in conformity with the Commission’s Spine Treatment Guideline (“STG”), 28 Tex. Admin. Code § 134.1001(e)(2)(A)(i-iii), (c)(2)(A)(ii), and (c)(2)(A)(v).
7. Petitioner timely requested a hearing with the State Office of Administrative Hearings.
8. The Commission mailed notice of the hearing to the parties at their addresses on June 12, 2002.
9. A hearing in this matter was convened on August 14, 2002, at the William P. Clements Building, 300 W. 15^th St., Austin, Texas, before Lilo Pomerleau, an Administrative Law Judge with the State Office of Administrative Hearings. All parties were present and represented.
10. At the time of the treatment noted in Finding of Fact No. 2, the claimant was about six months pregnant.
11. Since most pain-relieving medications are contra-indicated for pregnant patients, electrical stimulation of the type noted in Finding of Fact No. 2 represented the only reliable method of pain relief available to the claimant.
12. Claimant experienced some relief from pain (by both subjective and objective measurements) subsequent to the treatment noted in Finding of Fact No. 2.

VI. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented pursuant to the § 413.031 of the Act.
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 § 413.031(k) of the Act and Tex. Gov’t. Code Ann. ch. 2003.
3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t. Code Ann. ch. 2001, and the Commission’s rules, 28 TAC § 133.305(g) and §§ 148.001-148.028.
4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t. Code Ann. §§ 2001.051 and 2001.052.
5. Petitioner, the party seeking relief, bore the burden of proof in this case, pursuant to 28 Tex. Admin. Code § 148.21(h).
6. Based upon the foregoing Findings of Fact, the Petitioner’s medical treatment of claimant, as noted in Finding of Fact No. 2, was medically necessary and adequately documented in accordance with the Commission’s STG.
7. Based upon the foregoing Findings of Fact and Conclusions of Law, the Petitioner is entitled to requested reimbursement of $500.00 for medical services provided to the claimant on May 8, 2001.

ORDER

IT IS THEREFORE, ORDERED that Mobile Diagnostics of Texas’ request for reimbursement from Travelers Indemnity Company of $500.00 for medical services rendered to the claimant on May 8, 2001, is granted.

Signed this 25 ^th day of September, 2002.

LILO POMERLEAU
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The staff of the Commission was initially designated as a Respondent in the proceeding but formally elected not to participate, although it filed a “Statement of Matters Asserted” that was incorporated within the formal notice of hearing.↑
2. 28Tex. Admin. Code § 134.1001.↑