DECISION AND ORDER

Jesus E. Garcia, D.C. (the Petitioner) seeks reimbursement from Royal Indemnity Company (the Carrier) for $1,100 for 22 office visits and spinal manipulations provided to workers’ compensation Claimant____ between April 2, 2001 and May 30, 2001. The Carrier denied payment on the basis that the services provided were not medically necessary and were inadequately documented. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) reviewed the Carrier’s action and denied reimbursement for the same reasons. The Petitioner challenges that denial. This decision finds that reimbursement should be denied.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues regarding notice of the hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened November 5, 2002, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Kerry D. Sullivan. The Petitioner represented himself and appeared by telephone; the Carrier was represented by W. Jon Grove. After receipt of evidence, the record was closed the same day.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consists of the 197-page MRD record. Additionally, Dr. Paul Strube, D.C., testified on behalf of the Carrier.

A. The Evidence

The Claimant is a 25-year old male who sustained a compensable injury to his lower back on_______, after lifting a heavy object while employed as a pipe worker. The Claimant began receiving chiropractic care almost immediately.

The Petitioner relied upon the documentary record. These documents include the results of a functional capacity evaluation (FCE) of the Claimant undertaken on April 3, 2001 and the Petitioner’s SOAP notes. The Petitioner argues that these documents establish the need for the continuing chiropractic care in dispute in this matter. The Petitioner did not testify at the hearing or call any other witness.

The Carrier presented the testimony of Paul Strube, D.C. Dr. Strube had previously reviewed the Claimant’s medical records. On November 21, 2000 (well before the treatment at issue in this proceeding), Dr. Strube submitted a written report in which he stated that the Claimant had undergone sufficient chiropractic treatment to have reached maximum therapeutic benefit from chiropractic care, and that no further chiropractic care was warranted. At hearing, Dr. Strube testified that he felt even more strongly that there was no basis for chiropractic care for this Claimant to extend into the dates in April and May 2001 that are in dispute in this proceeding.

Applicable Law

Pursuant to the Texas Workers’ Compensation Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment.^[1]

The Commission’s Spine Treatment Guideline provides that:

Manipulations should be performed for the minimum appropriate duration. Minimum appropriate duration can be defined as that duration of time from the initiation of treatment that will result in continued improvement and where additional treatment will not further benefit the injured employee . . . . Substantive and continued improvement over time from the treatment should be objectively documented. . . .^[2]

As non-exhaustive examples of appropriate documentation, the Guideline lists diaries documenting home program, notes indicating increased ability in activities of daily living, notes describing quantified changes in pain behavior using tools such as pain drawing, and other similar types of documentation.^[3]

The Petitioner bears the burden of proof in this proceeding pursuant to 28 Tex. admin. code §§ 148.21(h) and (i).

C. Analysis

The ALJ concludes that the continuing chiropractic care at issue in this proceeding was not shown to been medically necessary and was inadequately documented. The ALJ accepts Dr. Strube’s testimony that chiropractic care should normally extend no more than eight weeks for an injury such as that suffered by the Claimant. In this instance, however, the chiropractic care extended over a period of months without clinical progress. The documentary record provides no support for deviating from Dr. Strube’s recommendation. To the contrary, the FCE performed prior to the work hardening program reflected numerous invalid efforts by the Claimant which appear to invalidate the tests, and there were no additional diagnostic tests performed to justify the office visits in dispute.

The ALJ also agrees with Dr. Strube and the MRD that each of the SOAP notes contained in the record provides essentially the same information and that they do not document that the Claimant was making significant functional progress. Accordingly, based on the record developed in this proceeding, the ALJ finds that the Claimant should have been released from chiropractic care prior to April 2, 2001, and that reimbursement for the office visits between April 2, 2001 and May 30, 2001 should be denied.

III. FINDINGS OF FACT

1. On__________, Claimant______ sustained a compensable injury to his low back after lifting a heavy object while employed as a pipe worker.
2. At the time of the Claimant’s compensable injury, Royalty Indemnity Company (the Carrier) was the workers’ compensation insurer for Claimant’s employer.
3. From April 2, 2001 through May 30, 2001, Jesus E. Garcia, D.C., (Petitioner) provided the Claimant 22 office visits and spinal manipulations. He charged $50 per visit for a total of $1,100.
4. The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
5. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
6. The MRD issued its findings and decision on July 12, 2002, concluding that the disputed expenses should be denied, and Petitioner timely appealed this decision.
7. The Claimant began receiving chiropractic care on August 17, 2000 and was treated on a regular basis through May 30, 2001.
8. On April 3, 2001, the Claimant underwent a Functional Capacity Evaluation (FCE). Many of the results from the evaluation were invalid, rendering the FCE unreliable as a basis for prescribing further chiropractic care.
9. No diagnostic tests other than the April 3, 2001 Functional Capacity Evaluation were performed prior to the disputed office visits.
10. The Claimant was not making significant functional progress as a result of ongoing chiropractic care and should have been released from chiropractic care prior to April 2, 2001.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. § 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 § 413.031(d) 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.
4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
5. The Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21.
6. The disputed services were not shown to be medically necessary health care for the Claimant.
7. The disputed services were not adequately documented.
8. Based on the foregoing, the Petitioner’s claim for reimbursement from the Carrier for the disputed chiropractic treatment should be denied.

ORDER

Theclaim by Petitioner Jesus E. Garcia, D.C., is denied.

Signed this 19^th day of November, 2002.

KERRY D. SULLIVAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Tex. Lab. Code Ann.§ 408.021(a).↑
2. 28 Tex. Admin. Code 134.1001 (Spine Treatment Guideline), Subsection (e)(2)(E).↑
3. Spine Treatment Guideline §’ (e)(2)(E), (3)(C) and 3(D).↑