DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate for certain procedures rendered to____ (Claimant) at Central Dallas Rehabilitation (Provider) between February 23, 2001, and September 6, 2001. Provider billed Southern Insurance Company (Carrier) $16,072.40 for office visits and other procedures administered to Claimant at Provider’s facility in connection with Claimant’s compensable injury she sustained on______. Carrier denied payment as not medically necessary and Provider filed a request for Medical Dispute Resolution with the Medical Review Division (MRD). The MRD held Provider was not entitled to reimbursement in its docket number M5-02-1285-01, issued June 27, 2002. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH). The hearing convened on November 7, 2002, before Steven M. Rivas, Administrative Law Judge (ALJ). Provider appeared and was represented by P. James Rainey, attorney. Carrier appeared and was represented by Neal Moreland, attorney. The record closed the same day. In this Order, the ALJ concludes Provider is not entitled any reimbursement.

I.

DISCUSSION

Applicable Law.

Under Tex. Lab. Code Ann. § 408.021(a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances an employee’s ability to return to or retain employment.

Evidence and Analysis.

Claimant sustained a compensable injury on_______, when a box of material she was lifting fell on her left thumbnail. Claimant reported her injury on_____, and was initially treated and then released by Ranil Ninala, M.D. The record does not contain any reports from Dr. Ninala but it does mention Dr. Ninala filed a TWCC-73 form, which stated Claimant could return to work on February 21, 2001, with restrictions through February 23, 2001.

Subsequently, Claimant began treatment at Provider’s facility with Dean Allen, D.C., and Ken Haycock, D.C. There is nothing in the record regarding Claimant’s condition or treatment from the time she was released by Dr. Ninala on February 23, 2001, to her first office visit with Provider on April 10, 2001. Furthermore, the record does not indicate that Dr. Ninala or any other health care provider referred Claimant to Provider for further treatment.

On Claimant’s first visit with Provider, Claimant underwent a mobilization and manipulation of her left wrist and fingers. Provider billed Carrier for these procedures and an office visit which Carrier denied as unnecessary medical treatment and attached a peer review in support of its denial.

The peer review was conducted by Joel Brandon Brock, D.C., and was submitted to Carrier and Provider on April 16, 2001.^[1] The peer review indicated the documentation about Claimant’s injury showed only a contusion to her left thumbnail and stated there was no need for additional diagnostics or care especially two months after the date of injury.^[2]

On April 23, 2001, Claimant was examined by Phillip Osborne, M.D., who found Claimant sustained an injury to her left thumbnail and that her injury had already healed.^[3] After Dr. Osborne performed a physical examination and administered several tests on Claimant, Dr. Osborne found evidence of “gross symptom magnification” on Claimant’s part. Dr. Osborne additionally concluded there was no physiological reason why Claimant could not return to work and that Claimant’s “chiropractic intervention has been totally unreasonable and unnecessary.”^[4]

Despite the foregoing reports, Provider treated Claimant through September 6, 2001, with more manipulations, a nerve conduction study, three functional capacity evaluations, and a work hardening program. The MRD denied reimbursement for treatment due to insufficient documentation or improper procedures followed. Carrier denied reimbursement claiming the treatment was not medically necessary under Tex. Lab. Code Ann. § 408.021(a). Therefore, the issue in this matter is whether the treatment provided to Claimant was reasonably required by the nature of the injury. Provider called Laurent Pelletier, D.C., treating doctor at Provider’s facility to testify on behalf of Provider.^[5]

1. Special reports – 99080.On four occasions, Provider billed Carrier $15 for special reports it allegedly prepared in connection with Claimant’s treatment under CPT code 99080. The Carrier denied reimbursement as not documented and not medically necessary. The MRD denied reimbursement because Provider was not in compliance with Commission’s rules that require treatment of an injury to be adequately documented.^[6] Provider conceded this issue at the hearing and therefore should receive no reimbursement for the special reports it billed Carrier under CPT code 99080.
2. Nerve conduction studies – 95900, 95925, 95935.

Provider billed Carrier for nerve conduction studies performed on Claimant on April 18, 2001. Dr. Pelletier testified these tests were conducted to “fully understand” the extent of Claimant’s injury. The notes from three office visits before the tests were performed show Claimant complained of “radiating pain” from her thumb to her neck. This might have been persuasive but the notes following the nerve conduction study also reflect Claimant complained of radiating pain on 22 office visits following the nerve conduction study. As for the study itself, it revealed Claimant’s nerve conduction of the upper extremities was within normal limits.^[7]

Carrier argued there was no evidence that Claimant required a nerve conduction test. Although Claimant’s subjective complaints of radicular pain might have been a proper basis for having the nerve conduction tests performed, there is no evidence in the record that any treating doctor or consultant recommended nerve conduction tests based solely on Claimant’s subjective complaints. Furthermore, Claimant’s continued complaints of radicular pain after the normal nerve conduction tests were performed leads the ALJ to believe Claimant’s complaints were exaggerated or Claimant was misdiagnosed by her treating doctors. In either case, the Carrier should not be liable for reimbursement.

Manipulations – 97265, 97122, 97110.

On four occasions, Claimant was treated with mobilizations and manipulations to her wrist and fingers. The record has ample documentation citing these procedures were performed but nowhere is there any evidence these procedures were necessary to treat Claimant’s injury. The medical records indicate Claimant sustained an injury to her left thumbnail bed when a box fell on top of it. There are no documents that support or recommend Claimant undergo any mobilizations or manipulations of her wrist and fingers. Furthermore, Dr. Pelletier did not offer any reasons why joint mobilizations and manipulations were reasonably required by the nature of the injury. Because, there was no evidence that these procedures were reasonably required, Carrier should not be liable for reimbursement.

Work hardening – 97545, 97546.

On 30 dates, Claimant underwent work hardening sessions that required Claimant to climb stairs and ride a stationary bike. Under the Commission’s Medical Ground Rules, work hardening is defined as a highly structured, goal-oriented, individual program designed to maximize the ability of the (Claimant) to return to work.^[8] Furthermore, work hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks.^[9] The record is silent about Claimant’s job functions. Claimant worked for______., a flag-making company, as a sewing machine operator. Other than that, there is no evidence regarding her actual job duties. As mentioned earlier, there is no shortage of documentation that establishes the work hardening sessions were performed. Unfortunately for Provider, there is no evidence work hardening was reasonably required by the nature of Claimant’s injury. For these reasons, Carrier should not be required to reimburse Provider for the work hardening sessions.

Functional capacity evaluations – 97750.

Claimant underwent three functional capacity evaluations at Provider’s facility. The first evaluation was performed on May 14, 2001. Dr. Pelletier testified the first evaluation determined Claimant was a suitable candidate for the work hardening program. The second evaluation was performed on June 7, 2001, after Claimant attended several work hardening sessions. Dr. Pelletier testified this evaluation was performed to measure how much Claimant had improved after attending the work hardening sessions. On June 27, 2001, Claimant underwent her final evaluation after she completed all 30 work hardening sessions. Each functional capacity evaluation should contain a physical and neurological examination, an evaluation of the injured area, and functional abilities tests that include measure of activities of daily life and hand function tests.^[10]

Carrier argued the functional capacity evaluations were not medically necessary because they were not reasonably required by the nature of Claimant’s injury. Claimant sustained an injury to her left thumbnail bed. The record indicates Claimant had completely healed from her injury after minimal treatment from her original treating doctor, Dr. Ninala.^[11] There is no evidence Claimant sustained an injury that required these types of evaluations and the accompanying work hardening program. For these reasons, Carrier should not be ordered to reimburse Provider for the functional capacity evaluations.

Office visits – 99213.

Provider billed Carrier for 25 office visits. The evidence reflects Claimant was seen by either Dr. Allen or Dr. Haycock on each visit for an examination and evaluation. With each office visit Claimant was treated with a nerve test, manipulation, work hardening session, or functional capacity evaluation. Dr. Pelletier testified each office visit was performed to evaluate Claimant’s condition and response to her ongoing treatment. Carrier argued there was no evidence the treatment rendered to Claimant was reasonably required by the nature of Claimant’s injury and Provider should not be reimbursed. Because the ALJ believes Provider’s treatment was not reasonably required by the nature of Claimant’s injury, Provider should not be reimbursed for the office visits that accompanied any of the unnecessary treatment.

Conclusion.

Provider administered (and billed) over $16,000 worth of treatment to Claimant for her injured thumbnail bed. Provider rendered chiropractic and work hardening treatment after Claimant had already been treated and released by Dr. Ninala. Provider justified the treatment because of Claimant’s subjective complaints of pain.

Dr. Pelletier testified the office visits, nerve conduction studies, and functional capacity evaluations were rendered to Claimant to determine the extent of Claimant’s injury. The ALJ found Carrier’s position more persuasive that it was unreasonable Claimant’s injury required these battery of tests. More importantly, Carrier argued, there was no evidence Claimant’s injury was severe enough to warrant these tests.

Similarly, there is no evidence Claimant’s injury required extensive chiropractic care like manipulations and work hardening. The fact that these procedures were performed does not substantiate why the Carrier should reimburse Provider for these services.

Under Tex. Lab. Code Ann. § 408.021(a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury that cures or relieves the effects naturally resulting from the compensable injury. Of the 461 pages in the Certified Record, there is no evidence Claimant’s injury to her thumbnail bed required over $16,000 of treatment especially after she was treated and released by Dr. Ninala.

For the foregoing reasons, Carrier should not be ordered to reimburse Provider for the services rendered to Claimant.

II.

FINDINGS OF FACT

1. Claimant,_____, suffered a compensable injury when she dropped a box of material on her left thumbnail bed on______. Claimant reported her injury on ______. Claimant was initially treated and released by Ranil Ninala, M.D. Dr. Ninala’s allowed Claimant to return to work on February 21, 2001, with restrictions through February 23, 2001. Dr. Ninala did not recommend any further treatment for Claimant.
2. At some point following the injury, Claimant came under the care of Dean Allen, D.C., and Ken Haycock, D.C., at Central Dallas Rehabilitation (Provider). Claimant was not referred to Provider by Dr. Ninala or any health care provider.
3. Drs. Allen and Haycock administered a series of tests and procedures on Claimant between February 23, 2001, and September 6, 2001.
4. Provider billed Southern Insurance Company (Carrier) for the tests and procedures it performed on Claimant which Carrier denied.
5. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the treatment rendered to Claimant.
6. On June 27, 2002, the Commission’s Medical Review Decision (MRD) concluded Provider was not entitled to any reimbursement.
7. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking reimbursement.
8. Notice of the hearing was sent September 17, 2002.
9. 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.
10. The hearing was held November 7, 2002, with Administrative Law Judge (ALJ) Steven M. Rivas presiding, and representatives of the Provider, and Carrier participating. The hearing was adjourned the same day.
11. Claimant sustained an injury to her left thumbnail, which was treated by Dr. Ninala. Claimant’s injury had completely healed before she ever visited Provider.
12. There was no evidence Claimant sustained an injury that required nerve conduction studies be administered to Claimant’s nerve path. There was no evidence of any nerve damage, therefore, the nerve conduction studies administered to Claimant were not reasonably required by the nature of Claimant’s injury.
13. There was no evidence Claimant sustained an injury that required mobilizations and manipulations be administered to Claimant’s wrist. There was no evidence of any injury to Claimant’s joints, therefore, the mobilizations and manipulations administered to Claimant were not reasonably required by the nature of Claimant’s injury.
14. There was no evidence Claimant sustained an injury that required Claimant undergo work hardening treatment. There was no evidence of any injury that required work hardening rehabilitation, therefore, the work hardening treatment administered to Claimant was not reasonably required by the nature of Claimant’s injury.
15. There was no evidence Claimant sustained an injury that required Claimant undergo any functional capacity evaluations. There was no evidence of any injury that required functional capacity evaluations, therefore, the functional capacity evaluations administered to Claimant were not reasonably required by the nature of Claimant’s injury.
16. There was no evidence Claimant sustained an injury that required Claimant attend 25 office visits. There was no evidence of any injury that required 25 office visits, therefore, the office visits Claimant made were not reasonably required by the nature of Claimant’s injury.

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. Under Tex. Lab. Code Ann. § 408.021(a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances an employee’s ability to return to or retain employment.
6. Provider is not entitled to reimbursement for any of the treatment it rendered to Claimant because it was not shown that the treatment rendered was reasonably required by the nature of Claimant’s injury.
7. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is not entitled to any reimbursement.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Central Dallas Rehabilitation, is not entitled to receive any reimbursement from the Carrier, Southern Insurance Company, for the treatment it rendered to Claimant between February 23, 2001, and September 6, 2001.

Signed this 6^th day of January 2003.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

1. Dr. Brock is a consultant with Professional Associates, and is a Certified Chiropractic Rehabilitation Doctor.↑
2. Peer review submitted by Dr. Brock dated April 16, 2001, pages 449 – 451 of the Certified Record. Provider did not respond to Dr. Brock’s request for information after Dr. Brock attempted to contact Dr. Allen on April 11, twice on April 12, and one more time on April 16, 2001. Dr. Brock was informed that Dr. Allen was not available. Furthermore, Dr. Allen did not return any of Dr. Brock’s phone calls. Dr. Allen visited with Claimant and performed the manipulations on Claimant on April 10 and April 16, 2001.↑
3. Report of Phillip M. Osborne, M.D., dated April 23, 2001, pages 446 – 448 of the Certified Record. Dr. Osborne was a Carrier-selected doctor.↑
4. See Id.↑
5. Dr. Pelletier currently runs and operates the clinic but testified he was not Claimant’s treating doctor.↑
6. Commission’s rule found at 28 Tex. Admin. Code §134.1002(e)(2).↑
7. Nerve conduction study results interpreted by Charles Tuen, M.D. Pages 321 and 322 of the Certified Record.↑
8. Medical Fee Guideline, Medicine Ground Rules II. Single and Interdisciplinary Programs. E. Work Hardening.↑
9. See id.↑
10. Medical Fee Guideline, Medicine Ground Rules I. Physical Medicine. E. Tests. 2. Functional capacity evaluations (FCEs).↑
11. Report of Dr. Osborne dated April 23, 2001, indicated Claimant had completely healed from her thumbnail bruise she sustained on______.↑