DECISION AND ORDER

The State Office of Risk Management (SORM) appealed the Findings and Decision of the Texas Worker’s Compensation Commission’s (Commission’s) Medical Review Division (MRD). The Findings and Decision granted the request of Respondent David R. Fedesna, D.C. to be reimbursed for chiropractic manipulations provided to Claimant ____. This decision finds that Dr. Fedesna’s documentation did not adequately establish the need for the chiropractic manipulations and that reimbursement should be denied.

I. JURISDICTION, NOTICE,

AND BACKGROUND

The hearing was held on May 15, 2003. SORM was represented by Jonathan Bow, an attorney. Dr. Fedesna represented himself. The Commission did not participate. Administrative Law Judge (ALJ) Katherine Smith presided. No contested issues of jurisdiction or notice were raised. At issue in this proceeding are chiropractic manipulations performed during four office visits on May 25, 2001; July 5, 2001; August 1, 2001; and August 25, 2001, to treat Claimant’s recurring headaches and dizziness.Claimant was involved in a motor vehicle accident while driving _______________ on_________. He suffered a compensable injury to his head and neck.

II. EVIDENCE AND ANALYSIS

A. Carrier’s Evidence and Argument

SORM denied reimbursement because of insufficiency of documentation and because the treatment was not related to the compensable injury. SORM contends that the documentation that Dr. Fedesna provided does not meet the standards set out in the Commission’s rules and guidelines. Pointing to the medical notes for the May 25, 2001, treatment, as the typical documentation provided, SORM asserts that relying on “usual perm. imp.-eats Tylenol like candy’”with a listing of six misaligned vertebrae to which Dr. Fedesna made adjustments,^[1] was insufficient documentation. SORM also counters that there is no record of permanent impairment and that the only reference in the record to an impairment rating is 0% provided by Dr. Janet Lindsey, an ophthalmologist. According to SORM, the record indicates that Claimant’s compensable injury was a cervical strain/sprain, which generally resolves in six to eight weeks. While SORM accepts that an injury occurred to Claimant’s head and neck because of the accident, it does not accept that his headaches are related to the compensable injury. Furthermore, SORM argues that Dr. Fedesna failed to show why he is also providing treatment to a number of lumbar and thoracic vertebrae when the injury was to the neck. In support of its position, SORM also relies on various medical records created by two neurologists and an ear, nose, and throat physician, and medical tests, such as an MRI, which pinpoint no neurological injury or impairment.

B. Petitioner’s Evidence and Argument

Dr. Fedesna’s Testimony

Dr. Fedesna contends that the documentation in toto justifies the care given. Based on his experience and education he believes that Claimant needs ongoing treatment for the injuries he received from the collision. According to Dr. Fedesna, all the medical records indicate that Claimant is still symptomatic, but that nothing that can be done for him to permanently relieve the injury. He contends, nevertheless, that the documentation shows that the manipulations relieve the symptoms in question and enable Claimant to function. Dr. Fedesna asserts that the need for ongoing treatment was established under the rules at the time of the injury. Relying on a recent neurological study, Dr. Fedesna believes that Claimant has chronic sensory deficits and chronic misalignment due to the traumatic brain injury caused by the accident. Dr. Fedesna believes that the Commission’s guidelines are subject to interpretation and discretion, much like the Kelly Bluebook, which provides only a suggested value for a car. Dr. Fedesna asserts that his documentation meets chiropractic guidelines.

Claimant’s Testimony.

Claimant testified that since the accident he has suffered from severe headaches and dizziness. He testified further that the manipulations provide relief from the symptoms, which allows him to work.

C. Analysis

An employee who sustains a compensable injury is 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. Tex. Labor Code Ann. § 408.021(a). The Commission put into effect the Spine Treatment Guideline (STG) for treatments and services provided after February 1, 2000, to aid health care providers in determining what is reasonable and medically necessary care for workers suffering from injuries to the spine. 28 Tex. Admin. Code. (TAC) § 134.1001.A substantial obligation rests with the health care provider to be responsible for providing efficient use of health care. Tex. Labor Code Ann. § 408.025(c). That responsibility includes identifying the extent and severity of the injury, ensuring the appropriateness of the services, relating the service to the injury, and ensuring that the treatment is necessary and effective. 28 TAC § 1001.134(c)(2)(A). An important requirement of the STG is the need for documentation. The treatment of a work related injury must be adequately documented, evaluated for effectiveness, objectively measured and demonstrated with functional gains, and consistently demonstrated with ongoing progress in the recovery process. 28 TAC §134.1001(e)(2)(A). Moreover, documentation must also conform with 28 TAC §134.1001(e)(3)(B), which requires documentation determining the phase of care to be provided and the necessity for that care, including a treatment plan, updates to the treatment plan, and objective notations about the clinical progress of the employee. Documentation should also show objective, quantified, substantive, and continued measures of improvement over time. 28 TAC §134.1001(e)(3)(E).

In this case the treatment was provided ten years after the injury, which is considerably beyond the tertiary level of care provided for in the STG. Although the STG recognizes that an injured worker may be found to be outside the guideline’s parameters, cases exceeding the guideline’s level of treatment require more careful scrutiny and documentation of the special circumstances justifying the treatment. 28 TAC § 134.1001(e)(1). Dr. Fedesna’s documentation is cursory. Although Dr. Fedesna insists that the record is replete with evidence that Claimant is permanently impaired, there is no evidence that a permanent impairment rating was given. The only documentation in the record of an impairment rating was 0% provided by Dr. Lindsey, albeit an ophthalmologist.

Dr. Fedesna diagnosed Claimant’s medical condition as first– multiple cervical subluxation,^[2] second–cervical strain/sprain, and third–headaches. Ten years after the injury, Dr. Fedesna is obligated to document how subluxation of the vertebrae is related to the compensable injury and why he is still treating a strain/sprain. It is apparent that Dr. Fedesna believes that Claimant’s headaches are due to chronic sensory deficits caused by a traumatic brain injury, but that is not clear from the documentation. Furthermore, contrary to Dr. Fedesna’s belief, the two neurologists who examined Claimant diagnosed no such medical condition. In addition, although there may be a justifiable reason for providing manipulations to the thoracic and lumbar vertebrae, there is no documentation tying the necessity of that treatment to the compensable injury to the neck. Dr. Fedesna should have documented what he was doing, why it would help, how it was helping, and what was expected to happen in the future. Dr. Fedesna failed to provide such documentation.

The ALJ finds that SORM has shown that Dr. Fedesna did not adequately document the medical necessity of the treatment provided and denies reimbursement.

III. FINDINGS OF FACT

1. Claimant ____ suffered a compensable injury to his head and neck on___________, in an automobile accident. _________ is self-insured and is represented by the State Office of Risk Management (SORM).
2. David R. Fedesna, D.C., began treating the Claimant in November 1991.
3. Dr. Fedesna performed chiropractic manipulations during four office visits on May 25, 2001; July 5, 2001; August 1, 2001; and August 25, 2001, to treat Claimant’s recurring headaches and dizziness.
4. SORM denied the request for reimbursement.
5. Dr. Fedesna requested a dispute-resolution review by the Texas Workers’ Compensation Commission (Commission).
6. The Commission’s Medical Review Division (MRD) issued a decision on September 3, 2002, ordering reimbursement.
7. SORM filed a timely appeal of the MRD decision on September 26, 2002.
8. The Commission issued the notice of hearing on February 13, 2003.
9. The medical record does not show that Claimant is permanently impaired.
10. Dr. Fedesna failed to provide sufficient documentation showing how the manipulations provided to correct dislocated cervical, thoracic, and lumbar vertebrae were necessary to treat the compensable injury to Claimant’s neck and head.
11. Dr. Fedesna’s documentation failed to show why he was treating a cervical strain/sprain ten years after the compensable injury occurred.
12. Dr. Fedesna provided insufficient documentation ten years after the injury showing how Claimant’s symptoms are related to the compensable injury.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act, Tex. Labor Code Ann. §413.031 (Vernon 1996 & Supp. 2002).
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 Ann. §413.031(k) and Tex. Gov’t Code Ann., Ch. 2003 (Vernon 2000 & Supp. 2003).
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 & 2001.052 (Vernon 2000).
4. An employee who sustains a compensable injury is 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. Tex. Labor Code Ann. § 408.021(a)
5. A substantial obligation rests with the health care provider to be responsible for providing efficient use of health care. Tex. Labor Code Ann. § 408.025(c).
6. The treatment of a work related injury must be adequately documented, evaluated for effectiveness, objectively measured and demonstrated with functional gains, and consistently demonstrated with ongoing progress in the recovery process.28 Tex. Admin Code (TAC) § 134.1001(e)(2)(A).
7. Cases exceeding the Spine Treatment Guideline’s level of treatment require more careful scrutiny and documentation of the special circumstances justifying the treatment. 28 TAC § 134.1001(e)(1).
8. SORM demonstrated that Dr. Fedesna failed to show that the manipulations provided to Claimant are health care reasonably required by the nature of the medical conditions derived from Petitioner’s compensable injury and are medical benefits to which he is entitled. Tex. Labor Code Ann. §§ 401.011(19) and (31) and 408.021(a).
9. SORM is not liable for the costs of treatments provided on May 25, 2001; July 5, 2001; August 1, 2001; and August 25, 2001.

ORDER

IT IS, THEREFORE, ORDERED that Dr. Fedesna shall not recover any of the disputed charges from SORM.

Signed this 9^th day of June 2003.

KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. “T3PLS, T7PR, LTPI, L5PPLSD, C7PLS, and C2PRS”↑
2. Subluxation means partial dislocation, Merriam Webster’s Medical Dictionary, 1995.↑