DECISION AND ORDER

I. Summary

Douglas A. Terry, D.D.S. (Provider), sought review of the decision of the Medical Review Division (MRD) of Texas Workers’ Compensation Commission (Commission) denying reimbursement for dental reconstruction procedures he performed on several dates in April through July 2001 for ____ (Claimant). The MRD determined that Liberty Mutual Insurance Company (Carrier) was not obligated to reimburse Provider on the basis that Provider had not gotten preauthorization to perform the dental procedures, although required to do so. The MRD also ruled that Provider had not timely filed his protest of Carrier’s denial of reimbursement for the three earliest dates of service April 2 and 27, and June 3, 2001. Based on the evidence in this case, the ALJ concluded no additional compensation is due Provider.

Administrative Law Judge (ALJ) Cassandra Church convened a hearing on this case on June 24, 2003, in Austin, Texas, and closed the record on July 2, 2003. Paul E. Nunu, attorney, appeared for Provider. Kevin J. Franta, attorney, appeared for the Carrier. The Commission did not participate. Notice and other jurisdictional facts were not contested, so are set forth below in the Findings of Fact and Conclusions of Law without further discussion here.

II. Discussion

A. Applicable Law

This case turns on application of the Commission’s rule on preauthorization as it applies to dental work and on the definition of an emergency. Provider’s claim is a medical bill which falls under these rules. In general, non-emergency dental work, including reconstructive dental care or dental appliances, must be preauthorized in order to be paid unless the emergency or other exception applies. 28 Tex. Admin. Code §134.600 (b) and (h). The Commission’s rule on emergency treatment, 28 Tex. Admin. Code § 131.1 (a)(7), defines that term as follows:

(7) Emergency–Either a medical or mental health emergency as described below:

(A) a medical emergency consists of the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health and/or bodily functions in serious jeopardy, and/or serious dysfunction of any body organ or part.

(B) a mental health emergency is a condition that could reasonably be expected to present danger to self or others.

The law regarding the timely submission of claims requires a health care provider to file a request for dispute resolution on a denied or reduced medical bill within one year of the date of service in dispute. 28 Tex. Admin. Code. § 133.307.(d)(1). Failure to timely file the request waives that party’s right to medical dispute resolution. §133.307 (d).

B.Facts and Argument

On_______, Claimant suffered severe injury to his mouth and teeth while on the job with a crane company. Staff at the hospital where Claimant received emergency care referred Claimant to Provider for emergency dental treatment. Provider performed and was reimbursed for emergency treatment he performed on the date of injury. Provider also performed additional dental reconstruction activities, including installation of dental implants and crowns, root canal therapy, and the application of veneers and bonding to both Claimant’s own teeth and the implants. Petitioner performed these reconstructive services over the course of five months, from April 2, 2001, through August 19, 2001.

There is no dispute that the extensive dental reconstruction performed on Claimant’s behalf was necessary medical treatment. It is likewise undisputed that Provider did not receive preauthorization from Carrier to perform any of the dental work. Provider argued that he had been authorized to proceed, both verbally and in writing, by Claimant’s employer, and that the employer’s preauthorization should be treated as sufficient to support reimbursement. In addition, Provider asserted that all work performed to remedy conditions arising from Claimant’s injury were part and parcel of the initial emergency treatment of Claimant’s compensable injury even if performed several months after the incident. For its part, Carrier argued that the Labor Code and TWCC rules specify that the responsible insurer is the only entity who can preauthorize a procedure so a provider cannot substitute approvals by the injured worker’s employer. Further, Carrier argued that dental treatments for any date after ___, did not fall within the definition of an emergency so had to be preauthorized in order to make the fees reimbursable.

Provider’s office manager, Terry Weeks, testified that she had sought and received verbal approval to proceed with treatment from a representative of Claimant’s employer. As she put it, she was to send their bills to the employer who would take care of it. Ms. Weeks was told the company carried workers’ compensation insurance but did not know the name of the responsible carrier until March 30, 2001, when the employer mentioned Carrier by name in a letter. Pet. Exh. 1, p. 8. Ms. Weeks stated she did not know that Provider should deal directly with Carrier, but rather believed that sending the bills to Claimant’s employer would be sufficient to have Provider’s claims for payment reviewed and paid. There is no dispute that Provider first sought reimbursement directly from the Carrier on July 25, 2001, when it submitted billings totaling $15,970 to it. Carrier paid for services performed on the date of injury, ___, but declined to pay for services for any later dates.

Notwithstanding Ms. Weeks’ dialog with Claimant’s employer, the Carrier’s reading of the law regarding who may preauthorize a treatment or procedure is accurate. The applicable rule, Rule 134.600 (h), provides expressly that the term preauthorization means approval from the responsible carrier.

(a) The following words and terms, used in this section shall have the following meanings, unless the context clearly indicates otherwise:

. . .

5) Preauthorization: prospective approval obtained from the insurance carrier (carrier) by the requestor or injured employee (employee) prior to providing the health care treatment or services (health care); . . . . (Emphasis supplied.

Based on the language above, the go-ahead from the employer did not constitute preauthorization within the meaning the Commission’s statutes and rules, so did not create an obligation for Carrier to pay Provider’s claim, absent an applicable exception.

As to Provider’s assertion that the ongoing reconstructive dental treatments constituted part of the original emergency treatment, the ALJ concludes that the evidence does not support such a conclusion. The applicable rule states that emergency treatment comprises only that immediate medical attention needed to prevent serious jeopardy or serious dysfunction of an injured worker’s health, bodily functions, organ, or body part. The lapse of time between the date of injury and the reconstructive treatment, coupled with the lack of medical evidence from Provider, was fatal to Provider’s request for reimbursement. Petitioner did not demonstrate how Claimant’s emergency persisted over a five-month period. Nor did Petitioner demonstrate that any of the treatments performed after ___, constituted a response to an unforeseen or later-developing emergency that may have occurred during this complex courseof dental treatment. The reconstructive dental services that Provider administered to Claimant after ___, were not emergency treatment exempting Provider from needing preauthorization in order to create a reimbursable claim.

Provider in this case also argued that it had requested medical dispute resolution within one year of the all disputed dates of service, so that all service dates from ___, forward should be included in the contested case.^[1] Carrier asserted that the MRD had rightly found that the claims for those dates before June 4, 2001, had not been timely filed and also asserted that the issue of timely filing was not properly before SOAH since it was not part of the dispute before the MRD. However, given the ALJ’s conclusion that the claim as a whole is not reimbursable, this decision need not reach the issue of which dates were timely filed or whether the matter was properly raised here.

In sum, Provider is not entitled to reimbursement for dental reconstruction services performed on any dates of service after_________, since they constituted non-emergency dental procedures for which he failed to get preauthorization from Carrier, as required by the controlling Commission rules.

III. Findings of Fact

1. On________,____ (Claimant) suffered a compensable injury, specifically a severe injury to his mouth and teeth while on the job with a crane company.
2. Liberty Mutual Insurance Company (Carrier) was the responsible insurer on Claimant’s date of injury.
3. On ___, Douglas A. Terry, D.D.S. (Provider), provided emergency dental treatment to Claimant. Staff at the hospital where Claimant received immediate care referred Claimant to Provider for emergency treatment. Carrier reimbursed Provider for all treatment provided on the date of injury.
4. On several dates of service after________, through July 19, 2001, Provider also administered extensive reconstructive dental work to Claimant, including installation of dental implants and crowns, root canal therapy, and the application of veneers and bonding both to own Claimant’s teeth and the implants. The reconstructive work was necessitated by Claimant’s compensable injury.
5. No treatments which Provider administered from after________, were administered in response to a medical emergency or to forestall immediate dysfunction of or harm to any of Claimant’s body parts.
6. Provider did not seek preauthorization from Carrier for any treatments he administered to Claimant.
7. On March 6, 2003, Medical Review Division (MRD) of Texas Workers’ Compensation Commission (Commission) disallowed Provider’s claims for dates of service before April 27, 2001, as being untimely filed, and disallowed Provider’s claims for dates of services on or after April 27, 2001, as lacking proof of required preauthorization.
8. On March 17, 2003, Provider requested a hearing at State Office of Administrative Hearings (SOAH).
9. On April 28, 2003, the Commission issued a notice of hearing which included the date, time, and location of the hearing, the applicable statutes under which the hearing would be conducted, and a short, plain statement on the nature of the matters asserted.
10. Administrative Law Judge Cassandra Church conducted a hearing on the merits of the case on June 24, 2003; the record closed on July 2, 2003, to permit the parties to file argument.

IV. Conclusions of Law

1. The Commission has jurisdiction to decide the issues presented pursuant to Tex. Labor Code Ann. § 413.031.
2. SOAH 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 and Tex. Gov’t CodeAnn. ch. 2003.
3. The notice of hearing issued by the Commission was sufficient under the terms of Tex. Gov’t Code Ann. § 2001.052.
4. As the petitioning party, Provider has the burden of proving by a preponderance of the evidence that it should prevail in this matter, pursuant to Tex. Labor Code Ann. § 413.031 and 28 Tex. Admin. Code §148.21(h).
5. Reconstructive dental work performed on any date of service after the Claimant’s date of injury of_________, was not emergency medical treatment within the meaning of 28 Tex. Admin. Code §131.1 (a)(7).
6. On dates of service after________, Provider performed the type of non-emergency dental work which must be preauthorized in order to be a health care service for which the responsible insurer must reimburse the provider, pursuant to Tex. Labor Code Ann. § 413.015 and 28 Tex. Admin. Code §134.600.
7. Carrier is not liable for reimbursement to the Provider for dental reconstruction services rendered to Claimant on any date of service after the date of injury of________, pursuant to 28 Tex. Admin. Code §134.600 (b).

ORDER

IT IS HEREBY ORDERED that Douglas A. Terry’s, D.D.S., request for reimbursement for reconstructive dental work performed on Claimant’s behalf on all dates of service after_______ is denied.

Issued August 28, 2003.

________________________________________ CASSANDRA J. CHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. There are three dates of service which were excluded by the MRD as being untimely, April 2 and 27, and June 3, 2001. The amounts billed for those three dates total $6,370, slightly over one third of Provider’s total claim for reimbursement. There was no evidence that the services provided on those three dates was not of the same type as provided on later dates. The Carrier denied each and every claim as lacking preauthorization.↑