DECISION AND ORDER

After an independent review organization (IRO) determined physical medicine treatments and related office visits provided by Howard Grant, M. D., were not medically necessary, Dr. Grant appealed. The City of Houston, the self-insured employer, argued the treatments were not medically necessary because the documentation to support them was inadequate. The administrative law judge (ALJ) generally agrees with the IRO’s decision and the City’s arguments, and orders reimbursement for two office visits only.

I. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

Notice and jurisdiction were not contested, and those issues are addressed only in the findings of fact and conclusions of law. The hearing was held September 23, 2003, before the undersigned ALJ. Attorney Tommy W. Leuders, II, represented the City, and Dr. Grant appeared pro se. The record closed at the conclusion of the hearing.

II. DISCUSSION

Evidence

A workers’ compensation claimant was injured in an accident at work on ___________, and sustained shoulder tendinosis and disc herniations at L4/L5 and L5/S1. After a May 14, 2002, re-evaluation, Dr. Grant prescribed a TENS unit for the claimant because he had occasional pain.^[1] In his evaluation report to the City’s third-party insurance administrator, Dr. Grant authorized the claimant’s full-duty return to work as of May 15, 2002.

The claimant returned to work, but his symptoms recurred. He was treated at Dr. Grant’s clinic on three dates in October and eleven dates in November 2002, under the following CPT codes:

97110 (therapeutic exercises to develop strength and endurance, range of motion, and flexibility);

97014 (electrical stimulation);

97024 (diathermy);

97035 (ultrasound);

97124 (massage);

99214 – WP (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination, medical decision-making of moderate complexity.

After the City declined to pay for the services and treatments, the issue was submitted to the IRO. The IRO was unable to determine the medical necessity of the services, primarily because of insufficient supporting clinical information.

Apart from the health claim insurance forms and explanations of benefits, the record contains little information about the physical medicine treatments provided in October and November 2002. Progress notes that are marginally legible and appear to be written by Tens. Exter DT. or Tens. Elder DT., describe the claimant’s pain on certain dates. The note for May 14, 2002, states, Pt. States [sic] his neck & shoulders are still hurting and lower back and lt hip are still hurting. After the note on that day, there is nothing recorded until October 25, 2002. Essentially the same statement is repeated for the treatment dates in October and November 2002, except the statements for those months mention that the claimant had some stiffness.^[2]

On the other hand, two office visits, one on May 14, and the other on October 25, 2002, are sufficiently documented, as required in the Commission’s description of CPT code 99214-WP, the code under which the office visits were billed. Dr. Grant’s notes for those dates show that he evaluated the claimant, recorded the claimant’s condition, and wrote prescriptions for care he believed was appropriate. The May 2002 report indicates the return to work status and a re-evaluation date.^[3] Dr. Grant also completed a Texas Workers’ Compensation Commission form on that date. In October, he recorded the claimant’s symptoms, made a diagnosis, prescribed specific types of physical medicine care, and wrote a letter to the City’s third party insurance administrator seeking preauthorization.^[4] There is no similar record for a November 25, 2002, office visit.

Parties’ Arguments

Because the claimant’s injury was exacerbated upon his return to work, Dr. Grant argued the medical care was necessary. He also asserted that all claim forms were submitted, and his notes detailed the claimant’s progress.

The City argued the medical documentation did not specify the type and length of treatment provided at each session.

III. APPLICABLE LAW

An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury, as and when needed. “Health care” includes all reasonable and necessary medical services. 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.^[5]

IV. ANALYSIS

With the exception of the two office visits, the ALJ finds Dr. Grant failed to meet his burden of proof. True, Dr. Grant prescribed physical therapy for the claimant and someone made a record of the claimant’s pain at various times. But, the pain reports did not change over time. Further, more day-to-day documentation than the claim forms and pain notes was necessary to show the type of care provided and the claimant’s response to treatment. Otherwise, it is impossible to determine whether the physical medicine care cured or relieved the claimant’s symptoms, promoted his recovery, or enhanced his ability to work.

In contrast, the two office visits were adequately documented; the reports and notes demonstrate that Dr. Grant made a detailed examination and made moderately complex medical decisions. Dr. Grant billed for the visits at the Commission’s maximum allowable reimbursement rate of $71 per visit. Therefore, the ALJ finds Dr. Grant should be reimbursed $142.

V. FINDINGS OF FACT

1. On ___________, a workers’ compensation claimant sustained a work-related injury when he worked for the City of Houston, a self-insured employer.
2. The claimant was diagnosed as having disc herniations at L4/L5 and L5/S1 and shoulder tendinosis.
3. On April 24, 2002, the claimant was determined to be at maximum medical improvement and given an eight percent impairment rating due to his shoulder and low back injuries.
4. On May 14, 2002, and October 25, 2002, Dr. Grant re-evaluated the claimant.
5. On these two re-evaluation dates, Dr. Grant made a detailed examination and made moderately complex medical decisions under CPT code 99214-WP (office or other outpatient visit for the evaluation and management of an established patient).
6. Dr. Grant billed for the two office visits at the maximum allowable reimbursement rate, $71 for each visit.
7. The claimant was treated at Dr. Grant’s clinic on three dates in October and eleven dates in November 2002, under office visit and physical medicine codes.
8. Apart from the health claim insurance forms, explanations of benefits, and generally repetitive pain descriptions, the record contains little information about the physical medicine treatments provided in October and November 2002.
9. On May 15, 2003, an Independent Review Organization (IRO) issued a decision that declined to order payment to Dr. Grant.
10. On May 30, 2003, the Medical Review Division of the Texas Workers’ Compensation Commission reviewed the IRO’s decision and forwarded it to the parties.
11. By request received June 20, 2003, Dr. Grant timely appealed the IRO’s decision.
12. The Commission sent the parties notice of the hearing on July 22, 2003.
13. The notice of hearing 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.
14. The hearing was held September 23, 2003, at the State Office of Administrative Hearings (SOAH), and both parties were represented.

VI. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Dr. Grant timely requested a hearing, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052 and 28 TAC § 148.4.
4. Dr. Grant had the burden of proving his treatment was medically necessary for the compensable injury. 28 TAC § 148.21(h).
5. Dr. Grant met his burden of proving office visits on May 14 and October 25, 2002, were medically necessary.
6. With the exception of the two office visits, Dr. Grant failed to sustain his burden of proving the medical necessity of physical medicine and other treatments provided between May 14, 2002, and November 25, 2002.

ORDER

It is ORDERED that the City of Houston reimburse Howard Grant, M.D., the sum of $142 for medical services provided May 14, 2002, and October 25, 2002. However, the City of Houston is relieved of any responsibility for paying other disputed claims for services on and between those dates.

Signed November 18, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

SARAH G. RAMOS
Administrative Law Judge

1. Ex. 1, p. 55-57.↑
2. Ex. 1, pp. 95-99.↑
3. Ex. 2, p. 39-41.↑
4. Ex. 1, pp. 51-54.↑
5. Tex. Lab. Code Ann. § 401.011(19); Tex. Lab. Code Ann. §408.021.↑