DECISION AND ORDER

American Home Assurance Company (Carrier) is appealing the decision of the Texas Workers’ Compensation Commission’s (Commission’s) designee, an independent review organization (IRO), which found that a right carpal tunnel release and right ulnar nerve transposition are medically necessary for the treatment of Claimant ____. This decision finds that the treatments are not medically necessary.

I.PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

Administrative Law Judge (ALJ) Katherine L. Smith convened the hearing on October 28, 2003, at the William P. Clements Building, 300 West 15^th Street, Austin, Texas. The Carrier was represented by Dan C. Kelley, an attorney. Claimant did not appear. The record closed the day of the hearing. No one contested notice or jurisdiction.

II.BACKGROUND

Claimant sustained a work-related injury on September 30, 2001, at Sam’s Club caused by cutting pizza with a dull knife. The IRO found that Claimant developed symptoms of right hand, wrist, forearm, arm and shoulder pain, and that nerve conduction studies revealed bilateral median and ulnar neuropathy. The IRO determined that surgical intervention was necessary because Claimant’s symptoms had not been resolved with chiropractic treatment, physical therapy, medication, and work restrictions.

III. DISCUSSION

The only evidence presented in this proceeding was the testimony of Carrier’s expert witness, Melissa Tonn, M.D., who is board certified in occupational medicine and pain management. Dr. Tonn examined Claimant in May 2002 and reviewed Claimant’s medical records. Dr. Tonn’s ultimate opinion was that the medical evidence supporting surgery is inconclusive and that it is doubtful that any amount of surgical intervention will resolve Claimant’s arm complaints. Dr. Tonn testified that even though Claimant presented at the time of her injury with expansive right, upper extremity complaints from her hand up to her neck, the medical record shows that there were no examination findings of numbness, dysfunction, or tingling in the hand. Dr. Tonn noted that when Claimant went for further treatments her complaints got worse, enough so that when a functional capacity evaluation was performed in January 2002, she complained that her injury was affecting her ability to sit, stand, sleep and travel. Dr. Tonn testified that various MRI studies of Claimant’s elbow and wrist were unremarkable. Dr. Tonn testified further that the electro-diagnostic testing was also inconclusive and did not reveal any discrete peripheral nerve injury that could be attributed to the pizza cutting. At one point Claimant returned to modified work duty answering the phone and paging through books, at which time she began to complain about pain in her left upper extremity. Her symptoms were diagnosed as bilateral.

Dr. Tonn testified that when she examined Claimant, she found non-specific, regional arm complaints and no reproducible findings. According to Dr. Tonn, if ulnar neuropathy had been caused by the injury in September 2001, she would have seen evidence of it in May 2002. Such evidence would have consisted of atrophy or change in the digits. She noted further that there was no indication in any of the medical record of atrophy or change in Claimant’s digits. Dr. Tonn testified that because Claimant was no longer exposed to the pizza cutting action, her injury should have resolved.

Although Claimant is entitled to Aall health care reasonably required by the nature of the injury as and when needed . . . that cures or relieves the effects naturally resulting from the compensable injury,^[1] that does not mean that the Claimant is entitled to every treatment available. Carrier has shown by a preponderance of the evidence that the treatments requested will not resolve Claimant’s non-specific regional arm complaints. Because the Carrier has met its burden of proof that the treatment requested is not medically necessary, the ALJ denies the request for preauthorization of right carpal tunnel release and right ulnar nerve transposition.

IV. FINDINGS OF FACT

1. Claimant ____ sustained a work-related injury on________, at _________caused by cutting pizza with a dull knife.
2. At the time of the injury, Claimant’s employer, _______, had its workers’ compensation insurance through American Home Assurance Company (Carrier).
3. Claimant continues to suffer from pain in her right hand and arm.
4. Claimant’s current treating doctor recommends right carpal tunnel release and right ulnar nerve transposition.
5. Preauthorization of the treatment was requested.
6. Carrier denied the treatments based on lack of medical necessity.
7. Claimant requested medical dispute resolution before the Texas Workers’ Compensation Commission (Commission).
8. On September 8, 2003, an independent review organization (IRO) found the requested treatments to be medically necessary.
9. Carrier filed a request for a hearing on September 8, 2003.
10. The Commission sent notice of the hearing to the parties on October 13, 2003. The hearing notice informed the parties of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the statutes and rules involved; and the matters asserted.
11. MRI studies and electro-diagnostic testing of Claimant’s right arm and elbow have been unremarkable and inconclusive.
12. Ulnar neuropathy was not present within six months of the injury.
13. No atrophy or change in Claimant’s right hand fingers is indicated in any of the medical records.
14. Claimant exhibits non-specific, regional arm complaints.
15. Right carpal tunnel release and right ulnar nerve transposition will not resolve Claimant’s non-specific regional arm complaints.

V. CONCLUSIONS OF LAW

1. The Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers’ Compensation 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 Tex. Lab. Code Ann. §§ 402.073 and 413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
3. The Carrier timely filed a notice of appeal of the IRO decision, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code Ann. ch. 2001 and 28 TAC § 148.4(b).
5. The Carrier had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC § 148.21(h) and (i).
6. An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the compensable 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. Tex. Lab. Code Ann. § 408.021(a).
7. Based on Findings of Fact Nos. 11 through 15 and Conclusion of Law No. 6, Carrier proved that a right carpal tunnel release and right ulnar nerve transposition are not medically necessary.

ORDER

It is, therefore, ordered that Claimant’s request for preauthorization of right carpal tunnel release and right ulnar nerve transposition is DENIED.

Signed November 4, 2003.

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

1. Tex. Lab. Code Ann. ‘ 408.021.↑