DECISION AND ORDER

I. SUMMARY

Waco Ortho Rehab (Provider) appealed the decision of Ziroc, an independent review organization (IRO) certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) tracking number M5-03-0955-01, denying reimbursement for medical services provided to the Claimant. Additionally, the Provider appealed the MRD’s decision denying reimbursement for services not considered by the IRO. The MRD ordered reimbursement to the Provider in the amount of $7,433, which was not appealed by Texas Mutual Insurance Company (Carrier). This decision orders that Carrier is not required to make further reimbursement.

The Administrative Law Judge (ALJ) convened the hearing on July 28, 2004. The hearing was concluded and the record closed that date. The Provider appeared telephonically and was represented by William Maxwell, attorney. The Carrier appeared through Katie Kidd, attorney.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this proceeding is whether the Carrier should reimburse the Provider $3,882.05^[1] plus interest for medical services provided between January 11, 2002, and July 8, 2002, and billed under CPT Codes 97110 (therapeutic exercises)^[2], 97265 (joint mobilization), 97150 (group therapeutic procedures), 99080-73 (form TWCC-73), 95851 (range of motion testing), 97750-MT (muscle testing), and 99070 (supplies and materials). The Carrier argued that the medical services, consisting of therapeutic exercises, joint mobilization, and group therapeutic exercises, provided to the Claimant from January 14, 2002, to July 8, 2002, were not medically necessary or reasonably required to treat the compensable injury. Further, reimbursement for the remaining services delivered January 8 and 11, March 14, April 22, and June 6, 2002, was denied as hereinafter set forth.

The documentary record in this case consisted of two packets of medical records (Pet. Exh. 1 – 284 pages, and Res. Exhs. 1 – 22 pages, 2 – 2 pages, and 4 – 4 pages). Also, David N. Bailey, D.C., testified for the Provider and David Alvarado, D.C., testified for the Carrier.

The record revealed that on____, the Claimant, a 52-year-old man, suffered neck sprain/strain, lumbar sprain/strain, and a contusion to the right elbow when the truck he was driving flipped over on its side. An MRI of the cervical and lumbar spines done on January 22, 2002, showed small to moderate abnormalities at four levels in the cervical spine and mild to moderate changes in the lumbar spine. An initial examination of the Claimant was completed by the Provider on November 27, 2001. The Claimant had blood pressure of 131/81 and was found to have a low to average tolerance to pain. The treatment plan developed by the Provider for the Claimant included a home therapy program of exercises and chiropractic management with passive and active therapy.

The Provider’s treatment included two hours of active one-on-one therapeutic exercise sessions per day of treatment. Dr. Bailey, who personally treated the Claimant on only one visit, testified that the Claimant needed one-on-one sessions instead of group sessions because the Claimant had documented high blood pressure during one session; he reported nose bleeds predominantly in the mornings, which may be indicative of a potential stroke; and he lacked sufficient motivation to successfully participate in a home exercise program.

Additionally, Dr. Bailey testified that the Provider should be reimbursed for joint mobilization because it was a service separate from office visits billed under CPT Code 99213. He pointed out that the manipulation modifier AMP’ had not been added to the office visit code, which made it allowable to bill for myofascial release separately. Further, Dr. Bailey complained that Provider was not reimbursed for preparing TWCC forms, providing group exercise sessions, and for providing muscle testing, which he stated was documented properly in the medical records.

Dr. Alvarado, the Carrier’s witness who also testified from reviewing the documentary record, stated that the Provider was not entitled to reimbursement for preparation of the TWCC forms because the forms did not reflect a change in work status as required. Further, he testified that the Provider should not be reimbursed for muscle testing because instead of an actual report the

Provider submitted a summary, which does not comply with the Medicine Ground Rules.^[3] Dr. Alvarado stated that other claims for reimbursement for muscle and range of motion testing should be denied because delivery of the services was not adequately documented.

According to Dr. Alvarado, joint mobilization is manipulation because its purpose is to restore motion. This procedure is part of an office visit and it should have been billed under the office visit CPT code with the modifier -MP added. The crux of his testimony was that the Provider could not bill for both an office visit and joint mobilization.

Regarding one-on-one and group therapeutic exercises, Dr. Alvarado testified that the reimbursement of one hour per day of treatment was more than adequate because the Provider did not show that one-on-one exercises were necessary or that there had been enough progression by the Claimant to justify continued units. From his review of the records, Dr. Alvarado could not find that the Provider documented blood pressure problems or that the Claimant’s blood pressure was monitored during exercise activities. Additionally, Dr. Alvarado pointed out that the Claimant had received a CT scan of the brain and that no stroke indicators had been identified. He concluded there were no health, safety, or educational issues that justified one-on-one supervision. He also testified that the Provider could not bill for both one-on-one and group exercise performed at the same time. Dr. Alvarado believed the Claimant would have benefitted from counseling or biofeedback instead of the one-on-one therapeutic exercises.

In conclusion, the Provider failed to prove that therapeutic exercises, either group or one-on-one, and joint mobilization were medically necessary. Further, the documentary record did not support reimbursement for muscle and range-of-motion testing, preparation of TWCC forms, and supplies and materials.

III. FINDINGS OF FACT

1. On____, the Claimant suffered compensable injuries to his neck, lower back, and elbow.
2. The Claimant’s injuries are covered by workers’ compensation insurance written for the Claimant’s employer by Texas Mutual Insurance Company (Carrier).
3. Medical services provided to the Claimant included CPT Codes 97110 (therapeutic exercises), 97265 (joint mobilization), 97150 (group therapeutic procedures), 99080-73 (form TWCC-73), 95851 (range of motion testing), 97750-MT (muscle testing), and 99070 (supplies and materials), which were delivered by Waco Ortho Rehab (Provider) following a diagnosis of neck sprain/strain, lumbar sprain/strain, and a contusion to the right elbow.
4. Reimbursement for CPT Codes 99080-73, 95851, 99070, and 97750-MT was denied by the Carrier on the basis that relevant information was not submitted to support delivery of the services.
5. Reimbursement for CPT Codes 97110, 97265, and 97150 was denied by the Carrier on the basis that the treatment was not medically necessary or reasonably required to treat the compensable injury.
6. The medical services referred to in Finding of Fact No. 3 were delivered from January 14, 2002, to July 8, 2002.
7. The Provider did not show a change in the Claimant’s work status on the TWCC-73’s (CPT Code 99080-73).
8. There was insufficient documentation in the medical records to support delivery of range of motion and muscle testing, and to support additional reimbursement for supplies and materials.
9. Direct one-on-one exercises were not necessary to treat the Claimant’s injury.
10. High blood pressure problems were not documented in the medical records.
11. Testing showed that the Claimant had no identified stroke indicators.
12. The Claimant could have performed exercises in either a group or home setting.
13. There were no health, safety, or educational issues justifying one-on-one supervision.
14. Joint mobilization is manipulation, and it should have been billed with CPT Code 99213 (office visit) by adding modifier -MP instead of separately.
15. It was not shown that group exercises in addition to one-on-one exercises were necessary to treat the Claimant’s injury.
16. The Provider timely requested dispute resolution by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC).
17. On September 3, 2003, the MRD issued its decision concluding that the disputed expenses should not be paid, and the Provider timely appealed this decision.
18. TWCC sent notice of the hearing to the parties on October 22, 2003. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented by counsel, the time and place of the hearing, and the statutes and rules involved.
19. The hearing on the merits convened July 28, 2004, before Michael J. Borkland, Administrative Law Judge. The Provider appeared telephonically and was represented by William Maxwell, attorney. The Carrier appeared through Katie Kidd, attorney.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §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. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
3. Based on Finding of Fact No. 12, the Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §§ 2001.051 and 2001.052.
4. The Provider has the burden of proving by a preponderance of the evidence that he should prevail in this matter. Tex. Labor Code §413.031.
5. The services referred to in Finding of Fact No. 3(b) were not medically necessary.
6. Based on Findings of Fact Nos. 5 – 9, the Provider failed to prove that additional reimbursement for treatment provided from January 14, 2002, to July 8, 2002, should be ordered.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company shall not be required to reimburse Waco Ortho Rehab for the disputed services provided in treating the Claimant.

Signed September 21, 2004.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. It was difficult to determine the exact amount in controversy from the TWCC Findings and Decision. This amount is an approximation.↑
2. The Provider claimed eight units (each unit is 15 minutes) for 23 days and seven units for one day. The IRO concluded that four units per day were medically necessary. This appeal concerns only the units denied by the IRO.↑
3. Medicine Ground Rule I.E.3.↑