DECISION AND ORDER

I. DISCUSSION

Continental Casualty Company, Petitioner, requested a hearing following the issuance of a September 12, 2003, decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) granting the request of Medway Health Centers, Respondent, for reimbursement. The amount in dispute is $6,872.00, plus interest and the independent review organization (IRO) fee of $460. The Administrative Law Judge (ALJ) concludes that the disputed services provided by Respondent were reasonable and medically necessary and should be reimbursed.

Respondent’s request for reimbursement was based on a claim of medical necessity of two disputed services, functional capacity evaluation (FCE) and a work hardening program. The disputed services were rendered during from May 21, 2002, through June 19, 2002. The IRO reviewed the disputed services and issued an independent review decision on August 20, 2003, that the disputed services should be reimbursed.

The matter was referred to the State Office of Administrative Hearings (SOAH) on October 29, 2003. After several continuances, the matter was heard on July 13, 2004. The parties prefiled all exhibits and testimony. ALJ Paul Keeper presided at the hearing. Courtney Leech represented Petitioner and appeared by telephone. William Maxwell represented Respondent and appeared in person. Neither party objected to notice or jurisdiction.

Claimant ___ began seeking medical care on ___ for pain in her left and right wrist and hand, right elbow and forearm, and lower neck and trapezius. She worked at a computer terminal as a customer services representative during the time that her condition first presented. She began taking over-the-counter medications to relieve her pain, and then she sought medical care.

Between January and April 2002, the claimant was seen by a chiropractor and orthopaedic surgeon. Their examinations revealed positive tests for as a series of muscular-skeletal conditions, including possible carpal tunnel syndrome, C7 radiculopathy, and deQuervain’s tenosynovitis. Her orthopaedic surgeon prescribed medication for her condition. Among his recommendations were that the claimant abstain from lifting more than 25 pounds, avoiding repetitive grasping, and restrict pulling and carrying. In November 2002, a physical evaluation of the claimant performed by a chiropractor for the Commission assigned a whole person impairment of 19%.

Respondent called Gretchen Jones as a witness during the hearing. Ms. Jones was the clinical director for the Respondent during the period May 21, 2002, through June 19, 2002. Ms. Jones testified that Respondent, a CARF-approved treatment center, provided the disputed services to the claimant pursuant to a doctor’s referral. The claimant completed the course of treatment and demonstrated improvement in her physical condition.

Respondent billed Petitioner $6,872.00 for the disputed services during the period listed. Petitioner denied the claim based on lack of medical necessity.

Petitioner had the burden of proof. In August 2002, the claimant was examined and her medical review files reviewed by Richard Levy, M.D. Dr. Levy determined that the claimant did not need a work hardening program because she was no longer employed by the same employer. He determined that her medical condition did not warrant further treatment. Petitioner was unable to show Dr. Levy’s area of medical specialization and the reasons for Dr. Levy’s conclusion that the claimant’s employment condition should prevent her from obtaining additional treatment. Petitioner did not address the conclusions of the other physicians and health care professionals who did recommend continued treatment. Petitioner did not address claimant’s improvement in her neurological condition following her completion of the disputed services. Petitioner failed to prove by a preponderance of the evidence that the disputed services provided to Claimant during the claim period were not reasonable and medically necessary. Respondent is entitled to reimbursement for the disputed services provided to the claimant during the claim period.

II. FINDINGS OF FACT

1. Claimant suffered a work-related injury on ___ for pain in her left and right wrist and hand, right elbow and forearm, and lower neck and trapezius.
2. Claimant worked at a computer terminal as a customer services representative during the time that her condition first presented.
3. She began taking over-the-counter medications to relieve her pain, and then she sought medical care.
4. Between January and April 2002, the claimant was seen by a chiropractor and orthopaedic surgeon.
5. Claimant’s doctors’ examinations revealed positive tests for as a series of muscular-skeletal conditions, including possible carpal tunnel syndrome, C7 radiculopathy, and deQuervain’s tenosynovitis.
6. Claimant’s orthopaedic surgeon prescribed medication for her condition.
7. Among his recommendations were that the claimant abstain from lifting more than 25 pounds, avoiding repetitive grasping, and restrict pulling and carrying.
8. In November 2002, a physical evaluation of the claimant performed by a chiropractor for the Commission assigned a whole person impairment of 19%.
9. Respondent, a CARF-approved treatment center, provided the disputed services to the claimant pursuant to a doctor’s referral.
10. The claimant completed the course of treatment and demonstrated improvement in her physical condition.
11. Respondent billed Petitioner $6,872.00 for the disputed services during the period listed, and Petitioner denied the claim based on lack of medical necessity.
12. On August 20, 2003, the Texas Workers’ Compensation Commission (Commission), acting through an Independent Review Organization (IRO) found that the disputed services provided by Respondent between May 21, 2002, and June 19, 2002, were medically necessary.
13. On September 12, 2003, the Medical Review Division (MRD) of the Commission granted the request of Medway Health Centers, Respondent, for reimbursement.
14. Petitioner timely requested a hearing before the State Office of Administrative Hearings (SOAH) regarding the medical necessity of the disputed services provided to the claimant between May 21, 2002, and June 19, 2002.
15. The parties prefiled all exhibits and testimony.
16. The hearing convened on July 13, 2004, with SOAH Administrative Law Judge Paul D. Keeper presiding. Courtney Leech represented Petitioner, and William Maxwell represented Respondent. The record closed upon the close of the hearing at 4:15 p.m., July 13, 2004.
17. The amount in dispute is $6,872,00, plus interest and the IRO fee of $460.
18. In August 2002, the claimant was examined and her medical review files reviewed by Richard Levy, M.D.
19. Dr. Levy determined that the claimant did not need a work hardening program because she was no longer employed by the same employer.
20. Dr. Levy determined that the claimant’s medical condition did not warrant further treatment.
21. However, Petitioner was unable to show Dr. Levy’s area of medical specialization and the reasons for Dr. Levy’s conclusion that the claimant’s employment condition should prevent her from obtaining additional treatment.
22. Petitioner did not address the conclusions of the other physicians and health care professionals who did recommend continued treatment.
23. Petitioner did not address claimant’s improvement in her neurological condition following her completion of the disputed services.
24. Petitioner failed to prove by a preponderance of the evidence that the disputed services provided to Claimant during the claim period were not reasonable and medically necessary.
25. Respondent is entitled to reimbursement for the disputed services provided to the claimant during the claim period.

III. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act, specifically Tex. Labor Code Ann. §413.031(k), and Tex. Gov’t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code §148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§2001.051 and 2001.052.
5. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §§148.21(h) and 133.308(w).
6. The disputed services provided by Respondent from May 21, 2002, through June 19, 2002, to the claimant (C.U.) were reasonable and medically necessary.

ORDER

THEREFORE IT IS ORDERED that Continental Casualty Company shall reimburse Medway Health Centers for charges, plus any applicable interest, associated with disputed services provided to the claimant ___ from May 21, 2002, through June 19, 2002.

Signed July 15, 2004.

PAUL D. KEEPER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS