DECISION AND ORDER

Healthview (Provider), on behalf of Markesha Beal (Claimant), challenged the decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission upholding Pacific Indemnity Company’s (Carrier) denial of preauthorization for a 20-day course of work hardening. Both Carrier and the MRD concluded that work hardening was not medically necessary to treat Claimant.

Based on the evidence, the ALJ concluded that 16 days of work hardening, or up to 128 hours, is medically necessary to treat Claimant’s injury. Provider is preauthorized to provide this treatment.

The hearing in this matter convened on January 28, 2004, in Austin, Texas, with Administrative Law Judge (ALJ) Cassandra Church presiding. The record closed that day. Provider was represented by Iris K. Forrest, LVN, case manager. Carrier was represented by Robert Josey, attorney. The Commission did not participate in the hearing.

I. DISCUSSION

Provider argued that Claimant needs a work hardening program to both restore her hand and arm strength and endurance and to address her depression and fear of re-injury. Provider acknowledged that workers with injuries such as Claimant experienced usually do not need work hardening, but asserted that in the case the combination of Claimant’s extreme level of deconditioning and atrophy, caused by the multiple surgical procedures, and her mental state warranted this program. Carrier argued that Provider had not demonstrated that a highly-structured program was needed to treat the effects of peripheral nerve decompression over two years after the injury. The MRD’s reviewer concluded that while Claimant did need to strengthen her hand and arm this conditioning could be accomplished through a home exercise program.^[1]

On August 3, 2001, Claimant injured her right forearm, wrist, and hand. Claimant was a data entry clerk. Her diagnosis was right carpal tunnel syndrome, right pronator syndrome, right radial tunnel syndrome, and right cubital tunnel syndrome. On March 27, 2003, Bruce Bryne, M.D., performed surgery consisting of concurrent releases of all affected nerves. Between the surgery and July 2003, Provider treated Claimant between three to five times per week with physical therapy and myofascial release. However, Claimant was unable to participate fully in the physical therapy due to continued pain in her hand. In July 2003, Claimant was suffering from depression. On July 17, 2003, Louise Lamarre, M.D., a pain specialist, recommended work hardening in order to return Claimant to work. Dr. Lamarre concluded that much of the depression Claimant was experiencing in mid-2003 arose from Claimant’s not feeling like a productive citizen because she was unable to return to work. As no mental health professional has evaluated Claimant since July 2003, her present mental state is unknown, although there is nothing in the record to suggest her depression has ended. In July 30, 2003, Dr. Bryne also recommended work hardening to restore her arm strength and enable her to return to work. After re-examining Claimant in December 2003, Dr. Bryne again recommended Claimant for work hardening, noting that she continued to experience arm and hand weakness. Dr. Bryne recommended therapy for four weeks, four times a week.

Since July 2003, Provider has treated Claimant occasionally. It is unknown whether she continued with any home exercise program. Claimant has been off work since her injury. Claimant received an offer of employment in July 2003, but it is unknown whether there is a clerical job currently available to her.

Dr. Bryne’s recent recommendation for additional structured therapy was persuasive, as were the consistent recommendations for work hardening from all medical professionals who have examined Claimant since July 2003. Recommendations for work hardening were made by her surgeon, a pain management specialist, and a counselor, as well as by Provider.

In sum, the medical opinion on Claimant’s condition supports the administration of a work hardening program. Since the most-recent recommendation from Dr. Bryne in December 2003 was for 16 days of treatment, that level of service is preauthorized.

II. FINDINGS OF FACT

1. On August 3, 2001, M.B. (Claimant) injured her right arm and hand while at a data-entry job. Pacific Indemnity Company (Carrier) was the responsible insurer.
2. Claimant was diagnosed as having suffered a right carpal tunnel syndrome, right pronator syndrome, right radial tunnel syndrome, and right cubital tunnel syndrome.
3. On March 27, 2003, Bruce Bryne, M.D., performed surgery, specifically, concurrent releases of all affected nerves.
4. Between March 17, 2003, and mid-July 2003 Provider administered physical therapy and myofascial release. Claimant was unable to participate fully in the physical therapy due to continued pain in her hand and forearm.
5. In June 2003, Louise Lamarre, M.D., board-certified in pain management, recommended work hardening to order improve Claimant’s physical functioning and enable her to return to work.
6. In July 2003 and in December 2003, Dr. Bryne recommended work hardening to improve Claimant’s physical functioning and allow her to return to work.
7. Claimant has been off work since her date of injury.
8. In July 2003, Claimant experienced depression, arising primarily from her inability to work and be a productive citizen.
9. In December 2003, Claimant continued to have weakness in her right hand and forearm, as well as some pain.
10. On June 30, 2003, Provider denied preauthorization for a 20-day course of work hardening.
11. Provider appealed the Carrier’s denial of preauthorization to the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission).
12. On October 23, 2003, based on the review by an Independent Review Organization (IRO), Forte, the MRD declined to preauthorize work hardening on the basis that it was not medically necessary.
13. On November 14, 2003, Provider requested a hearing on the MRD decision denying preauthorization for work hardening.
14. On December 11, 2003, the Commission issued a notice of hearing that included the date, time, and location of the hearing, the applicable statutes under which the hearing would be conducted, and a short, plain statement of matters asserted.
15. Administrative Law Judge Cassandra Church conducted a hearing on the merits of this case on January 28, 2004, and the record closed that day.

III. CONCLUSIONS OF LAW

1. 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. ‘413.031 and Tex. Gov’t Code Ann. ch. 2003.
2. Provider timely requested a hearing, as specified in 28 Tex. Admin Code ‘ 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann.” 2001.051 and 2001.052.
4. Provider, as the petitioning party, has the burden of proof in this proceeding pursuant to Tex. Lab. Code Ann. ‘ 413.031 and 28 Tex. Admin Code ‘ 148.21 (h).
5. Provider met its burden of proof to show that 16 days, up to 128 hours, of work hardening is medically necessary to treat or reasonably required to relieve the effects of or promote recovery from a compensable injury suffered by Claimant, within the meaning of Tex. Lab. Code Ann. ” 408.021 and 401.011(19).
6. ORDER

IT IS ORDERED that Provider is preauthorized to provide 16 days of work hardening, up to 128 hours of service, to M. B. (Claimant).

Signed February 25, 2004.

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

1. The MRD’s review was conducted in this case by an independent review organization, Forte. The medical speciality of the reviewer is unknown. In the course of this application for preauthorization of work hardening, Claimant had been evaluated by a counselor, a physical therapist, a chiropractor, and two medical doctors.↑