DECISION AND ORDER

I. SUMMARY

Main Rehab and Diagnostic, (Provider) appealed the decision of an independent review organization certified by the Texas Department of Insurance in Texas Workers= Compensation Commission (TWCC) Medical Review Division (MRD) denying reimbursement for medical services provided to Claimant. This decision orders that Texas Builders Insurance Company (Carrier) is not required to reimburse the Provider for the amount claimed.

The Administrative Law Judge (ALJ) convened and closed a hearing on March 24, 2004. Attorney Scott Hilliard appeared by telephone for Provider, and attorney Beverly Vaughn appeared for Carrier.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this proceeding is whether Carrier should reimburse Provider for medical services provided from April 9, 2003, through May 7, 2003. The services consisted of therapeutic procedures, joint mobilization, range of motion testing, and electrical stimulation. Carrier argued that the medical services provided to Claimant were not medically necessary or reasonably required to treat the compensable injury.

Claimant suffered a complex fracture of his right ankle when he fell approximately 10 feet on ________. He underwent surgery on June 9, 2001, but continued to have problems with pain and swelling. After extensive physical therapy he underwent as second surgery on February 13, 2003.

Following this surgery Provider provided the services described above for a period of ten weeks. Carrier agreed to reimbursement for the first six weeks but denied the final four weeks. During the entire ten week period, Provider was treating Claimant four times a week. Carrier argues that this was excessive and that after the initial six weeks Claimant should have progressed to a home exercise program instead of an ongoing supervised exercise program. Further, Claimant’s condition did not improve during the time Provider treated him and he eventually required a third surgery. Provider argues that the injuries were complex and extensive and that Claimant recovered as a result of the disputed services.

Dr. Osler Kamath, D. C., testified that he provided the services to Claimant and that Claimant benefitted from the treatment. The treatment was extended beyond the usual length of time because of the complexity of the injuries. Claimant could have done the exercises at home, but patients tend not to be diligent doing the exercises if not supervised by a health care provider.

Both parties offered extensive documentary evidence. A review of the documents indicates that six weeks is the maximum accepted time of supervised treatment for an injury such as Claimant=s. Further, the documents show that Claimant did not improve during Provider’s services. In fact, Claimant was in worse pain and had a more limited range of movement at the end of the treatment than when it commenced and could have done the same exercises unsupervised at home.

Based on the evidence, the ALJ concludes that the treatment provided to the Claimant from April 9, 2003, through May 7, 2003, was not medically necessary and reasonably required to treat the Claimant’s injury.

III. FINDINGS OF FACT

1. On ________, Claimant suffered a compensable injury to his right ankle.
2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Texas Builders Insurance Company (Carrier).
3. Following surgery, Main Rehab and Diagnostic (Provider) provided Claimant with therapeutic procedures, joint mobilization, range of motion testing, and electrical stimulation for a period of ten weeks.
4. Six weeks is the maximum accepted time of supervised treatment for an injury such as Claimant=s.
5. Claimant’s condition did not improve during the time of Provider’s treatment.
6. Claimant was in worse pain and had a more limited range of movement at the end of the treatment than when it commenced.
7. Claimant could have done the exercises unsupervised at home.
8. Carrier denied reimbursement for the final four weeks of treatment as not being medically necessary.
9. Provider timely requested dispute resolution by the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC).
10. On November 19, 2003, an independent review organization certified by the Texas Department of Insurance, issued its decision finding that the medical services referred to in Findings of Fact No. 3 were not medically necessary and Provider timely appealed this decision.
11. TWCC sent notice of the hearing to the parties on January 13, 2004. 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.
12. The hearing on the merits convened and closed March 24, 2004, before John H. Beeler, Administrative Law Judge. Provider appeared by telephone though attorney Scott Hilliard and Carrier was represented by Beverly Vaughn, 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 the above Findings of Fact the Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov=t Code ‘2001.052.
4. 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. Based on the above Findings of Fact, Provider failed to prove that reimbursement for treatment should be ordered.

ORDER

IT IS, THEREFORE, ORDERED that Texas Builders Insurance Company is not required to reimburse Main Rehab and Diagnostic for the disputed services provided in treating Claimant.

Signed May 24, 2004.

JOHN H. BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS