DECISION AND ORDER

I. SUMMARY

John C. Torres, D.C., (Provider) appealed the decision of Independent Review Incorporated, an independent review organization certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) tracking number M5-04-0125-01, denying reimbursement for medical services provided to the Claimant. This decision orders that Employers General Insurance Company (Carrier) is not required to reimburse the Provider for the amount claimed.

The Administrative Law Judge (ALJ) convened a hearing on March 22, 2004. The hearing was concluded and the record closed that date. The Provider appeared pro se. The Carrier appeared through Neal Moreland, Director, TWCC Services.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this proceeding is whether the Carrier should reimburse the Provider $2,632 plus interest for medical services provided between September 12, 2002, and May 8, 2003, and billed under CPT Codes 99213 (office visit) and 99250 (myofascial release). The Carrier argued that the medical services provided to the Claimant were not medically necessary or reasonably required to treat the compensable injury.

The documentary record in this case consisted of two packets of medical records (Exh. 1 – 175 pages, and Exh. 2 – 91 pages). Also, the Provider testified in his own behalf.

The record revealed that on____, the Claimant, a 46-year-old woman, suffered an injury to her shoulder and cervical areas while holding two chickens in her left hand and bending down to pick up two more chickens. The Claimant has been treated over the years with epidural steroid injections, chiropractic rehabilitation, nerve blocks, botox injections, and cervical fusion.

The Claimant continued to suffer from pain and began seeing the Provider for chiropractic care. Treatment notes in the record showed that the Claimant had no appreciable improvement in pain level from the services provided during the contested dates of service. Thus, the Provider did not prove that the services provided to the Claimant were medically necessary.

Based on the evidence, the ALJ concludes that the Provider’s appeal should be denied. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

1. On____, the Claimant suffered a compensable injury to the shoulder and cervical areas.
2. The Claimant’s injury is covered by workers’ compensation insurance written for the Claimant’s employer by Employers General Insurance Company (Carrier).
3. The Claimant was treated with epidural steroid injections, chiropractic rehabilitation, nerve blocks, botox injections, and cervical fusion prior to seeking chiropractic care from John R. Torres, D.C. (Provider) for continued pain.
4. The Provider’s treatment of the Claimant’s injury was billed under CPT Codes 99213 (office visit) and 99250 (myofascial release).
5. The medical services in dispute were provided from September 12, 2002, to May 8, 2003.
6. According to an independent medical examination performed by Wright W. Singleton, M.D., the Claimant was not a candidate for further pain management, chiropractic care, physical therapy, or medication.
7. The Claimant had no appreciable improvement from treatment provided from September 12, 2002, to May 8, 2003.
8. The Carrier denied payment in the amount of $2,632 for the medical services referred to in Findings of Fact Nos. 5 and 6, on the basis that treatment was not medically necessary.
9. The Provider timely requested dispute resolution by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC).
10. On December 18, 2003, Independent Review Incorporated, 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 Nos. 5 and 6 were not medically necessary. The MRD issued its findings and decision on December 19, 2003, concluding that the disputed expenses should not be paid, and the Provider timely appealed this decision.
11. TWCC sent notice of the hearing to the parties on January 27, 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 March 22, 2004, before Michael J. Borkland, Administrative Law Judge. The Provider appeared pro se, and the Carrier appeared through Neal Moreland, Director, TWCC Services.

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. 11, the Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §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. Based on Findings of Fact Nos. 7 and 8, the Provider failed to prove that reimbursement for treatment should be ordered.

ORDER

IT IS, THEREFORE, ORDERED that Employers General American Casualty Company shall not be required to reimburse John R. Torres, D.C. for the disputed services provided in treating the Claimant.

Signed April 13, 2004.

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