DECISION AND ORDER

I. INTRODUCTION

Russell Baker, D.C. (Dr. Baker) has appealed a decision of the Texas Workers’ Compensation Commission’s (TWCC) Medical Review Division (MRD) regarding medical services he provided ___ (Claimant) from August 12, 2002, to December 18, 2002, but for which ACIG Insurance Company (Carrier) denied reimbursement. MRD, relying on a determination of an independent review organization (IRO), found that Dr. Baker failed to show that those services were medically necessary to treat Claimant’s compensable injury. MRD further decided that reimbursement should be denied because Dr. Baker neither documented that Claimant’s injury was severe enough for one-to-one therapy nor documented that the procedure was done in a one-to-one setting.

The amount in dispute is $9,689.00. The disputed issue is whether the services were medically necessitated by the compensable injury. As set out below, the Administrative Law Judge (Judge) finds that only the initial office visit and the office visits of September 3, 2002, and October 4, 2002, were medically necessary and grants Dr. Baker’s request for reimbursement for those services for a total amount of $196.00. The Judge finds that all other services were not medically necessary and denies Dr. Baker’s request for reimbursement for those remaining services.

II. FINDINGS OF FACT

1. On ___, ___ (Claimant) sustained a work-related injury to his left knee as a result of his work activities (compensable injury).
2. On the date of injury, Claimant’s employer was ___, and its workers’ compensation insurance carrier was ACIG Insurance Company (Carrier).
3. After being hit by a pickup truck as it was backing up, Claimant was seen at the Round Rock Medical Center.
4. On July 16, 2002, Claimant was noted at his initial examination at Concentra Medical Centers to have swelling in his left thigh, knee, and lower leg and contusions to his thigh and lower leg. Claimant was told he could return to work with restrictions on July 17, 2002.
5. On July 17, 2002, Claimant began receiving physical therapy at Concentra Medical Centers. Claimant had modest improvement with the therapy that continued through July 25, 2002.
6. On July 29, 2002, Gregg Vagner, M.D., examined Claimant and concluded he had a medial collateral ligament (MCL) tear and questionable medial meniscal tear. Dr. Vagner recommended a brace for Claimant’s knee and released Claimant to return to work with restrictions (light duty).
7. On August 12, 2002, Claimant changed treating doctors to Russell Baker, D.C. (Dr. Baker), who conducted an initial evaluation. Dr. Baker took Claimant off work and added the diagnoses of radiculitis and myofascitis.
8. Dr. Baker provided the following medical services to Claimant on the dates and with the Current Procedural Terminology (CPT) codes shown below. Carrier denied all of the maximum allowable reimbursement (MAR) for each medical service on each date shown below:

CPT CODE	SERVICE DESCRIPTION	DATES	TOTAL MAR NOT REIMBURSED
99204	Office/outpatient visit, new	8/12/2002	$100.00
99213	Office/outpatient visit, est.	8/14, 16, 20, 21, 23, 26, 28, & 30/2002; 9/3, 4, 6, 9, 11, 13, 18, 23, 25, 27, & 30/2002; 10/4, 7, 14, 16, 18, 21, 23, 28, & 30/2002; 11/1, 4, 6, 11, 13, 15, 20, 22, 25, & 27/2002; 12/2, 4, 5, 9, 13, 16, & 18/2002	$2,160.00
97110	Therapeutic exercises	10/28 & 30/2002; 11/1, 4, 6, 11, 13, 15, 20, 22, 25, & 27/2002; 12/2, 4, 5, 9, 13, 16, & 18/2002	$1,645.00
97265	Joint mobilization	8/14, 16, 20, 21, 23, 26, 28, & 30/2002; 9/3, 4, 6, 9, 11, 13, 18, 23, 25, 27, & 30/2002; 10/4, 7, 14, 16, 18, 21, 23, 28, & 30/2002; 11/1, 4, 6, 11, 13, 15, 20, 22, 25, & 27/2002; 12/2, 4, 5, 9, 13, 16, & 18/2002	$1,935.00
97250	Myofascial release/soft tissue mobilization	8/14, 16, 20, 21, 23, 26, 28, & 30/2002; 9/3, 4, 6, 9, 11, 13, 18, 23, 25, 27, & 30/2002; 10/4, 7, 14, 16, 18, 21, 23, 28, & 30/2002; 11/1, 4, 6, 11, 13, 15, 20, 22, 25, & 27/2002; 12/2, 4, 5, 9, 13, 16, & 18/2002	$1,935.00
97032	Electrical stimulation	8/14, 16, 23, 26, 28, & 30/2002; 9/3, 4, 6, 9, 11, 13, 18, 23, 25, 27, & 30/2002; 10/4, 7, 14, 16, 18, 21, 23, 28, & 30/2002; 11/1, 4, 6, 11, 13, 15, 20, 22, 25, & 27/2002; 12/2, 4, 5, 9, 13, 16, & 18/2002	$1,914.00

9. After treatment at Concentra Medical Centers, Claimant required no further passive modalities to treat range of motion abnormalities.
10. On October 8, 2002, Claimant underwent a diagnostic arthroscopy and restructure of the medial collateral ligament. Brannan Smoot, M.D., who performed the surgery, found that Claimant had only medial collateral ligament (MCL) instability, not MCL tear.
11. Prior to Claimant’s surgery, it was medically unnecessary for Dr. Baker to continue treating Claimant with physical therapy to prevent muscle atrophy. Indeed, Dr. Baker’s treatment made Claimant’s medical condition worse.
12. Joint mobilization is incorrect and harmful treatment for MCL laxity.
13. Dr. Smoot performed post-operative office visits and evaluations of Claimant from October 14, 2002, until January 15, 2003.
14. Dr. Smoot in his follow-up visit with Claimant on October 14, 2002, instructed Claimant on how to perform quadriceps-strengthening exercises, which could have been performed at home. Dr. Smoot did not recommend physical therapy.
15. All recommended post-surgery exercises could have been performed at home.
16. The post-operative office visits with physical therapy performed by Dr. Baker were not medically necessary.
17. Dr. Baker sought reimbursement from Carrier for the provided medical services.
18. Carrier sent explanations of benefit (EOBs) to Dr. Baker, denying the requested reimbursement as unnecessary treatment.
19. Dr. Baker filed a request for medical dispute resolution with TWCC.
20. An independent review organization (IRO) reviewed the medical dispute and found that the office visits with manipulation, ultrasound therapy, myofascial release, electrical stimulation, joint mobilization, radiological exam, special services report, and therapeutic procedures from August 12, 2002, to December 18, 2002, were not medically necessary to treat Claimant’s condition.
21. Based on the IRO’s findings, TWCC’s Medical Review Division (MRD) on January 5, 2004, determined that Dr. Baker did not prevail on the issue of medical necessity.
22. MRD also decided that the services Dr. Baker provided Claimant on December 5, 2002, had not been addressed by the IRO. MRD concluded that documentation confirmed that the office visit with manipulation and the electrical stimulations provided Claimant on that date had been delivered as billed and ordered Carrier to reimburse Dr. Baker $92.00.
23. After the MRD decision was issued, Dr. Baker asked for a contested-case hearing before a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
24. Required notice of a contested-case hearing concerning the dispute was mailed to Carrier and Dr. Baker.
25. On August 23, 2004, Carol Wood, a SOAH ALJ, held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded, and the record closed on that same day.
26. Carrier appeared at the hearing through its attorney, Douglas Pruett.
27. Dr. Baker appeared at the hearing and was represented by his attorney, Allen Craddock.

IV. Conclusions of Law

1. SOAH 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 Ann. (Labor Code) §§ 402.073(b) and 413.031(k) (West 2004) and Tex. Gov’t Code Ann. (Gov’t Code) ch. 2003 (West 2004).
2. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
3. Based on the above Findings of Fact and Gov’t Code §§ 2003.050 (a) and (b); 1 Tex. Admin. Code (TAC) § 155.41(b) (2004); and 28 TAC §§ 133.308(v) and 148.21(h) (2004), Dr. Baker has the burden of proof in this case.
4. An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Labor Code § 408.021 (a).
5. Claimant only required evaluation of his initial injury, institution of basic physical therapy and follow-up, compliance with a written home program of exercise and activity, and return to work at an appropriately restricted level for a brief period of time.
6. There was no medical necessity for Claimant to receive any chiropractic care following the initial care and physical therapy from Concentra Medical Centers.
7. The three weeks of passive therapy that Dr. Baker provided Claimant post-surgery were not medically necessary.
8. In-office physical therapy and rehabilitative treatment provided Claimant by Dr. Baker were medically unnecessary after Claimant’s surgery.
9. The initial office visit of August 12, 2002, and the office visits of September 3, 2002, and October 4, 2002, performed by Dr. Baker as Claimant’s treating doctor, were medically necessary.
10. Other than the initial office visit and the office visits of September 3, 2002, and October 4, 2002, the medical services that Dr. Baker provided Claimant were neither medically necessary nor effective for treatment of Claimant’s compensable injury.
11. Based on the above Findings of Fact and Conclusions of Law, only the initial office visit of August 12, 2002, and the office visits of September 3, 2002, and October 4, 2002, were medically necessary and Dr. Baker’s request for reimbursement for those services should be granted for a total amount of $196.00.
12. Based on the above Findings of Fact and Conclusions of Law, all other medical services provided by Dr. Baker were not medically necessary and Dr. Baker’s request for reimbursement for those remaining services should be denied.

ORDER

IT IS THEREFORE ORDERED that Dr. Baker’s request for reimbursement for the initial office visit of August 12, 2002, and the office visits of September 3, 2002, and October 4, 2002, is granted for a total amount of $196.00. Dr. Baker’s request for reimbursement for all remaining medical services is denied.

Signed October 21, 2004.

CAROL WOOD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS