DECISION AND ORDER

This is a dispute over reimbursement for medical services provided by Richard Guerrero, D.C., to workers’ compensation claimant ___ (Claimant). The Administrative Law Judge (ALJ) concludes the services should be reimbursed.

I. HISTORY

The Claimant suffered a crushing injury to her right forearm on ___, when it was caught in machinery at work. After surgery, she began receiving rehabilitative services from Dr. Guerrero on November 14, 2001. The workers’ compensation carrier, Liberty Mutual Insurance Company (LMIC) reimbursed Dr. Guerrero for those services until January 30, 2002. It refused to reimburse him for most of the services provided after that date. For a few services, no explanations of benefits (EOBs)were provided. Most, however, were refused because LMIC found them not to be medically necessary.

On June 6, 2003, Dr. Guerrero filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission). The disputed dates of service set out in that request were from January 30, 2002, through September 19, 2002. The Commission declined to consider services provided before June 6, 2002, pursuant to its one-year rule, 28 Tex. Admin. Code (TAC) §133.305. Therefore, the dates of service in dispute in this case extend from June 6, 2002, through September 19, 2002. The services include therapeutic procedures, kinetic activities, myofascial release, and office visits.

The Commission referred the medical necessity issues to an Independent Review Organization (IRO), which found in Dr. Guerrero’s favor. The Commission’s Medical Review Division (MRD) considered the few services for which no EOBs were provided. It found Dr. Guerrero had adequately documented most of those services, which were provided on August 14, September 5, and September 16, 2002, and ordered the maximum allowable reimbursement for them to be paid to Dr. Guerrero.

LMIC filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH). ALJ Henry D. Card presided over that hearing, which was held August 25,2004, with both parties participating. Additional documents were filed by Dr. Guerrero, as agreed at the hearing, and were admitted into evidence on September 23, 2004. The record was closed on that date.

II. DISCUSSION

Thomas Sato, D.C., conducted a peer review of the Claimant’s medical records. In Dr. Sato’s opinion, the treatments provided by Dr. Guerrero were excessive. Phil Elizondo, M.D., who examined the Claimant on several occasions, expected her to be done with therapy by mid-April or May of 2002.

On the other hand, the Commission’s designated doctor, Mark Zuber, M.D., who examined the Claimant on July 25, 2002, found she was not yet at maximum medical improvement. The IRO reviewer found the medical notes to show “slow, but consistent improvement and response to the treatment and rehabilitation.” The records themselves were in evidence and support the IRO’s interpretation.

The ALJ finds the medical records, Dr. Zuber’s examination, and the IRO review to be convincing. LMIC did not meet its burden of proving the services provided were not medically necessary. The evidence also shows Dr. Guerrero provided the services on August 14, September 5, and September 16, 2002, for which the MRD ordered reimbursement.

The ALJ concludes LMIC should be ordered to reimburse Dr. Guerrero for the disputed services he provided the Claimant from June 6, 2002, through September 19, 2002.

III. FINDINGS OF FACT

1. Workers’ compensation claimant ___ (the Claimant) suffered a crushing injury to her right forearm on ___, when it was caught in machinery at work.
2. After surgery, the Claimant began receiving rehabilitative services from Richard Guerrero, D.C., on November 14, 2001.
3. The workers’compensation carrier, Liberty Mutual Insurance Company (LMIC) reimbursed Dr. Guerrero for those services until January 30, 2002. It refused to reimburse him for most of the services provided after that date.
4. For a few services, LMIC provided no explanations of benefits (EOBs). Most, however, were refused because LMIC found them not to be medically necessary.
5. On June 6, 2003, Dr. Guerrero filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission). The disputed dates of service set out in that request were from January 30, 2002, through September 19, 2002.
6. The Commission declined to consider services provided before June 6, 2002, pursuant to its one-year rule, 28 Tex. Admin. Code (TAC) ‘ 133.305.
7. The dates of service in dispute in this case extend from June 6, 2002, through September 19, 2002.
8. The disputed services include therapeutic procedures, kinetic activities, myofascial release, and office visits.
9. The Commission referred the medical necessity issues to an Independent Review Organization (IRO), which found in Dr. Guerrero’s favor.
10. The Commission’s Medical Review Division (MRD) considered the few services for which no EOBs were provided. It found Dr. Guerrero had adequately documented most of those services, which were provided on August 14, September 5, and September 16, 2002, and ordered the maximum allowable reimbursement for them to be paid to Dr. Guerrero.
11. LMIC filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
12. Notice of the hearing was sent March 23, 2004.
13. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
14. Administrative Law Judge (ALJ) Henry D. Card presided over that hearing, which was held August 25,2004, with both parties participating.
15. Additional documents were filed by Dr. Guerrero, as agreed at the hearing, and were admitted into evidence on September 23, 2004. The record was closed on that date.
16. The Claimant’s medical records show a slow, but consistent, improvement and response to Dr. Guerrero’s treatment and rehabilitation.
17. Dr. Guerrero provided the services on August 14, September 5, and September 16, 2002, for which the MRD ordered reimbursement.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘ 413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. ‘ 2001.052.
3. Under 28 TAC ‘ 148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann.’ 413.031.
4. LMIC failed to prove the disputed treatments were not medically necessary.
5. LMIC should be ordered to reimburse Dr. Guerrero for the disputed services provided the Claimant from June 6, 2002, through September 19, 2002.

ORDER

It is, therefore, ordered that the Carrier, Liberty Mutual Insurance Company, shall reimburse Richard Guerrero, D.C., for the disputed treatments provided Claimant ___ from June 6, 2002, through September 19, 2002.

Signed November 22, 2004.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS