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Title: 

453-04-3781-m5-etal

Date: 

October 14, 2004

Type: 

Retrospective Medical Necessity

453-04-3781-m5-etal

DECISION AND ORDER

I. DISCUSSION

The dockets in this matter were administratively joined by the State Office of Administrative Hearings (SOAH) for purposes of administrative economy. The parties and the Claimant (___) are the same in each case. The hearings on the two dockets were held on the same date, and the evidence in the dockets were the same. Accordingly, a single order will be issued in these two cases.

In SOAH Docket No. 453-04-3781.M5 on February 18, 2004, Texas Mutual Insurance Company (TMIC), Petitioner, requested a hearing regarding the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through ZRC Services, doing business as Ziroc, an Independent Review Organization (IRO). The IRO disagreed with TMIC’s prior adverse decision to deny reimbursement to Main Rehab & Diagnostic, (Main Rehab), Respondent, based on medical necessity and documentation of physical medicine services, special reports, and office visits from November 7, 2002, through March 24, 2003, for ___ (Claimant).

In SOAH Docket No. 453-04-4659.M5, on April 5, 2003, TMIC requested a hearing regarding the Findings and Decision of the Commission acting through Texas Medical Foundation, an IRO. The IRO disagreed with TMIC’s prior adverse decision to deny reimbursement to Main

Rehab based on medical necessity and documentation of therapeutic exercises, physical performance evaluation (muscle testing), and range of motion testing from April 7, 2003, through May 7, 2003, and the office visit on April 21, 2003. However, the IRO agreed with TMIC that the office visits from April 7, 2003, through April 17, 2003, and from April 22 through June 2, 2003, should not be reimbursed based on documentation and medical necessity.[1]

A hearing was convened in both cases on August 5, 2004. The Administrative Law Judge (ALJ) was Paul Keeper. R. Scott Placek represented TMIC, and Scott C. Hilliard represented Main Rehab. At the conclusion of the hearing, counsel agreed to provide the ALJ with a revised table of services in dispute by August 18, 2004.[2] On October 5, 2004, TMIC submitted a revised table in each docket, and the record was closed.

Claimant sustained a work-related injury while performing repeated packaging on ____.[3] On November 7, 2002, she presented to Main Rehab for evaluation and treatment.[4] Dr. Osler Kamath, D.C., a clinician at Main Rehab, made an initial diagnosis of tenosynovitis (inflammation of the tendon and the tendon sheath that supply the hand of the hand and wrist), carpal tunnel syndrome (damage to the median nerve as it courses through the wrist), paresthesia (numbness and tingling), and muscle spasms.[5] Main Rehab began treatment of the Claimant on November 8, 2002.[6] On November 26, 2002, the Claimant had an MRI and on February 4, 2003, an EMG.[7] These diagnostic

procedures confirmed that the Claimant had sustained neurological damage, including having developed carpal tunnel syndrome.[8]

Dr. Kamath testified regarding the therapies delivered to the Claimant during Main Rehab’s provision of services to the Claimant.[9] Over the course of the Claimant’s initial evaluation and treatment during November 7, 2002, through January 13, 2003, Dr. Kamath maintained billing records for the following services rendered to the Claimant: range of motion testing, (CPT Code 95851), muscle testing (CPT Code 97750-MT), office visits (CPT Code 99213), therapeutic procedures (CPT Code 97122), diagnostic and therapeutic studies (CPT Code 95999-WP), myofascial release (CPT Code 97250), joint mobilization (CPT Code 97265), and physical therapy (CPT Code 97110).

During this initial treatment period, Dr. Kamath performed with the Claimant the following one-on-one exercises:

  • wrist exercises that involved extending the fingers in the hand and moving the wrist upwards and downwards[10]
  • forearm exercises that involved rotating the hand up and down while extended with the palm up[11]
  • wrist/ulnar exercises that involved moving the hand from side to side[12]
  • isometric wrist flexion exercises that involved flexing the hand against a resistive spring[13]
  • isometric wrist exercises that involved the resistance of a force with the outward movement of the fingers[14]
  • resistive wrist extension, wrist flexion, and wrist radial deviation exercises that involved the patient’s attempts to negate resistance and perform motion[15]

The foregoing exercises were performed while the Claimant was sitting or standing. In none of them did the exercises pose a safety threat to the Claimant.[16] The Claimant was cooperative, did not miss appointments, followed instructions, and was of normal intelligence and alertness.[17] Dr. Kamath performed these services and supervised exercises on a one-on-one basis for the initial treatment period of November 2002 until the Claimant’s surgery.

On March 11, 2003, the Claimant underwent surgery to correct her carpal tunnel symptoms.[18] Following the surgery, on March 24, 2003, and from April 2, 2003, through June 2, 2003, Dr. Kamath continued to provide one-on-one supervision for many of the same exercises and services that Dr. Kamath provided to the Claimant before the surgery.

The medical history created by Dr. Kamath does not include his comments on the severity of the Claimant’s pain.[19] Without documentation on the severity of the Claimant’s pain, the office notes are insufficient to document improvement in the level of pain.[20] Dr. Kamath did not include in his records any charts of the exercises that the Claimant performed, either pre- or post-surgery.[21]

TMIC offered the testimony of Mark Miller, a licensed physical therapist. Mr. Miller reviewed Main Rehab’s treatment records of the Claimant during the periods in dispute. Mr. Miller administers the same types of treatments to patients within his care as were provided to the Claimant.[22] Mr. Miller testified that: (1) Dr. Kamath’s pre-surgery documentation was less than complete with respect to the Claimant’s progress in motion, strength, and function,[23] (2) the joint mobilization and therapeutic exercises were medically necessary for only the initial two-week period after which a home exercise program was appropriate,[24] and (3) the joint mobilization and supervised therapeutic exercises were not medically necessary after the initial two-week period.[25]

With respect to the post-surgical period between April 2 and June 2, 2003, Mr. Miller testified that Dr. Kamath’s post-surgical medical records were well documented[26] and that “some [of the therapeutic exercises were] necessary.”[27] Specifically, he recommended that two to three visits for two weeks of supervised therapeutic exercise would have been medically necessary and safe for the Claimant to perform. In addition, Mr. Miller stated that medical necessity existed for the Claimant to be reexamined once a week to ensure that the home exercise program was being performed correctly. During these once a week visits, Mr. Miller testified, the Claimant would have benefitted from one to two units of one-to-one therapeutic exercise, but only for a few weeks, after which a home exercise program should be in place.[28]

The revised table of disputed services reflects that TMIC withdrew its objection to the following services that were rendered by Dr. Kamath: 1 unit of new outpatient visit (CPT code 99204) at $106.00 per unit, 6 units of joint mobilization (97265) at $43.00 per unit, and 37 units of physical therapy (CPT code 97110) at $175.00 per unit. In addition, TMIC documented that it had made $350.00 in payments to Main Rehab on these services. The undisputed amount owed by TMIC to Main Rehab is $6,139.00

TMIC had the burden of proof in this proceeding. That burden was to show that the services in dispute rendered were not medically necessary. TMIC conceded that some of the services were medically necessary, as reflected in the testimony of its expert witness and in the table of withdrawn disputed amounts. In light of the evidence submitted, the ALJ concludes that TMIC has met its burden of proof as to some, but not all, services and that TMIC owes Main Rehab the difference between $6,489.00 and $350.00, or $6,139.00.

II. FINDINGS OF FACT

  1. Claimant sustained a work-related injury while performing repeated packaging on ____.
  2. On November 7, 2002, she presented to Main Rehab for evaluation and treatment.
  3. Dr. Osler Kamath, D.C., a clinician at Main Rehab, made an initial diagnosis of tenosynovitis (inflammation of the tendon and the tendon sheath that supply the hand of the hand and wrist), carpal tunnel syndrome (damage to the median nerve as it courses through the wrist), paresthesia (numbness and tingling), and muscle spasms.
  4. Main Rehab began treatment of the Claimant on November 8, 2002.
  5. On November 26, 2002, the Claimant had an MRI, and on February 4, 2003, an EMG. These diagnostic procedures confirmed that the Claimant had sustained neurological damage, including having developed carpal tunnel syndrome.
  6. Dr. Kamath testified regarding the therapies delivered to the Claimant during Dr. Kamath’s care.
  7. Over the course of the Claimant’s initial evaluation and treatment during November 7, 2002, through January 13, 2003, Dr. Kamath maintained billing records for the services rendered to the Claimant.
  8. On March 11, 2003, the Claimant underwent surgery to correct her carpal tunnel symptoms.
  9. During this period, Dr. Kamath performed joint mobilization, myofascial release, manual traction, and physical therapy, as well as a series of supervised wrist and forearm exercises.
  10. Following the surgery, on March 24, 2003, and from April 2, 2003, through June 2, 2003, Dr. Kamath continued to provide many of these same services to Claimant.
  11. The medical history created by Dr. Kamath for the Claimant does not include his comments on the severity of the Claimant’s pain but does include his notes on the existence of the complaint.
  12. Without documentation on the severity of the Claimant’s pain, the office notes are insufficient to document improvement in the level of pain.
  13. The Claimant performed these exercises while she was sitting or standing, and in none of them did the exercises pose a safety threat to the Claimant.
  14. The Claimant was cooperative, did not miss appointments, followed instructions, and was of normal intelligence and alertness.
  15. Dr. Kamath’s pre-surgery documentation was less than complete with respect to the Claimant’s progress in motion, strength, and function.
  16. The pre-surgical joint mobilization and other therapeutic exercises were not medically necessary after the initial two week period.
  17. Joint mobilization and therapeutic exercises were medically necessary for the initial two weeks during the period beginning November 7, 2002, until the Claimant’s surgery. Following the initial two week period, neither the joint mobilization nor the supervised therapeutic exercises were medically necessary.
  18. With respect to the post-surgical period between April 2 and June 2, 2003, Dr. Kamath’s post-surgical medical records were well documented.
  19. Post-surgically, two to three office visits for two weeks of therapeutic exercise were medically necessary and safe for the Claimant to perform.
  20. In addition, medical necessity existed for the Claimant to be reexamined once a week to ensure that the home exercise program was being performed correctly.
  21. During these once a week visits, one unit of one-to-one therapeutic exercise was medically necessary for two weeks, after which a home exercise program should have been in place.
  22. In SOAH Docket No. 453-04-3781.M5, the Independent Review Organization (IRO) ZRC Services Ziroc disagreed with TMIC’s prior adverse decision to deny reimbursement to Main Rehab. The IRO based its decision on the existence of medical necessity and sufficiency of documentation for physical medicine services, special reports, and office visits from November 7, 2002, through March 24, 2003, for Claimant.
  23. In SOAH Docket No. 453-04-4659.M5, the IRO, Texas Medical Foundation, disagreed with TMIC’s prior adverse decision to deny reimbursement to Main Rehab. The basis of the IRO’s decision based on medical necessity and documentation of therapeutic exercises, physical performance evaluation (muscle testing), and range of motion testing from April 7, 2003, through May 7, 2003, and the office visit on April 21, 2003.
  24. However, the IRO agreed with TMIC that the office visits from April 7, 2003, through April 17, 2003, and from April 22 through June 2, 2003, should not be reimbursed based on documentation and medical necessity.
  25. A hearing was convened on August 5, 2004, in the two cases that had been administratively joined, and the he Administrative Law Judge (ALJ) was Paul Keeper.
  26. R. Scott Placek represented TMIC, and Scott C. Hilliard represented Main Rehab.
  27. At the conclusion of the hearing, the record was held open for counsel to provide the ALJ with a revised table of services in dispute. On October 5, 2004, TMIC submitted a revised table in each docket.
  28. In light of the evidence submitted, the ALJ concludes that TMIC has met its burden of proof as to some, but not all, services and that TMIC owes Main Rehab the difference between $6,489.00 and $350.00, or $6,139.00.

III. 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 Tex. Admin. Code §148.21(h), TMIC has the burden of proof, pursuant to Tex. Lab. Code Ann. §413.031.
  4. TMIC sustained its burden of proof in showing by a preponderance of the evidence that Main Rehab was not entitled to reimbursement, except on the services on which TMIC’s expert witness withdrew its appeal.

ORDER

Texas Mutual Insurance Co. is not required to reimburse Main Rehab & Diagnostic for the disputed services provided Claimant from November 7, 2002, through June 2, 2003, with the exception of $6,139.00 in billed but unpaid services.

Signed October 14, 2004.

PAUL D. KEEPER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Main Rehab initially appealed the IRO decision with respect to the adverse decision on office visits. However, at the hearing on the merits on August 5, 2004, Main Rehab withdrew its appeal on these claims.↑
  2. As described in greater detail in this Decision and Order, the revised table was needed because TMIC’s expert witness had agreed that some of the services rendered by Main Rehab during the periods in dispute were “definitely” required. TMIC Ex. 1 at 14. The deadline for submission is extended for receipt of the document.↑
  3. Main Rehab Ex. 1 at 1.↑
  4. Id.↑
  5. Main Rehab Ex. 5 at 7-8.↑
  6. Main Rehab Ex. 5 at 13.↑
  7. Main Rehab Ex. 1 at 27 and45.↑
  8. Main Rehab 5 at 8-9.↑
  9. Main Rehab 5.↑
  10. Id. at 41-42.↑
  11. Id. at 42.↑
  12. Id. at 42-43.↑
  13. Id. at 43-44.↑
  14. Id. at 44.↑
  15. Id.↑
  16. Id at 44-45.↑
  17. Id. at 45.↑
  18. Main Rehab Ex. 1 at 47.↑
  19. Id. at 35.↑
  20. Id. at 36.↑
  21. Id. at 38-40.↑
  22. TMIC Ex. 1 at 11 and 13.↑
  23. Id. at 18. Mr. Miller observed that Dr. Kamath’s post-surgical notes are well documented. Id. at 32.↑
  24. Id. at 13-18.↑
  25. Id. at 20-22.↑
  26. Id. at 32.↑
  27. Id. at 29.↑
  28. Id. at 15 and 17-19. Mr. Miller described these exercises as “quite simple,” Id. at 23, and that require no special equipment, Id. at 25.↑