DECISION AND ORDER

Texas Mutual Insurance Company (Carrier) has appealed the decision of the Independent Review Organization (IRO) granting reimbursement for physical therapy treatments provided to injured worker ____ (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Carrier has shown by a preponderance of the evidence that the majority of services billed under CPT Code 97110 were not medically necessary. However, Carrier has not shown that the other services were not medically necessary. Therefore, as set forth in more detail below, Maximum Therapeutic Initiative (Provider) is entitled to reimbursement in the sum of $1,287.

I. BACKGROUND

Claimant suffered compensable, work-related injuries to his feet, back, and wrists when he fell approximately 20 feet from a staircase on ____. At the time, Claimant was 59 years old. As a result of his fall, Claimant fractured his spine, right wrist, and both feet. Claimant was placed in casts and splints and was limited in his movement for a number of months following his injury. During that time, Claimant’s primary treating doctor indicated he would likely need reconstructive surgery for his injuries. On February 18, 2002, Claimant began receiving physical therapy/rehabilitation treatment from Provider and received this treatment through May 24, 2002, after which Claimant began a work hardening program. In this case, the only dates of service in dispute are May 13, 2002, through May 24, 2002, which are the treatment dates immediately prior to Claimant beginning work hardening. Carrier, as the workers’ compensation insurance carrier for Claimant’s employer, declined to reimburse the treatments, contending they were not medically necessary. The total amount in dispute is $3,492.

Based on Carrier’s denial of reimbursement, Provider sought medical dispute resolution through the Texas Workers’ Compensation Commission (Commission). The matter was referred to an IRO designated by the Commission for the review process. The IRO determined that the services in issue were medically necessary treatment for Claimant’s compensable injury. Carrier then requested a hearing before the State Office of Administrative Hearings (SOAH). The hearing convened on September 13, 2004, with ALJ Craig R. Bennett presiding. Provider appeared through its representatives, Charles Blevins and William Ellis. Carrier appeared through its attorney, Katie Kidd. The hearing concluded and the record closed that same day. No parties objected to notice or jurisdiction.

II. DISCUSSION AND ANALYSIS

This case involves a dispute over the necessity of various physical therapy treatments following Claimant’s injury. The services in issue involve one-on-one therapy (CPT Code 97110), group therapy (CPT Code 97150), aquatic therapy (CPT Code 97113), myofascial release (CPT Code 97250), and neuromuscular re-education (CPT Code 97112).^[1] Carrier argues that none of the disputed services were necessary because, by May 13, 2002, Claimant received the maximum benefit from physical therapy and should have begun work hardening at that point. Carrier asserts that any additional benefits from therapeutic exercises could have been obtained through a home exercise program and should not have required extensive supervision or in-office treatment. Therefore, Carrier contends the treatments provided to Claimant between May 13, 2002, and May 24, 2002, were unnecessary. In support of its position, Carrier offered the testimony of numerous physicians who reviewed the medical documentation and opined that Claimant had reached a plateau in his improvement level on or before May 13, 2002. The various doctors testified that Claimant did not need continued monitored treatment, but could have achieved any additional benefits through the use of a home exercise program. Carrier also notes that Provider conceded that Claimant was ready for work hardening by May 15, 2002, so additional physical therapy treatment should not have been needed at that point.

In response, Provider points out that it provided exceptional treatment that allowed Claimant to return to work without the need for reconstructive surgery. Provider asserts that the medical documentation shows that Claimant had not improved to the point that he was able to return to work and still needed gait training and treatment for his limited plantar flexion strength before beginning work hardening. Provider asserts that, as soon as it was apparent that Claimant had reached a plateau in his improvement level from the physical therapy, additional treatment was stopped and he was moved into work hardening. Provider contends that Claimant showed improvement from the physical therapy all the way up until the final week of therapy, at which time he reached a plateau.

Ultimately, the ALJ agrees that Carrier has shown that the majority of services billed under CPT Code 97110 were not medically necessary for Claimant on or after May 13, 2002. The medical and legal authority is amply clear that CPT Code 97110 is to be used only when the health care provider has worked directly one-on-one with the patient in regard to that patient’s therapy alone.^[2] In this case, Claimant had progressed significantly and, by May 7, 2002, was limited in his plantar flexion strength only (which also impacted his ability to walk). Otherwise, Claimant had met all of his other treatment goals by that point. As Carrier’s expert testimony shows, Claimant should not have continued to need additional one-on-one therapy on a daily basis after that point.^[3] Rather, at most, it would have been appropriate for Provider to be with Claimant one-on-one just for purposes of instruction on exercises to be performed that day. In light of this, the ALJ concludes that Provider

is entitled to recover only one unit of one-on-one therapy (billed under CPT Code 97110) for each of the nine dates of service in issue. This is a total of nine units at a reimbursement of $35 per unit, for a total reimbursement of $315 for services billed under CPT Code 97110. Otherwise, Carrier is not required to reimburse any other services billed under CPT Code 97110.

As for the other treatment, though, the ALJ concludes that Carrier has not shown that the treatment provided was not medically necessary. First, virtually everyone involved agrees that Provider did a very good job at rehabilitating Claimant. Even Carrier’s own expert doctors testified

that the treatment rendered by Provider was “excellent” or “very good.” Ultimately, Carrier disputes that Claimant continued to receive any benefit from the ongoing treatment that could not have been achieved through prior therapy or a home exercise program. However, the ALJ finds Carrier’s witnesses unpersuasive on this point.

For example, Dr. Pearce equivocated during much of his testimony regarding the different treatments in issue.^[4] Given Dr. Pierce’s equivocal comments, the ALJ finds his ultimate opinions of limited persuasiveness. Similarly, physical therapist Scott Herbowy seemed to acknowledge that group therapy was a possible treatment option, although he thought home therapy was “better.”^[5] Moreover, Mr. Herbowy gave no explanation for his conclusory opinion that aquatic therapy was not necessary for Claimant. In general, Mr. Herbowy discounted the treatment because he thought the same results could have been achieved through a home exercise program. However, the evidence does not show-and the ALJ is not aware of-how aquatic therapy could have been properly provided in a home exercise program. Given Claimant’s continued limitations in plantar flexion strength and the need for Claimant to continue to learn how to walk properly after his serious foot injuries, the ALJ concludes that Claimant did continue to benefit from Provider’s treatment through May 24, 2002. While the evidence does show that Claimant reached a plateau, it was reached sometime

between May 15 and May 29, 2002. Given the uncertainty at which point it occurred, and the extensive nature of Claimant’s injury, it was appropriate for Provider to continue to treat Claimant to verify that a plateau had been reached and Claimant could start work hardening. The total reimbursement for these services, not including one-on-one therapy, is $924.

In summary, then, the ALJ concludes that the evidence indicates that Provider was justified in continuing to treat Claimant through May 24, 2002, but does not warrant the 2-3 hours of one-on-one therapy per day that was billed by Provider. Therefore, Provider is entitled to reimbursement of nine units each of one-on-one therapy (CPT Code 97110), group therapy (CPT Code 97150), and

neuromuscular re-education (CPT Code 97112). Further, Provider is entitled to reimbursement for six units of myofascial release (CPT Code 97250) and three units of aquatic therapy (CPT Code 97113). Total reimbursement for these treatments is $1,287, and Carrier is ordered to reimburse Provider that amount. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. Claimant ____ suffered compensable, work-related injuries to his feet, back, and wrists when he fell approximately 20 feet from a staircase on ____. At the time, Claimant was 59 years old.
2. Texas Mutual Insurance Company (Carrier) is the provider of workers’ compensation insurance covering Claimant for his compensable injury.
3. As a result of his fall, Claimant fractured his spine, right wrist, and both feet.
4. Claimant was placed in casts and splints and was limited in his movement for a number of months following his injury. During that time, Claimant’s primary treating doctor indicated he would likely need reconstructive surgery for his injuries.
5. On February 18, 2002, Claimant first began receiving physical therapy/rehabilitation treatment from Maximum Therapeutic Initiative (Provider).
6. Claimant received physical therapy from Provider until May 24, 2002, after which Claimant began a work hardening program.
7. The dates of service at issue in this case are from May 13, 2002, to May 24, 2002, which are the treatment dates immediately prior to Claimant beginning work hardening. The total amount in dispute is $3,492.
8. The group therapy, neuromuscular re-education, myofascial release, and aquatic therapy provided to Claimant during the dates of service in issue were reasonable, medically necessary, and designed to relieve Claimant’s pain and/or improve his mobility and functioning.
9. For each of the dates of service in issue, one unit of one-on-one therapy was reasonable, medically necessary, and designed to relieve Claimant’s pain and/or improve his mobility and functioning.
10. Carrier denied reimbursement for the services, contending they were not medically necessary.
11. Provider requested medical dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which referred the matter to an Independent Review Organization (IRO).
12. MRD ordered reimbursement on March 15, 2004, based on the IRO physician reviewer’s determination that the services in issue were medically necessary.
13. On April 6, 2004, Carrier requested a hearing and the case was referred to the State Office of Administrative Hearings (SOAH).
14. Notice of the hearing was sent by the Commission to all parties on May 17, 2004.
15. On September 13, 2004, Administrative Law Judge Craig R. Bennett convened a hearing in this case. Provider appeared through its representatives, Charles Blevins and William Ellis. Carrier appeared through its attorney, Katie Kidd. The hearing concluded and the record closed that same day.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act, specifically Tex. Labor Code Ann. §413.031(k), and Tex. Gov’t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code §148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
5. Carrier has the burden of proof. 28 Tex. Admin. Code §§ 148.21(h) and 133.308(w).
6. Carrier has shown, by a preponderance of the evidence, that all but nine units of treatment provided to Claimant between May 13, 2002, and May 24, 2002, and billed under CPT Code 97110 were not medically necessary for treatment of Claimant’s compensable injury.
7. Carrier has not shown, by a preponderance of the evidence, that the services provided to Claimant between May 13, 2002, and May 24, 2002, and billed under CPT Codes 97112, 97113, 97150, and 97250 were not medically necessary for treatment of Claimant’s compensable injury.
8. Carrier is liable to reimburse Provider the total sum of $1,287 for: (1) nine units of one-on-one therapy (CPT Code 97110); (2) nine units of group therapy (CPT Code 97150); (3) nine units of neuromuscular re-education (CPT Code 97112); (4) six units of myofascial release (CPT Code 97250); and (5) three units of aquatic therapy (CPT Code 97113).

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company reimburse Maximum Therapeutic Initiative the sum of $1,287 plus interest for the specified treatments provided to Claimant between May 13, 2002, and May 24, 2002.

Signed September 28, 2004.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Aquatic therapy is used for certain injuries because fluid resistance can be more beneficial than hard, inflexible resistance when rehabilitating certain muscles or body parts. Neuromuscular re-education, in this case, consisted of gait training used to help Claimant to learn to walk correctly after the significant injuries to his feet.↑
2. See SOAH Docket No. 453-01-1188.M5 (April 3, 2002)(ALJ Smith); SOAH Docket No. 453-00-2051.M4 (December 1, 2000)(ALJ O’Malley); SOAH Docket No. 453-01-1081.M4 (May 25, 2001)(ALJ Smith); SOAH Docket No. 453-01-1492.M5 (July 23, 2001)(ALJ Cunningham); see the American Medical Association’s CPT Assistant.↑
3. Carrier’s Ex. 7, pp. 20-22.↑
4. See, e.g., Carrier’s Ex. 7, p. 19 (regarding CPT Code 97112, Dr. Pearce testified about treatment he “thought” they would have already provided; he did not base his testimony on what the records did or did not show actually was provided); p. 20 (regarding CPT Code 97250, Dr. Pearce testified the treatment was initially warranted but was “probably not” necessary during the dates in dispute).↑
5. Carrier’s Ex. 8, p. 32 (testifying that much of the treatment billed under CPT Code 97110 could have been performed as group therapy or “better yet” as part of a “comprehensive home program.”)↑