DECISION AND ORDER

I. INTRODUCTION

Mega Rehab (Provider) contested the decision of the Texas Workers= Compensation Commission’s Medical Review Division (MRD)denying reimbursementof$794.39for services provided to Claimant from December 6, 2002, through April 17, 2003.^[1]The Administrative Law Judge (ALJ) finds thatProvider did not prove the disputed treatments were reasonable or medically necessary, and that reimbursement for those services from Pacific Employers Insurance Company (Carrier) is not warranted.

II. PROCEDURAL HISTORY

ALJ Sharon Cloninger convened the hearing on October 25, 2004, in the William P. Clements Building, 300 West 15^th Street, Fourth Floor, Austin, Texas.Stephen Dudas, D.C., appeared and represented Provider. P. Brook Swilley, attorney, represented Carrier.The parties agreed to recess the hearing for two weeks to attempt to settle the matter. They agreed that the hearing would reconvene November 8, 2004. The hearing reconvened as scheduled, and the parties reported that they had not reached a settlement agreement. Provider requested a continuance to have time to review Carrier’s documents. The continuance was granted, and the hearing reconvened November 17, 2004. Both parties appeared, evidence was heard, and the record closed that same day.

The parties did not contest notice or jurisdiction, which are addressed in the Findings of Fact and Conclusions of Law below.

III. BACKGROUND

On ___, Claimantinjured her back, left hand, right knee, and right ankle when she fell down in the parking lot of the daycare center where she worked while chasing an unattended child. She suffered a right knee sprain with internal derangement, and lumbar sprain.

Provider began treating Claimant on May 25, 2001.Prior to the disputed dates of service, Provider’s treatment of Claimant consisted mainly of physical therapy. Almost a year later, on May 15, 2002, Claimant underwent arthroscopic surgery to treat the compensable injury to her knee.On October 10, 2002, Claimant was found to have reached maximum medical improvement (MMI) with a nine percent whole body impairment.^[2]

After Claimant reached MMI, Provider continued to treat her. Between December 6, 2002, and April 17, 2003, Provider’s disputed treatment of Claimant included preparation ofa special report, therapeutic exercises, neuromuscular re-education, office visits, a physical performancetest,supplies and materials, and disposable underpants.^[3]

IV. EVIDENCE AND DISCUSSION

Dr. Dudas testified, and offered one exhibit, which was admitted. Carrier offered 10 exhibits, which were admitted.

A. Applicable Law

The only issue in this case is whether, by a preponderance of the evidence, there was medical necessity for the treatment rendered to Claimant by Provider. Medical necessity is defined inTex. Lab. Code Ann. ‘ 408.021, which states:

(a) 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. The employee is specifically entitled to health care that:

1. cures or relieves the effects naturally resulting from the compensable injury;
2. promotes recovery; or
3. enhances the ability of the employee to return to or retain employment.

B. Evidence

Retrospective peer reviews by K. L. Blanchette, M.D., and Roger Clifford, D.C.

a. November 15, 2002 Retrospective Peer Review^[4]

K. L. Blanchette, M.D., and Roger Clifford, D.C., concluded no further treatment was medically necessary, given the stability of Claimant’s condition, along with negative orthopedic and neurological testing. Dr. Blanchette and Dr. Clifford said that after Claimant’s right knee surgery on May 15, 2002, physical therapy and chiropractic care would have been appropriate with an end treatment date of July 15, 2002. They concluded that beyond that date there was no medical necessity for any follow-up chiropractic office visits, and Claimant needed to be discharged to an independent home exercise program. They pointed out that Claimant’s lumbar and knee MRIs were unremarkable, that her knee had been documented to be stable without any significant orthopedic or objective findings, and that any lumbar problems seem to have been minimal and more apparently resolved.

b. April 10, 2003 Retrospective Peer Review^[5]

Dr. Blanchette and Dr. Clifford concluded that further treatment for Claimant’s compensable injuries was not medically necessary, and that Claimant would not be a candidate for spine surgery or any additional surgery to her knee.

c. April 11, 2003 Retrospective Peer Review^[6]

Dr. Blanchette and Dr. Clifford concluded that any future treatment plan for Claimant should consist of a home program. They said there was no medical necessity for any further chiropractic care, physical therapy, durable medical equipment, or further complex rehabilitation.

Rhonda Rosencrantz, MPT

Physical therapist Rhonda Rosencrantz discharged Claimant from physical therapy to a home

exercise program on December 6, 2002.^[7]

C. Analysis

Provider did not present sufficient evidence to prove that treatments rendered to Claimant from December 6, 2002, through April 17, 2003, were reasonable and medically necessary. The peer review doctors stated that care to Claimant’s knee should have ended by July 15, 2002. Their November 15, 2002 peer review, prepared before the disputed services began, concluded further care was not reasonable or medically necessary.

On December 6, 2002, the first disputed date of service, Ms. Rosencrantz released Claimant to a home exercise program. There is nothing in the record to indicate an exacerbation of Claimant’s condition after she was released to the home exercise program.

Alan B. Hurschman, M.D., conducted an outpatient consultation on January 29, 2003. Although Dr. Hurschman recommended that Claimant undergo physical therapy with Provider three times a week for four weeks, there is no indication that the physical therapy was medically necessary to treat Claimant’s compensable injuries, or that she had suffered an exacerbation of her injuries that would warrant a new round of treatment.^[8]

The ALJ therefore concludes the disputed treatments were neither reasonable nor medically necessary to treat Claimant’s compensable injuries.

V. CONCLUSION

Provider failed to prove that reimbursement is warranted for the disputed treatments. Accordingly, the ALJ orders that Carrier is not to reimburse Provider for the treatment rendered to Claimant from December 6, 2002, through April 17, 2003.

VI. FINDINGS OF FACT

1. Claimant sustained compensable work-related injuries on ___, when she fell at work and injured her low back, right knee, ankle, and left wrist.
2. Theworkers= compensation insurance carrier for Claimant’s employer was Pacific Employers Insurance Company (Carrier).
3. Mega Rehab (Provider) began treating Claimant on May 25, 2001, primarily with physical therapy.
4. The diagnoses for Claimant’s compensable injuries have included lumbar intravertravertebral disorder without myelopathy, lumbar radiculopathy, and right knee medical meniscus tear.
5. On___, nearly a year after she was injured, Claimant underwent arthroscopic surgery to her right knee.
6. Post-operative care following the arthroscopic surgery was reasonable and medically necessary through July 15, 2002.
7. On October 10, 2002, Claimant was found to be at maximum medical improvement (MMI) with a whole body impairment rating of nine percent.
8. Claimant did not suffer an exacerbation of any of her compensable injuries following the October 10, 2002 MMI evaluation.
9. By November 15, 2002, there was no medical necessity for any follow-up chiropractic office visits.
10. By November 15, 2002, Claimant’s lumbar and knee MRIs were unremarkable.
11. By November 15, 2002, Claimant’s knee was stable, without any significant orthopedic or objective findings.
12. By November 15, 2002, Claimant’s lumbar injury was minimal and, more apparently, resolved.
13. On December 6, 2002, Rhonda Rosencrantz, MPT, released Claimant from physical therapy to a home exercise program.
14. Provider’s treatment of Claimant from December 6, 2002, through April 17, 2003, included a special report, therapeutic exercises, neuromuscular re-education, office visits, a physical performance test, supplies and materials, and disposable underpants.
15. Provider sought reimbursement from Carrier for services rendered to Claimant between December 6, 2002, and April 17, 2003.
16. Carrier denied reimbursement for the treatments and services.
17. Provider filed a request for medical dispute resolution with the Texas Workers= Compensation Commission’s Medical Review Division (MRD).
18. On April 19, 2004, after reviewing a February 24, 2004, independent review organization (IRO) decision recommending non-payment, the MRD denied reimbursement of the disputed treatment and services.
19. On April 28, 2004, Provider requested a hearing before the State Office of Administrative Hearings (SOAH) to contest the MRD decision.
20. On June 7, 2004, notice of the hearing was mailed to Provider and Carrier, informing the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statues and rules involved.
21. ALJ Sharon Cloninger convened the hearing on October 25, 2004, in the William P. Clements Building, 300 West 15^th Street, Fourth Floor, Austin, Texas.Stephen Dudas, D.C., appeared and represented Provider. P. Brook Swilley, attorney, represented Carrier.
22. The parties agreed to recess the hearing for two weeks to attempt to settle this dispute informally. They agreed on the record that the hearing would reconvene November 8, 2004. The hearing reconvened as scheduled, and the parties reported that they had not reached a settlement agreement. Provider requested a continuance, which was granted, and the hearing reconvened November 17, 2004. Evidence was presented and the record closed that same day.

VII. CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘ 413.031(d) and Tex. Gov=t Code Ann. ch. 2003.
2. Provider timely filed notice of appeal of the decision of TWCC’s Medical Review Division (MRD), as specified in 28 Tex. Admin. Code (TAC) ‘ 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ” 2001.051 and 2001.052 and 28 TAC ‘ 148.4(b).
4. As the party appealing the MRD decision, Provider had the burden of proving the case by a preponderance of the evidence, pursuant to 28 TAC ‘148.21(h) and (i).
5. Based on the above Findings of Fact, Providerfailed to prove Claimant’s treatment from December 6, 2002, through April 17, 2003, was reasonable or medically necessary as defined in Tex. Lab. Code Ann. ‘ 408.021(a).
6. Based on the above Findings of Fact and Conclusions of Law, Carrier should not reimburse Provider for the disputed treatment and services.

ORDER

IT IS ORDERED THATPacific Employers Insurance Companyis not to reimburse Mega Rehabfor the disputed services and treatments.

Signed January 14, 2005.

______________________________

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. See Table of Disputed Services (Provider’s Exh. 1).↑
2. Carrier’s Exh. B.↑
3. At the hearing, Dr. Dudas stated on the record that Provider no longer requests reimbursement for the lumbar steroid injection.↑
4. Carrier’s Exh. C.↑
5. Carrier’s Exh. E.↑
6. Carrier’s Exh. F.↑
7. Provider’s Exh. 1, 10-11.↑
8. Provider’s Exh. 1, 15-16.↑