DECISION AND ORDER

Neuromuscular Institute of Texas (Petitioner) seeks reimbursement of $788 for seven sessions of physical therapy following trigger point injections provided to injured worker ___ (Claimant). The Texas Workers’ Compensation Commission (Commission), acting through an independent review organization (IRO) denied reimbursement on the basis that the services were not medically necessary. This decision orders Southwestern Bell Telephone Company (Carrier) to reimburse the Petitioner $644 for the disputed services.

I. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

There are no contested issues of notice or jurisdiction in this proceeding. Those matters are addressed in the findings of fact and conclusions of law. The hearing convened and closed on November 8, 2004, before Administrative Law Judge (ALJ) Kerry D. Sullivan. The Petitioner was represented by Allen Craddock. The Respondent was represented by Kevin Franta.

II. BASIS FOR DECISION

On ___, the Claimant injured her neck, shoulder and upper extremities in a compensable repetitive motion injury while employed with the Carrier. Since then, the Petitioner has treated the Claimant for multiple problems associated with her compensable injury, including, carpal tunnel, cervical strain, myofascial findings, and rotator cuff surgery. The Claimant’s condition is complicated by diabetes and cirrhosis (a disease of the liver). Her treatment has included several sets of trigger point injections to control pain and muscle spasms. These include injections performed on March 11, 2003. Between March 12 and March 28, 2003, the Petitioner provided the Claimant the seven sessions of physical therapy that form the basis of this dispute. The sessions included myofascial release, ultrasound therapy, physical medical treatment and associated office visits and equipment.

The ALJ finds that the Petitioner should be reimbursed $596 for the physical therapy services provided and an additional $48 for one of the four disputed office visits. The Carrier paid for the trigger point injections and acknowledges that it cannot now claim they were unnecessary. Brad Burdin, D.O., testified on behalf of the Petitioner that the physical therapy in dispute is appropriate

after trigger point injections. In his view, physical therapy improves circulation and helps distribute the medicine. He testified that the physical therapy provided was particularly important for this Claimant because she also suffers from diabetes, which can interfere with proper circulation. Dr. Burdin also testified that peer review studies document the benefit of such treatment.

In the ALJ’s view, Dr. Burdin’s testimony overcomes the rationale of the IRO doctor, who based his denial primarily on the lack of need for the trigger point injections in the first place, and his belief that a home exercise program would have been adequate to distribute the medication if the injections were, in fact, necessary. It may be that home exercise could sometimes be employed rather than the more intensive and expensive physical therapy route chosen in this proceeding. But in light of Dr. Burdin’s specific testimony and the complication posed by the Claimant’s diabetes, the ALJ finds that the Petitioner has shown by a preponderance of the credible evidence that the disputed physical therapy services were medically necessary.

Three of the four office visits billed under CPT Code 99213 were not, however, shown to be necessary. This code requires two of the following: an expanded problem focused history, an expanded problem focused examination, or medical decision making of low complexity.^[1] The IRO determined there was no reason for this relatively high level of care to be provided four times over a period of twelve days. The ALJ concurs with the IRO that only one office visit was required for this established patient who has repeatedly received physical therapy treatment of this type during the last two years. The other physical therapy sessions could have been provided without the need for an office visit with the doctor.

III. FINDINGS OF FACT

1. Claimant ___ suffered a compensable, work-related injury on ___.
2. At the time of the injury, the Claimant’s employer, Southwestern Bell Telephone Company (Carrier), was self-insured for workers’ compensation claims.
3. On March 11, 2003, the Claimant received a series of trigger point injections to control pain and muscle spasms associated with her compensable injury. The Carrier paid for these services.
4. Between March 12, 2003 and March 28, 2003, the Petitioner provided seven sessions of physical therapy to the Claimant. The disputed physical therapy services included myofascial release, ultrasound therapy, physical medical treatment and associated office visits and equipment.
5. The Carrier denied reimbursement of $788 billed for the services described in Finding of Fact No. 4 on the basis that they were not medically necessary.
6. The Petitioner made a timely request to the Texas Workers= Compensation Commission (Commission) for medical dispute resolution.
7. The independent review organization (IRO) to which the Commission referred the dispute concluded that the disputed services were not medically necessary.
8. The Petitioner timely requested a hearing on the IRO decision, which the Commission adopted.
9. Notice of the hearing was sent on June 10, 2004.
10. The notice contained a statement of the time, place, and nature of the hearing, and the legal authority and jurisdiction under which the hearing was to be held; a reference to the sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
11. On November 8, 2004, Administrative Law Judge Kerry D. Sullivan convened a hearing in this case. The Petitioner was represented by Allen Craddock. The Respondent was represented by Kevin Franta. The hearing concluded and the record closed that same day.
12. The physical therapy described in Finding of Fact No. 4 was medically necessary after the trigger point injections in order to improve circulation and distribute the medicine. It was particularly required for this Claimant because she also suffers from diabetes, which can interfere with proper circulation.
13. Only one of the four office visits billed at $48 each under CPT Code 99213 was shown to be necessary for this established patient who has repeatedly received physical therapy treatment of the type provided here during the last two years. The other physical therapy sessions could have been provided without an office visit with the doctor.

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 (the 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. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
6. Petitioner established by a preponderance of the evidence that one office visit billed under CPT Code 99213 and the physical therapy described in Finding of Fact No. 4 were medically necessary.
7. Petitioner failed to establish that three additional office visits were medically necessary.
8. Petitioner’s request for reimbursement for one office visit billed under CPT Code 99213 and the physical therapy described in Finding of Fact No. 4 should be granted.
9. Petitioner’s request for reimbursement for three additional office visit billed under CPT Code 99213 should be denied.

ORDER

IT IS ORDERED that Southwestern Bell Telephone Company reimburse Petitioner $644 for one office visit and the disputed physical therapy and equipment provided between March 12, 2003, and March 28, 2003.

Signed January 3, 2005.

KERRY D. SULLIVAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. MFG at 19.↑