DECISION AND ORDER

I. INTRODUCTION

Texas Mutual Insurance Company (Carrier) disputes the decisions of two independent review organizations (IROs) and the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services for ____ (Claimant). Carrier disputes that it should be required to reimburse Main Rehab and Diagnostic (Provider) $6,833.55 for those services.

As set out below, the Administrative Law Judge (ALJ) finds that the Carrier should reimburse the Provider $2,044 for some of those services and that all other matters requests for reimbursement should be denied.

II. FINDINGS OF FACT

1. On ___, Claimant sustained a work-related injury to his right shoulder and lumbar back (compensable injury) as a result of his work activities.
2. On the date of injury, the Claimant’s employer was ___, and the Carrier was its workers’ compensation insurance carrier.
3. The Provider furnished medical services to the Claimant on the dates and with the Current Procedural Terminology (CPT) codes shown below:

CPT CODES	SERVICE DESCRIPTIONS	DATES 2003
97110	Exercises	April 24, 25, 28, 29, and 30 May 1, 2, 5, 6, 7, 8, 9, 7, 13, 14, 15, 16, 20, 21, 22, 23, 27, 28, 29, and 30 June 3, 4, 5, 6, 10, 17, 18, 19, 20, 24, 25, 26, and 27 July 1, 2, 3, 8, 9, 10, 11, 16, 17, 18, 22, 23, 24, 25, 30, and 31 August 1, 6, 7, and 8
95999	Neurological procedure	May 7
97213	Subsequent office visit	May 29, and 30 June 3, 4, 5, 6, and 10 July 1 August 6, and 27
97250	Myofascial release	May 29, and 30 June 3, 4, 5, 6, and 10
97750MT	Performance test	June 10, and 24 July 10, August 14
97122	Manual traction	May 29, and 30 June 3, 4, 5, 6, and 10
95851	Range of motion measurements	April 24 May 8, and 22 June 5, and 19 July 9
E1300	Whirlpool portable	May 14
99214	Office/outpatient visit	May 21
97265	Joint mobilization	June 4, 6, and 10

1. The Provider sought reimbursement from the Carrier for the above medical services, but the Carrier denied that reimbursement.
2. Without explaining why, the Carrier did not reimburse the Provider for the following services:

CPT CODES	DATE	Maximum Allowable Reimbursement (MAR)
97750MT	June 10, 2003 (two units)	$43 per unit
95851	May 8, 2003 (two units)	$36 per unit

1. The Carrier sent an explanation of benefit (EOB) to the Provider denying the requested reimbursement for the following services for the following reasons:

CPT CODES	DATE	DENIAL REASONS	MAR
95851	June 5, 2003 (two units)	Fee guideline MAR reduction	$36 per unit
97750MT	June 24, 2003 (two units)	Fee guideline MAR reduction	43 per unit
99214	May 21, 2003	Not appropriately documented	71

1. In objecting to the fee for the 95851 service on June 5, 2003, the Carrier appeared to assume that only one unit of service was provided to the Claimant; however, the Provider sufficiently documented that it furnished two units of 95851 service on June 5, 2003.
2. In objecting to the fee for the 97750MT service on June 24, 2003, the Carrier appeared to assume the only unit of service was provided to the Claimant; however, the Provider sufficiently documented that it furnished two units of 97750MT service on June 24, 2003.
3. The Provider sufficiently documented that it furnished a 99214 service when its employee, Dr. Osler Kamath, D.C., visited with the Claimant in the Provider’s office on May 21, 2003.
4. For each of the other services in dispute, the Carrier sent an EOB to the Provider denying the requested reimbursement as not having been medically necessary.
5. With rare exception, on each date that the 97110 exercise services were provided, the Claimant performed and the Provider billed for one hour and fifteen minutes of exercise.
6. There is no documentation to show which exercises, if any, the Claimant performed under CPT Code 97110 on April 24, 25, or 28, 2003.
7. On April 29, 2003, and many dates of services thereafter, under CPT Code 97110, the Claimant performed very simple shoulder flexion, rotation, and mobilization exercises with one-on-one supervision from the Provider.
8. On May 20, 2003, and many dates of service thereafter, under CPT Code 97110, in addition to the simple shoulder exercises, the Claimant performed very simple lumbar back mobility and flexibility and general flexibility exercises.
9. A reasonably intelligent and cooperative patient could have learned the above simple exercises in 15 to 30 minutes and thereafter performed them at home without supervision other than perhaps one additional 30-minute review session to ensure he was performing them properly.
10. The Claimant was reasonably intelligent and cooperative.
11. The Provider did not document that any exercises other than the shoulder and lumbar back exercises described above were performed by the Claimant under CPT 97110 for which the Provider seeks reimbursement in this case.
12. In addition to the services in dispute, the Carrier paid for 15 minutes of CPT Code 97110 services on each date of service from April 24 through May 28, 2003, and an additional 15 minutes from May 13 through 16, 2003.
13. The CPT Code 97110 services for which the Provider seeks reimbursement in this case were not reasonably medically necessary due to the Claimant’s compensable injury.
14. Beyond the services in dispute, the Carrier reimbursed the Provider for the following services to the Claimant from April 18, 2003, through May 28, 2003:
15. 21 CPT Code 97213 office visits;
16. 22 units of CPT Code 97265 joint mobilization;
17. 21 units of CPT Code 97250 myofascial release; and
18. 22 units of CPT Code 97122 manual traction.
19. On June 12, 2003, the Claimant reported to a designated doctor that his shoulder felt fine, though he still complained of lower back pain.
20. On June 12, 2003, the designated doctor:
21. Could find no objective sensory or motor deficit of the Claimant’s lumbar spine, lower extremities, or right upper extremity;
22. Found that the Claimant had reached maximum medical improvement (MMI); and
23. Assigned the Claimant a whole person impairment rating of zero
24. The disputed services provided after June 12, 2003, were not reasonably medically necessary due to the Claimant’s compensable injury.
25. Except as otherwise noted, there is not sufficient evidence to show that the disputes services provided before June 12, 2003, were unnecessary.
26. The Provider filed a request for medical dispute resolution with the TWCC concerning the above-described disputed services.
27. Upon referral by TWCC, the IROs reviewed the services that were alleged not to be medically necessary and found that they were so necessary.
28. MRD reviewed the other disputed services
29. After the IRO decisions and the MRD order were issued, the Carrier asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
30. The required notice of a contested-case hearing concerning the dispute was mailed to the Carrier and the Provider.
31. On November 18, 2004, SOAH ALJ William G. Newchurch held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
32. The Carrier appeared at the hearing through its attorney, Ryan Willett.
33. The Provider appeared at the hearing through its attorney, Scott Hilliard.

III. CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. (Labor Code) §§ 402.073(b) and 413.031(k) (West 2004) and Tex. Gov’t Code Ann. (Gov’t Code) ch. 2003 (West 2004).
2. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
3. Based on the above Findings of Fact and Gov’t Code § 2003.050 (a) and (b), 1 Tex. Admin. Code (TAC) § 155.41(b) (2004), and 28 TAC §§ 133.308(v) and 148.21(h) (2004), the Carrier has the burden of proof in this case.
4. At the time an insurance carrier makes payment or denies payment on a medical bill, the insurance carrier shall send, in the form and manner prescribed by the Commission, the explanation of benefits to the appropriate parties. A generic statement that simply states a conclusion such as “not sufficiently documented” or other similar phrases with no further description of the reason for the reduction or denial of payment does not satisfy the requirements of this section. 28 TAC §133.304 (c).
5. 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 that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Labor Code § 408.021 (a).
6. Based on the above Findings of Fact and Conclusions of Law, the CPT Code 97110 services for which the Provider seeks reimbursement in this case were not reasonably medically necessary due to the Claimant’s compensable injury and the Provider’s request to be reimbursed for them should be denied.
7. Based on the above Findings of Fact and Conclusions of Law, none of the services that the Provider furnished to Claimant on June 12, 2003, or thereafter was reasonably medically necessary due to the Claimant’s compensable injury and the Provider’s request to be reimbursed for them should be denied.
8. Based on the above Findings of Fact and Conclusions of Law, the Carrier should be ordered to reimburse the Provider a total of $2,044 for the following services that it furnished to the Claimant:

CPT CODES	SERVICE DESCRIPTIONS	MAR PER DATE	DATES 2003
95999	Neurological procedure	$384	May 7
97213	Subsequent office visit	48	May 29, and 30 June 3, 4, 5, 6, and 10 July 1
97250	Myofascial release	43	May 29, and 30 June 3, 4, 5, 6, and 10
97750MT	Performance test	43	June 10 (two units)
97122	Manual traction	35	May 29, and 30 June 3, 4, 5, 6, and 10
95851	Range of motion measurements	36	April 24 (two units) May 8 (two units), and 22 (two units) June 5 (two units)
E1300	Whirlpool portable	204	May 14
99214	Office/outpatient visit	71	May 21
97265	Joint mobilization	43	June 4, 6, and 10

1. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request to be reimbursed for the other disputed services should be denied.

ORDER

IT IS ORDERED THAT the Carrier shall reimburse the Provider $2,044 for the reasons set out above and the Provider’s remaining requests for reimbursement are denied.

Signed January 14, 2005.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS