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Title: 

453-04-6356-m5-etal

Date: 

February 8, 2005

Type: 

Retrospective Medical Necessity

453-04-6356-m5-etal

DECISION AND ORDER

This proceeding concerns appeals from two decisions by Independent Review Organizations (IROs) that were joined for hearing at the State Office of Administrative Hearings (SOAH). At issue in both cases is the medical necessity of services Main Rehab and Diagnostic (Provider) rendered to Claimant ___ The first dispute, SOAH Docket No. 453-04-6356.M5, covers services provided June 4 – July 15, 2003, and on July 23, 2003.[1] An IRO chiropractor (Maximus) determined those services were medically necessary, and Texas Mutual Insurance Company (the Carrier) appealed. The amount in dispute in the first docket is $4,198.00. The second dispute, SOAH Docket No. 453-04-6581.M5,covers services provided between July 15, 2003, and October 30, 2003, with the exception of July 23, 2003.[2] Another IRO chiropractor (Envoy Medical Systems, LP) found these services were not medically necessary, and the Provider appealed. The amount in dispute in the second docket is $12,797.46. (Carrier Ex. 1, pp. 9-19.) In this Decision and Order, the ALJ finds that most of the disputed services did not constitute reasonable and medically necessary treatment for Claimant; however, Provider is entitled to reimbursement for medically necessary services totaling $322.00.

I. PROCEDURAL HISTORY

Notice and jurisdiction were not contested and are set forth in the Findings of Fact and Conclusions of Law. SOAH Administrative Law Judge (ALJ) Renee Rusch convened the hearing in these matters on November 29, 2004, at SOAH’s hearings facility in the William P. Clements Building, in Austin, Texas. Attorney R. Scott Placek represented the Carrier. Attorney Scott Hilliard represented the Provider. Though the hearing closed the same day, the record remained open until December 13, 2004, in order to give the parties an opportunity to submit written closing argument.

II. THE LAW AND ISSUES

The issue in this case is whether the services provided were medically necessary. Medical necessity is defined at Tex. Lab. Code Ann. § 408.021(a):

(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.

Under 28 TAC § 148.21(h) and (I), the appealing party has the burden of proof by a preponderance of the evidence in hearings, such as these, conducted pursuant to Tex. Lab. Code Ann. § 413.031. Thus, the Carrier had the burden of proof in Docket No. 453-04-6356.M5, and the Provider had the burden of proof in Docket No. 453-04-6581.M5.

In these cases, the issue of medical necessity broke down into two primary subissues:

  1. How long did passive modalities constitute reasonable and medically necessary treatment for Claimant?
  2. How long was it reasonable and medically necessary for Claimant to perform therapeutic exercises in a one-on-one setting?

III. DISCUSSION AND ANALYSIS

FACTUAL BACKGROUND

On ___, Claimant suffered a job-related injury when he slipped and fell, twisted his back, and struck his neck on a piece of wood. Claimant did not seek treatment until he visited an emergency room on or about May 28, 2003. On June 2, 2003, Claimant sought treatment from Provider. Claimant complained of cervical pain and lumbar pain extending into the left lower extremity. Osler Kamath, D.C., examined Claimant and became Claimant’s treating doctor. Initially, Dr. Kamath diagnosed Claimant as having cervical disc disorder, lumbar disc disorder, lumbosacral neuritis/radiculitis,[3] and paresthesia muscle spasms. The Provider characterized Claimant’s injury as “a serious job injury to his cervical and lumbar spine” (Provider’s closing brief at 2). The Carrier’s expert witness, David Alvarado, D.C., however, believed it likely Claimant suffered a soft tissue injury, i.e., a sprained ligament and strain in the muscles involving the cervical and lumbar spine.

Initially, Dr. Kamath prescribed a combination of active and passive therapies five times per week for two weeks, then four times per week for three weeks.[4] Thereafter, another four weeks of both passive and active therapies were prescribed. (Kamath Dep. pp. 6-7.) Both the passive and active therapies began June 3, 2003.

The Passive Modalities

The passive therapies comprised joint mobilization (therapist moves vertebrae in various planes of motion); myofascial release (a kind of massage in which therapist manipulates soft tissues); and manual traction (therapist exerts pulling force to increase spaces in the apophyseal joints). (Kamath Dep. 7-11.) The Carrier reimbursed Provider for dates of service involving passive modalities through July 3, 2003. The first disputed date of service involving passive modalities is July 8, 2003.

Dr. Alvarado, the Carrier’s expert witness, agreed that a trial of conservative care was warranted for what he characterized as Claimant’s “musculoskeletal spinal injury.” According to Dr. Alvarado, the “consensus in the field” is that passive modalities are warranted for six to eight weeks following a soft tissue injury such as he believes Claimant suffered. The purpose of the passive modalities is to address the acute symptoms of the injury. The norm would be for a patient to be treated three times a week initially, and thereafter, the number of weekly visits would decrease as the patient progressed. If, two months after an injury, a patient still had some residual dysfunction in an area of the body, one would expect to see that documented in the health care provider’s SOAP notes.

By Dr. Alvarado’s reading, Dr. Kamath’s SOAP notes do not contain such specific documentation, although Dr. Kamath’s records reflect some improvement in Claimant’s range of motion (ROM). Dr. Alvarado did not believe ROM measurements, by themselves, establish the medical necessity of passive modalities more than two months post-injury, i.e., after July 3, 2003. Dr. Alvarado believed Claimant’s acute phase of care and the passive modalities should have ended by July 8, 2003 (the first disputed date of service involving passive modalities). In Dr. Alvarado’s opinion, passive modalities did not constitute reasonable and necessary treatment for Claimant as of July 8, 2003.

The Therapeutic Exercises

The first SOAP notes identifying the therapeutic exercises assigned Claimant were dated June 12, 2003. Those notes list the following exercises: press up, lumbar rotation, quadriceps stretch, hamstring stretch, neck flexion, neck extension, neck rotation, upper trapezius stretch, and levator scapula stretch. (Carrier Ex. 1, p. 489.) The exercises were relatively simple; most were performed in a seated or prone position. (See Kamath Dep. pp. 12-17.) From the first day of treatment, June 3, 2003, Claimant performed at least 75 minutes of exercise per visit.[5]

On most days, Provider billed for five units of one-on-one therapeutic exercises (CPT Code 97110) and an office visit (CPT Code 99213). (Kamath Dep. 12-16.) Dr. Kamath explained that he billed for an office visit because “[i]t is my encounter with the patient.” (Kamath Dep. 26:15.)

Dr. Kamath prescribed that Claimant perform the therapeutic exercises in a one-on-one environment, “[b]ecause [of] the nature of the injury and the severity the patient absolutely needed one-on-one attention, and that would be more beneficial and efficacious.” (Kamath Dep. 12:1-3.) According to Dr. Kamath, patients make better progress in a one-on-one setting.[6] (Kamath Dep. 12.) He described the one-on-one setting: “B]asically it is like having a coach give one-to-one attention to the patient so that he can get the maximum benefit.” (Kamath Dep. 46:12-14.) The only exercises Dr. Kamath believed could be performed in a group setting were walking a treadmill and using an exercise bike. (Kamath Dep. 28-29.)

Dr. Kamath testified that Claimant made progress, both in terms of pain and ROM, and therefore, ca. July 1, 2003, Claimant was put on a slightly more aggressive regimen to strengthen his pelvic girdle. (Kamath Dep. 23:5-8.)

The Carrier paid for six hours of one-on-one therapeutic exercises for Claimant during his first six visits with Dr. Kamath. For 13 sessions thereafter, the Carrier paid for one unit (15 minutes) of therapeutic exercises in a one-on-one setting. The last date of service for which the Carrier paid for one unit of one-on-one therapeutic exercises was July 3, 2003.

Dr. Alvarado testified that one-on-one therapeutic exercises (CPT Code 97110) are medically reasonable and necessary only for purposes of instruction, safety (in circumstances where a provider

fears a patient might injure himself or herself), assessing a patient’s progress, and documenting a patient’s progress. According to Dr. Alvarado, the exercises Provider prescribed for Claimant could have been learned on one day, practiced and monitored on another, and thereafter performed in a less intensely supervised environment, i.e., in either a group setting or at home. However, Dr. Alvarado testified that he believed an office visit on July 8, 2003, and one unit of one-on-one therapeutic exercises on July 8 and 10, 2003, respectively, were medically necessary to complete Claimant’s trial of care.[7]

B. FIRST IRO DECISION (SOAH DOCKET NO. 453-04-6356.M5) (DATES OF SERVICE JUNE 4 – JULY 15, AND JULY 23, 2003)

The first IRO chiropractor assumed that Claimant’s diagnoses included cervical segmental dysfunction, lumbar disc disorder, lumbosacral neuritis/radiculitis, and muscle spasm. (Carrier Ex. 1, p. 3.) Impliedly acknowledging that Provider’s treatment of Claimant in this time frame extended beyond the norm, the IRO chiropractor opined that because of the nature of Claimant’s injury, Claimant’s progress A may be” slow and erratic, and thus, the chiropractor concluded the services at issue in this first docket were medically necessary to treat Claimant’s condition. (Carrier Ex. 1, pp. 3-4.)

C. SECOND IRO DECISION (SOAH DOCKET NO. 453-04-6356.M5) (DATES OF SERVICE JULY 15 – OCTOBER 30, 2003)

The second IRO chiropractor determined that the passive modalities and therapeutic exercises performed in this time frame were not medically necessary. The IRO chiropractor opined that Claimant should have responded well to conservative treatment “within six to eight weeks.”[8] The IRO chiropractor found Provider’s notes to be “very simple and repetitive” and to lack evidence that treatment was relieving Claimant’s symptoms or improving his function. Moreover, after approximately five months of treatment by Provider, Claimant still complained of low back pain radiating into his left thigh and left foot numbness.

D. ALJ’S ANALYSIS

First Docket, No. 453-04-6356.M5, Dates of Service June 4 – July 15, and

July 23, 2003

a. Passive Modalities

Based on the testimony of Dr. Alvarado, the ALJ finds that eight weeks following Claimant’s injury was a reasonable amount of time to treat Claimant with passive modalities. Provider submitted hundreds of pages of what appear to be computer-generated reports, and Dr. Kamath’s handwritten notes repeatedly state Claimant was making “good progress,” “steady progress,” and “further progress” (see, e.g., Provider Ex. 2, pp. 37, 70, 83, and 199). However, the ALJ did not find, in Provider’s voluminous documentation, objective indications of Claimant’s progress as he proceeded through the course of treatment Dr. Kamath provided.[9] For example, Provider did not attempt to quantify Claimant’s pain level on a scale of one to ten, but instead, reported that Claimant felt better or worse. On this record, the Carrier met its burden of proving passive modalities were not reasonable and medically necessary after July 3, 2003. Therefore, Provider is not entitled to reimbursement for the services billed beyond July 3, 2003, under CPT Codes 97122, 97250, 97265, and 99213.

b. One-on-One Therapeutic Exercises

Dr. Kamath’s rationale for prescribing one-on-one therapeutic exercises was, essentially, the conclusory statement that patients make better progress when they have the equivalent of a personal coach. In contrast, Dr. Alvarado testified that one-on-one therapeutic exercises are medically reasonable and necessary only for purposes of instruction, safety, monitoring a patient’s progress, and documenting a patient’s progress. Again, the ALJ found Dr. Alvarado’s testimony to be more persuasive. No evidence was presented suggesting Claimant had trouble understanding, learning, or performing the exercises; nor was there any evidence that Claimant was uncooperative, experienced dizziness, or had any safety-related issues that required one-on-one monitoring. Indeed, there is no indication in Provider’s records that Claimant did not complete all of his exercises on any given day. Most of Dr. Kamath’s SOAP notes simply list the exercises performed without any specific indications of Claimant’s performance or response.

The Carrier paid for six hours of one-on-one therapeutic exercises during Claimant’s first six visits with Dr. Kamath and for one unit (15 minutes) of therapeutic exercises in a one-on-one setting for 13 visits thereafter. Based on Dr. Alvarado’s testimony, the weak and conclusory nature of Dr. Kamath’s justification for the one-on-one setting, and the repetitive nature of Provider’s records, the ALJ concludes the Carrier demonstrated that one-on-one attendance was not medically necessary beyond the 37 units for which the Carrier has already paid, plus one unit of CPT Code 97110 on dates of service July 8 and 10, 2003, each, for which Provider has agreed to compensate Provider.

c. Tub Whirlpool Unit

Dr. Kamath’s SOAP notes for June 24, 2003, state that Claimant “was prescribed a tub whirlpool unit to help alleviate pain and assist in tolerating aggressive rehab.” (Provider Ex. 1, p. 167.) The Carrier did not offer evidence to establish that the tub whirlpool unit (CPT Code E1300) did not constitute reasonable and medically necessary treatment for Claimant as of June 24, 2003. Although the first IRO chiropractor did not discuss this item specifically, the chiropractor found all of the disputed services in the first docket to be medically necessary. Based on this record, the ALJ cannot determine whether the whirlpool unit actually was medically necessary. Because the Carrier had the burden or proof on this issue, but did not meet that burden, the ALJ concludes Provider is entitled to recover $204 for the tub whirlpool unit.

d. Unlisted Procedures (CPT Code 95999-WP)

Provider billed the Carrier $348 for unlisted procedures provided under CPT Code 95999-WP on June 20, 2003. Neither the first IRO chiropractor nor the parties to this proceeding addressed this item. At the hearing, Provider placed into evidence more than 800 pages of medical records and billing records, plus Dr. Kamath’s deposition transcript. The Carrier placed over 540 pages into evidence. The ALJ ordered the parties to provide, in their post-hearing closing briefs, citations to the specific pages in the record that support their respective positions. Provider cited one document, page 133 of Provider Exhibit 1, but that document does not relate to this issue. As far as the ALJ has been able to determine, no party directed her to any evidence regarding the unlisted procedures. On page 29 of Provider’s Exhibit 1, the ALJ found an audited Explanation of Benefits, dated August 8, 2003, listing six units of “WP Neurological Procedure” billed at a rate of $64 dollars per unit to CPT Code 95999; at page 74 of Provider’s Exhibit 1, the ALJ found another audited Explanation of Benefits, dated September 16, 2003, listing six units of “unlisted procedures” billed at the same rate to the same code. The ALJ was unable to locate, amid the more than 1340 pages of documents in evidence, a description of what the unspecified procedures were. Nor do Provider’s SOAP notes for June 20, 2003, and the days immediately preceding and following appear to shed any light on the question.[10]

The ALJ does not understand how the first IRO chiropractor was able to opine that unlisted procedures were medically necessary and reasonable. However, she can understand how the Carrier could deny reimbursement for procedures that were not identified. Without knowing what the unlisted procedures were, the ALJ cannot find that they were reasonable and medically necessary. She has only the Carrier’s determination that “unlisted services” were not medically necessary. She concludes, therefore, that the Provider is not entitled to reimbursement for such unidentified services.

The Second Docket, No. 453-04-6356.M, Dates of Service July 15 –

October 30, 2003

The Provider did not meet its burden of proving the disputed treatments were reasonable and medically necessary. Dr. Alvarado’s testimony established that joint mobilization, myofascial release, and manual traction were not medically necessary to improve Claimant’s function at this point in Claimant’s recovery. The ALJ agrees with the second IRO chiropractor’s characterization of Provider’s records as being repetitious and lacking objective information regarding Claimant’s progress. Dr. Alvarado established that while Claimant may have needed to perform therapeutic exercises after July 3, 2003, he did not need one-on-one supervision after that date and should instead have been performing exercises at home or in a group setting. Thus, the evidence did not establish that any of the disputed services in this docket were reasonable or medically necessary to cure or relieve the effects naturally resulting from Claimant’s compensable injury, to promote his recovery, or to allow him to retain employment, as provided in Tex. Labor Code Ann. § 408.021(a). Therefore, Provider is not entitled to reimbursement for any of the services in dispute in the second docket.

E. Conclusion

For the reason sets forth above, the ALJ finds that Provider is entitled to reimbursement for an office visit on July 8, 2003 (CPT Code 99213), two units of one-on-one therapeutic exercises (CPT Code 97110)(one unit on July 8 and 10, 2003, each), and one tub whirlpool unit (CPT Code E1300) in Docket No. 453-04-6356.M5, but that Provider is not entitled to reimbursement for any of the services in dispute in Docket No. 453-04-6581.M5.

IV. FINDINGS OF FACT

  1. ___ (Claimant) suffered a compensable injury on ___, when he slipped and fell, twisted his back, and struck his neck on a piece of wood.
  2. At the time Claimant sustained the compensable injury, Texas Mutual Insurance Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
  3. On June 2, 2003, Claimant first saw Osler Kamath, D.C., a chiropractor with Main Rehab & Diagnostic (Provider). Claimant complained of lumbar and cervical pain.
  4. Dr. Kamath diagnosed Claimant as having cervical disc disorder, lumbar disc disorder, lumbosacral neuritis/radiculitis, and paresthesia muscle spasms.
  5. Initially, Dr. Kamath prescribed a combination of active and passive therapies five times per week for two weeks, then four times per week for three weeks. Thereafter, another four weeks of both passive and active therapies were prescribed.
  6. The passive and active therapies began June 3, 2003.
  7. The passive therapies comprised joint mobilization, myofascial release, and manual traction.
  8. The purpose of passive modalities is to address the acute symptoms of an injury.
  9. Passive modalities constituted reasonable and medically necessary treatment forClaimantfor six to eight weeks following Claimant’s injury.
  10. If, two months after his injury, Claimant had some residual dysfunction in an area of the body, that information should have been documented in Provider’s SOAP notes.
  11. Range of motion (ROM) measurements, by themselves; do not establish the medical necessity of passive modalities more than two months post-injury.
  12. Provider’s records do not reflect objective medical reasons for continuing passive modalities beyond July 3, 2003.
  13. Passive modalities performed on Claimant by Provider after July 3, 2003, did not promote Claimant’s recovery from his compensable injury, and therefore, were not reasonable or medically necessary.
  14. The therapeutic exercises Claimant performed were relatively simple; most were performed in a seated or prone position.
  15. During each visit, Claimant performed five units of therapeutic exercises. From the first day of treatment by Provider, Claimant performed at least 75 minutes of exercise per visit.
  16. The Carrier paid for six hours of one-on-one therapeutic exercises for Claimant during his first six visits with Dr. Kamath. For 13 sessions thereafter, the Carrier paid for one unit (15 minutes) of therapeutic exercises in a one-on-one setting.
  17. One-on-one therapeutic exercises are reasonable and medically necessary for purposes of instruction, safety, monitoring a patient’s progress, and documenting a patient’s progress.
  18. Claimant did not have trouble understanding, learning, or performing the exercises. Nor did Claimant fail to cooperate, experience dizziness, or have any safety-related issues that required one-on-one monitoring.
  19. Appropriate active physical therapy for Claimant, beginning on June 3, 2003, would have included implementation of a group or home exercise program in which he performed therapeutic exercises.
  20. Therapeutic exercises provided to Claimant on the dates of service at issue, other than July 8 and 10, 2003, did not require one-on-one supervision for education, safety, or any other reason.
  21. An office visit on July 8, 2003, and one unit of one-on-one therapeutic exercises on July 8 and 10, 2003, each, were reasonable and medically necessary.
  22. On June 24, 2003, Claimant was prescribed a tub whirlpool unit to help alleviate pain and assist Claimant in tolerating rehabilitation.
  23. Following Carrier’s denial of reimbursement for the disputed services provided June 4 – July 15, 2003, and on July 23, 2003, Provider filed a timely request with the Commission for medical dispute resolution.
  24. The Texas Workers’ Compensation Commission (Commission), acting through an Independent Review Organization (IRO), Maximus, found that the disputed services provided by Provider June 4 – July 15, 2003, and on July 23, 2003, were medically necessary.
  25. The Carrier timely requested a hearing before the State Office of Administrative Hearings (SOAH) regarding the medical necessity of the services at issue. SOAH assigned Docket No. 453-04-6356.M5 to this dispute.
  26. Following Carrier’s denial of reimbursement for the disputed services provided July 15 – October 30, 2003, and on July 23, 2003, Provider filed a timely request with the Commission for medical dispute resolution.
  27. The Commission, acting through an IRO (Envoy Medical Systems, LP), found that the disputed services provided by Provider July 15 – October 30, 2003, and on July 23, 2003, were not medically necessary.
  28. Provider timely requested a hearing before SOAH regarding the medical necessity of the services at issue. SOAH assigned Docket No. 453-04-6581.M5 to the dispute.
  29. Notice of the hearing was sent to the parties in SOAH Docket No. 453-04-6356.M5 on June 22, 2004.
  30. Notice of the hearing was sent to the parties in SOAH Docket No. 453-04-6581.M5 on June 30, 2004.
  31. The notices contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  32. On October 25, 2004, the dockets were joined for hearing at SOAH.
  33. SOAH Administrative Law Judge (ALJ) Renee Rusch convened the hearing in these matters on November 29, 2004, at SOAH’s hearings facility in the William P. Clements Building, in Austin, Texas. Attorney R. Scott Placek represented the Carrier. Attorney Scott Hilliard represented the Provider. Though the hearing closed the same day, and record closed on December 13, 2004, following the parties’ submission of written closing argument.

V. CONCLUSIONS OF LAW

  1. The State Office of Administrative Hearings has jurisdiction over this proceeding, 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. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t CodeAnn. ch. 2001 and SOAH’s rules, 1 Tex. Admin. Code (TAC) ch. 155.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§§ 2001.051 and 2001.052.
  4. The Carrier did not meet its burden of establishing that the tub whirlpool unit did not constitute reasonable and necessary medical care for Claimant.
  5. Based on the foregoing Findings of Fact and Conclusions of Law, Provider is entitled to reimbursement for the following services; $70.00 for two units of one-on-one therapeutic exercises (CPT Code 97110) (one unit on July 8 and 10, 2003, each); $48 for one office visit (CPT Code 99213, July 8, 2003); and $ 204 for one tub whirlpool unit (CPT Code E1300), pursuant to Tex. Lab. Code Ann. § 408.021(a).
  6. With the exception of the services identified in Conclusion of Law No. 5, Provider is not entitled to reimbursement for the dates of service in dispute in this proceeding.

ORDER

IT IS ORDERED thatTexas Mutual Insurance Company pay Main Rehab & Diagnostic a total of $322.00 for the services in dispute in this proceeding.

Signed February 8, 2005.

RENEE M. RUSCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The services in dispute include one-on-one therapeutic exercises (CPT Code 97110); unlisted procedures (provided June 20, 2003, and billed under CPT Code 95999-WP); office visits (CPT Code 99213); and passive modalities comprising joint mobilization (CPT code 97265), myofascial release (CPT Code 97250), manual traction (CPT code 97122); and purchase of a portable whirlpool (CPT Code E1300). At the hearing, the Carrier withdrew its appeal regarding one unit of one-on-one therapeutic exercises (CPT Code 97110) performed on each of two dates, July 8 and 10, 2003, thereby leaving in dispute for each of those dates only the charges for passive modalities and four additional units of CPT Code 97110.↑
  2. Services at issue in this docket include office visits, joint mobilization, myofascial release, manual traction, therapeutic exercises, range of motion (ROM) measurements, special reports, and muscle testing.↑
  3. Dr. Kamath testified that in saying Claimant had cervical and lumbar disc disorder, he meant that a disc may have moved. (Kamath Dep. P. 35.) On June 18, 2003, MRIs of Claimant’s lumbar spine and cervical spines indicated disc protrusion at several levels and small annular tears. However, Claimant never required surgery. The Carrier’s expert witness, David Alvarado, D.C., testified that lumbosacral neuritis/radiculopathy involves inflammation of the sciatic nerves that exit the lumbosacral spine and feed the lower extremities. An EMG/nerve conduction study performed in mid-July 2003 showed no electrophysiological evidence that Claimant’s sciatic nerve distribution was compromised. (Carrier Ex. 1, pp. 4-5, 363; Dr. Alvarado Testimony.)↑
  4. Passive therapies are administered to a patient; active therapies are exercises the patient performs. (Kamath Dep. p. 20.) In August 2003, Claimant received Epidural Steroid Injections (ESIs); however, the medical necessity of the ESIs is not at issue in these dockets.↑
  5. Claimant performed five to ten sets of five to ten repetitions. During each visit, Claimant performed five units of therapeutic exercises; one unit equals 15 minutes. (Kamath Dep. 16.)↑
  6. During his initial examination, Dr. Kamath told Claimant to do some stretching exercises at home. When asked whether he considered it medically necessary for the home exercises to be performed in a one-on-one environment, Dr. Kamath responded, “Oh, it would be nice, but obviously not. . . . There was no substitute for a one-on-one setting. The home exercises would just be supplemental.” (Kamath Dep. 19:13-17.)↑
  7. In light of Dr. Alvarado’s testimony, the Carrier withdrew its appeal with respect to the office visit on June 8, 2003, and one unit of CPT Code 97110 on July 8 and 10, 2003, each.↑
  8. The chiropractor did not specify whether he or she meant six to eight weeks of conservative treatment or six to eight weeks after Claimant’s injury.↑
  9. Though voluminous, Provider’s documentation was not identified or organized so as to effectively support Provider’s position, for example, a document entitled “3-Work Endurance Performance Ratings” purportedly reflects testing performed “1-10-80.” (Provider Ex. 2, pp. 11-23.)↑
  10. The ALJ notes that page 124 of Provider’s Exhibit 1 indicates that nerve conduction studies, evoked potential studies, and needle EMG studies were performed by Texas Neurodiagnostic Associates, Inc. on July 15, 2003. Those tests cannot, of course, be the unspecified studies billed on June 20, 2003. The ALJ cannot state with certainty that the evidentiary record does not contain an explanation of the unlisted procedures billed on June 20, 2003. She states merely that she was unable to find an explanation in the record, and the parties, though ordered to identify relevant pages in the record, did not do so.↑