DECISION AND ORDER

___ (Claimant) challenged the decision of American Home Assurance (Carrier), denying preauthorization for carpel tunnel release procedures of Claimant’s left and right wrists. In this decision, the Administrative Law Judge (ALJ) finds that Claimant did not meet her burden of showing that the requested procedures are reasonable and necessary medical care and should be preauthorized. Therefore, preauthorization for the proposed procedures are denied.

The hearing convened and closed on March 24, 2005, before ALJ Steven M. Rivas. Claimant appeared and represented herself. Carrier appeared and was represented by Dave Floyd, attorney.

I. DISCUSSION

A. Background Facts

Claimant sustained a compensable left wrist injury on ___, as a result of repetitive motion working as a cashier at ___.^[1] As part of her treatment, Claimant underwent physical therapy, and diagnostic testing. She had undergone a prior carpel tunnel release procedure on her left wrist on October 2, 2002.

Claimant’s treating doctor, Andrew J. Palafox, M.D., recommended Claimant undergo two carpel tunnel release procedures, and Carrier denied preauthorization for the procedures as not medically necessary. The dispute was referred to an Independent Review Organization (IRO), which agreed with Carrier. Provider appealed the IRO decision to the State Office of Administrative Hearings.

B. Applicable Law

Pursuant to the Texas Workers’ Compensation Act (“the Act”), Tex. Lab. Code Ann. § 408.021, an employee who sustains a compensable injury is entitled to all health care 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.

Under § 401.011(19) of the Act, health care includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

Certain categories of health care identified by the Commission require preauthorization, which is dependant upon a prospective showing of medical necessity under §413.014 of the Act and 28 Tex. Admin. Code (TAC) § 134.600. Under 28 TAC§ 134.600(h), preauthorization is required for the carpel tunnel release procedures requested by Claimant.

C. Evidence and Analysis

The requested carpel tunnel releases should not be authorized at this time. At the hearing, Claimant’s medical records were offered by Carrier, and Claimant testified that she continues to suffer from wrist pain. Fortunately for Claimant, the report of her treating doctor who recommended the requested procedures was included in Carrier’s evidence as she did not offer any additional documents or call any witnesses in support of her position.

Based on the record, Claimant’s injury occurred as a result of repetitive movements while operating a cash register. Additionally, Claimant testified she already completed a brief physical therapy program, which did not improve her wrist pain.

However, at the hearing Carrier presented Melissa Tonn, M.D., who testified that based on her review of Claimant’s medical records, Claimant should not undergo the requested carpel tunnel release procedures. Dr. Tonn admitted it is possible that Claimant may suffer from “extremity discomfort,” but she does not suffer from carpel tunnel syndrome in either wrist. Therefore, she would not benefit from carpel tunnel release procedures. Dr. Tonn also noted the results of the “electro-diagnostic” tests rendered normal results in both wrists. Furthermore, Dr. Tonn testified, Claimant had already undergone one carpel tunnel release procedure on her left wrist, which was ineffective, and that “re-releasing it would do no good either.” Dr. Tonn also asserted that if Claimant’s symptoms were due to repetitive actions, a reasonable course of action would be for Claimant to stop working as a cashier.

In this case, Claimant had the burden of proving the requested procedures were medically necessary to treat her compensable injury. As such, Claimant relied only on the recommendation of her treating doctor for the requested procedures, which was noted in his report dated January 5, 2004. However, Claimant offered no other evidence to support this recommendation. The IRO found that most of Claimant’s physical exams, including the exam by her treating doctor, were “cursory at best.” Additionally, the IRO concluded the diagnostic tests revealed “nothing grossly abnormal” about Claimant’s wrists. Carrier, on the other hand, presented testimony of Dr. Tonn, who after reviewing Claimant’s records, found that she would benefit by abstaining from repetitive motions rather than undergoing the requested procedures. The ALJ finds not only that Claimant provided insufficient evidence to support authorization of the requested carpel tunnel release procedures, but also that Dr. Tonn’s testimony relating to the nature of the injury and approach to treatment was more persuasive.

II. FINDINGS OF FACT

1. ___ (Claimant) sustained a compensable left wrist injury on ___, due to repetitive motion working as a cashier.
2. Claimant underwent various treatment modalities following her injury including physical therapy, diagnostic tests, and a carpel tunnel release on her left wrist.
3. Claimant’s treating doctor, Andrew J. Palafox, M.D., recommended Claimant undergo carpel tunnel release procedures in both wrists.
4. Claimant sought preauthorization for the procedures from American Home Assurance Company (Carrier), which was denied.
5. Claimant sought medical dispute resolution with the Texas Workers’ Compensation Commission’s Medical Review Division, which referred this matter to an Independent Review Organization (IRO). The IRO report concurred with Carrier and denied preauthorization.
6. Claimant timely requested a hearing before the State Office of Administrative Hearings (SOAH).
7. Notice of the hearing in this case was mailed to the parties on June 10, 2004. The notice 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.
8. The hearing convened and closed on March 24, 2005, before Steven M. Rivas, Administrative Law Judge (ALJ). Claimant appeared and represented herself. Carrier appeared and was represented by Dave Floyd, attorney.
9. Claimant does not suffer from carpel tunnel syndrome.
10. Claimant underwent a prior carpel tunnel release on her right wrist, which was ineffective.
11. The requested carpel tunnel release procedures would not render any relief for Claimant.

III. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. §401.001et seq. (“the Act”).
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to ‘ 413.031(k) of the Act and Tex. Gov’t Code Ann. ch. 2003.
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 Claimant, as Petitioner, had the burden of proof on appeal by a preponderance of the evidence under ‘ 413.031 of the Act, and 28 Tex. Admin. Code ‘148.21(h).
5. The requested carpel tunnel release procedures are not medically necessary for treating Claimant’s compensable injury.

ORDER

IT IS, THEREFORE, ORDERED that the requested carpel tunnel release procedures not be preauthorized.

Signed April 22, 2005.

STEVEN M. RIVAS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. ¹ Claimant’s First Report of Injury reflects ___, as the date of injury. However, other records indicate Claimant sustained wrist injuries ___, ___, and ___.↑