DECISION AND ORDER

This is a dispute over reimbursement of $3,456.00 for work hardening services performed by Respondent Ergonomic Rehabilitation of Houston (Ergo Rehab). The Administrative Law Judge (ALJ) orders reimbursement.

I. HISTORY OF THE CASE

The workers’ compensation claimant, ___ (the Claimant), sustained an injury to her left wrist on ___. She underwent surgical tendon release and carpal tunnel release, but continued to complain of problems with strength and range of motion. She received work hardening from February 4, 2003, to March 18, 2003, and a functional capacity evaluation (FCE) on March 18, 2003, from Ergo Rehab.

The workers’ compensation carrier, Twin City Fire Insurance Company (Twin City) declined to reimburse Ergo Rehab for the work hardening and FCE described above. The basis for the denial was inadequate documentation. Ergo Rehab resubmitted at least some of the dates of service for reconsideration. Twin City denied those for lack of medical necessity. Twin City did not provide explanations of benefits (EOBs) on resubmission for some of the dates.

Ergo Rehab then filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission). The medical necessity issues were submitted to an Independent Review Organization (IRO), which found the services were not medically necessary. The Commission’s Medical Review Division (MRD) considered the other dates of service, for which lack of medical necessity had not been raised. It found those services to have been documented adequately, and ordered reimbursement for them.

Twin City filed a request for a hearing before the State Office of Administrative Hearings (SOAH). Ergo Rehab did not file such a request. Therefore, the services for which the MRD ordered reimbursement were the only ones at issue at SOAH. Those services were work hardening services (CPT Codes 97545-WH and 97546-WH) provided the Claimant on February 19, 20, 21, 24, 26, and 27, and March 10, 11, 13, and 14, 2003. The amount in dispute is $3,456.00.

After proper and timely notice, the SOAH hearing was held January 4, 2005, before ALJ Henry D. Card. Both parties participated in the hearing. The hearing was adjourned and the record closed the same day.

II. DISCUSSION

Twin City contended there were no EOBs for the disputed dates of service because Ergo Rehab had not submitted requests for reconsideration for those dates. Therefore, it contended, Ergo Rehab had waived its right to reimbursement for those dates of service and the MRD decision was in error.

Stephen V. Sopher, P.T., the owner of Ergo Rehab, stated he had resubmitted all the dates of service to Twin City, which had simply failed to address all of them.

The documentary evidence supports Ergo Rehab’s position. One of the resubmitted health insurance claim forms is for February 18, 19, and 20, 2003. Twin City sent an EOB for February 18, but not for the other two dates.^[1] If the claim form had not been submitted, Twin City would not have addressed the claim for February 18. That evidence suggests Ergo Rehab submitted requests for not only those dates, but for the other disputed dates of service as well. Twin City did not present any convincing evidence to the contrary. The ALJ finds Ergo Rehab submitted requests for reconsideration for the dates in dispute.

Ergo Rehab used photocopied forms, including photocopied signatures, for its progress notes. Twin City argued that practice violated CARF standards and therefore the services were not adequately documented.

The evidence did not show Ergo Rehab’s progress notes violated CARF record-keeping standards. Even if it had, the evidence still showed the services were provided. Under 28 TAC §148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann.§ 413.031. Twin City did not carry its burden of proof. The ALJ finds Ergo Rehab provided the services in dispute and should be reimbursed $3,456.00 for them, as ordered by the MRD.

III. FINDINGS OF FACT

1. Workers’ compensation claimant ___ (the Claimant) sustained an injury to her left wrist on ___.
2. The Claimant underwent surgical tendon release and carpal tunnel release, but continued to complain of problems with strength and range of motion.
3. The Claimant received work hardening from February 4, 2003, to March 18, 2003, and a functional capacity evaluation (FCE) on March 18, 2003, from Ergonomic Rehabilitation of Houston (Ergo Rehab).
4. The workers’ compensation carrier, Twin City Fire Insurance Company (Twin City) declined to reimburse Ergo Rehab for the work hardening and FCE described above. The basis for the denial was inadequate documentation.
5. Ergo Rehab resubmitted the disputed services for reconsideration.
6. Twin City denied some of the resubmitted dates of service for lack of medical necessity.
7. After resubmission, Twin City did not provide explanations of benefits (EOBs) for work hardening services (CPT Codes 97545-WH and 97546-WH) provided the Claimant on February 19, 20, 21, 24, 26, and 27, and March 10, 11, 13, and 14, 2003.
8. The amount in dispute for the dates of service set forth in the preceding finding of fact is $3,456.00.
9. One of the resubmitted health insurance claim forms is for February 18, 19, and 20, 2003. Twin City sent an EOB for February 18, but not for the other two dates.
10. Ergo Rehab submitted requests for reconsideration for all the disputed services.
11. Ergo Rehab filed a timely request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission).
12. The medical necessity issues were submitted to an Independent Review Organization (IRO), which found the services were not medically necessary.
13. The Commission’s Medical Review Division (MRD) considered the other dates of service, for which lack of medical necessity had not been raised. It found those services to have been documented adequately, and ordered reimbursement for them.
14. Twin City filed a request for a hearing before the State Office of Administrative Hearings (SOAH).
15. Ergo Rehab did not file a request for hearing.
16. Notice of the hearing was sent July 6, 2004.
17. 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.
18. The SOAH hearing was held January 4, 2005, before ALJ Henry D. Card. Both parties participated in the hearing. The hearing was adjourned and the record closed the same day.
19. Ergo Rehab provided the services in dispute.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
3. Ergo Rehab did not waive its right to reimbursement for the disputed dates of service.
4. Ergo Rehab should be reimbursed $3,456.00 for work hardening services provided the Claimant on February 19, 20, 21, 24, 26, and 27, and March 10, 11, 13, and 14, 2003.

ORDER

It is, therefore, ordered that Twin City Fire Insurance Company reimburse Ergonomic Rehabilitation of Houston $3,456.00 for work hardening services provided the Claimant on 19, 20, 21, 24, 26, and 27, and March 10, 11, 13, and 14, 2003.

Signed March 3, 2005.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. See Ergo Ex. 2, pages 42 and 55.↑