DECISION AND ORDER

Injury 1 Treatment Center (Provider) requested a hearing to contest a medical fee dispute resolution order issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding $8,500 in medical services provided to __. (Claimant). In its order, the Division found that Provider was entitled to no reimbursement from Texas Association of Counties RMP (Carrier). After considering the evidence and arguments presented, the Administrative Law Judge (ALJ) finds that Provider is entitled to reimbursement of $8,500.

I. PROCEDURAL HISTORY, NOTICE AND JURISDICTION

The hearing convened and concluded on October 12, 2009, with ALJ Steven M. Rivas presiding. Provider appeared and was represented by Allen T. Cradock, attorney. Carrier appeared and was represented by Jason Musick, attorney. The record closed that same day.

II. DISCUSSION

A. Background Facts

Claimant suffered a compensable back injury on __, while preventing a metal door from slamming. Thereafter, she received extensive treatment for her injury. On or about April 16, 2008, Provider sought preauthorization from Carrier to provide 10 sessions of chronic pain management to Claimant over two weeks.^[1] In its preauthorization request, Provider identified treatment diagnosis codes 839.0 “closed disloc cervical” and 839.3 “open disloc thoracic.” The parties referred to this condition generally as cervical and lumbar “displaced discs.” Thereafter, Carrier preauthorized 10 sessions of chronic pain management.

On May 16, 2008, Provider again sought preauthorization from Carrier to provide 10 sessions of chronic pain management to Claimant under the same diagnosis codes (839.0 and 839.3).^[2] Carrier granted this request on May 19, 2008. In each approval notice, Carrier advised Provider that it limited Claimant’s compensable injury to a cervical and lumbar sprain/strain.

Between April and June 2008, Provider rendered 11 pain management sessions to Claimant and billed Carrier $8,500 for these sessions.^[3] The bills and treatment records indicated the pain management sessions were rendered under diagnosis codes that were different than the codes listed on the preauthorization request. The bills indicated Claimant suffered from cervical and lumbar sprain/strain, codes 847.0 and 847.2, and not displaced discs.

Carrier argued it owed no reimbursement to Provider because Provider treated Claimant under diagnosis codes 847.0 and 847.2 (cervical and lumbar sprain/strain), which was different than the diagnosis codes 839.0 and 839.3 (displaced discs) it used when it sought preauthorization for the chronic pain management sessions.

B. Provider’s position

Phil Bohart, Provider’s medical director, argued that under the Occupational Disability Guidelines (ODG), Provider was not required to specify a diagnosis on its preauthorization request. Instead, according to Mr. Bohart, the ODG stipulates that Claimant need only have a condition that “hinders” her in order to be a candidate for a chronic pain management program. In addition, Mr. Bohart asserted, that because Provider is CARF-accredited, it is not required to seek preauthorization, but routinely does so voluntarily, especially for pain management. In addition, the treatment itself proved beneficial to Claimant as she was able to return to work following the program, according to Mr. Bohart.

Provider argued that a diagnosis code is not particularly necessary, because it does not specifically treat the diagnosis, but instead addresses the pain that is associated with the diagnosis and the subjective complaints of the patients. The treatment, according to Provider, is geared toward helping the patient overcome vocational and psychological limitations regardless of the source. Provider testified that pain and loss of function can come about from a sprain/strain as well as disc injury.

C. Carrier’s position

Carrier initially denied reimbursement for the services provided citing “extent of injury” as a basis of its denial. On ___, a hearings officer with the Division of Workers’ Compensation found that Claimant had “cervical, thoracic and lumbar displaced discs at multiple levels,” on the date of injury. The hearing officer also stated Claimant’s displaced discs were not “worsened, enhanced or accelerated” by the compensable injury. Because the preauthorization request cited displaced discs, which the Division found was not a compensable injury, Carrier argued it is not liable for any payment because Claimant was found to have suffered a sprain/strain and not displaced discs. Thus, Carrier contends that Claimant’s compensable injury was not the basis for the chronic pain management rendered by Provider. Therefore, Carrier argued, it is not liable for reimbursement of any of the services.

D. Analysis

Carrier’s denial of reimbursement rests solely on the fact that Provider listed a diagnosis code the Division eventually determined was not compensable. This position would have merit if Provider actually treated Claimant for displaced discs, but it did not.

To the extent that a diagnosis code matters in a chronic pain management program, Provider rendered treatment for cervical and lumbar sprain/strain, the exact type of injury the Division found compensable. While the Division’s order found Claimant’s displaced discs were not a result of her injury, the order does note that the parties agreed Claimant sustained a compensable cervical and lumbar sprain/strain on the date of injury.^[4]

Moreover, Carrier approved the treatment with a “caveat” that limited Claimant’s injury to a lumbar and cervical sprain/strain on its preauthorization approval notices. Carrier also should have known Claimant’s treatment was rendered under a sprain/strain diagnosis because the bills (that were denied) and Provider’s treatment records contained codes 847.0 and 847.2 indicating a sprain/strain diagnosis.

It is undisputed that Carrier approved the treatment and limited the injury to a sprain/strain. Carrier also reviewed the bills which reflected the treatment was rendered under a sprain/strain diagnosis code, and stipulated in the Division’s order that Claimant suffered a cervical and lumbar sprain/strain.

The ALJ finds Carrier’s basis of denial to be disingenuous by taking the Division’s finding (that Claimant’s injury played no part in her displaced discs) and using it as a basis to deny reimbursement because Provider’s preauthorization request diagnosed Claimant with displaced discs. This action fails to consider that Claimant was actually treated under a sprain/strain diagnosis, which benefited Claimant by returning her to work following the treatment.

Under the circumstances presented, therefore, the ALJ concludes that the chronic pain management in issue was provided for Claimant’s compensable back injury. Thus, Claimant’s denial of reimbursement based upon the diagnosis codes on the preauthorization request is not justified.

Having determined that Carrier’s basis for denial was not justified, the ALJ still must determine the services for which Provider has shown itself entitled to reimbursement, and the proper amount of reimbursement allowed under the law. Because Provider was the party first requesting a hearing in this docket, it has the burden of proving its entitlement to reimbursement. Provider presented documentation of the various procedures in issue and reflecting what services were provided. According to the record, Provider billed for 11 sessions at a total of $14,178. This amount was reduced to $8,500 pursuant to the Maximum Allowable Reimbursement rate of the Medical Fee Guideline. The parties did not dispute the costs associated with the treatment rendered. Therefore, the ALJ need not go into detail regarding the treatment.

In conclusion, then, the ALJ finds that Provider is entitled to reimbursement of $8,500 for the chronic pain management services provided to Claimant. In support of this decision, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. ___. (Claimant) suffered a compensable injury to her back on ___, when she attempted to prevent a metal door from slamming.
2. On the date of injury, Texas Association of Counties RMP (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
3. Claimant received extensive treatment for her compensable injury.
4. On or about April 16, 2008, Injury 1 Treatment Center (Provider) sought preauthorization from Carrier to provide 10 sessions of chronic pain management to Claimant.
5. In the request for preauthorization, Provider identified the treatment diagnosis with codes 839.0 “closed disloc cervical” and 839.3 “open disloc thoracic.”
6. Carrier preauthorized 10 sessions of pain management.
7. On May 16, 2008, Provider sought preauthorization from Carrier to provide an additional 10 sessions of chronic pain management to Claimant.
8. Provider identified the same diagnosis codes of 839.0 and 839.3 on the preauthorization request form on May 16, 2008.
9. Carrier preauthorized another 10 sessions of pain management.
10. On each preauthorization approval form, Carrier advised Provider that it limited the compensable injury to a cervical and lumbar sprain/strain.
11. Between April and June 2008, Provider rendered 11 sessions of pain management to Claimant.
12. After the treatments were rendered, Provider billed Carrier the total amount of $8,500 for the services related to the chronic pain management program.
13. Carrier denied reimbursement for all services, citing “extent of injury” as the basis for its denial.
14. After Carrier denied reimbursement for the services, Provider requested medical fee dispute resolution through the Texas Department of Insurance, Division of Workers’ Compensation (Division).
15. On ___, the Division issued its findings and decision, holding that Carrier was not obligated to reimburse Provider anything for the disputed services.
16. On July 10, 2009, Provider requested a hearing by the State Office of Administrative Hearings (SOAH) to challenge the Division’s order.
17. The Division referred the matter to SOAH on July 14, 2009.
18. All parties received adequate notice of not less than 10 days of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
19. On October 12, 2009, SOAH Administrative Law Judge Steven M. Rivas held a contested case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. At the hearing, Provider appeared through its attorney, Allen T. Craddock, and Carrier appeared through its attorney, Jason Musick.
20. The chronic pain management program at issue in this case was provided for Claimant’s compensable injury.
21. The fair and reasonable reimbursement for the services provided in this case is $8,500.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order. Tex. Lab. Code Ann. §§ 402.073(b), 413.031, 413.0311, and 413.055; and Tex. Gov’t. Code Ann. ch. 2003.
2. 1. Notice of the hearing was proper and timely. Tex. Gov’t. Code Ann. §§ 2001.051-.052.
3. 1. Provider had the burden of proving by the preponderance of the evidence that it was entitled to reimbursement for the disputed services. 1 Tex. Admin. Code § 155.427; 28 Tex. Admin. Code § 148.14(a).
4. 1. Based on the above findings of fact and conclusions of law, Carrier is liable to Provider for $8,500, and is required to pay that amount to Provider, because the procedures in issue were properly preauthorized, were provided for Claimant’s compensable injury, and have not been previously reimbursed by Carrier.

ORDER

THEREFORE, IT IS ORDERED THAT Texas Association of Counties RMP is required to pay the sum of $8,500 to Injury 1 Treatment Center in reimbursement for the chronic pain management program services rendered in this case.

Signed December 11, 2009.

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

1. Petitioner’s Ex. No. 3 at page 1.↑
2. Petitioner’s Ex. No. 3 at page 9.↑
3. Although Carrier preauthorized 20 dates of service, the parties disputed only 11 at the hearing.↑
4. Petitioner’s Ex. No 2 at page 9, TDI/DWC order ______, stipulated facts.↑