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At a Glance:
Title:
453-01-1822-m5
Date:
January 22, 2002
Status:
Retrospective Medical Necessity

453-01-1822-m5

January 22, 2002

DECISION AND ORDER

I. INTRODUCTION AND DISCUSSION

Both Dean Allen, D.C. (Dr. Allen) and the Dallas Independent School District (DISD) appealed the Findings and Decision of the Texas Workers' Compensation Commission's (Commission) Medical Review Division (MRD) for treatment provided to__________________.[1]

At the August 9, 2001 hearing on the merits, the parties agreed on the record to resolve certain issues as follows: (1) the DISD agreed to reimburse Dr. Allen for the costs of a TENS unit on December 7, 1999; and (2) the DISD agreed to reimburse Dr. Allen for all services provided through November 22, 1999, that were not previously reimbursed. Therefore, the only items in dispute were services provided after November 22, 1999. Following these agreements, the remaining amount in dispute was $16,313.20.[2]

The Administrative Law Judge finds that the DISD is liable to reimburse Dr. Allen for all of the services rendered and that Dr. Allen is entitled to recover interest on all unpaid sums to the extent allowed by law.

The DISD argued that the physical therapy provided after November 22, 1999, was not medically reasonable and necessary. With respect to the work-hardening, the DISD contended Dr. Allen failed to adequately document that the work-hardening services were provided, that the work-hardening criteria of the Commission were not satisfied, that no exit discharge criteria were established and that the work simulation provided was not an actual work simulation program individually tailored for ___________

The Commission contended the physical therapy rendered after November 22, 1999, was reasonable and necessary but that the provision of work-hardening services did not comply with Commission criteria because there was no documentation supporting that a mental health evaluation was done on ___________

Dr. Allen posited that the treatment provided to ________to treat her injury was medically necessary and reasonable and that the services provided were adequately documented. Dr. Allen also contended the work-hardening services provided to __________met the Commission's guidelines and were medically necessary.

The DISD preauthorized an extension of services for both the physical therapy and the work-hardening services. With respect to both the physical therapy services and the work-hardening program, the DISD did not allege or prove (1) fraud or deceit to obtain the preauthorization or (2) nonperformance of the preauthorized service.[3] Given the preauthorization of the extended services, the DISD cannot now complain about medical necessity.[4] With respect to the work-hardening program, the applicable Medical Fee Guidelines (Guideline)[5] does not require an initial mental health evaluation per se.[6] Dr. Allen considered ___________medical and psychological conditions and determined that they did not prohibit her participation in the program.

II. FINDINGS OF FACT

  1. _______, an employee of the DISD, injured her lower back on_________, when she slipped on a wet floor while performing food service/custodial duties.
  2. She began receiving chiropractic treatment from Dr. Allen for her lower back on October 4, 1999.
  3. On November 23, 1999, Dr. Allen requested preauthorization for 12 additional visits.
  4. The preauthorization request, approved on November 24, 1999, authorized treatment from November 29, 1999, through December 27, 1999.
  5. The December 27, 1999 deadline is a projected endpoint and not an absolute deadline. The purpose of the end point is to ensure the services are provided on a timely basis.
  6. The treatments of December 28 and December 29, 1999, fall within the treatments preauthorized by the DISD.
  7. On or about November 15, 1999, ________underwent a Functional Capacity Evaluation (FCE). Another FCE was performed January 24, 2000, prior to her enrollment in a work-hardening program. A third FCE was performed on March 3, 2000.
  8. On January 3, 14 and 21, 2000, Dr. Allen met with ________to determine ________future care.
  9. As a result of those visits, __________was enrolled in a work-hardening program.
  10. Dr. Allen considered ________medical and psychological conditions and determined that they did not prohibit her participation in the program.
  11. On March 9, 2000, the DISD preauthorized a two-week extension of _________work-hardening program.
  12. The Commission denied the work-hardening services because the "[d]ocumentation does not support the entrance/admission criteria. There was no documentation supporting that a mental health evaluation was done on claimant."
  13. The applicable Medical Fee Guideline does not require an initial mental health evaluation for admission to a work-hardening program.
  14. On November 1, 2000, the Commission received Dr. Allen's request for Medical Dispute Resolution.
  15. The MRD issued a decision on December 19, 2000, in Docket No. M5‑01-0395-01, authorizing reimbursement of $3,630.00 and disallowing the balance of the request.
  16. By letter dated January 8, 2001, and received by the Commission on that same date, the DISD requested a hearing to contest that portion of the MRD decision of December 19, 2000, that was adverse to the DISD.
  17. By letter dated December 27, 2000, and received by the Commission on January 2, 2001, Dr. Allen requested a hearing to contest that portion of the MRD decision of December 19, 2000, that was adverse to Dr. Allen.
  18. By letter dated January 30, 2001, the Commission issued a notice of hearing.
  19. A hearing in this matter convened on August 9, 2001, at the Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas, with Administrative Law Judge Howard S. Seitzman presiding. All parties were represented by counsel. The record closed on December 17, 2001.

III. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act, Tex. Lab. Code Ann. § 413.031.
  2. 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. Lab. Code Ann. § 413.031(d) and Tex. Gov't Code Ann. § 2003.
  3. Both Dr. Allen and the DISD timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) §§ 102.7 and 148.3.
  4. Notice of the hearing was proper and complied with the requirements of Tex. Gov't Code Ann. § 2001.052.
  5. Pursuant to 28 TAC §§148.21(h) and (i), Dr. Allen had the burden of proof, the preponderance of evidence standard, in those matters from which he appealed, and the DISD had the burden of proof, the preponderance of evidence standard, in those matters from which it appealed.
  6. Tex. Lab. Code Ann. § 408.021(a) provides that an employee who has sustained 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 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.
  7. The DISD failed to meet the burden of proof on the issues from which it appealed.
  8. Dr. Allen met the burden of proof on those issues from which he appealed.
  9. The applicable Medical Fee Guideline does not require an initial mental health evaluation per se for admission into a work-hardening program.
  10. __________________met the work-hardening entrance/admission criteria.
  11. The physical therapy services and the work-hardening services provided to ________were medically necessary and reasonable.

ORDER

THEREFOREIT IS ORDERED that the Dallas Independent School District pay to Dean Allen, D.C. the sum of $16,313.20 in addition to any sums of money that Dallas Independent School District has previously agreed to pay. IT IS FURTHER ORDERED that the Dallas Independent School District pay to Dean Allen, D.C. interest on all unpaid sums to the extent allowed by law.

Signed this 22nd day of January 2002.

Howard S. Seitzman
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The DISD appealed that portion of the MRD decision ordering reimbursement for services totaling $3,630.00. Dr. Allen appealed the denial of $19,369.80 in reimbursement. Dr. Allen provided two types of service-physical therapy and work-hardening.
  2. The ALJ issued a post-hearing Order on November 27, 2001, requiring Dr. Allen to clarify the remaining amount in dispute. Dr. Allen complied with a filing dated December 6, 2001. The DISD was required to respond to Dr. Allen's filing and did so on December 14, 2001. The parties agreed on the remaining amount in dispute. The record closed on December 17, 2001.
  3. Although effective to dates of service on or after July 15, 2000, Commission Rule 133.301 provides guidance on the retrospective review of medical bills:
  4. (a) The insurance carrier shall retrospectively review all complete medical bills and pay for or deny payment for medical benefits in accordance with the Act, rules, and the appropriate Commission fee and treatment guidelines. The insurance carrier shall not retrospectively review the medical necessity of a medical bill for treatment(s) and/or service(s) for which the health care provider has obtained preauthorization under Chapter 134 of this title (relating to Guidelines for Medical Services, Charges, and Payments).

  5. The DISD conceded this issue in its December 14, 2001 filing.
  6. Guideline E.1.c. provides that entrance/admission criteria shall enable the program to admit persons whose medical, psychological, or other conditions do not prohibit participation in the program. Guideline E.2. states that an initial evaluation to determine the injured worker's readiness for the program may be performed prior to entrance into the program.
  7. The Guideline does provide that if an initial evaluation is performed prior to entrance into the program to determine the individual's readiness for the program, then the evaluation is not considered to be part of the program and the evaluation must be billed separately.
End of Document
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