Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-1831-m5
Date:
April 9, 2002
Status:
Retrospective Medical Necessity

453-01-1831-m5

April 9, 2002

DECISION AND ORDER

This case is a dispute over whether the Texas Workers’ Compensation Insurance Fund[1] (Carrier) should reimburse the Respondent, Curtis Adams, D.C., $1,115[2] for certain joint mobilizations performed and office visits occurring between 11/19/99 and 6/1/00. Although duly notified of the hearing, Dr. Adams failed to appear.

Based upon the evidence presented, the ALJ finds that the Carrier is not required to pay for the joint mobilizations. The ALJ’s reasoning is detailed in the Findings of Fact and Conclusions of Law.

I. Findings of Fact

  1. The injured worker suffered a compensable injury on ___________.
  2. The Texas Workers’ Compensation Insurance Fund (Carrier) provided Workers’ compensation insurance coverage to the injured Workers’ employer on the date of the injury.
  3. The Carrier reimbursed the Respondent for all joint manipulations performed and billed by the Respondent. The Carrier, however, did not reimburse the Respondent for 29 joint mobilizations billed under CPT code 97265, or 12 eight office visits billed under CPT code 99212-MP.
  4. Curtis D. Adams, D.O. (Respondent) filed a Request for Medical Dispute Resolution with the Medical Review Division of the Texas Workers’ Compensation Commission (MRD), seeking reimbursement for joint mobilizations performed and office visits occurring between 11/19/99 and 6/1/00.
  5. On December 13, 2000, the MRD found that the Carrier was required to reimburse the Respondent for 17 of the 29 joint mobilizations performed on the injured worker, as well as eight of the twelve disputed office visits and ordered the Carrier to pay the Respondent $1,115. For the remaining services, the MRD found that the Respondent’s documentation was insufficient.
  6. The Carrier filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  7. The original notice of hearing was sent January 30, 2001.
  8. 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.
  9. On October 8, 2001, SOAH issued an order of continuance resetting the hearing for February 12, 2002.
  10. The hearing was held February 12, 2002, with Administrative Law Judge (ALJ) Janet Dewey presiding and the Carrier participating. The hearing was adjourned and the record closed the same day.
  11. The Respondent did not appear at the hearing, and did not file a motion for continuance or notify the ALJ of any reason why he was prevented from appearing at the hearing.
  12. At the hearing, the Carrier agreed to pay the Provider for eight office visits: 5/10/00, 5/11/00, 5/16/00, 5/19/00, 5/23/00, 5/26/00, 5/30/00, 6/1/00. The total amount the Carrier agreed to reimburse the Provider is $48 per office visit, totaling $384. The remaining amount in controversy is $731, consisting of 17 separate joint mobilizations billed under CPT code 97265.
  13. When a chiropractor performs a manipulation on a certain body part, it is necessary to first perform a mobilization on that body part.
  14. The treatment notes for the dates of service at issue do not specifically reflect that the Respondent ever performed any joint mobilizations to any body part.
  15. The treatment notes show that manipulations were performed; therefore, joint mobilizations were performed because a manipulation cannot be performed without first mobilizing the specific body part.
  16. It is not customary for chiropractors to bill for a mobilization of a body part when a manipulation has been performed on the same body part during the same office visit.
  17. It is not reasonable for the Respondent to be reimbursed for mobilizations performed as part of a joint manipulation.

II. 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. ch. 401 et seq.
  2. SOAH 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.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. The Carrier has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
  5. Amounts billed for joint mobilizations were not reasonably required health care under Tex. Lab. Code Ann. § 401.011 (19) (A) (Vernon 1996).
  6. The Carrier is not required to reimburse the Respondent $731 for joint mobilizations performed on the injured worker between 11/19/99 and 6/1/00.

Order

IT IS, THEREFORE, ORDERED that the Texas Workers’ Compensation Insurance Fund’s appeal is granted, and it is not required to pay Curtis Adams, D.O. the outstanding amount in dispute, $731.

Signed this 9th day of April, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JANET R. DEWEY
Administrative Law Judge

  1. The Texas Workers’ Compensation Insurance Fund is now known as the Texas Mutual Insurance Company.
  2. At the hearing, the Carrier agreed to reimburse the Provider for eight office visits, leaving $731 in dispute.
End of Document
Top