DECISION AND ORDER
I. PROCEDURAL HISTORY
Petitioner Scientific Therapy and Advanced Treatment (STAT) seeks reimbursement from the Carrier Liberty Mutual Insurance Company for durable medical equipment (DME) that it provided to workers’ compensation claimant,___. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement because the DME claim was in excess of the $500 per item allowed in Commission’s rule 134.600(h)(13) without preauthorization. The MRD also relied on QRL #98-63. STAT appealed the decision and seeks reimbursement of $310 for rental of the NeuroMuscular Electrical Stimulator (NMES) and related supplies provided the claimant on August 12, 1999.
The Administrative Law Judge (ALJ) convened the hearing on March 4, 2002. Paula Sadovsky appeared by telephone for Petitioner. Attorney Garry B. Mahon appeared for the Carrier. The record was left open until March 14, 2002, to allow Mr. Mahon to obtain and submit a copy of the Commission’s QRL # 98-63 to the ALJ and Petitioner, and to allow the parties to submit written closing arguments. Upon receipt of the QRL and closing arguments, the record of the hearing closed on March 14, 2002.
II. EVIDENCE AND DISCUSSION
The issue in this case is whether Petitioner was required to get preauthorization before it rented the NMES to claimant on August 12, 1999, in order to get reimbursement for that rental.
The evidence in this case consists of the 28-page certified record of the MRD proceeding, Respondent’s Ex. 1 (nine pages of bills for DME submitted for claimant dating back to December 2, 1998, and related correspondence), and Respondent’s Ex. 2, a copy of the Commission’s QRL, which addresses the following question: When is preauthorization required for rented durable medical equipment. QRL #98-63 states as follows:
Rule 134.600(h)(13) states “all durable medical equipment in excess of $500 per item . . . ” needs preauthorization. When a health care provider orders the rental of a durable medical equipment for a period of time at $500 or less, then preauthorization is not required. If after the initial period, the health care provider extends the rental of the durable medical equipment for an additional time and the total rental costs exceed $500, preauthorization would be required for the additional time period.
Although the above statement was introduced, there was no evidence presented that indicated what was the significance of a QRL or what authority, if any, a QRL should be accorded. This point was made by Petitioner in its closing argument. The ALJ agrees that without evidence indicating its significance or authority, the ALJ will not consider QRL #98-63 an authoritative statement. Nonetheless, the ALJ will consider it as showing how the Commission has dealt in the past with the question of DME rentals that result in charges that exceed $500 for a particular item. The ALJ believes that QRL # 98-63 is consistent with Commission rule at 28 TAC ' 134.600(h)(13), which provides that preauthorization is required for “all durable medical equipment in excess of $500 per item . . .” Because the cost of one month’s rental of the NMES in this case was less than $500, preauthorization was not required. However, rental of the unit for a second month would cost more than $500, and thus, preauthorization should have been obtained.
Based on the evidence and arguments presented, the ALJ finds Petitioner was required to obtain preauthorization, because rental of the NMES for the second month would exceed the $500 limit for the NMES item. However, Petitioner should be reimbursed for that portion of the claim ($170) that was within the $500limit.
III. FINDINGS OF FACT
- On ________,_______ (claimant),employed by _______________, suffered a compensable injury that resulted in injury to her right shoulder and rotator cuff.
- ___________ had workers' compensation coverage with Liberty Mutual Insurance Company (Carrier) at that time.
- After receiving a three-month prescription from the treating physician, on July 12, 1999, Petitioner began treating claimant with a NeuroMuscular Electrical Stimulator (NMES) to reduce the pain and spasms in her right shoulder.
- Petitioner supplied claimant with a NMES for one month on July 12, 1999, billed for it and related supplies, and received payment of $310 from the Carrier.
- Without seeking preauthorization, Petitioner supplied claimant the NMES for a second month, beginning August 12, 1999.
- On August 23, 1999, Petitioner billed $225 (CPT Code E1399 RR) and $85 (CPT Code E1399) for the NMES and related supplies, but received no reimbursement from the Carrier.
- The Carrier denied payment for the August 12, 1999, rental of the NMES, indicating that preauthorization had not been obtained as required by Commission rules.
- Petitioner requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on May 10, 2000, seeking reimbursement for the August 1999 rental.
- On January 4, 2001, the MRD issued a decision denying payment of the claim, indicating preauthorization was required for the second month’s rental of the DME. The MRD noted that while Commission rules did not expressly state such a requirement, QRL #98-63 did, and reasoned that when read together with Commission rules 134.600 (h)(13) and (h)(10), the QRL indicated preauthorization was required for continued rentals that exceeded $500.
- On January 19, 2001, Petitioner appealed the MRD’s decision.
- On February 13, 2001, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
- The hearing was held on March 4, 2002, before the State Office of Administrative Hearings. Paula Sadovsky appeared on behalf of Petitioner, and Garry B. Mahon appeared for the Carrier. The Commission did not appear.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. § 413.031.
- 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 § 413.031(d) of the Act; Tex. Gov't Code Ann. ch. 2003 (Vernon 2000), and 28 Tex. Admin. Code (TAC) chs. 148 and 149.
- Petitioner timely appealed the MRD’s decision, pursuant to 28 TAC § 148.3.
- The notice of hearing sent by the Commission complied with the requirements of Tex. Gov’t Code § 2001.052 and of 28 TAC § 148.4(b).
- Petitioner had the burden of proof to show by a preponderance of the evidence that it should prevail in this matter, pursuant to § 413.031 of the Act and 28 TAC § 148.21(h) and (i).
- Section 408.021 of the Act and 28 TAC § 134.1 provide that health care providers shall bill carriers only for treatments and services rendered that are medically necessary to treat the compensable injury, and in accordance with Commission rules and guidelines.
- The Durable Medical Ground (DME) Ground Rules provide guidance to health care providers concerning the DME and supplies rendered for compensable work-related injuries and illnesses and the coding to be used in billing for such equipment and supplies. The following are specific provisions in the DME Ground Rules:
II. Covered Services
The carrier shall reimburse for the purchase or rental of DME and supplies, provided that all such items are approved by the injured worker’s doctor. . . .
NOTE: Preauthorization may be required for some DME items. Please refer to the preauthorization rule to confirm the need for preauthorization.
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- Pursuant to the Commission’s DME Ground Rules and Health Care Providers Code System (HCPCS) Code E-series, a neuromuscular stimulator, electronic shock unit (NMES, CPT Code E0745) is durable medical equipment.
- According to Commission rule at 28 TAC ' 134.600(h)(13) “all durable medical equipment (DME) in excess of $500 per item and all TENS units” require preauthorization.
- Petitioner’s continued rental of the NMES to claimant in August 1999 required preauthorization because the cost of such rental exceeded the $500 reimbursement limit (without preauthorization) set out in 28 TAC § 134.600(h)(13).
- Based on the foregoing Findings of Fact and Conclusions of Law, Petitioner's request for reimbursement of $310 should be denied. However, Petitioner should be reimbursed $170 for rental of the NMES, because that amount ($170) when added to the previous amount paid ($330) would total $500, which is allowed in 28 TAC § 134.600(h)(13).
It is hereby ordered that the appeal of Petitioner Scientific Therapy and Advanced Therapy is denied in part and granted in part. The Carrier is ordered to reimburse Petitioner $170 for the durable medical equipment supplied to claimant on August 12, 1999, pursuant to Tex. Lab. Code Ann. ' 408.021 and reimbursable as set forth in 28 TAC §§ 134.1 and 134.600(h)(13).
Signed this 16th day of April 2002.
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS
- The Carrier supplied a copy of QRL #98-63 (referenced in the MRD decision in this case) to the ALJ and Petitioner. Upon its receipt, it was marked as Respondent’s Ex. 2 and was admitted into evidence.
Because of unfamiliarity with the term, “QRL,” the ALJ researched TWCC decisions issued by other SOAH ALJs to determine the meaning of QRL. The ALJ found that QRL represents a list or log of questions and resolutions prepared by the Texas Workers’ Compensation Commission Employee/Employer Services. (See 453-98-1240.M2, dated January 1999). However, the ALJ did not determine that QRL #98-63 is a statement of Commission policy or a Commission rule. The significance or weight to be given the QRL in this case was not addressed at the hearing by either party, but the issue was raised by Petitioner in its closing argument.↑