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Title:
453-01-2023-m5
Date:
December 19, 2001

453-01-2023-m5

December 19, 2001

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Jacob Rosenstein, M.D., seeks reimbursement from AIU Insurance Company (the Carrier) for $636.70 in medical services associated with lumbar facet injections that Dr. Rosenstein administered to workers compensation claimant _________on February 25, 2000. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement for these expenses. Petitioner challenges that denial.

The Administrative Law Judge convened a hearing on these issues on November 21, 2001. The hearing was concluded and the record closed that date. Petitioner Rosenstein represented himself; the Carrier was represented by Allain P. Collins; and the Commission was represented by Jacqueline Harrison.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consisted of the 44-page certified record of the MRD proceeding and a two page summary of the disputed items offered by the Carrier. Dr. Rosenstein also testified on his own behalf, and Dr. Randolph Veazey, who examined the Claimant on February 9, 2000, testified on behalf of the Carrier. Based on the evidence, the ALJ concludes that Petitioner’s claim should be approved. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law. In summary, however, the ALJ accepts Dr. Rosenstein’s testimony that Dr. Rosenstein’s physical examination of the Claimant indicated lumbar facet syndrome and that the lumbar facet injections that Dr. Rosenstein administered constituted reasonable and necessary treatment for lumbar facet syndrome.

III. FINDINGS OF FACT

  1. On __________(Claimant) suffered a compensable injury to his back when the truck he was driving was struck by a train as it attempted to cross railroad tracks.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by AIU Insurance Company (the Carrier).
  3. Petitioner Jacob Rosenstein, M.D., seeks reimbursement from the Carrier for $636.70 in medical services associated with lumbar facet injections provided to the Claimant on February 25, 2000.
  4. The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
  5. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  6. The MRD issued its findings and decision on January 11, 2001, concluding that the disputed expenses should be denied, and Petitioner timely appealed this decision.
  7. Dr. Rosenstein’s examination of the Claimant indicated the Claimant was in significant pain, particularly upon extension and rotation of his lower back.
  8. The symptoms identified in Finding 7 indicate lumbar facet syndrome, and Dr. Rosenstein diagnosed the Claimant with this condition.
  9. The existence of lumbar facet syndrome must generally be based on clinical evaluation because the syndrome cannot be identified through diagnostic imaging procedures.
  10. The lumbar facet injections administered by Dr. Rosenstein were reasonable and necessary treatment for lumbar facet syndrome.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §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. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Gov’t Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. The treatment provided to the Claimant was reasonably required by Tex. Lab. Code Ann. §408.021.
  6. Petitioner should be reimbursed for the fees incurred in providing treatment to Claimant in the amount of $636.70.

ORDER

IT IS THEREFORE, ORDERED that AIU Insurance Company reimburse Petitioner for fees incurred in treating the Claimant on February 25, 200, in the amount of $636.70.

Issued December 19, 2001.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Kerry D. Sullivan
Administrative Law Judge

End of Document
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