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At a Glance:
Title:
453-01-2094-m5
Date:
October 22, 2001
Status:
Retrospective Medical Necessity

453-01-2094-m5

October 22, 2001

DECISION AND ORDER

Liberty Mutual Fire Insurance Co. (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (the Commission) ordering partial reimbursement to Dean Allen, D.C. (Respondent) for medical services rendered to ______________ (Claimant).This decision holds that Carrier should reimburse Respondent $448.00.

I. JURISDICTION AND NOTICE

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law.

II. PROCEDURAL HISTORY

The hearing in this matter convened September 20, 2001, in the Stephen F. Austin Building, 1701 North Congress Avenue, Austin, Texas. Administrative Law Judge (ALJ) Sharon Cloninger presided. Carrier was represented by Mahon B. Garry, Jr., attorney. Respondent appeared by telephone, as did his attorney Scott Hilliard. Attorney Susan Goggan represented the Commission. The record closed the same day.

III. BACKGROUNDAND APPLICABLE LAW

A. Background

Respondent treated Claimant for an inguinal hernia[1] incurred on August 10, 1999, in a compensable, job-related injury. Respondent used myofascial release, manual traction, manipulation, and therapeutic exercises to treat Claimant’s pain and muscle spasms. Respondent requested reimbursement for those services from Carrier, who denied payment on the grounds that services provided to Claimant on two of the dates in question -- December 20, 1999, and January 10, 2000 -- were unrelated to the inguinal hernia, and because charges for services rendered on the third date in question -- January 26, 2000 -- were a duplicate billing.

Following Carrier’s denial of payment for services provided on the three above dates, Respondent submitted a request for dispute resolution to the MRD on November 20, 2000, seeking reimbursement of $1,528.00. The MRD’s Findings and Decision dated January 18, 2000, ordered partial payment of $448.00. Carrier seeks a decision from the ALJ disallowing the $448.00 payment.

B. APPLICABLE LAW

The sole issue in this proceeding is whether Carrier should reimburse Respondent $448.00 for services rendered to Claimant on December 20, 1999, January 10, 2000, and January 26, 2000.

Under the Texas Workers Compensation Act, an employee who sustains 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: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.Tex. Labor Code Ann. § 408.21(a).

To assist health care providers and insurance carriers in determining the medical necessity of specific services, and the maximum allowable reimbursement for those services, the Commission established Medical Fee Guidelines (MFG) in 1996, as authorized under Tex. Labor Code Ann. § 413.011.

Under the MFG, medical procedures are assigned CPT[2] codes. In most instances, the MFG lists a maximum allowable reimbursement (MAR) for each CPT code. The insurance carrier is to reimburse the health care provider either the billed charge, or the MAR, whichever is less.[3]

IV. EVIDENCE AND ANALYSIS

A. Carrier’s Evidence and Argument

Carrier offered no evidence, relying on the MRD record admitted as TWCC Ex. 1.

Counsel for Carrier conceded the reason for non-payment of the January 26, 2000, services was not valid. At the time the billing was submitted, Carrier denied payment in the belief that the bill was a duplicate. Carrier has since decided the bill was not a duplicate.

Carrier stated its position regarding the December 20, 1999, and January 10, 2000, charges in a November 28, 2000, letter to the MRD. (TWCC 1, 44). Carrier contends Respondent’s treatment of Claimant was not medically indicated for the diagnosis of inguinal hernia. To support the contention, the letter referred to results of a Peer Review conducted by Thomas Sato, D.C. following a March 30, 2000, request by Carrier. Dr. Sato determined that no chiropractic or physical therapy services were medically necessary or appropriate for treatment of Claimant’s inguinal hernia after November 29, 2000. The letter pointed out that on January 13, 2000, Carrier’s in-house reviewing physician denied [spinal] manipulation, because Claimant’s injury is not to the lower back.

Dr. Sato concluded in a letter dated March 30, 2000, that at the time of his Peer Review, the necessity of chiropractic intervention for an inguinal hernia had not been documented for necessity, and further clinical information was needed. He also said the use of passive modalities to the inguinal region had not been supported for necessity, and the necessity for therapeutic exercise had not been documented. (TWCC 1, 55).

In a follow-up letter dated June 7, 2000, Dr. Sato said his March 30, 2000; recommendations remained unchanged, even after receiving additional information about Claimant’s treatment. He said that according to the newly received documentation, there was no information that would suggest the necessity of Claimant receiving passive modalities, joint mobilization, therapeutic exercises, myofascial release, and traction. He said the modalities and exercises were neither reasonable nor necessary. (TWCC 1, 56).

Counsel for Carrier defended Carrier’s non-payment for office visits with manipulation, myofascial release, and traction, because those services were not related to the treatment of the inguinal hernia. He said that although Respondent testified the services were related to treatment of Claimant’s inguinal hernia, the ALJ should rely on Dr. Sato’s Peer Review, and disallows the $448.00 payment.

B. Respondent’s Evidence and Argument

Respondent testified in his own behalf, and offered no documentary evidence.

Respondent’s testimony

Respondent testified that the disputed medical services were both reasonable under the MFG and were necessary to treat Claimant following the September 1999 surgery for his inguinal hernia. When Claimant first sought treatment from Respondent in December 1999, he was suffering pain, and had severe muscle spasms in his hip and groin area.

Respondent said the symptoms were related to Claimant’s hernia. Respondent used therapeutic exercises, myofascial release and manual traction to alleviate Claimant’s symptoms. Respondent also manipulated Claimant’s lower spine and pelvic area to relieve the pain.

On cross examination by Carrier, Respondent explained that although the record refers to a full spinal manipulation, the record is incorrect.(TWCC 1, 21). He said he manipulated the Claimant’s lower spine, but not the thoracic or cervical spine. He said he treated Claimant for pain that was a side-effect of the inguinal hernia surgery, and had Claimant do exercises that would strengthen the inguinal hernia area in preparation for Claimant’s return to work. He said he personally performed the myofascial release, and that it was not performed by a therapist.

On cross examination by the Commission, Respondent said as far as he knew, Claimant did not receive any post-surgery therapy before Respondent treated him. Respondent said the normal treatment for inguinal hernia includes surgical repair, and physical therapy to strengthen muscles in the surrounding area, which should aid in healing and prevent recurrence of the hernia.

Business record

According to Respondent’s Daily Notes Reports, Claimant described symptoms of left groin pain and minimal swelling on all three office visits in question, with less groin pain on the January 26, 2000, visit. On the December 20, 1999, visit, Claimant had severe muscle spasms at the inner thigh on the left. He did not have those spasms on the following two visits. During the first two visits, Claimant had a moderate measure of tenderness in the groin area on the left. Each time, the treatment included manipulation of the spine, myofascial release, and manual traction. Claimant also performed therapeutic exercises at each visit, to strengthen the inguinal hernia area. (TWCC 1, 21).

Respondent alleged all treatments in dispute were related treatments for compensable injury. (TWCC 1, 8). The office visits were necessary to evaluate Claimant’s condition, and determine what treatment was required at each visit. The disputed myofascial release was needed to treat severe muscle spasms in the groin area and upper thigh. Because of the muscle spasms, Claimant was experiencing pain in his hip joint. Manual traction was applied to the leg to release the hip joint. Both of these therapies were necessary for pain control, and to aid healing by increasing circulation to the area. Therapeutic exercise served to minimize muscle spasms and strengthen the affected muscles. This therapy was necessary to allow the affected muscles in the groin area to heal. (TWCC 1, 9).

C. Commission’s Evidence and Argument

The Commission introduced the business record in this case, which was admitted. The Commission presented no witnesses.

Counsel for the Commission argued that Dr. Sato formed an opinion without examining Claimant, while Respondent treated the Claimant. She urged the ALJ to defer to Respondent’s best judgment.

D. Analysis

Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the ALJ should disallow partial payment for the disputed services. 28 Tex. Admin. Code (TAC) § 148.2(h)(i).Carrier is limited on appeal to its reasons for denial as set forth in the record admitted as TWCC 1.

Charges related to office visits of December 20, 1999, and January 10, 2000

Carrier declined to pay Respondent for services rendered to Claimant on December 20, 1999, and January 10, 1999, on the grounds that the treatment was unrelated to Claimant’s injury. Although Carrier presented evidence from its Peer Review physician in support of its position, the ALJ finds Respondent’s testimony that the services were related to Claimant’s inguinal hernia to be more persuasive.

Respondent testified that the myofascial release, manual traction, and manipulation were all necessary to treat Claimant’s muscle spasms and his pain -- which resulted from the September 1999 surgery to repair the inguinal hernia -- during the December 20, 1999, office visit. Respondent testified the therapeutic exercise was necessary to strengthen the inguinal hernia area to prepare Claimant to return to work and to reduce the likelihood of a recurrence of the hernia. While Dr. Sato, the Peer Review physician, stated no physical therapy was needed after November 29, 1999, the statement is not supported by any further information.

There is credible evidence that the disputed services were related to Claimant’s compensable injury.Respondent’s testimony was not controverted, and Respondent’s Daily Notes Report supports provision of the disputed treatments. Therefore, the ALJ finds Carrier should reimburse Respondent $126.00 for treatment rendered on December 20, 1999, and $126.00 for treatment rendered on January 10, 2000.

Charges related to January 26, 2000, office visit

Carrier conceded at the hearing that the January 26, 2000, charges were not a duplicate billing, which was the reason given to Respondent for non-payment. Therefore, Carrier should reimburse Respondent the MAR for medical services rendered to Claimant on that date, or $196.00.

Conclusion

The ALJ finds the Petitioner did not prove that the medical services provided to Claimant by Respondent were unrelated to treatment of Claimant’s inguinal hernia,that the bill submitted for services rendered January 26, 2000, was a duplicate, or that Respondent is not entitled to reimbursement per the MFG. Therefore, the ALJ finds Carrier should reimburse Respondent a total of $448.00 for the services rendered on the three dates in question.

V. FINDINGS OF FACT

  1. In _________________(Claimant) incurred an inguinal hernia that was a compensable injury under the Texas Workers’ Compensation Act,while working for an employer who had workers’ compensation insurance coverage with Liberty Mutual Fire Insurance Company (Carrier).
  2. Claimant’s inguinal hernia was surgically repaired in September 1999.
  3. Dean Allen, D. C., (Respondent) treated Claimant on December 20,1999, January 10, 2000, and January 26, 2000, for pain resulting from the inguinal hernia surgery and for muscle spasms related to the inguinal hernia.
  4. Respondent’s treatment of Claimant for the symptoms listed in Finding of Fact No. 3 included manipulation of the lower spine, manual traction, and myofascial release during office visits on December 20, 1999, January 10, 2000, and January 26, 2000.On those same dates, Respondent also had Claimant do therapeutic exercises which strengthened the inguinal hernia area, to allow Claimant to return to work and as a preventive measure against recurrence of the hernia
  5. Carrier denied Respondent’s request for reimbursement for the treatments outlined in Finding of Fact No. 4 on the grounds that the treatments on December 20, 1999, and January 10, 1999, were unrelated to Claimant’s injury, and that the January 26, 2000, billing was a duplicate charge.
  6. On November 20, 2000, Respondent sought medical dispute resolution through the Texas Workers Compensation Commission (the Commission), requesting a reimbursement of $1,528.00 from Carrier.
  7. The Commission’s Medical Review Division (MRD) issued a decision granting partial reimbursement of $448.00 on January 18, 2001.
  8. Carrier filed a timely appeal of the MRD decisionon January 31, 2001, which culminated in a hearing before the State Office of Administrative Hearings on September 20, 2001.
  9. Respondent’s treatment of Claimant on December 20, 1999, and January 10, 2000, was related to Claimant’s injury.
  10. Respondent’s charges for the January 26, 2000, treatment were not a duplicate billing.
  11. The total maximum allowable reimbursement (MAR) under the Commission’s Medical Fee Guidelines (MFG) for the disputed services is $448.00.

VI. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act, Tex. Labor 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. Labor Code Ann. §413.031(d), 28 Tex. Admin. Code (TAC) §145.3 and Tex. Gov't Code Ann., Ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with 28 TAC § 148.4.
  4. Carrier bears the burden of proof by a preponderance of the evidence on the question of whether the Administrative Law Judge should disallow partial payment for the disputed services. 28 Tex. Admin. Code (TAC) § 148.2(h)(i).
  5. Pursuant to Findings of Fact Nos. 9 and 10, Carrier failed to prove Respondent’s treatment of Claimant was either unrelated to the extent of injury or was a duplicate charge.
  6. Pursuant to Finding of Fact No. 11, Carrier should reimburse Respondent a total of $448.00.

ORDER

IT IS, THEREFORE, ORDERED that Liberty Mutual Fire Insurance Company shall reimburse Dean Allen, D.C., a total of $448.00.

Signed this 22nd day of October 2001.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. An inguinal hernia is located at the groin, or junctural region between the abdomen and the thigh. A hernia is the protrusion of a loop or knuckle of an organ or tissue through an abdominal opening. (Dorland’s Illustrated Medical Dictionary, 28th Edition, 1994, W. B. Saunders Co.)
  2. The Commission has incorporated usage of the American Medical Association’s 1995 Current Procedural Terminology (CPT) codes in its Medical Fee Guidelines. (See MFG, General Instructions, I.)
  3. MFG General Instructions VI (Reimbursement).
End of Document
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