DECISION AND ORDER

Rehab 2112 (the Petitioner) appealed the Findings and Decision issued by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) in a fee dispute case. The MRD declined to order the New Hampshire Insurance Company (the Carrier) to pay any additional reimbursement to Petitioner for the work-hardening program it provided to the Claimant. Petitioner argued it should be paid for the work-hardening program because the program was medically necessary and helped the Claimant return to his job. The Carrier and the Commission argued the MRD decision was correct because Petitioner had submitted insufficient documentation to prove it complied with the Commission’s rules and that the program was medically necessary. The Administrative Law Judge (ALJ) finds the Petitioner failed to meet its burden of proof, and therefore, is not entitled to additional reimbursement.

I. NOTICEANDJURISDICTION

On November 1, 2001, ALJ Ruth Casarez convened the hearing at the Stephen F. Austin Building, 1700 North Congress Avenue, Austin, Texas. Thomas Rhudy, D.C., appeared by telephone and represented the Petitioner; Attorney Jacqueline Harrison represented the Commission staff (Staff); Attorney Ron Johnson represented the New Hampshire Insurance Company. Notice and jurisdiction were not contested and will be addressed in the findings of fact and conclusions of law without further discussion here. At the conclusion of the evidentiary hearing, the record of the hearing closed on November 1, 2001.

II. DISCUSSION

The issue in this case is whether Petitioner complied with the Commission’s documentation requirements and should be reimbursed for the work-hardening program it provided the Claimant.

Pertinent Statutory Provisions and Rules

Pursuant to 28 Tex.Admin. Code (TAC) §148.21(h), Petitioner has the burden of proof.

In accordance with §408.021 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. §§401.001, et seq.(the Act), an injured worker is entitled to all health care reasonably required by the nature of the injury as and when needed. That care includes that which would cure or relieve the effects naturally resulting from the compensable injury, promote recovery, or enhance [the worker’s] ability to return to work. According to §401.011(19) of the Act, “Health care” includes “all reasonable and necessary medical . . . services.” Commission rule at 28 TAC § 133.3 sets out the general responsibilities of treating doctors in providing medical services to injured workers. Among those responsibilities are to coordinate the claimant’s health care for an injury, and to maintain efficient utilization of health care for the claimant.

The Commission has also adopted rules to implement its medical dispute resolution (MDR) program. The rules cover what parties must do prior to requesting MDR and what must be done in requesting dispute resolution. The Commission rule at 28 TAC § 133.301 provides what the parties must do when the carrier challenges a provider’s bill. Subsection (c) requires the provider to submit “to the carrier, no later than 10 days from receipt of a request [for a desk or on-site audit], any additional documentation, records, or information related to the treatments, services or the charges billed.” Unresolved disputes may be submitted to the commission for resolution. If the parties request dispute resolution, 28 TAC § 133.305 (d) provides they must submit documents that are legible and specifies the request shall include the following information:

1. (1)the claimant’s full name, address, and social security number;
2. (2)the workers’ compensation number assigned to the claim by the commission, if known;
3. (3)the date and nature of the injury or illness;
4. (4)the employer’s name and address;
5. (5)the insurance carrier’s name and address;
6. (6)the health care providers’ name, address, federal tax identification number; and professional license number;
7. (7)copies of all written communications and memoranda relating to the dispute;
8. (8)documentation indicating efforts have been made to attempt to resolve this dispute between the parties;
9. (9)copies of all medical bills, which are disputed as originally submitted to the insurance carrier;
10. (10)a summary of the requesting party’s position regarding the dispute; and
11. (11)the date of this request.

Under the Commission’s Medical Fee Guidelines (MFG) in Section II E of the Medicine Ground Rules,^[1] “work hardening” is described as a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the person served to return to work. Activities are used to progressively improve biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning.

A work-hardening program may admit those:

a. who are likely to benefit from the program;

b.whose current level of functioning due to illness or injury interferes with their ability to carry out specific tasks required in the workplace;

c.whose medical, psychological, or other conditions do not prohibit participation in the program; and

d.who are capable of attaining specific employment upon completion of the program.

Additionally, the Spine Treatment Guidelines also set out general and specific documentation requirements for treatment of injured employees with spine or back injuries. These applicable requirements are found at 28 TAC §134.1001 (e)(2)(O) and at §134.1001 (e)(3)(B) and (D).

Evidence and Analysis

(1) Petitioner’s Evidence

(Claimant) was injured on_______, as he pulled a spring-loaded rope that released or secured a load on his truck. Apparently the rope broke, striking him in the face and knocking him to the ground. He suffered injury to his teeth, neck, upper back and right shoulder. Within a day of the accident, Claimant was examined by a company doctor, who sent him for x-rays. The x-rays reported negative, except for evidence of an old rib fracture. He was diagnosed with strain injuries to the cervical and right shoulder regions, was given physical therapy and later a home physical therapy program and some Tylenol. About a week later (February 8, 2000), Claimant was released to return to “regular duty.”

Petitioner’s Anthony E. Smith, D.C., testified as to Claimant’s injury and treatment through August 16, 2000, and as to the records associated with the treatment rendered by Petitioner. After seeing the company doctor, Claimant sought treatment from another doctor. On March 23, 2000, after examining Claimant, Gilbert Gonzales, D.C., diagnosed him with injuries to the “teeth, neck, back, and his ribs” and took him off work. Dr. Gonzales^[2] recommended chiropractic treatment for four weeks and also referred Claimant to Marlon D. Padilla, M.D., who examined him on April 5, 2000. Dr. Padilla found the injuries were related to lifting and noted symptoms to include “neck, middle back, and low back pain and spasm, occipital headaches, right shoulder pain and rib fractures.” He also diagnosed Claimant with a concussion. Although Dr. Padilla reported a normal physical examination including neurologic and range of motion evaluation, he recommended multiple imaging studies and continuation of “conservative treatment,” and prescribed various medications, including some narcotics. On May 19, 2000, an MRI of the cervical spine showed “disc dessication at every level of the cervical spine” with disc bulges at C5-6 and C7-T1 and “oseophyte formation at C4 and C5.” An MRI of the left shoulder indicated severe arthritic changes “likely to result in clinical symptoms.”

Thereafter, according to Petitioner, Dr. Campbell referred Claimant for a functional capacity evaluation (FCE). Petitioner’s Frank J. Siebenaler, D.C., who performed the initial FCE on June 8, 2000, found that Claimant was (1) limited in static postures and general job endurance; (2) currently did not meet his job requirements, and (3) would benefit from work-hardening. He recommended Claimant begin work hardening to increase endurance, strength and range of motion and to meet the physical demand capacity (PDC) of his job, which he indicated was MEDIUM-HEAVY, so as to return to work. Dr. Siebenaler indicated Claimant’s current PDC was LIGHT-MEDIUM. (C.R. p. 11). On July 21, 2000, Dr. Siebenaler performed an interim FCE, after which he reported Claimant had shown good compliance and participation during the six weeks of work-hardening, which had resulted in Claimant’s improved ranges of motion and increased functional strength and endurance. He also indicated Claimant’s job required a MEDIUM PDC level, but that Claimant continued at the LIGHT-MEDIUM level. Thus, Claimant was not yet ready to return to work and should continue to build up his strength and endurance by participating in two more weeks of work-hardening. (C.R. p. 16). On August 15, 2000, Dr. Siebenaler performed a final FCE, in which he reported Claimant’s job required a PDC level of MEDIUM and that Claimant demonstrated occasional and frequent lifting at a HEAVY PDC level. Thus, Dr. Siebenaler concluded Claimant had progressed from LIGHT-MEDIUM to HEAVY PDC level, his ranges of motion of the right shoulder cervical spine and lumbar spine had increased by 10% overall, his tolerance to reaching, squatting and bending activities had improved, and his cardiovascular condition had improved. He found Claimant was “capable of performing the critical demands of his job, however, due to an anatomical predisposition to impingement in both of his shoulders, it is recommended that he perform primarily the driving portion of his job description, if possible, and refrain from lifting objects above the horizontal.” (C.R. p. 30).

In summary, Petitioner argued Claimant needed the work-hardening program in order to return to his job. The progress made during the eight weeks of work-hardening strengthened him and increased his PDC level so he could perform his job duties. Therefore, Petitioner should be reimbursed for the program.

(1)Respondent’s Evidence

The Carrier’s counsel cross-examined Dr. Smith about the apparent inconsistencies given by Claimant regarding his progress during the work-hardening program. Claimant indicated at the time of the interim FCE on July 21, 2000, that his pain was “mild” and that he could do his usual work, but could not lift heavy weights due to the pain. On August 15, 2000, at the final FCE, he rated his pain as “moderate,” and indicated he could not do his job at that time (end of the eight-week work-hardening program). Dr. Smith responded that Claimant’s response on August 15, 2000, could reflect Claimant’s anxiety about returning to work as well as his fear that he might re-injure himself. Dr. Smith indicated the response only reflected Claimant’s emotional or psychological state and not his physical state, which had, in fact, improved. When asked to show a written referral from Dr. Campbell to the work-hardening program, Dr. Smith pointed to pages 7 and 11 in the certified record, in which he stated Dr. Campbell had agreed to Petitioner’s findings and recommendations.

James B. Campbell, Safety Coordinator for________ and Claimant’s supervisor, testified his duties included watching over the truck drivers to ensure the trucks were safe to be driven and also to train drivers on safety matters. He described Claimant’s duties as follows: checking that his truck was in proper working order for the day’s work; tarping his load; driving his truck to the various job sites; untarping and unloading his load, and returning to the employer’s plant for additional loads, if necessary. After a load was unloaded by the conveyor belt, a driver was required to walk around the truck and inspect the conveyor belt to ensure no debris or small rocks remained on it; a driver was to rerun the belt to get rid of any debris. ___ testified there was no lifting involved in performing the truck driver duties. Because of the spring-loaded mechanism on the tarp, the force required to tarp a load was comparable to the force required to pull a child two or three years of age in a small wagon. Untarping a load simply required releasing the rope that secured the tarp from the truck’s T-bar or hook. The spring mechanism automatically retracted the tarp and rolled it up, leaving the rope free, which could then be pulled to tarp another load when necessary. ___ testified he did not believe his drivers would ever have to lift 75 pounds; in fact, the drivers probably would not have to lift any weight at all.

___ also testified that Claimant reported on________, that the tarp rope had broken and he had fallen to the ground. Claimant had not appeared physically hurt and, in fact, worked through the end of the day. On the next day, however, Claimant reported feeling sore, and ___ referred him to the clinic to be checked out. ___ did not recall that Claimant had been off work due to the injury, except for an hour or so to go to physical therapy, but he did not believe Claimant had taken any days off due to the injury. Claimant performed his regular job duties after the injury through March 22, 2000, but on March 23 and 24, 2000, he did not report to work (___ did not know if Claimant had called to say why he was not coming in) and was terminated due to absence.

After Claimant began receiving treatment from Dr. Gonzales, the Carrier requested an independent medical evaluation. On June 22, 2000, Marc T. Taylor, M.D., examined Claimant and rendered a medical evaluation report. He certified Claimant was at Maximum Medical Improvement (MMI)^[3] and indicated he had 0% impairment. The Claimant’s treating doctor disagreed with Dr. Taylor’s impairment rating and requested another medical evaluation by a designated doctor. After evaluating Claimant on August 7, 2000, designated doctor David A. Potts, D.C., reported Claimant had a 5% whole person impairment and that the date of MMI was August 7, 2000. (C.R. pp. 90-92). Dr. Potts also reported that based on neuromuscular examination, Claimant showed no objective sensory deficit and no objective motor deficit of the upper extremities, and that on review of his medical records and physical examination, Claimant showed no specific disorders for the cervical spine or right shoulder that would be ratable. Dr. Potts did not mention the work-hardening program that Claimant had undertaken.

On August 18, 2000, at the Carrier’s request, Ahmed A.H. Khalifa, M.D., board-certified in occupational and physical medicine, performed a peer review of Claimant’s medical records. Dr. Khalifa’s opinion was that a work-hardening program had not been necessary because Claimant had been performing his job prior to entering the work-hardening program. Because work-hardening was intended to be a transition from a claimant’s inactivity to physical functioning that would be required in order to return to work, Claimant did not need work-hardening if he had already been doing his job. Dr. Khalifa testified Claimant did not meet work-hardening entry criteria because (1) Claimant was not likely to benefit from work-hardening; (2) Claimant was already at the level of functioning required to perform his job, i.e., after the injury, he had been driving his truck; (3) Claimant had no significant medical or psychological impairments that required treatment via interdisciplinary approach offered by work-hardening; (4) work-hardening does not cure arthritic problems; (5) Claimant could perform his job with his arthritis prior to and after the injury; (6) the chiropractic treatment that Claimant received should have already improved his condition, and since it had not, there was no need for work-hardening to cure the arthritis; and (7) there was no evidence that Claimant showed acute pathology. Furthermore, Dr. Khalifa opined that even if Claimant had qualified for work-hardening (which he did not believe was the case), the work-hardening program he received was not adequate because there was no showing the program provided appropriate work-simulation activities. For example, it provided no activities that focused on Claimant’s essential duties, getting in and out of the truck cab, shifting the manual transmission, and pulling the tarp rope to cover or release a load. According to Dr. Khalifa, Petitioner’s records indicated Claimant was given only about 10 minutes per day of job simulation activities, which was inadequate.

In general, Dr. Khalifa opined that considering the soft tissue nature of the injuries to Claimant’s neck, upper back, and right shoulder, it was reasonable to expect he would have recovered within six to eight weeks. Thus, given all the circumstances, Dr. Khalifa did not believe work-hardening was medically necessary for Claimant.

(1)The Medical Bills

Dr. Smith did not point to any document in the record that expressly showed Dr. Campbell referred Claimant to Petitioner’s work-hardening program. He referred to pages 7 and 11 of the certified record, stating they showed Dr. Campbell agreed with Petitioner’s recommendations, but Dr. Campbell’s signature does not appear on those pages. In addition, Dr. Smith testified Petitioner had not submitted the specific documents related to Claimant’s work-hardening program. The documents, which were admitted as Petitioner’s Ex. 2 and detailed Claimant’s weekly progress during the program, should have been submitted to the MRD. Dr. Smith could not explain why the progress reports had not been sent to the MRD at the time the claim was filed, other than it was a “reporting” error.

Analysis and Conclusion

The Act imposes specific duties on all who participate in the workers’ compensation system. Claimants are required to report work-related injuries to their employers within a certain period of time, as well as to cooperate with the prescribed treatment or referrals of their health care providers. Treating physicians are required to efficiently manage the health care of the claimants, to make whatever referrals might be necessary and appropriate, and to bill for the treatment provided according to the Commission’s rules and guidelines. Similarly, insurance companies are required to respond within a set period when preauthorization is sought for claimants’ treatment and to pay claims or seek additional information within a certain time frame when they receive charges from providers. The Commission imposed those and other requirements to facilitate the system’s orderly operation. In general, participants are well informed of the various requirements of the Act and of the applicable procedures set out in the Commission’s rules and guidelines.

Petitioner in this case appeared quite knowledgeable of the provisions of the workers’ compensation system, and quite familiar with the processing of workers’ compensation claims. Thus, it appeared unusual that Petitioner failed to submit all the required documentation to justify its claim for the work-hardening program when it requested medical dispute resolution. Its own witness acknowledged the correctness of the MRD’s decision not to order reimbursement, considering the information that was sent (or not sent) to it. As stated earlier, the Commission established an internal process intended to resolve claim disputes between providers and carriers, in order to help minimize formal and more expensive proceedings, but the success of that process depends on the participants following the applicable rules. Petitioner in this case did not comply with 28 TAC 133.305; it had not sent the Carrier all the documentation that was related to the claim, and it did not send all the relevant documentation to the MRD when it sought dispute resolution. This clear disregard for the Commission’s rules should not be tolerated.

Because Petitioner finally supplied the required documentation at the hearing, however, the ALJ will review whether it proved the work-hardening program was medically necessary for the Claimant. Although Petitioner repeatedly asserted that Claimant’s treating doctor had referred Claimant into the work-hardening program, it could point to no written document in the record that showed such referral. The only documents Petitioner could point to were the form requesting MRD review and the report of the initial FCE that was conducted by Petitioner. The only thing those two pages reflected was that Dr. Campbell was the treating physician. Petitioner also claimed Dr. Campbell agreed that work-hardening would benefit Claimant, but there is no independent evidence to substantiate the assertion, other than Petitioner’s self-serving statements. Petitioner contended throughout the process that Dr. Campbell had referred Claimant to the program; therefore, it was incumbent on Petitioner to provide written verification of the referral. It did not. Considering the lack of independent evidence that the program was medically necessary and that Petitioner and its employees have a significant financial interest in proving that the referral was made, the statements of Petitioner’s employees’ are given little weight.

In addition, the evidence related to medical necessity for Claimant to enroll in the work-hardening program was inconsistent at best. First, the evidence showed the original treating doctor prescribed some short-term physical therapy and mild medications immediately after the injury and after a week of therapy released Claimant to his normal job. In fact, Claimant performed his job as a truck driver for approximately six weeks after the injury, from February 8, 2000, to March 22, 2000. Thus, the evidence was that soon after the injury, Claimant was able to perform his job. Second, Claimant’s injuries were soft tissue injuries, which generally take six to eight weeks to heal. Although Dr. Padilla characterized Claimant’s injuries as other than soft tissue injuries, there were clear factual discrepancies (e.g., stated the injury was related to lifting instead of pulling the tarp rope, and he ordered an MRI of the left shoulder, when it was the right shoulder that was injured) in his diagnosis. The ALJ gave little credence to that diagnosis.

Third, Petitioner’s evidence related to Claimant’s current physical demand capacity (PDC), and the PDC required by his job was also inconsistent, as indicated below:

Date Claimant’s PDC Level Claimant’s Job’s PDC Level

June 8, 2000	light-medium	medium-heavy
July 21, 2000	light-medium	medium
August 15, 2000	light-medium to heavy[4]	medium

Although in the final FCE report Petitioner indicated Claimant’s PDC level had improved from light medium to heavy, the rating was not without qualification. The ALJ doubts Claimant actually achieved a PDC level of heavy.

Furthermore, Petitioner presented no evidence that it obtained a job description or other information from Claimant’s employer about the specific duties Claimant was required to perform so it could determine the correct PDC for Claimant’s job. It simply asserted that employers almost never respond to requests for job descriptions. Thus, Petitioner appears to have operated under the wrong impression that Claimant was required to do heavy lifting in his job and apparently worked to get Claimant to the point where he could lift 75 pounds. In fact, the evidence presented by both parties was that heavy lifting was not a requirement of Claimant’s job: Claimant’s supervisor testified that heavy lifting was not required, and Dr. Smith testified that the Dictionary of Occupational Titles listed the PDC for truck drivers as medium. Thus, as Claimant was already at the light-medium PDC, and in fact, had been performing his job, the ALJ finds Petitioner did not prove that an eight-week work-hardening program was medically necessary to get Claimant ready to return to work. Petitioner’s evidence also did not establish that the work-hardening program, in fact, provided Claimant with appropriate work simulation exercises that would help return him to his job. Additionally, the fact the designated doctor did not mention the work-hardening program at all in his evaluation (conducted after Claimant had completed eight weeks of work hardening) minimizes the likelihood that the program had improved his condition. Otherwise, it is reasonable to believe Dr. Potts would have indicated the program’s effect on Claimant’s condition.

Therefore, because Petitioner failed to comply with the Commission’s documentation requirements set forth in 28 TAC 133.305, and because the documentation that was ultimately presented did not comply with the provisions of 28 TAC 134.1001(e), the MRD’s decision is affirmed.

III. FINDINGS OF FACT

1. On________________ (Claimant), a truck driver employed by_____________, suffered a compensable injury that resulted in neck, upper back, and right shoulder sprains.
2. ___________had workers’ compensation coverage with the New Hampshire Insurance Company (Carrier) at the time.
3. On January 27, Claimant was examined at the company clinic. He was given non-prescription medication and short-term physical therapy for his injuries and was released to return to work on February 8, 2000.
4. Claimant returned to his work and performed his regular job duties until March 23, 2000, when he sought further treatment by another doctor.
5. Claimant’s job duties included: inspecting his truck to ensure it was in proper working order; securing and releasing loads onto his truck; using a tarp equipped with a spring-loaded mechanism that was activated by pulling an attached rope; driving his truck within the city; and inspecting the truck’s conveyor belt to ensure it was clean after unloading a load. In performing his duties, Claimant had to get in and out of the truck cab, shift the manual transmission, and sit for certain periods of time.
6. According to the Dictionary of Occupational Titles, the physical demand capacity (PDC) required of a truck driver is medium.
7. On March 23, 2000, Claimant sought treatment from Gilbert Gonzales, D.C., who diagnosed him with injuries to his teeth, neck, back and ribs. Dr. Gonzales prescribed chiropractic treatment and took him off work. Sometime later, Dr. Gonzales moved from San Antonio, and Dr. Kyle Campbell became Claimant’s treating physician.
8. In June 2000, Dr. Campbell referred Claimant to Rehab 2155 (Petitioner) for a functional capacity evaluation (FCE).
9. On June 8, 2000, Frank Siebenaler, Petitioner’s medical director, conducted an FCE to assess Claimant’s ability to perform his job requirements. He noted in the FCE report that because Claimant was required to lift 75 pounds occasionally and 35 pounds frequently, he would benefit from a work-hardening program to strengthen him and to raise his PDC, which was at “light-medium.”
10. Petitioner supplied no written statement explicitly showing Dr. Campbell referred Claimant to the work-hardening program or that Dr. Campbell believed the program would benefit Claimant.
11. As Petitioner’s medical director who would be involved in Claimant’s work-hardening program, Mr. Siebenaler had a pecuniary interest in having Claimant enroll in the work-hardening program.
12. Petitioner did not obtain a copy of Claimant’s job description or information from the employer about Claimant’s job duties, which would allow Petitioner to determine the correct PDC for the job, and which would allow it to formulate appropriate job simulation exercises for Claimant.
13. After six weeks of the work-hardening program, Claimant remained at the light-medium PDC level.
14. The work-hardening program began on June 12, 2000, and continued to August 16, 2000, when a final FCE report was prepared indicating Claimant’s PDC level had improved from light-medium to heavy, his ranges of motion of the right shoulder, cervical spine and lumbar spine had increased by 10% overall, and his tolerance to other physical activities had improved, and recommending that he return to work per his treating doctor’s orders.
15. In the final FCE report, Dr. Siebenaler also recommended Claimant return primarily to the driving portion of his job description and refrain from lifting objects above the horizontal.
16. Claimant achieved maximum medical improvement on August 7, 2000, and received 5% whole person impairment rating by David Potts, a designated doctor of chiropractic.
17. Petitioner submitted its charges ($10,880.00) for the work-hardening program and ($500) for two FCEs it provided Claimant to the Carrier.
18. The Carrier denied payment for the entire claim, indicating the work-hardening program was not medically necessary.
19. Petitioner requested dispute resolution by the Texas Workers’ Compensation MRD on November 9, 2000, seeking reimbursement for the work-hardening program.
20. Petitioner did not submit documentation related to the weekly progress Claimant had made in the work-hardening program to the Carrier or to the MRD prior to the hearing on November 1, 2001.
21. On January 26, 2001, the MRD issued a decision approving $500.00 reimbursement for the two functional capacity evaluations that Petitioner performed on June 8, 2000, and August 15, 2000, but declining to order payment for the work-hardening program because the documentation supplied did not support the service was provided.
22. On February 7, 2001, Petitioner appealed the MRD’s decision.
23. On March 1, 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.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Lab. Code (the Act) §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 § 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 (2001).
3. Petitioner filed timely notice of appeal, pursuant to 28 TAC §148.3.
4. 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).
5. 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).
6. Pursuant to§413.031 of the Act and 28 TAC §134.1, Petitioner is required to bill the Carrier according to the Commission’s Medical Fee Guidelines (MFG) for the treatments and services it rendered Claimant that were medically necessary.
7. Pursuant to§413.031 of the Act and the Commission’s MFG found at 28 TAC §134.1001(e)(2)(O) and §134.1001 (e)(3)(B) and (D), Petitioner was required to provide detailed documentation to determine the phase of care to be provided and the necessity for that care. With regard to work-hardening programs, documentation was required to show objective substantive and continued improvement over time that correlated to the job description the injured employee would most likely undertake on completion of the program.
8. The Petitioner failed to comply with the documentation requirements set out in 28 TAC § 134.1001(e) and also failed to show the medical necessity for an eight-week work-hardening program provided to the Claimant.
9. Based upon the foregoing Findings of Fact and Conclusions of Law, Petitioner’s request for reimbursement should be denied.

ORDER

It is hereby ordered that the appeal of Rehab 2112 is denied.

Signed this 7^th day of January 2002.

RUTH CASAREZ
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The Medicine Ground Rules, part of the Commission’s Medical Fee Guidelines, were adopted as rules at 28 TAC §134.201. Pursuant to 28 TAC § 134.1, health care providers are to bill the carriers for their services according to the provisions of the Commission’s Medical Fee Guidelines.↑
2. At some point, Dr. Gonzales moved his office to Austin, and Dr. Kyle Campbell, who remained in the San Antonio Office, became the Claimant’s treating doctor.↑
3. Maximum medical improvement (MMI) is the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.↑
4. Although Claimant was rated at being at the light-medium to heavy level, the evaluator recommended that he “perform primarily the driving portion of his job description, if possible, and refrain from lifting objects above the horizontal.”↑