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At a Glance:
Title:
453-01-2297-m5
Date:
April 5, 2002
Status:
Retrospective Medical Necessity

453-01-2297-m5

April 5, 2002

DECISION AND ORDER

I. Introduction

The Carrier, Insurance Company of the State of Pennsylvania, appealed the decision of the Texas Workers’ Compensation Commission Medical Review Division (MRD) granting $600 in reimbursement to Metroplex Sports Care (Metroplex) for work conditioning services provided. The Carrier challenged the medical necessity and reasonableness of the services. The Administrative Law Judge (ALJ) finds that the services met the appropriate requirements and that reimbursement as ordered by MRD is due.

II. Discussion and Analysis

On March 29, 1999, six weeks after the Claimant had spinal surgery, his surgeon referred him for physical therapy three times a week "and then to a work hardening program. (Ex. 1, 28.) The Carrier’s peer reviewer, Samuel M. Bierner, M.D., who is board certified in physical medicine and rehabilitation, found the program Metroplex provided to the Claimant lacked sufficient multi-disciplinary aspects because there was no occupational or psychological therapy. He thought the program should have been coded as conventional physical therapy. However, Dr. Bierner evaluated the program using guidelines applicable to work hardening, and the services provided were for work conditioning.

Metroplex obtained preauthorization for work conditioning services to be provided from June 15, 1999, through July 23, 1999. The Medicine Ground Rules (MGR) of the Medical Fee Guideline describe work conditioning as a “highly structured, goal-oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks.” It is a single disciplinary approach. MGR II.D.

As reflected in the Findings of Fact and Conclusions of Law, the ALJ finds that the Carrier did not meet its burden of proving the services were not medically necessary and reasonable. The work conditioning program was supervised by a physical therapist, appeared to be quite intense, and each activity was documented. At the program’s conclusion, the Claimant was able to lift the heavy weights required by his job. Therefore, the ALJ denies the Carrier’s appeal.

III. FINDINGS of Fact

  1. The Claimant, a clerk, sustained a compensable work-related injury on _____
  2. At the time of Claimant’s injury, his employer, _________, had workers’ compensation insurance coverage with the Carrier, the Insurance Company of the State of Pennsylvania.
  3. The Claimant had spinal fusion surgery at the L5-S1 level on February 12, 1999. A total diskectomy was performed and interbody fusion cages were inserted.
  4. The Claimant’s functional capacity examination on June 11, 1999, showed he would meet medium physical demands, including lifting 33 pounds with a pain level of three out of ten.
  5. The Claimant’s job required him to meet heavy physical demands and to be able to lift 100 pounds.
  6. Six weeks after the Claimant’s surgery, his surgeon referred him to physical therapy and then to work hardening.
  7. Metroplex Sports Care (Metroplex) obtained preauthorization for work conditioning from June 15, 1999, through July 23, 1999.
  8. Metroplex provided services during the time covered by the preauthorization.
  9. Metroplex’s work conditioning program notes list several physical activities performed each day, such as aerobic machine work (treadmill, bicycle, etc.), followed by weight machines (leg press, leg curl, chest press, arm curl, etc.). Finally, other non-machine and stretching exercises are listed.
  10. The exercises the Claimant performed each day were documented in some detail. A grid showing each aerobic and weight machine includes the time or number of repetitions, and when applicable, the weight lifted or pressed.
  11. For the dates when code 99213, pertaining to evaluation, was charged the physical therapist wrote a brief activity summary and assessment.
  12. The assessments indicate how the Claimant was to proceed, whether or not he had improved, and whether he should continue the work conditioning.
  13. For many exercises, the Claimant’s performance improved between June 25 and July 23, 1999.
  14. After work conditioning, the Claimant met the requirements of his job. He could lift heavy weights of 100 pounds off the ground.
  15. For the services it provided, Metroplex requested $8,250 in reimbursement, which the Carrier denied.
  16. Metroplex appealed, and the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) ordered the Carrier to pay Metroplex the following amount:

Date of Service

CPT Code

Amount MRD Awarded

6/25/99

99213[1]

$48

6/28/99

97545 WC[2]

97546 WC

$36 times four hours = $144

6/29/99

97545 WC

97546 WC

$36 times four hours = $144

7/22/99

99213

$48

7/22/99

97545 WC

97546 WC

$36 times six hours = $216

Total

$600

  1. The Carrier appealed the MRD decision, but Metroplex did not.
  2. Notice of the hearing on the appeal was sent to both parties on May 29, 2001.
  3. The hearing convened on January 15, 2002, and both parties entered appearances. Because the incorrect MRD record had been filed in the case, the hearing was recessed to February 7, 2002, in the Stephen F. Austin Building, 1700 North Congress, Austin, Texas, before the undersigned ALJ. Attorney Robert Josey represented the Carrier, and Chuck Stephenson, physical therapist, represented Metroplex. The hearing concluded and the record closed on that same day.
  4. The Claimant met the admission criteria required for work conditioning, in that he:
  5. was likely to benefit from the program;
  6. had a current level of functioning that interfered with his ability to carry out specific identifiable tasks required in the work place; and
  7. had no medical, psychological, or other conditions that prohibited participation in the program. Medicine Ground Rule (MGR) II.D.1.
  8. The claimant’s individualized work conditioning program was supervised by a physical therapist. MGR II.D.6.
  9. For the dates considered in this appeal, daily treatment and patient response to treatment were documented and reviewed to ensure continued progress. MGR II.D.7.
  10. Even though there was no exit or discharge summary in the record, the claimant was able to return to work after completing the program.

IV. CONCLUSIONS of Law

  1. TWCC has jurisdiction to decide the issues presented in this case, pursuant to the Texas Workers’ Compensation Act (the Act), TEX. LABOR CODE ANN. §413.031 (Vernon 2002).
  2. SOAH has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to §413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003 (Vernon 2002).
  3. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T. CODE ANN. §2001.052.
  4. As the party appealing the MRD decision, the Carrier had the burden of proof in this matter, pursuant to 28 Tex. Admin. Code §148.21(h).
  5. The treatment Metroplex provided relieved the effects naturally resulting from the compensable injury, promoted recovery, and enhanced the employee’s ability to return to employment. Tex. Labor Code §408.021 (a).
  6. Based on the above Findings of Fact and Conclusions of Law, the Carrier failed to meet its burden of proving that the services were not medically reasonable and necessary.

ORDER

IT IS ORDERED THAT the Carrier reimburse Metroplex Sports Care the amount of $600.

Signed April 5, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

SARAH G. RAMOS
Administrative Law Judge

  1. This code represents evaluation and management for an established patient in an outpatient visit.
  2. WC is the abbreviation for work conditioning. The code 99545 is used for the first two hours in a day and 99546 for additional hours.
End of Document
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