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At a Glance:
Title:
453-01-2381-m4
Date:
February 13, 2002
Status:
Medical Fees

453-01-2381-m4

February 13, 2002

DECISION AND ORDER

The Petitioner seeks reimbursement for acupuncture treatments provided beginning January 26, 2000, and ending June 21, 2000. The amount in controversy is $2300.40.

The Administrative Law Judge (ALJ) concludes the Petitioner did not meet his burden of proving the acupuncture treatments were provided to the patient. Therefore, the ALJ denies reimbursement.

The Petitioner had the burden of proving by a preponderance of the evidence that the acupuncture services were provided to the patient on the dates specified in Petitioner's claim. Although the Petitioner provided claim forms, the Petitioner did not submit any office records or patient notes and provided no testimony specific to the issue. The claims forms are evidence the procedure was billed and may be some evidence the procedure was performed. The claims forms are insufficient to meet the Petitioner's burden of proof.

Having determined the Petitioner failed to meet his burden of proof on an essential element of his case, the ALJ does not reach or address the other issues raised by the parties.

I. Findings of Fact

  1. The patient suffered a compensable injury on______________.
  2. On October 20, 1999, pursuant to a referral by Dr. Jeremy Rauhauser, Petitioner, Steven B. Eustice, D.C., evaluated the patient and began acupuncture treatment.
  3. Dr. Eustice submitted claims for payment under CPT Code 97799.
  4. Respondent Pacific Employers Insurance Company paid claims for acupuncture treatment through January 10, 2000, and then ceased paying claims.
  5. In July 2000, Dr. Eustice agreed to resubmit claims for acupuncture treatment on and after January 12, 2000, under CPT Code 97139-AC.
  6. Pacific Employers Insurance Company denied reimbursement for lack of preauthorization.
  7. On January 5, 2001, Dr. Eustice filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (Commission), seeking reimbursement of $2300.20 for the period January 26, 2000, through June 21, 2000.
  8. On February 6, 2000, the Commission’ Medical Review Division (MRD) denied the request for reimbursement.
  9. Dr. Eustice filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  10. Notice of the hearing was sent March 28, 2001.
  11. Following a continuance, the hearing was convened by telephone conference on December 19, 2001, with ALJ Howard S. Seitzman presiding and representatives of Dr. Eustice, Pacific Employers Insurance Company and the Commission participating. The hearing was adjourned the same day.
  12. Following adjournment, the Petitioner requested the record be reopened for the testimony of Ms. Shari Turner, an employee of Petitioner.
  13. By Order dated January 8, 2002, the ALJ reopened the record and Ms. Turner's written testimony was filed January 16, 2002.
  14. By Order dated January 25, 2002, the ALJ extended until February 8, 2002, the Respondents' time to object to Ms. Turner's written testimony and request cross-examination.
  15. Pacific Employers Insurance Company, by pleading filed February 7, 2002, waived its right to cross-examine Ms. Turner.
  16. The record closed on February 11, 2002.
  17. The Petitioner submitted bills for visits and acupuncture treatments but did not submit office records, medical records or specific testimony to document the provision of service on the dates claimed.

II. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. The Petitioner has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
  5. Dr. Eustice failed to prove his entitlement to reimbursement.
  6. The Petitioner's request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Steven B. Eustice's request for reimbursement of $2300.40 from Pacific Employer's Insurance Company for acupuncture treatments provided beginning January 26, 2000, and ending June 21, 2000, is DENIED.

Signed AT AUSTIN, TEXAS the 13th day of February 2002.

HOWARD S. SEITZMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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