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At a Glance:
Title:
453-01-2433-m5
Date:
March 21, 2002
Status:
Retrospective Medical Necessity

453-01-2433-m5

March 21, 2002

DECISION AND ORDER

Kenneth Haycock, D.C., (Petitioner) appealed the Findings and Decision of the Texas Workers' Compensation Commission's (the Commission) Medical Review Division (MRD) in a preauthorization dispute, MDR Docket No. M5-02-0780-01. The MRD upheld the denial of reimbursement by Colonial Casualty Insurance Company (Carrier) for work hardening services provided workers’ compensation claimant L.H. (Claimant). This decision finds the reimbursement should be paid.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues regarding notice of hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened February 19, 2002, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Ann Landeros. Attorney Scott Hilliard represented Petitioner. Carrier did not appear and was not represented despite having actual notice of the hearing. Pursuant to its written announcement, the Commission chose not to participate in the hearing. After receipt of evidence, the record was closed the same day.

II. DISCUSSION

A. Background Facts

In_______, Claimant sustained an injury to his back that was compensable under the Texas Workers’ Compensation Act (Act). At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance coverage with Carrier. This dispute concerns work hardening services Claimant received from February 8 through March 6, 2000, from Petitioner.

Claimant underwent a functional capacity evaluation (FCE) in January 2000. That assessment revealed that Claimant, whose job as a furniture mover required heavy lifting as defined in the United States Department of Labor guidelines, could not perform more than light lifting. (Exh. 1, p. 71). Claimant’s treating doctor, Dr. Dean Allen, referred him to a work hardening program supervised by Petitioner, Dr. Allen’s associate. (Exh. 1, p. 13). While in the work hardening program, Claimant participated in body mechanic training, therapeutic exercises, and job stimulation activity as shown by the work hardening program daily progress reports. (Exh. 1; pp. 105, 108, 112, 116, 126, 130). Claimant also participated in psychological group therapy. (Exh. 1; pp. 124, 156, 161, 166). His specific exercises and progress were noted in the SOAP notes of his supervising physician. (Exh. 1, pp. 172-190).

B. Basis Of The MRD Decision

The MRD found that Petitioner failed to provide the information required under the Commission’s Spine Treatment Guideline, 28 TEX. ADMIN. CODE § 134.1001.[1] Specifically, the decision cited a lack of information regarding: the program’s entrance criteria; Claimant’s individual treatment plan with specific program goals; and a pre-entrance mental health evaluation. The MRD further found no clinical indicators to support the medical necessity for Claimant to participate in the program.

C. Petitioner’s Argument

Petitioner pointed out that Carrier originally denied payment under the ”U” code, meaning that Carrier found the services not medically necessary. After Petitioner filed its request for reconsideration, Carrier changed the basis for the denial to the “L” code, which mean Carrier found the services were not provided by the treating doctor as required.

According to Petitioner’s witness, chiropractor Dr. Laurent Pelletier, Claimant’s treating doctor, Dr. Dean Allen, D.C., was on the premises during the work hardening program and supervised Claimant’s participation in the program, as shown by the SOAP notes for Claimant on February 17, 18, 23-25, 29 and March 1-3, 6, 8-10, 13, 15-17, 2000. (Exh. 1, p. 172-190). Dr. Pelletier described the work hardening program as using the method-time management rating system in which machines simulate work stress and measure both the time and effort needed for the participant to complete the task. He stated Claimant was a good candidate for the program. In March 2000, Claimant underwent another FCE after which he was released to return to work. Dr. Pelletier asserted the release back to work proved the program was both medically necessary and effective. Dr. Pelletier also noted that while the Commission’s Medicine Ground Rule II.E. mentions that an initial evaluation to determine the Worker’s readiness for the program may include a mental health evaluation, such evaluation is not required and not is considered part of a work hardening program.

D. Carrier’s Argument

As Carrier did not appear at the hearing, it’s only known arguments in favor of denying reimbursement were those contained in the denial letters and the MRD record. In its response to the MRD, Carrier claimed denial of reimbursement was appropriate because the work hardening services were provided after Claimant had reached MMI in January 2000. (Exh. 1, pp. 235-236).

E. Analysis

Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i). Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a). Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).Work hardening is defined, at 28 TAC § 134.1001(g)(69) and the Commission’s Medicine Ground Rules, Rule II.E., as a multidisciplinary program tailored to improve the Worker’s functional, physical, behavioral, and vocational needs.[2]

When denying a claim, an insurance carrier must send the commission, the health care provider, and the injured employee a report that sufficiently explains the reasons for the reduction or denial of payment for health care services provided the employee. TEX. LAB. CODE ANN. § 408.027(d). Carrier originally denied reimbursement on the grounds the services were medically unnecessary. On request for reconsideration, Carrier changed its reason for the denial to a claim that the services were required to be, but had not been, provided by Claimant’s treating physician. The latter claim is unclear. Treating doctors are entitled to refer claimants to other doctors. Commission Evaluation and Management Ground Rule X. In this case, the evidence established that Dr. Allen referred Claimant to the work hardening program.[3] Because Claimant was treated under a referral from Dr. Allen, Carrier was not entitled to deny reimbursement for the reason the service was not provided by the treating doctor.

The argument found in Carrier’s response to the MRD, that Claimant was not entitled to work hardening services because he had reached maximum medical improvement (MMI ) before he entered the program, was insupportable. As Carrier should well know, a determination of MMI affects only compensation for impairment income benefits and has no bearing on whether or not a claimant is entitlement to medical benefits. TEX. LAB. CODE ANN. § 408.121et seq. Carrier’s argument on this point was ill-advised.

The MRD incorrectly found that a mental health evaluation was required before Claimant could enter the program. According to the Commission Medicine Ground RuleII.E.2, that sort of evaluation is optional and is not considered part of the work hardening program

The MRD also incorrectly found the medical necessity of the work hardening program unsubstantiated. In fact, the MRD record contained sufficient daily progress reports, test results, and SOAP notes to establish that Claimant was a candidate for the program, actively and successfully participated in appropriate work hardening exercises, and benefitted from the program. This information, coupled with Dr. Pelletier’s testimony, was sufficient to establish the medical necessity of the program for Claimant.

If nothing else, the efficacy of the program was established by the results it produced. Before the program, Claimant could not work at his former job. After the program, he was released back to work. The work hardening program served its intended purpose: it avoided more invasive and costly surgical intervention and promoted Claimant’s return to work. Petitioner is entitled to reimbursement for the unpaid work hardening services provided Claimant.

III. FINDINGS OF FACT

  1. In 1999, L.H. (Claimant) suffered an injury compensable under the Texas Workers’ Compensation Act (Act).
  2. At the time of Claimant’s compensable injury, Colonial Casualty Insurance Company (Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. In 2000, Claimant’s treating physician referred him to participate in a work hardening program supervised by Kenneth Haycock, D.C. (Petitioner).
  4. The work hardening program included functional, physical, behavioral, and vocational exercises and training.
  5. After completing the work hardening program, Claimant was released to return to work.
  6. The MRD record contained sufficient daily progress reports, test results, and SOAP notes to establish that Claimant was a candidate for the program, actively and successfully participated in appropriate work hardening exercises, and benefitted from the program.
  7. Carrier refused to reimburse Petitioner for the work hardening program provided Claimant, first on the basis that the service was not medically necessary and then on the basis that the service had not been provided by Claimant’s treating physician.
  8. At the MRD, Carrier claimed Petitioner was not entitled to reimbursement because Claimant had reached maximum medical improvement (MMI) before entering the work hardening program.
  9. The Texas Worker’s Compensation Commission’s Medical Dispute Resolution division upheld Carrier’s denial of reimbursement.
  10. Petitioner timely appealed the MRD decision denying reimbursement.
  11. Despite having actual notice of the hearing, Carrier did not appear and was not represented at the hearing.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (the 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 § 413.031(d) of the Act and TEX. GOV'T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i).
  6. Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a).
  7. Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A).
  8. A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).
  9. Work hardening is a multidisciplinary program tailored to improve the Worker’s functional, physical, behavioral, and vocational needs. 28 TAC § 134.1001(g)(69) and the Commission’s Medicine Ground Rules, Rule II.E.
  10. Treating doctors are entitled to refer claimants to other doctors. Commission Evaluation and Management Ground Rule X.
  11. A determination of MMI affects only compensation for wage benefits and has no bearing on whether or not a claimant is entitlement to medical benefits. TEX. LAB. CODE ANN. § 408.121 et seq.
  12. Petitioner’s work hardening program was medically necessary health care for Claimant.
  13. Based on the foregoing, Petitioner’s claim for reimbursement from Carrier for the work hardening program provided Claimant in 2000 should be granted.

ORDER

IT IS ORDERED that Petitioner, Kenneth Haycock, D.C., be reimbursed by Colonial Casualty Insurance Company for the work hardening program provided Claimant L.H. in 2000.

Signed this 21st day of March 2002.

ANN LANDEROS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. 28 TAC § 134.1001 (e)(2)(L). Rehabilitation programs such as work hardening, work conditioning and outpatient medical rehabilitation are required to meet the definitions/criteria set forth in the current Medical Fee Guideline. Work conditioning and work hardening program goals should be tailored to physical demands required by job specificity. When the injured employee does not have a specific job that he/she is returning to, the goal of these programs should be to restore a reasonable level of physical functioning. Work conditioning programs at the job site or a combination of work conditioning/work hardening and modified duty as part of a progressive return to work program can also be utilized to meet these goals when the employer has these programs in place. After completion of a rehabilitation program, re-enrollment or repetition in the same rehabilitation program for the same condition or injury would not be medically warranted.
  2. The rule states: Work Hardening--a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured employee. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of the persons served.
  3. Medicine Ground Rule II.E. states: Work Hardening. A highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured worker. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cariovascular/metabolic, behavioral, attitudinal, and vocational functioning of the persons served.

  4. Petitioner’s claim that Dr. Allen actually participated in the work hardening program was not clearly established in the record, as the SOAP notes attributed to Dr. Allen were unsigned. Exh. 1, pp. 172-190.
End of Document
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