DECISION AND ORDER

This case is a dispute over payment for the placement of BAK cage instrumentation during spinal surgery.

The Administrative Law Judge (ALJ) finds the Petitioner provided adequate documentation for the placement of the BAK cages and showed that a fair and reasonable payment for that procedure was $3,400.00. He orders additional reimbursement in that amount.

I. Findings of Fact

1. The patient suffered a compensable injury on
2. Dr. M. David Dennis of South Texas Spinal Clinic (the Petitioner) performed spinal fusion surgery on the patient on July 13, 1999.
3. The Petitioner billed Atlantic Mutual Insurance Company (the Carrier) for $24,884.00 under several CPT Codes for the spinal surgery and related procedures.
4. The Carrier paid for all but two of the CPT Codes at the Maximum Allowable Reimbursement (MAR) levels, leaving two CPT codes in dispute.
5. The Petitioner filed a timely request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission).
6. On March 2, 2001, the Commission’s Medical Review Division (MRD) ordered reimbursement for CPT Code 22612-51 at the MAR level and denied reimbursement for CPT Code 22899.
7. The Petitioner filed a timely request for a hearing.
8. Notice of the hearing was sent to the parties April 3, 2001.
9. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
10. The hearing was held November 13, 2001, before the undersigned Administrative Law Judge (ALJ), with representatives of the Petitioner and the Carrier participating.
11. The CPT Codes used by the Commission do not include a separate code for placement of BAK cage instrumentation.
12. The Petitioner requested reimbursement for placement of the BAK cage instrumentation under CPT Code 22899.
13. CPT Code 22899 is used for reimbursement of unlisted musculoskeletal procedures, and requires documentation of the procedure.
14. The Petitioner adequately documented the need and procedure for the placement of the BAK cage instrumentation in Exhibit 1, pages 11-19, and Exhibit 2.
15. The Petitioner adequately documented, in Exhibit 1, page 19, that a fair and reasonable payment for the placement of the BAK cage instrumentation was $3,400.00.

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. 28 Tex. Admin. Code §148.21(h).
5. The Petitioner met its burden of proving it was entitled to additional reimbursement of $3,400.00.

ORDER

IT IS, THEREFORE, ORDERED that Atlantic Mutual Insurance Company reimburse South Texas Spinal Clinic $3,400.00 for the placement of BAK cage instrumentation (CPT Code 22899) on July 13, 1999.

Signed February 19, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge