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At a Glance:
Title:
453-01-2564-m5
Date:
December 11, 2001
Status:
Retrospective Medical Necessity

453-01-2564-m5

December 11, 2001

DECISION AND ORDER

I.

SUMMARY

Stephenson Chiropractic Center (Petitioner) sought reimbursement of $5,670 for treatment rendered to an injured worker. Liberty Mutual Fire Insurance Company (the Carrier) paid $5,005 and denied reimbursement of the balance based on a lack of medical necessity. The Medical Review Division (the Division) of the Texas Workers' Compensation Commission determined no additional reimbursement was due. Petitioner requested a hearing to challenge the reimbursement denial.

On November 14, 2001, Georgie B. Cunningham, Administrative Law Judge (ALJ), convened the hearing at the Stephen F. Austin Building, 1700 North Congress Avenue, Austin, Texas. Jackie Stephenson, Office Manager, represented Petitioner, and Shannon P. Butterworth, Attorney, represented the Carrier. The Division's staff waived an appearance. The parties did not contest notice or jurisdiction. After evidence was presented, the ALJ closed the hearing on November 14, 2001.

II.

DISCUSSION

The evidence consisted of a certified copy of the Division's official record and Ms. Stephenson's testimony. Ms. Stephenson asserted that the claims should be paid because spinal manipulations do not require preauthorization. Preauthorization, however, is not an issue in this case. For the same reason, the ALJ rejected Ms. Stephenson's argument that she may have used an incorrect code in submitting the claims. The Carrier denied reimbursement based on a lack of medical necessity, and the Division issued its decision on the same basis.

Ms. Stephenson further asserted that the Division's decision failed to address claims for March 23, April 20, May 25, and June 22, 1999. Although the request for dispute resolution specified the disputed dates of service included September 1, 1998, through June 22, 1999, Petitioner failed to provide the Division copies of disputed medical claims, reimbursement denials, or medical records for any services provided on these dates. Thus, the amount in dispute was actually $525 rather than $665, as Petitioner asserted.

After reviewing the official record related to other dates of service, the ALJ agrees with the Carrier's and the Division's decisions that Petitioner failed to provide documentation to establish that the treatments were medically necessary or that the claim should be paid. The Commission adopted documentation requirements in the Spine Treatment Guideline found at 28 Tex. Admin. Code § 134.1001(e).

In addition to the obvious lack of documentation, the official record contained a peer review report prepared by Mary Lou Skelton, D.C. Dr. Skelton reviewed the Claimant's medical records and spoke with Dr. Stephenson. Dr. Skelton questioned Dr. Stephenson about the necessity of chiropractic intervention for a patient with broken ribs and the necessity of x-raying the Claimant again at the office following the hospital x-rays. Dr. Skelton found that Dr. Stephenson's daily progress notes did not provide any information regarding exacerbation or any other reason for extending care beyond the date the Claimant reached maximum medical improvement. In her opinion, Dr. Stephenson failed to show the therapeutic necessity for continued treatment.

Based on the evidence, the ALJ concludes that Petitioner’s claim should be denied. The facts and reasoning in support of this decision are set forth in the findings of fact, and the legal conclusions derived from those facts appear in the conclusions of law.

III.

FINDINGS OF FACT

  1. On ___________, ________ (the Claimant) sustained injuries in a work-related accident.
  2. At the time of the Claimant's injury, Liberty Mutual Fire Insurance Company (the Carrier) provided workers' compensation insurance to the Claimant's employer.
  3. The Claimant sought emergency care and received pain medication for fractured ribs.
  4. On April 1, 1998, the Claimant sought further medical treatment from Ted Stephenson, D.C. of Stephenson Chiropractic Center (Petitioner).
  5. Dr. Stephenson was the Claimant's treating doctor.
  6. Dr. Stephenson determined the Claimant had a cervical sprain or strain, thoracic sprain/strain, thoracic/intercostal neuritis, and cervicobrachial syndrome.
  7. Petitioner submitted claims of $5,670 to the Carrier for reimbursement of services provided to the Claimant between April 1, 1998, and June 22, 1999.
  8. The Carrier reimbursed Petitioner for $5,005.
  9. On August 28, 1999, Petitioner appealed the disputed amount of $665 to the Medical Review Division (the Division) of the Texas Workers' Compensation Commission (the Commission).
  10. On February 26, 2001, the Division issued its decision that Petitioner was not entitled to further reimbursement. The decision found that the documentation submitted did not support the medical necessity of the services provided from September 1, 1998, through February 23, 1999.
  11. On March 19, 2001, Petitioner filed a request for a hearing regarding reimbursement of the disputed balance.
  12. The Commission sent notice of the hearing to the parties on April 10, 2001, and a statement of matters asserted on November 2, 2001. The hearing notice and the statement of matters asserted informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  13. The Claimant returned to limited duty on April 20, 1998, and full duty on May 25, 1998.
  14. The Claimant reached maximum medical improvement on July 28, 1998.
  15. The Claimant requested the weekly treatments provided after July 31, 1998.
  16. The treatment provided between September 1, 1998, and February 23, 1999, was not adequately documented.
  17. The documentation did not specify expected outcomes or probable duration for the treatment.
  18. The documentation did not substantiate the need for the treatment provided or show that the care was appropriate for the injury.
  19. Petitioner did not objectively measure the Claimant’s clinical progress.
  20. Petitioner did not demonstrate that the treatment would be provided in the least intensive setting.
  21. Petitioner did not demonstrate the treatment would be cost effective.
  22. The documentation did not include any objective measurements to show the Claimant's progress.
  23. Petitioner did not show the need for prolonged treatment for the Claimant’s injury.
  24. Petitioner failed to provide copies of disputed medical claims, reimbursement denials, or medical records for any treatment provided on March 23, April 20, May 25, and June 22, 1999.

IV.

CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers' Compensation Act, Tex. Lab. Code Ann. § 413.031 (Vernon Supp. 2000).
  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 Tex. Lab. Code Ann. §§ 402.073 and 413.031(d) and Tex. Gov't Code Ann. ch. 2003 (Vernon 2000).
  3. Petitioner timely filed notice of appeal, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was provided to the parties according to Tex. Gov't Code Ann. ch. 2001 (Vernon 2000) and 28 TAC § 148.4(b).
  5. Petitioner had the burden of proof, pursuant to 28 TAC § 148.21(h) and (i).
  6. A treating physician is responsible for maintaining efficient utilization of health care for a claimant, pursuant to Tex. Lab. Code Ann. § 408.025(c).
  7. Petitioner failed to meet the documentation requirements of 28 TAC § 134.1001(e).
  8. Petitioner failed to establish the treatment provided was medically necessary, as required by Tex. Lab. Code Ann. § 408.021.
  9. Based on the foregoing findings of fact and conclusions of law, Petitioner failed to show it is entitled to the reimbursement sought.

ORDER

It is hereby ordered that the appeal of Stephenson Chiropractic Center is denied because the documentation submitted did not meet the documentation requirements of 28 Tex. Admin. Code § 134.1001(e) to show the treatment provided was medically necessary as required by Tex. Lab. Code Ann. § 408.021.

This decision is final on the date when the party is notified of the decision according to 28 Tex. Admin. Code § 148.22(h). If the decision is mailed, a party or the party's representative is presumed to have been notified on the date on which the notice was sent.

Signed this 11th day of December, 2001.

GEORGIE B. CUNNINGHAM
Administrative Law Judge
State Office of Administrative Hearing

End of Document
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