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At a Glance:
Title:
453-01-2567-m5
Date:
June 4, 2002
Status:
Retrospective Medical Necessity

453-01-2567-m5

June 4, 2002

DECISION ANDORDER

At issue in this consolidated case is whether Texas Imaging and Diagnostic Center (TIDC) should be reimbursed by Liberty Mutual Fire Insurance Company (Carrier) for intraoperative neurophysiology monitoring[1] services performed on Patient ZB and Patient T during their respective spinal surgeries. TIDC seeks reimbursement in the amounts of $2,055.00 for monitoring Patient ZB and $1,485.00 for monitoring Patient T.

The Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission) denied reimbursement for both patients on the grounds that TIDC failed to submit an operative report from the surgeon or other adequate documentation explaining the medical necessity of the monitoring used during the patients= spinal surgeries. After considering the evidence and arguments presented at the hearing on the merits,[2] the ALJ finds that TIDC is entitled to reimbursement for the services rendered to Patient ZB, but is not entitled to reimbursement for Patient T.

I. REASONS FOR DECISION

At the hearing before the State Office of Administrative Hearings (SOAH), TIDC argued that Exhibit 3, a letter from Roger S. Blair, M.D., the neurologist who monitored the patients, supports reimbursement for Patient ZB's lumbar 360 (global) fusion with instrumentation. For Patient T, TIDC argued that the patient's surgeon, Bruce Hinkley, M.D., ordered the monitoring and the Carrier should not second guess the surgeon. The Carrier responded that the necessity of the procedures was not adequately documented as required by the Spinal Surgery Ground Rules.

Patient ZB

While it would be preferable to have the surgeon's operative report in the record for more complete detail of the surgery and its implications, the ALJ accepts as credible Exhibit 3, Dr. Blair's March 27, 2002 letter asserting that intraoperative monitoring is indicated in surgical procedures involving fusion with instrumentation. According to documentation in the MRD certified record, Patient ZB's surgery involved a lumbar 360 fusion with instrumentation. Therefore, the ALJ concludes TIDC is entitled to reimbursement for Patient ZB's monitoring and related charges in the amount of $2,055.00.

Patient T

Patient T's surgery involved a lumbar laminectomy with decompression from L-2 to the sacral region. Nothing in the record explains why intraoperative monitoring was necessary during this surgery. Because the documentation in evidence is insufficient, TIDC failed to prove that intraoperative monitoring was medically necessary for this spinal surgery and reimbursement in the amount of $1,485.00 is denied.

Separate vs. Global Fee

The Carrier also questioned whether the monitoring services were part of the global fee for the surgery under the Spine Treatment Guideline's global fee concept. The Commission's Surgery Guideline I. E.7 allows for non-global billing of a separate procedure, which is defined as a procedure performed independently of other services. The evidence in the record indicates that the monitoring was performed separately by a specialist, not the surgeon. Therefore, the ALJ rejects the Carrier's argument on this point.

II. FINDINGS OF FACT

  1. Texas Imaging and Diagnostic Center (TIDC) billed Liberty Mutual Fire Insurance Company (Carrier) for six hours of intraoperative monitoring services for Patient ZB under CPT Code 95920 and services related to the monitoring under CPT codes 95925, A4556, and A4215 in the amount of $2,055.00.
  2. The Carrier refused to pay TIDC's $2,055.00 reimbursement claim for the monitoring services performed during Patient ZB's spinal surgery under denial code U- unnecessary treatment.
  3. TIDC billed the Carrier for four hours of intraoperative monitoring services for Patient T under CPT Code 95920 and services related to the monitoring under CPT codes 95925, A4556, and A4215 in the amount of $1,485.00.
  4. The Carrier refused to pay TIDC's $1,485.00 reimbursement claim for the monitoring services performed during Patient T's spinal surgery under denial code U-unnecessary treatment.
  5. TIDC requested medical dispute resolution from the Texas Workers' Compensation Commission's Medical Review Division for both claims on December 14, 1999.
  6. On March 8, 2001, a medical dispute resolution officer determined that TIDC was not entitled to reimbursement for Patient T's intraoperative monitoring.
  7. On March 26, 2001, a medical dispute resolution officer determined that TIDC was not entitled to reimbursement for Patient ZB's intraoperative monitoring.
  8. TIDC appealed to the State Office of Administrative Hearings and an administrative law judge convened a hearing on April 2, 2002 at which all parties except the Commission's Staff appeared after receiving notice of the date, time, and nature of the hearing in a SOAH court order issued November 12, 2001, and a statement of the applicable rules, statutes, and jurisdiction issued by the Commission. The record closed the same day.
  9. On January 4, 1999, Bruce Hinkley, M.D. performed a lumbar global fusion of the spine with instrumentation on Patient ZB.
  10. On January 8, 1999, Bruce Hinkley, M.D. performed a lumbar laminectomy with decompression from L-2 to the sacral region on Patient T.
  11. Bruce Hinkley, M.D. referred both Patient ZB and Patient T to neurologist Roger S. Blair, M.D. with TIDC who performed intraoperative neurophysiology monitoring during their spinal surgeries.
  12. Intraoperative neurophysiological monitoring is indicated for spinal surgical procedures involving fusion with instrumentation and Patient ZB's lumbar global fusion with instrumentation surgery was documented in the record.
  13. The evidence failed to show that intraoperative neurophysiological monitoring is indicated for spinal surgical procedures involving a lumbar laminectomy with decompression and the record contained inadequate documentation of the medical necessity of the monitoring during Patient T's spinal surgery.

III. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission (Commission) has jurisdiction to decide the issue presented, pursuant to Tex. Lab. Code Ann. ' 413.031 (Vernon 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 2002).
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=t Code Ann. ch. 2001 (Vernon 2002), and the Commission's rules, 28 Tex. Admin. Code '' 148.001-148.028.
  4. The Petitioner timely requested a hearing to challenge the Commission's Medical Review Division's (MRD) decisions, as specified in 28 Tex. Admin. Code '148.3.
  5. The parties were given adequate and timely notice of the hearing in accordance with Tex. Gov=t Code Ann. '' 2001.051 and 2001.052.
  6. The Petitioner had the burden of proof by a preponderance of the evidence in this matter, pursuant to 28 Tex. Admin. Code '148.21 (h) and (i).
  7. A treating physician is responsible for maintaining efficient utilization of health care and for approving or recommending appropriate health care for an injured employee, pursuant to Tex. Lab. Code Ann. '' 408.025(c) and 408.021.
  8. Pursuant to 28 Tex. Admin. Code133.3, the treating physician is required to document the services rendered to a claimant. Commission's rule, 28 Tex. Admin. Code ' 134.1001(e)(2)(A)(1995) (Spine Treatment Guideline), and the Commission's Medical Fee Guidelines (MFG) set out specificdocumentation requirements that are required of a treating physician who performs surgery on an employee who suffered a compensable injury.
  9. Based on Findings of Fact Nos. 1, 3, 4, and 6, the record contained sufficient documentation to establish that the intraoperative monitoring procedures performed on Patient ZB in the amount of $2,055.00 were medically necessary.
  10. Based on Findings of Fact Nos. 2, 3, 5, 7, and 9, TIDC failed to submit sufficient documentation to establish that the intraoperative monitoring procedures performed on Patient T in the amount of $1,485.00 were medically necessary
  11. Based on Findings of Fact Nos. 1, 3, and 9-11, the intraoperative monitoring procedure was performed independently of the surgery and meets the definition of separate procedures in the Commission's Surgery Ground Rule I. E.7, 28 Tex. Admin. Code '134.201.
  12. Based on Conclusion of Law No. 9, TIDC met the documentation requirements and guidelines as provided in Tex. Lab. Code Ann. ' 413.011 and 28 Tex. Admin. Code '' 133.3 and 134.1001(e)(2)(A) for the intraoperative monitoring procedures rendered to Patient ZB.
  13. Based on Conclusion of Law No. 10, TIDC failed to meet the documentation requirements and guidelines as provided in Tex. Lab. Code Ann. ' 413.011 and 28 Tex. Admin. Code '' 133.3 and 134.1001(e)(2)(A) for the intraoperative monitoring procedures rendered to Patient T.

ORDER

IT IS HEREBY ORDERED that Liberty Mutual Fire Insurance Company shall pay Texas Imaging and Diagnostic Center $2,055.00 for the intraoperative monitoring services it provided Patient ZB on January 4, 1999.

IT IS FURTHER ORDERED that Texas Imaging and Diagnostic Center's claim for reimbursement in the amount of $1,485.00 for the intraoperative monitoring services it provided Patient T on January 8, 1999, is denied.

Issued this 4th day of June, 2002.

Deborah L. Ingraham
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. According to the record, intraoperative neurophysiology monitoring or testing is a procedure that monitors the activity and responses of certain nerves during surgery.
  2. No party objected to notice or jurisdiction at the hearing .
End of Document
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