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At a Glance:
Title:
453-01-2595-m5
Date:
September 13, 2002
Status:
Retrospective Medical Necessity

453-01-2595-m5

September 13, 2002

DECISION AND ORDER

This is a dispute over reimbursement for physical medicine treatments and related office visits, work hardening services, and TENS unit supplies. The total amount in dispute is $18,488.80.

The Administrative Law Judge concludes the physical medicine treatments and related office visits were reasonable and necessary medical treatments. He concludes the work hardening services and the TENS unit supplies were not. He orders additional reimbursement of $6,995.00 plus interest.

I. Discussion

The Claimant, a kitchen worker for the ________________ (____ ISD), sustained a compensable injury_________. She began treatment with Pete McRee, D.C. of the Back & Joint Clinic, on March 3, 1999. The Claimant underwent a series of physical medicine treatments at the Back & Joint Clinic from March 3, 1999, through May 7, 1999. On May 11, 1999, the Clinic performed a Functional Capacity Evaluation (FCE), after which the Claimant began a work hardening program. The work hardening program lasted from May 17, 1999, through June 28, 1999. After a couple of additional physical medicine sessions and another FCE, the Claimant returned to work August 3, 1999.

_____ ISD declined to reimburse the Back & Joint Clinic for virtually all the services it performed. After the Back & Joint Clinic filed a Request for Medical Dispute Resolution, the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) ordered _____ ISD to reimburse the Back & Joint Clinic for the physical medicine treatments from March 3 through March 19, 1999; a few later office visits and treatments; and FCEs on May 13 and July 2, 1999.

It declined to order reimbursement for most of the physical medicine services rendered from March 23, 1999, through May 7, 1999; for any of the work hardening; or for TENS units supplies provided on March 8, 1999. The Back & Joint Clinic requested a hearing before SOAH. _____ ISD did not.

The three groups of services or items at issue are:

  1. the physical medicine services provided from March 23, 1999, through May 7, 1999 ($6,995.00 in dispute);
  2. the work hardening services provided from May 17, 1999, through June 25, 1999 ($11,468.80 in dispute); and
  3. the TENS unit supplies ($25.00 in dispute).
  4. Physical Medicine Services from March 23, 1999, through May 7, 1999

The Carrier contended these physical medicine services were unnecessary. The MRD agreed, and declined to order reimbursement.

According to Dr. McRee’s clinical evaluation of March 23, 1999, which occurred approximately six weeks after the injury, the Claimant stated her pain had improved, but she was still unable to work or do housework. The testing caused the Claimant pain as well. She did not meet the minimum acceptable performance levels on the physical capacity tests. Dr. McRee recommended additional treatment of three sessions per week for about six weeks. Ex. 1, pp. 200-208.

William E. Blair, Jr., M.D., who reviewed the Claimant’s medical records for _____ ISD in January of 2000, was very critical of Dr. McRee and of the extent of his treatment of the Claimant. He stated Dr. McRee’s diagnoses “appear to be pulled out of thin air.” Ex. 1. p. 417. However, he did not dispute the need for some additional treatment after March 23, 1999:

Maximum benefit from chiropractic care is expected by the end of 8 weeks of care. Ongoing chiropractic services were reasonable through 04-18-99 with a possible extension through 05-05-99.

Ex. 1 at 419.

Dr. Blair believed the Claimant was essentially “held hostage” by the Back & Joint Clinic and ultimately decided to return to work on her own. Although that interpretation reflects badly on the Back & Joint Clinic, it also implies the Claimant was motivated to return to work and that her complaints of pain on March 23, 1999, were legitimate.

The ALJ concludes the Back & Joint Clinic met its burden of proving the medical necessity of the physical medicine treatments it provided the Claimant from March 23, 1999, through May 7, 1999.

B. Work Hardening Services from May 17, 1999, through June 25, 1999

“Work hardening” is

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. . . .

TWCC 1996 Medical Fee Guideline, p. 37

The evidence does not show the Claimant to be a legitimate candidate for work hardening. The May 11, 1999, FCE states the Claimant was experiencing only mild pain and could concentrate fully. Her range of motion was fair. According to Dr. McRee,

There does not appear to be evidence of significant anxiety in the patient. There appears to be evidence of significant signs of depression in the patient.[1]

Ex. 1, p. 347.

Although Dr. McRee believed the Claimant displayed “significant psychosocial dysfunctions” during the evaluation, those are not described in any detail. Nowhere does Dr. McRee’s evaluation explain how a work hardening program, as defined above, was necessary to enable the Claimant to return to work.

The ALJ concludes the Back & Joint Clinic did not prove the work hardening program was medically necessary. He denies reimbursement for those services.

Because he concludes the work hardening program was not medically necessary, the ALJ does not address the issue of whether the conduct of the program was properly documented.

C. TENS Unit Supplies

It is possible that the Claimant did need a transcutaneous electric nerve stimulator (TENS unit). If so, she needed the supplies. The ALJ could not find anything in the record addressing the need for the unit, however. Therefore, he denies reimbursement.

II. Findings of Fact

  1. The Claimant, a kitchen worker for the _________ (_____ ISD), sustained a compensable injury _______.
  2. The Claimant began treatment with Pete McRee, D.C. of the Back & Joint Clinic, on March 3, 1999.
  3. The Claimant underwent a series of physical medicine treatments at the Back & Joint Clinic from March 3, 1999, through May 7, 1999.
  4. On May 11, 1999, the Clinic performed a Functional Capacity Evaluation (FCE), after which the Claimant began a work hardening program. The work hardening program lasted from May 17, 1999, through June 28, 1999.
  5. After a couple of additional physical medicine sessions and another FCE, the Claimant returned to work August 3, 1999.
  6. _____ ISD declined to reimburse the Back & Joint Clinic for virtually all the services it performed.
  7. After the Back & Joint Clinic filed a Request for Medical Dispute Resolution, The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) ordered ____ ISD to reimburse the Back & Joint Clinic for the physical medicine treatments from March 3 through March 19, 1999; a few later office visits and treatments; and FCEs on May 13 and July 2, 1999.
  8. The MRD declined to order reimbursement for most of the physical medicine services rendered from March 23, 1999, through May 7, 1999; for any of the work hardening; or for TENS units supplies provided on March 8, 1999.
  9. The Back & Joint Clinic requested a hearing before SOAH; ______ ISD did not.
  10. Notice of the hearing was sent to the parties April 11, 2001.
  11. 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.
  12. The hearing was held May 22, 2002, before the undersigned Administrative Law Judge (ALJ), with representatives of both parties participating.
  13. The three groups of services or items at issue are:
  14. the physical medicine services provided from March 23, 1999, through May 7, 1999 ($6,995.00 in dispute);
  15. the work hardening services provided from May 17, 1999, through June 25, 1999 ($11,468.80 in dispute); and
  16. the TENS unit supplies ($25.00 in dispute).
  17. The total amount in dispute is $18,488.80.
  18. On March 23, 1999, the Claimant was experiencing pain and was still unable to work or do housework.
  19. The Claimant did not meet the minimum acceptable performance levels on the physical capacity tests conducted March 23, 1999.
  20. The Claimant was motivated to return to work and her complaints of pain on March 23, 1999, were legitimate.
  21. The physical medicine services provided to the Claimant from March 23, 1999, through May 7, 1999, were medically necessary.
  22. On May 11, 1999, the Claimant was experiencing only mild pain and could concentrate fully. Her range of motion was fair.
  23. Although the Claimant may have been depressed, she did not need a highly structured, goal-oriented, individualized, interdisciplinary treatment program such as work hardening.
  24. The Claimant did not need a TENS unit or supplies for such a unit.

III. 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. Govt Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Govt Code Ann. §2001.052.
  4. The Back & Joint Clinic has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. The Back & Joint Clinic met its burden of proving it was entitled to additional reimbursement of $6,995.00 for physical medicine services provided to the Claimant from March 23, 1999, through May 7, 1999.
  6. The Back & Joint Clinic did not meet it burden of proving it was entitled to additional reimbursement for work hardening services provided to the Claimant from May 17, 1999, through June 25, 1999.
  7. The Back & Joint Clinic did not meet it burden of proving it was entitled to additional reimbursement for TENS unit supplies provided to the Claimant.

ORDER

IT IS, THEREFORE, ORDERED that ___________ reimburse the Back & Joint Clinic the amount of $6,995.00, plus interest, for physical medicine services provided to the Claimant from March 23, 1999, through May 7, 1999. All other requests for reimbursement are denied.

Signed this 13th day of September, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. After completion of the work hardening program, the Claimant no longer showed evidence of significant depression, but did show evidence of significant anxiety. Ex. 1, p. 372.
End of Document
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