Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-2630-m5
Date:
January 14, 2002
Status:
Retrospective Medical Necessity

453-01-2630-m5

January 14, 2002

DECISION AND ORDER

This case is a dispute over whether a medical procedure received preauthorization. _____ (Claimant) underwent a selective nerve root block & lumbar epidural steroid injection procedure on May 14, 1999, at Houston Spine and Neurosurgery Center (Provider). Provider billed Carrier for this procedure. Carrier refused to reimburse Provider for this procedure claiming there was no preauthorization. Provider claims it received preauthorization to perform this procedure. The amount in controversy is $828.00.

The Administrative Law Judge (ALJ) concludes the Petitioner met its burden of proving the medical procedure in question had not received preauthorization. Therefore, the ALJ finds Carrier is not required to reimburse Provider for medical procedures performed without preauthorization.

FINDINGS OF FACT

  1. Claimant suffered a compensable injury on_______
  2. Claimant was referred to the Co-Respondent, Houston Spine and Neurosurgery Center for treatment (Provider).
  3. On April 16, 1999, Provider faxed a preauthorization request form (request) to Texas Workers’ Compensation Insurance Fund, now known as Texas Mutual Insurance Company (Carrier).
  4. The request indicated Claimant’s diagnosis was lumbar stenosis.
  5. The request identified the treatment/procedure as selective nerve root block & lumbar epidural steroid injection.
  6. Normally the selective nerve root block & lumbar epidural steroid injection procedure does not require preauthorization from the Carrier.
  7. Under 28 Tex. Admin. Code ' 134.600(h)(1) and (2), preauthorization is necessary for any treatment that is performed at a hospital or ambulatory surgery center. Preauthorization was necessary in this case because the procedure was to be performed at Columbia Clear Lake Regional Hospital.
  8. On April 8, 1999, a preauthorization approval letter was forwarded to Keith Shauder, M.D., claimant’s treating doctor. The letter indicated the selective nerve root block and lumbar epidural steroid injection procedure was approved. A case number of 99096plt902 was assigned to this procedure. The letter contained all necessary material in compliance with 28 Tex. Admin. Code ' 134.600(e)(3) and (4).
  9. Lumbar stenosis is usually treated with a series of selective nerve root block and lumbar epidural steroid injection treatments.
  10. Depending on how a claimant reacts to the first treatment, a claimant usually undergoes two or three separate selective nerve root block treatments for lumbar stenosis.
  11. The approval letter of April 8, 1999, stipulated only one treatment was approved.
  12. On April 16, 1999, Claimant underwent selective nerve root block and lumbar epidural steroid injection treatment as authorized.
  13. On May 14, 1999, Provider administered another selective nerve root block and lumbar epidural steroid injection treatment on Claimant.
  14. The selective nerve root block and lumbar epidural steroid injection administered to Claimant on May 14, 1999, required preauthorization.
  15. Provider billed Carrier for the selective nerve root block and lumbar epidural steroid injection administered to Claimant on May 14, 1999.
  16. Carrier denied reimbursement to Provider for the procedure performed on May 14, 1999, claiming Provider had not obtained preauthorization to administer any procedure on May 14, 1999, on Claimant.
  17. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the procedure performed on May 14, 1999, on Claimant.
  18. On March 6, 2001, the Commission’s Medical Review Decision (MRD) found Provider was entitled to a reimbursement of $828.00 for services performed on May 14, 1999. Carrier was ordered to remit $828.00 to Provider.
  19. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  20. Notice of the hearing was sent April 12, 2001.
  21. 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.
  22. The hearing was held November 20, 2001, with ALJ Steven M. Rivas presiding and representatives of the Carrier, Provider, and the Commission participating. The hearing was adjourned the same day.
  23. Provider received preauthorization for the medical procedure administered to Claimant on April 16, 1999. Provider needed, but did not obtain preauthorization for the additional selective nerve root block and lumbar epidural steroid injection treatment administered to Claimant on May 14, 1999.
  24. Provider failed to offer sufficient evidence that it received preauthorization for the procedure performed on May 14, 1999.

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 Carrier, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code ' 148.21(h).
  5. Title 28 Tex. Admin. Code §134.600 outlines the procedure for requesting preauthorization for applicable medical procedures. Because Provider did not receive preauthorization for the procedure performed on May 14, 1999, Provider is not entitled to reimbursement of $828.00.
  6. Carrier has met its burden of proving Provider had not received preauthorization for the medical procedure performed on May 14, 1999.
  7. Carrier is not required to reimburse Provider for medical procedures performed without preauthorization.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Houston Spine and Neurosurgery Center, is not entitled to reimbursement of $828.00 from the Carrier, Texas Mutual Insurance Company, for the medical procedure performed on May 14, 1999.

Signed January 14, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

End of Document
Top