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At a Glance:
December 20, 2001
Retrospective Medical Necessity


December 20, 2001


This case is a dispute over medical services rendered by Petitioner to claimant ____ __________ on __________. Respondent Pacific Indemnity Company (Carrier) determined that __________ injury was not compensable under workers’ compensation and, consequently, denied Petitioner’s claim for reimbursement for the services rendered. Petitioner then pursued resolution of the claim through the medical dispute resolution process, resulting in this proceeding. The amount in controversy is $1,072.00.

The Administrative Law Judge (ALJ) finds that Carrier is liable to reimburse Petitioner for the services rendered. Specifically, the ALJ notes that Carrier preauthorized the services prior to its determination of non-compensability. Then, its determination of non-compensability was made only a few days prior to the medical services being performed–without the treating physician being notified of Carrier’s determination of non-compensability. Under these circumstances, the ALJ finds that Carrier is estopped from contesting Petitioner’s right to reimbursement and is liable for reimbursing the services it authorized.

I. Findings of Fact

  1. The patient, __________, suffered an injury on or about ___________.
  2. The patient was referred by her primary treating physician to Dr. Michael Vengrow of Neurological Doctors of Dallas (Petitioner).
  3. On March 3, 2000, Petitioner consulted with Carrier regarding the proposed treatment. Carrier’s representative, Ms. Roberts, confirmed that the proposed treatment was authorized by Carrier.
  4. On March 10, 2000, Carrier determined that __________injury was not compensable under workers’ compensation insurance. Dr. Vengrow was not made aware of Carrier’s determination of non-compensability. __________ did not challenge Carrier’s determination and the injury has not been found to be compensable.
  5. On March 14, 2000, Dr. Vengrow treated _________at his office. His treatment consisted of (1) an office consultation; (2) EMG-muscle test; (3) nerve conduction testing; (4) motor nerve testing; and, (5) sensory nerve testing.
  6. The treatment was medically reasonable and necessary and consistent with the Commission’s guidelines.
  7. For the services rendered by Dr. Vengrow, Petitioner billed Carrier $1,460.00. The maximum allowable reimbursement under the Commission’s guidelines for the services rendered is $1,072.00.
  8. On April 18, 2000, Carrier denied reimbursement for the services rendered by Dr. Vengrow on the basis of its prior determination of non-compensability of _____ ________ injury.
  9. Petitioner a filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement of $1,072.00.
  10. On March 16, 2001, the Commission’s Medical Review Division (MRD) determined that only $181.00 was due Petitioner. Further, MRD concluded this amount was due only in the event that _____________ injury was determined to be compensable.
  11. Petitioner filed a timely request for hearing before the State Office of Administrative Hearings (SOAH).
  12. Notice of the hearing was sent April 30, 2001.
  13. 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.
  14. The hearing was held December 10, 2001, with Administrative Law Judge Craig R. Bennett presiding and representatives of the Carrier and Petitioner participating. The hearing was adjourned the same day.

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. Petitioner has met its burden of proving it was entitled to reimbursement.
  6. Petitioner’s request for reimbursement in the amount of $1,072.00 should be granted.


IT IS, THEREFORE, ORDERED that the request by Michael Vengrow, M.D., on behalf of Neurological Doctors of Dallas, for reimbursement in the amount of $1,072.00 from Pacific Indemnity Company for services rendered on March 14, 2000, is GRANTED. Pacific Indemnity Company is ORDERED to reimburse Michael Vengrow, M.D., on behalf of Neurological Doctors of Dallas, the sum of $1,072.00 for the services at issue in this contested case proceeding.

Signed December 20, 2001.


Administrative Law Judge

End of Document