DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Walter J. Mellgren, Jr., D.C., seeks reimbursement from Employers Insurance of Wausau (the Carrier) for the chiropractic treatments administered to workers compensation Claimant ____________on an as-needed basis in 2000. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement for the charges. Petitioner challenged the denial.

The Administrative Law Judge (ALJ) convened the hearing on December 11, 2001; the hearing concluded and the record closed on that date. Petitioner appeared in his own behalf by telephone. Attorney Shannon Butterworth represented the Carrier.

II. EVIDENCE AND BASIS FOR DECISION

The issue in this case is whether Petitioner complied with the Commission’s documentation requirements and should be reimbursed for the chiropractic manipulations he provided the Claimant.

The documentary evidence consisted of the 113-page certified record of the MRD proceeding. Dr. Mellgren nd Claimant testified that Claimant needed the treatments in order to perform his job. The Carrier cross-examined the witnesses. Based on the evidence, the ALJ concludes that Petitioner’s claim should be denied. The particular facts, reasoning, and legal analysis in support of this decision are set out below in the Findings of Fact and Conclusions of Law. In summary, the ALJ finds Petitioner’s documentation did not establish that Claimant’s condition was improved by the chiropractic treatments.

III. FINDINGS OF FACT

1. On _______________(Claimant), a sheet metal mechanic employed by _______, suffered a compensable injury that resulted in a lumbar sprain.
2. _________ had workers’ compensation coverage with the Employers Insurance Company of Wausau (Carrier) at that time.
3. Petitioner treated Claimant, who suffered from low back pain, low back stiffness, and pain radiating down the left leg, since 1994 with chiropractic manipulation. Claimant was diagnosed as having acute lumbar sprain/strain (grade II).
4. Petitioner did not sign the daily clinical notes that were submitted to substantiate the medical necessity for the chiropractic treatment. The notes also failed to include Petitioner’s comments about updates to the treatment plan, including Claimant’s clinical progress, and any changes needed to the treatment plan based on Claimant’s response to the treatment.
5. On June 26, 2000, Petitioner noted great improvement in Claimant’s condition since the last treatment, but on July 25 & 26, 2000, he indicated Claimant’s condition was slightly worse since the last treatment. Petitioner’s notes did not indicate that any changes were required in the treatment plan to address Claimant’s changed condition.
6. Petitioner’s daily clinical notes did not show how Claimant rated his pain after each chiropractic treatment was administered.
7. The documentation supplied by Petitioner to substantiate the medical necessity for the manipulation treatment did not show Claimant made substantive and continued improvement over the course of the treatment.
8. Petitioner submitted his charges for the chiropractic treatment he provided Claimant between February 28, 2000, and October 4, 2000, (amounting to $896.00) to the Carrier.
9. The Carrier denied payment of the charges, indicating the treatment was not medically necessary.
10. Petitioner requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on January 11, 2001, seeking reimbursement for the chiropractic treatment.
11. On March 16, 2001, the MRD issued a decision denying reimbursement for the chiropractic treatment because the documentation supplied did not substantiate the medical necessity for the treatments provided.
12. On April 10, 2001, Petitioner appealed the MRD’s decision.
13. On April 30, 2001, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.

IV. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
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 § 413.031(d) of the Act; Tex. Gov’t Code Ann. ch. 2003 (Vernon 2000), and 28 Tex. Admin. Code (TAC) chs. 148 and 149 (2001).
3. Petitioner timely appealed the MRD’s decision, pursuant to 28 TAC §148.3.
4. The notice of hearing sent by the Commission complied with the requirements of Tex. Gov’t Code §2001.052 and of 28 TAC §148.4(b).
5. Petitioner had the burden of proof to show by a preponderance of the evidence that he should prevail in this matter, pursuant to §413.031 of the Act and 28 TAC §148.21(h) and (i).
6. Section 408.021 of the Act and 28 TAC §134.1 provide that health care providers shall bill carriers only for treatments and services rendered that are medically necessary to treat the compensable injury, and in accordance with Commission rules and guidelines.
7. Petitioner failed to show through the documentation supplied that the chiropractic treatments were medically necessary to relieve the effects of the compensable injury.
8. Pursuant to 28 TAC §134.1001(e)(2)(E), manipulation should be performed for the minimum appropriate duration. The health care provider is required to provide objective documentation that shows substantive and continued improvement over time from the treatment.
9. Petitioner failed to show that the manipulation treatment performed was for the minimum appropriate duration.
10. Pursuant 28 TAC §134.1001(e)(3)(B), (C) and (D), Petitioner was required to provide detailed documentation to determine the phase of care to be provided and the necessity for that care. With regard to chiropractic treatments, documentation should show objective substantive and continued measures of improvement over time.
11. The Petitioner failed to show through objective documentation the chiropractic treatment he provided resulted in substantive and continued improvement in Claimant’s condition, pursuant to the requirements of 28 TAC §134.1001(e).
12. Based upon the foregoing Findings of Fact and Conclusions of Law, Petitioner’s request for reimbursement should be denied.

ORDER

It is hereby ordered that the appeal of Walter J. Mellgren, Jr., D.C., is denied because the documentation submitted did not meet the requirements of 28 Tex. Admin. Code § 134.1001 (e) to show the treatment was medically necessary as required by Tex. Lab. Code Ann. § 408.021 or reimbursable as set forth in 28 Tex. Admin. Code §134.1.

Signed this 15^th day of January 2002.

RUTH CASAREZ
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS