Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-2926-m5
Date:
January 9, 2002
Status:
Retrospective Medical Necessity

453-01-2926-m5

January 9, 2002

DECISION AND ORDER

I. Summary

-

Claimant sustained a compensable back injury on ________. John Michael Dulak, D.C., treated Claimant on several occasions in March and April 2000 for continuing pain and restricted range of motion. The treatments consisted of manipulation. Dr. Dulak sought reimbursement under CPT Code 99213. The carrier, Reliance National Indemnity Company (Reliance), denied payment on the grounds that the treatments addressed symptoms too remote in time from the 1998 injury and were not beneficial. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission ordered Reliance to reimburse Dr. Dulak in the amount of $240.00. Reliance appeals. The Administrative Law Judge (ALJ) convened a hearing on these issues on January 7, 2002; the record closed that same day. This Decision finds that the disputed manipulation treatments were medically necessary and are reimbursable under the terms of the Medical Fee Guideline.

II. Evidenceand Discussion

The documentary record in this case consisted of the 97-page certified record of the MRD proceeding (Ex. TWCC 1) and the curriculum vitae of Bill Timberlake, D.C. (Carrier 1), an expert witness for Reliance who testified based on his review of the medical record.

At hearing, Dr. Timberlake testified that most injuries like that of Claimant B a soft tissue strain or sprain B resolve within six to eight weeks. He testified that diagnostic tests showed some degenerative disc changes and suggested chronic radiculopathy that likely pre-dated the July 1998 injury. These conditions, according to Dr. Timberlake, are the probable cause of Claimant’s continuing lower back pain. He stated that Dr. Dulak’s notes lack objective findings supporting continued treatment relating to the 1998 injury.

Dr. Dulak testified that he believes Claimant’s back symptoms in early 2000 represented lingering effects of her compensable injury. He opined that she may have had soft tissue tears slow to heal. He stated that while Claimant reached maximum medical improvement (MMI) in February 1999, she was given an impairment rating of 6%, and may never recover totally. According to Dr. Dulak, Claimant had no back problems prior to her ________ injury, and she has shown improvement in response to the manipulation.

The ALJ finds that Reliance has not shown that the five treatments in March and April 2000 were not medically necessary. The Spine Treatment Guideline provides that some patients are entitled to continuing treatment for pain after MMI has been reached, and further provides that such treatment may include office visits and manipulations. 29 Tex. Admin. Code § 134.1001(g)(6). Over the course of the five disputed treatments, Claimant’s pain improved from a subjective report of 4 on March 6, 2000, to 1-2 on April 24, 2000. In addition, Claimant was noted to have restricted range of motion on March 6 and 22, 2000, and “good” range of motion on April 24, 2000.[1] See TWCC 1, pp. 11 - 19. The notations of Claimant’s range of motion fall within the Spine Treatment Guideline’s examples of objective documentation. See 29 Tex. Admin. Code §134.1001(e)(3)(c)(ii) (“description of patient’s capabilities”). That Claimant had suffered no back difficulties before the 1998 accident, but experienced continued (though declining) problems afterward, suggests that her symptoms 20 months following the accident were linked to her work-related injury. While a doctor indicated in October 1998 that Claimant showed early signs of chronic pain syndrome, see TWCC 1, pp. 51 - 54, Claimant subsequently resumed working and has apparently needed fewer visits over time.

III. FINDINGS OF FACT

  1. On ________, Claimant suffered a compensable back injury diagnosed as lumbar strain/sprain.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Reliance National Indemnity Company (Reliance).
  3. John Michael Dulak, D.C., treated Claimant’s pain and limited range of motion with manipulation on: March 6, March 22, March 24, April 7, and April 24, 2000.
  4. Dr. Dulak billed Reliance for these services under CPT Code 99213.
  5. Reliance denied payment for the March and April 2000 visits on the grounds that the visits were not necessary to treat the compensable injury.
  6. Dr. Dulak requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD).
  7. On April 5, 2001, the MRD ordered Reliance to pay Dr. Dulak $240.00 for the March and April 2000 visits.
  8. Claimant’s symptoms in March and April 2000 were attributable to her work-related injury.
  9. Dr. Dulak’s notes show that Claimant’s pain and restricted range of motion improved over the course of the treatments.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §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 Tex. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Gov’t Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. Reliance has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. The Spine Treatment Guideline indicates that some patients are entitled to continuing treatment for pain after MMI has been reached, and further provides that such treatment may include office visits and manipulation if medically necessary. 29 Tex. Admin. Code § 134.1001(g)(6).
  6. The Spine Treatment Guideline provides that where a patient is treated with manipulation, improvement should be objectively documented. 29 Tex. Admin. Code § 134.1001(e)(2)(E). Objective documentation is described in 29 Tex. Admin. Code § 134.1001(e)(3)(C) and (E), and includes descriptions of a patient’s capabilities.
  7. Based on Findings of Fact 8 and 9, the disputed treatments were medically necessary and reimbursable under the Spine Treatment Guideline.
  8. Dr. Dulak is entitled to reimbursement in the amount of $240.00.

ORDER

It is therefore ordered that the carrier, Reliance National Indemnity Company, shall reimburse John Michael Dulak, D.C., $240.00 for office visits on March 6, March 22, March 24, April 7, and April 24, 2000.

Issued January 9, 2002.

Shannon Kilgore
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Neither Claimant’s pain nor her range of motion showed linear improvement over the five treatments; in particular, there seemed to have been a setback around the April 7 visit.
End of Document
Top