Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-2998-m5
Date:
August 20, 2002
Status:
Retrospective Medical Necessity

453-01-2998-m5

August 20, 2002

DECISION AND ORDER

Montgomery PM&R (the Petitioner) seeks reimbursement from American Home Assurance Company (the Carrier) for $8,754.80 in medical services associated with manipulations, physical medicine modalities, work hardening, and testing provided to workers’ compensation Claimant E.M. between March 20, 2000 and September 15, 2000. The Carrier denied payment on the basis that the services provided were not medically necessary. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) reviewed the Carrier’s action and denied reimbursement for the services for the same reason. The Petitioner challenges that denial. This decision finds the reimbursement should be paid.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues regarding notice of hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened June 24, 2002, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Kerry D. Sullivan. John Schmidt, D.C., appeared by telephone and represented the Petitioner. Allain Collins appeared in person and represented the Carrier. The Commission did not to participate in the hearing. After receipt of evidence, the record was closed the same day.

II.EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consisted of the 478-page certified record of the MRD proceeding. Dr. Schmidt also testified on behalf of the Petitioner. The Carrier presented no witnesses. Based on the evidence, the ALJ concludes the Petitioner’s claim should be approved.

A. The Evidence

Documentary evidence. The Claimant suffered a compensable back injury on_________, when he fell from a garbage truck. He initially saw another doctor, but began going to the Petitioner on December 29, 1999. The Petitioner evaluated the Claimant and placed him on a treatment regime of passive and active therapy. The Petitioner also recommended X-rays and an MRI of the Claimant’s thoracic spine, and these were performed in January 2000. The X-Rays showed no fractures or dislocations, but the Doctor who conducted the MRI made the following observation: “At the L4-5 level, a 2MM broad-based annular bulge is seen to touch and slightly efface the thecal sac with minimal bulging of the disc annulus complex into the inferior neuroforaminal epidural fat bilaterally.” (MRD record at 165).

Dr. Schmidt referred the Claimant to neurosurgeon Roland F. Chalifoux, Jr., who evaluated the Claimant on February 10, 2000, for possible surgical intervention. Dr. Chalifoux noted that he suspected the Claimant’s pain was “due to herniated disk at L4-L5 as demonstrated on MRI study.” (MRD record 338). He deferred a decision on surgical intervention, recommending a more conservative course of action including pain medication, a brace, aquatic therapy, and a muscle stimulator. Dr. Chalifoux also referred the Claimant to Steven W. Eaton, M.D. for consultation regarding pain management. On June 13, 2000, Dr. Eaton examined the Claimant and on June 13, 2000, reported that the Claimant had “valid pain,” which two epidural steroid injections had not helped.

During this time and up to September 15, 2000, the Petitioner continued to provide chiropractic care to the Claimant. Again, the billing dates in dispute in this proceeding are for services provided from March 20, 2000, through September 15, 2000. Until August 15, 2000, the treatment consisted of electrical muscle stimulation, joint mobilization, traction to the lumbar region, massage therapy, myofascial release, ultrasound, aquatic therapy, and other forms of passive and active therapy. From August 15, 2000, through September 15, 2000, the treatment consisted of a work hardening program.

The documentation regarding the Claimant’s work hardening program indicated that the Claimant had a good attitude and was anxious to get back to work but that he felt his pain was holding him back. The program had physical and psychological components and included job- specific tasks such as climbing a ladder and filing as well as more generic physical exercise.

On February 28, 2000, Chiropractor Troy W. Clark conducted a Carrier-requested peer review of the need for ongoing chiropractic care for the Claimant. His assessment is in stark contrast to that offered by Dr. Chalifoux and Dr. Eaton, as well as that of Dr. Schmidt, addressed below. Based on his review of the documentation, Dr. Clark concluded that further chiropractic care was unrelated to the compensable injury and was not reasonable or medically necessary. He concluded the “Claimant has sustained, at worst, a sprain/strain injury” that should have resolved by the date of Dr. Chalifoux’s review.

Testimony. Dr. Schmidt provided the only live testimony offered during the hearing. Dr. Schmidt is a licensed chiropractor and serves as a designated doctor for the Commission. He testified that he began treating the Claimant’s pain with conservative therapy. The Claimant was getting relief but could not sustain it. This led to more invasive and extensive procedures including steroidal injections and referral to the neurosurgeon as a surgical candidate. According to Dr. Schmidt, Dr. Clark must have simply overlooked the documentation of the Claimant’s herniated disc. He concurred with Dr. Chalifoux’s interpretation of the MRI, and testified that there was definitely a structural problem with the Claimant’s spine at L4-L5.

B. Analysis

Pursuant to the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a). Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).

The preponderance of the credible evidence indicates that the Claimant suffered from a herniated disc during the time frames in dispute in this proceeding. Dr. Clark’s conclusion that further chiropractic care was unwarranted because the Claimant suffered nothing more than a strain conflicts with this evidence and should not be accepted. Dr. Clark’s apparent belief that the Claimant was malingering or inventing his symptoms is also disputed by a number of objective tests performed on the Petitioner, including reflex examination, a pinwheel test, and Adams’ sign and Bragard’s sign for identification of disease to the nerve root.

The ALJ found Dr. Schmidt to be a credible witness and accepts his course of treatment as reasonable and necessary. The Claimant’s situation was evaluated and reevaluated on an ongoing basis, and appropriate referrals were made. Pending those, the Petitioner continued to treat the Claimant to provide him with what temporary relief he could. In view of the Claimant’s positive attitude, his desire to return to work, and his need to for further assistance in dealing with his pain, the work hardening program was shown to be medically necessary. As it turns out, the Claimant did not achieve significant improvement during the course of that program. A caregiver’s right to reimbursement should not, however, be made contingent on the results obtained. The decision to place the Petitioner in the work hardening program was reasonable and adequately documented and the fees associated with it should be reimbursed.

III. FINDINGS OF FACT

  1. In_______, (the Claimant) suffered an injury compensable under the Texas Workers’ Compensation Act (Act).
  2. At the time of the Claimant’s compensable injury, American Home Assurance Company (the Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. The Petitioner Montgomery PM&R seeks reimbursement from the Carrier for $8,754.80 in medical services associated with manipulations, modalities, work hardening, and testing provided to the Claimant between March 20, 2000 and September 15, 2000.
  4. The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
  5. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  6. The MRD issued its findings and decision on March 15, 2001, concluding that the disputed expenses should be denied, and the Petitioner timely appealed this decision.
  7. The Claimant suffers from a herniated disc incurred in his ________ compensable injury when he fell from a garbage truck and hit his back. Between March 20, 2000 and September 15, 2000, the Claimant continued to suffer significant pain from this injury.
  8. The course of treatment described in Finding of Fact 3 was reasonable treatment that provided a conservative plan of care for the Claimant. The treatment provided the Claimant with some temporary pain relief.
  9. The treatment program was assessed and reassessed and appropriate referrals were made to assess other options.
  10. The work hardening program included functional, physical, behavioral, and vocational exercises and training.
  11. The MRD record contained sufficient daily progress reports, test results, and SOAP notes to support the need for the disputed expenses.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (the Act), TEX. LABOR 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 and TEX. GOV'T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. The Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i).
  6. Pursuant to the Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a).
  7. Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A).
  8. A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).
  9. The disputed services were medically necessary health care for Claimant.
  10. Based on the foregoing, the Petitioner’s claim for reimbursement from the Carrier for the disputed expenses described in Finding of Fact No. 3 should be granted.

ORDER

IT IS ORDERED that the Petitioner, Montgomery PM&R be reimbursed by American Home Assurance Company for the expenses described in finding of Fact No. 3.

Signed this 20th day of August, 2002.

KERRY D. SULLIVAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
Top