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At a Glance:
Title:
453-01-3241-m5
Date:
December 27, 2002

453-01-3241-m5

December 27, 2002

DECISION AND ORDER

Don R. Bennett, D.C. (Dr. Bennett or the Provider), appealed the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD). MRD denied the Provider’s reimbursement request for chiropractic services because the Provider submitted no office visit notes to demonstrate the treatment’s medical necessity. The Carrier also asserted that the documentation was inadequate and further contended that the services were not related to the compensable injury. This decision agrees with MRD and the Carrier as to the documentation issue and denies the reimbursement request.

I. JURISDICTION, NOTICE AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed only in the findings of fact and conclusions of law.

II. APPLICABLE LAW

When treatment was provided, the Spine Treatment Guideline (STG), 28 Tex. Admin. Code §34.1001 (1999), required documentation that described the injury, the events surrounding the injury, and the extent and severity of the injury; any pre-existing, complicating, or non-related conditions; a treatment plan, including proposed methods of treatment, expected outcomes, and probable duration of treatment; updates to the treatment plan as needed, including the claimant’s clinical progress and changes based on the claimant’s response to treatment; education [sic] information regarding the injury and treatment plan and the claimant’s compliance with the plan; and documentation substantiating the need for deviation from the guideline, if necessary. STG (e)(3)(B).

An employee who sustains 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:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment. Tex. Lab. Code § 408.021

Under 28 Tex. Admin. Code §148.21(h), the Provider has the burden of proof.

III. DISCUSSION

Facts and Argument

On_______, the claimant suffered a compensable injury to her lower back. Dr. Bennett diagnosed the claimant as having acute lumbar and sacral sprain and discopathy. The claimant did not undergo magnetic resonance imaging or see an orthopedic surgeon for additional diagnostic testing. She was treated by Dr. Bennett and reached maximum medical improvement on May 9, 1996, with a twelve-percent impairment rating.

Payment for office visits and manipulations provided during nine treatment dates from March 1, 1999, to November 9, 1999, is disputed in this case. According to Dr. Bennett, who testified at the hearing, he decompressed a disc to give her relief for activities of daily living.

Dr. Bennett’s charges for completing five TWCC-64 forms, Specific and Subsequent Medical Reports, are also contested. To the question about the injured employee’s condition, Dr. Bennett responded the same way on all the forms, “Paraspinal pain L5/S1 (intermittant) [sic]. Restricted Lumbar ROM (Flexion) Minors (+).” On two TWCC 64 forms, the additional words, “Improved” and “Followup PRN” are added. The treatment plan on the forms states, “Patient has completed corrective care and ME was performed -- documenting 12% permenant [sic] impairment due to lumbar disc injury. Patient will be treated PRN for (permenant ) [sic] residual.” (Ex. 1, 64-65.)

In response to cross-examination, Dr. Bennett admitted that these notes are the only evidence of his treatment plan. There are no office visit notes in the record, and in submitting the request for dispute resolution, Dr. Bennett affirmed that all medical records were included with the supporting documentation.

The Carrier’s peer review chiropractor determined that even though chiropractic treatment may have relieved discopathy pain, the pain was not related to the compensable twisting injury suffered almost four years before the treatment in question. In the peer reviewer’s opinion, the claimant’s intervertebral disc spacing at L5-S1 would have been expected from a 66-year old person based on the wear and tear that occurs through life. (Ex. 1, 14-15.) On the other hand, Dr. Bennett’s initial medical report indicates that the claimant had no prior symptoms in her mid-to-low back. (Ex. 1, 44.)

Analysis

In the ALJ’s opinion, the TWCC 64 forms do not meet the STG documentation requirements. Also, because documentation was inadequate, the Provider failed to meet his burden of proving the relationship of the compensable injury and the treatment provided so long after the injury date. Nothing in the record outlines a treatment plan, including proposed methods of treatment, expected outcomes, and probable duration of treatment. There are no updates to the treatment plan based on the claimant’s treatment response. Apart from the CPT code and billing, the records do not even indicate the nature of treatment provided, and nothing reflects that educational information was provided to the claimant, as required by the STG.

Without the documentation, the ALJ cannot determine whether the treatment met the Labor Code requirements of curing or relieving the effects naturally resulting from the compensable injury, promoted the claimant’s recovery, or enhanced her ability to return to or retain employment. Therefore, the ALJ agrees with MRD and the Carrier that there is insufficient documentation to support reimbursement.

IV. FINDINGS OF FACT

  1. On______, the claimant suffered a compensable injury to her lower back.
  2. The petitioner, Don R. Bennett, D.C. (Dr. Bennett or the Provider), treated the claimant, who reached maximum medical improvement on May 9, 1996, with a twelve-percent impairment rating.
  3. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) issued a decision on April 23, 2001, denying any reimbursement for treatment provided from March 1, 1999, to November 9, 1999, and for Specific and Subsequent Medical Report form charges.
  4. Dr. Bennett appealed the MRD decision by letter received May 10, 2001.
  5. Notice of the hearing was served on all parties on June 21, 2001, and the Commission’s Statement of Matters Asserted was filed February 19, 2002.
  6. Together, the notice and the statement of matters asserted included a statement of the time, place, and nature of the hearing; 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.
  7. After continuances were granted upon Dr. Bennett’s request, the hearing on the appeal convened on October 25, 2002.
  8. Both Dr. Bennett and the Carrier were represented at the hearing.
  9. The record closed on October 28, 2002, after the Carrier and Provider supplied copies of pertinent rules.
  10. Although Dr. Bennett testified that his treatment relieved the claimant’s pain and that he decompressed the disc to give her relief for daily living activities, no office visit notes indicate: the proposed methods of treatment, expected outcomes, and probable duration of treatment; updates to the treatment plan as needed, including the claimant’s clinical progress and changes based on the claimant’s response to treatment; educational information was provided to the claimant regarding the injury and treatment plan and the claimant’s compliance with the plan; and documentation substantiating any needed deviation from the guideline. 28 Tex. Admin. Code § 134.1001, STG (e)(3)(B)(1999).
  11. With the exception of a few references to treatment as needed for residual care, there is no treatment plan in the record.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide this case, pursuant to the Texas Workers’ Compensation Act, Tex. Lab. 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. Lab. Code §413.031(d) and Tex. Gov't Code, Ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov't Code §§ 2001.051 and 2001.052.
  4. Because of inadequate documentation, it is impossible to determine whether the treatment was medically necessary.
  5. Dr. Bennett bore the burden of proof in this proceeding. 28 Tex. Admin. Code §148.21(h).
  6. The reimbursement request should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the reimbursement request of Don R. Bennett, D.C. is denied.

Signed this27thday of December 2002.

SARAH G. RAMOS
Administrative Law Judge

STATE OFFICE OF ADMINISTRATIVE

End of Document
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