DECISION AND ORDER
Lois Hansen, M.A., L.P.C., (Petitioner) seeks reimbursement for the cost of a mental health evaluation provided to Claimant, _____., under Current Procedural Terminology (CPT) Codes 90801, 90825, and 90889. The City of Houston (Carrier) denied reimbursement, claiming that the evaluation constituted psychological testing, such testing requires preauthorization, and Petitioner failed to seek such authorization. The Texas Workers’ Compensation Commission (Commission) did not appear at the hearing. The amount in controversy is $650.00.
The Administrative Law Judge (ALJ) concludes Petitioner met her burden of proving the services were medically necessary and did not require preauthorization under the Commission’s Medical Fee Guideline (Guideline). Therefore, she is entitled to reimbursement.
In support of its conclusion that the service rendered by Petitioner amounted to psychological testing requiring preauthorization, Carrier referred to § 134.600(h)(2) of the Guideline, which requires preauthorization for psychiatric or psychological therapy or testing, except where performed as a part of work hardening. Because Petitioner’s services were not related to work hardening, Carrier reasoned, preauthorization was required.
Petitioner agreed that psychological therapy or testing required preauthorization, but asserted that her services to Claimant constituted neither therapy nor testing as contemplated in § 134.600(h)(2). Instead, the purpose of her evaluation of Claimant was to determine the need for testing and for such treatments as biofeedback and behavioral pain management, as contemplated by § 134.1000(g)(1) of the Commission’s Mental Health Treatment Guideline. Consequently, the services provided constituted neither therapy nor testing and, therefore, did not require preauthorization.
The ALJ agrees with Petitioner that the services she provided did not constitute psychological testing or therapy as contemplated by the Mental Health Treatment Guideline. Therefore, preauthorization was not required, and Petitioner should be reimbursed.
II. FINDINGS OF FACT
- Claimant, ____., sustained a compensable injury on ___________
- At the time of Claimant’s injury, his employer, The Houston Fire Department, held workers’ compensation insurance coverage through the City of Houston (Carrier).
- Pursuant to a referral from Claimant’s treating doctor, William Langeland, D.C., Lois Hansen, M.A., P.C. (Petitioner) conducted a psychiatric evaluation of Claimant consisting of a clinical interview, a review of Claimant’s medical records, and the preparation of a medical report.
- Petitioner billed Carrier $650.00 for her services, consisting of $360.00 billed under CPT Code 90801, $120.00 billed under Code 90825, and $170.00 billed under Code 90889.
- Petitioner made treatment recommendations based on the evaluation.
- Petitioner did not seek preauthorization for the services.
- Carrier declined to reimburse Petitioner because the services had not been preauthorized.
- Petitioner filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission.
- The Commission’s Medical Review Division (MRD) found in favor of Carrier because Petitioner had failed to seek preauthorization from Carrier.
- Petitioner filed a timely appeal of the MRD decision.
- Notice of the hearing was sent June 27, 2001.
- 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.
- The hearing was held February 28, 2002, with Administrative Law Judge (ALJ) Gary W. Elkins presiding and representatives of Petitioner and Carrier participating. The Texas Workers’ Compensation Commission did not participate. The hearing was closed on March 7, 2002.
- The amount in controversy is $650.00.
- The involved services did not constitute psychological testing or therapy.
III. CONCLUSIONS OF LAW
- 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.
- 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.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
- Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
- Subpart (h)(2) of 28 TAC § 134.600 does not require preauthorization for the types of services provided by Petitioner.
- Petitioner met her burden of proof.
- Petitioner’s request for reimbursement should be granted.
IT IS ORDERED that The City of Houston shall reimburse Lois Hansen, M.A., L.P.C., $650.00 for the services provided under CPT codes 90801, 90825, and 90889.
Signed May 6, 2002.
Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS