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Title: 

453-01-3392-m5

Date: 

May 14, 2002

Type: 

Retrospective Medical Necessity

453-01-3392-m5

DECISION AND ORDER

Bridgestone Healthcare Management (Petitioner) appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in MDR Docket No. M5-01-1334-01 which denied reimbursement for work hardening services and an office visit provided _____ (Claimant). The MRD decision, issued May 21, 2001, upheld a denial of reimbursement by American Home Assurance Company (Carrier) based on lack of documentation of medical necessity. This decision finds Carrier should reimburse Petitioner for the work hardening services but not for the office visit.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing in this matter was held April 25, 2002, at the State Office of Administrative Hearings, 300 W. 15th Street, Austin, Texas, with Administrative Law Judge (ALJ) Ann Landeros presiding. Petitioner appeared through its attorney Scott Hilliard. Respondent Carrier was represented by attorney Scott Bouton. The Commission did not participate. The record closed that day.

II. DISCUSSION

A. Background Facts

In_____, Claimant fell on her buttocks, sustaining an injury to her lower back that was compensable under the Texas Workers’ Compensation Act (Act). At the time of the compensable injury, Claimant’s employer had workers’ compensation insurance coverage with Carrier.

In_______, Claimant began receiving chiropractic care from Dr. Osler Kamath, D.C. Dr. Kamath referred Claimant to Petitioner’s work hardening program in June 2000. Petitioner billed Carrier for the work hardening program and was paid for all dates of service except June 20, 23, and 26, 2000. Out of a six-week program, Carrier denied payment only for those dates of service as being medically unnecessary. Carrier paid for exactly the same services provided earlier and later in the program. Carrier also claimed an office visit billed on July 28, 2000, was not medically necessary. The MRD found no reimbursement due for the three work hardening dates or the office visit, stating that Petitioner failed to adequately document that services were medically necessary for Claimant.

B. Applicable Statutes and Rules

Petitioner has the burden of proof in this proceeding. 28 TAC §§148.21(h) and (I). 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). Work hardening is defined in 28 TAC § 134.1001(g)(69) and the Commission’s Medicine Ground Rule II.E. as a interdisciplinary program tailored to improve the worker’s functional, physical, behavioral, and vocational needs.[1]

C. Petitioner’s Evidence

Petitioner claimed the work hardening program and office visit were medically necessary health care for Claimant. In support of its position, Petitioner submitted a letter from Dr. Kamath which listed Claimant’s improved muscle strength and range of motion during her treatment.[2] Dr. Kamath explained that he sent Claimant to the work hardening program after her improvement with chiropractic treatment reached a plateau. He noted her post-program FCE on July 28, 2000, showed the following improvements:

Whole body range of motion activities reported using Methods-Time-Measurement (MTM) improved from 47 to 72 for stooping; 50 to 72 for kneeling; 38 to 57 for crouching; 57 to 78 for forward and 37 to 59 for overheard. (Exh. 1, p. 20).

Petitioner also pointed to the report of Dr. Richard Klics, D.C., who performed the independent medical examination of Claimant’s impairment rating assessment on July 31, 2000. Dr. Klics stated Claimant “reported she has been treating with Dr. Osler Kamath whose specialty is chiropractic. The treatment plan has consisted of physical medicine modalities and chiropractic manipulative therapy at the affected areas. It appears that all treatment to this date was appropriate and clinically indicated.”(Exh. 2, p. 6). Petitioner submitted copies of daily treatment reports with notations of Claimant’s progress in the work hardening program on June 20, 23, and 26, 2000.

Dr. Kamath testified his lumbar disc disorder diagnosis was based on the pain radiating into Claimant’s buttocks, which established the injury had a neurological component, as opposed to being simply a muscular strain or sprain. Along with clinical observations, he pointed to an MRI which showed bulges and an EMG with a prolonged signal on the right side of Claimant’s spinal cord as supporting his diagnosis. He also testified that the July 28, 2000, office visit was medically necessary because as Claimant’s treating physician, he needed to evaluate her future care based on her progress in the work hardening program.

D. Carrier’s Position

Carrier agreed with the MRD’s finding that Petitioner failed to document that the work hardening program was medically necessary for Claimant. It concluded that although Dr. Kamath diagnosed Claimant with lumbar disc disorder; she actually just had a lumbar strain, as shown by the reports of the designate and IME doctors, Dr. Derek Martin, D.C. and Dr. Klics, and by an MRI and EMG. According to Carrier, generally, work hardening is not medically necessary for lumbar strain injuries. Carrier noted Dr. Klics did not specifically mention the work hardening program when he agreed all treatment had been appropriate in his report.

Carrier argued that the July 28th office visit was unnecessary because on that date the same services were provided as part of the work hardening program.

E. Analysis

According to the Commission’s Spine Treatment Guideline (STG), at the time she was referred to the work hardening program, Claimant was at the secondary level of care for which work hardening is an approved treatment. 28 TAC §134.1001 (g)(7)(B). Petitioner’s evidence showed that Claimant was sent to the work hardening program because her progress with chiropractic care had reached a plateau; Dr. Kamath thought the program would enable her to enable her to stoop, lift, and carry objects, all activities necessary in her job as a kitchen assistant; and she was able to benefit from and participate in the program. This evidence met the entrance criteria of Medicine Ground Rule II.E.1, 28 TAC § 134.201, which requires the person be able to participate in and a benefit from the program and that the program be tailored to enhance the ability to perform identifiable job tasks. Petitioner provided daily notes for June 20, 23, and 26, 2000, which showed the type and duration of activities Claimant participated in on those dates, the purpose of each activity, and her performance results. This sufficiently documented the daily treatment and Claimant’s response thereto as required by Medicine Ground Rule II. E.8, 28 TAC § 134.201.

Although Dr. Kamath’s diagnosis was not supported by the other doctors or the diagnostic test results, all of which found Claimant’s lumbar spine to be essentially normal, his referral to the work hardening program was supported not only by the IME doctor, Dr. Klics, but also by a Dr. Guess who evaluated Claimant in August 2000 and recommended a work hardening program for her. (Exh. 2, p. 1). Carrier failed to prove its contention that work hardening programs are not suitable for persons with lumbar sprains or strains. Indeed, neither the Medicine Ground Rules nor the STG disapprove work hardening for a specific type of injury.

Petitioner justified Claimant’s office visit with Dr. Kamath that day as necessary to evaluate further treatment needs. The one document in the record regarding the office visit failed to describe the components required by the Commission’s rules to document an office visit under billed under CPT code 99213: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Evaluation/Management Ground Rules, CPT 99213, 28 TAC §134.201. Whether necessary or not, Dr. Kamath failed to adequately document the office visit on July 28, 2000, so Petitioner is not entitled to reimbursement for that service.

III. FINDINGS OF FACT

  1. In_______, ____ (Claimant) fell, sustaining an injury to her lower back that was compensable under the Texas Workers’ Compensation Act (Act).
  2. At the time of Claimant’s compensable injury, American Home Assurance Company (Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. In_______, Claimant began receiving chiropractic care from Dr. Osler Kamath, D.C. for ongoing pain.
  4. In June 2000, Dr. Kamath referred Claimant to Bridgestone Healthcare Management’s (Petitioner) work hardening program, which she attended from June 19 through July 28, 2000.
  5. At the time she was referred to the work hardening program, Claimant was at the secondary level of care.
  6. On July 28, 2000, Dr. Kamath had an office visit with Claimant which was billed to Carrier under CPT code 99213.
  7. Carrier paid all dates of service for Claimant’s work hardening program except June 20, 23, and 26, 2000.
  8. Neither Petitioner nor Dr. Kamath provided Carrier with documentation of an expanded problem focused history, an expanded problem focused medical examination, or medical decision making of low complexity regarding Claimant’s July 28th office visit.
  9. Petitioner provided daily notes for June 20, 23, and 26, 2000, which showed the type and duration of activities Claimant participated in on those dates, the purpose of each activity, and her performance results.
  10. Claimant was sent to the work hardening program because her progress with chiropractic care had reached a plateau; Dr. Kamath thought the program would enable her to enable her to stoop, lift, and carry objects, all activities necessary in her job as a kitchen assistant; she had specific employment available as a kitchen assistant if the program was successful; and she lacked other impediments to participating in the program.
  11. The Commission’s Medical Review Division sustained Carrier’s denial of reimbursement for the work hardening services on June 20, 23, and 26, 2000, and for the office visit on July 28, 2000, based on lack of documentation to support medical necessity.
  12. Petitioner timely appealed the MRD decision.
  13. Pursuant to proper notice, Petitioner and Carrier were represented at the hearing held April 25, 2002.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (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 and the Commission’s rules, 28 TEX.ADMIN.CODE (TAC) § 133.305(g).
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. 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). 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).
  8. Work hardening is an interdisciplinary program tailored to improve the worker’s functional, physical, behavioral, and vocational needs. 28 TAC § 134.1001(g)(69) and the Commission’s Medicine Ground Rule II.E, 28 TAC § 134.201.
  9. Work hardening is an approved treatment at the secondary level of care. 28 TAC §134.1001 (g)(7)(B).
  10. To be a candidate for work hardening, Medicine Ground rule II.E.1. requires the participant be likely to benefit from the program; not be hindered from participate by medical, psychological or other conditions; and have an illness or injury that interferes with performance of identifiable job tasks. 28 TAC §134.201.
  11. Medicine Ground Rule II.E.8. requires daily treatment and patient response to treatment be documented during the work hardening program. 28 TAC § 134.201.
  12. Petitioner did adequately document work hardening services provided Claimant on June 20, 23, and 26, 2000, and is entitled to reimbursement from Carrier for those dates of service.
  13. To be entitled to reimbursement under CPT Code 99213, the Commission’s Evaluation/Management Ground Rule, 28 TAC §134.201, requires documentation of an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity.
  14. Petitioner did not adequately document the office visit billed under CPT Code 99213 for Claimant on July 28, 2000, and is not entitled to reimbursement for that service.

ORDER

IT IS ORDERED that Bridgestone Healthcare Management be reimbursed by American Home Assurance Company for work hardening services provided Claimant ____ on June 20, 23, and 26, 2000. It is further ORDERED that Bridgestone Healthcare Management is not entitled to reimbursement from American Home Assurance Company for an office visit with Claimant on July 28, 2000, billed under CPT code 99213.

Signed this 14th day of May 2002.

ANN LANDEROS
Administrative Law Judge

STATEOFFICEOFADMINISTRATIVE HEARINGS

  1. The rule and Medicine Ground Rule II.E. both state: Work Hardening–a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. Work Hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured employee. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of the persons served.↑
  2. Dr. Kamath wrote: “. . . The response to treatment has been good. Since her initial visit, the patient’s muscle strength has improved. Rectus abdominus and intercostal muscle strength, which was 8 lbs on 3/22, increased to 18 lbs on 06/05. Errector spinae muscle strength increased from 15 lbs. On 03/22 to 27 lbs. On 06/05. Range of motion exhibits an improvement overall. Left and right SLR, which was 23 and 27 degrees on 03/22, increased to 73 and 57 degrees respectively. Lumbar flexion continued to be within normal limits while lumbar extension exhibited moderate progress from 18 degrees on 03/22 to 24 degrees on 06/13/00. In mid June Ms. [M]’s progress reached a plateau. At this time she was transitioned to a more aggressive strengthening type regimen.” (Exh. 1, p. 20).↑