Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-01-3469-m5
Date:
May 28, 2002
Status:
Retrospective Medical Necessity

453-01-3469-m5

May 28, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Joseph Neustein, M.D., seeks reimbursement from Western Indemnity Insurance Company (the Carrier) for $174.00 in medical services associated with three office visits by the Claimant on November 12, 1999, January 12, 2000, and February 4, 2000, and the preparation of a required report. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement for these services. Petitioner challenges that denial. The ALJ finds that the services should be reimbursed.

The Administrative Law Judge convened a hearing on this matter on April 17, 2002. The hearing was concluded and the record closed that date. Petitioner Neustein represented himself; the Carrier was represented by Steven M. Tipton; and the Commission did not participate.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consisted of the 121-page certified record of the MRD proceeding. Dr. Neustein also testified on his own behalf. The Carrier presented no witnesses. Based on the evidence, the ALJ concludes that Petitioner’s claim should be approved. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law. In summary, however, the ALJ accepts Dr. Neustein’s testimony that the Claimant suffers from two herniated discs incurred in ___ in a compensable injury while working for _____. The injury was covered by workers compensation insurance written for Claimant’s employer by Western Indemnity Insurance Company. The injury was exacerbated by an additional compensable injury that occurred on ________, while the Claimant was employed by the same employer that remained covered by the same Carrier. The continuing office visits and the report were reasonable and necessary elements of a conservative plan of care for this Claimant.

III. FINDINGS OF FACT

  1. On ___________, _____ (Claimant) suffered a compensable injury to his back.
  2. Claimant’s injury is covered by workers compensation insurance written for Claimant’s employer by Western Indemnity Insurance Company (the Carrier).
  3. Petitioner Joseph Neustein, M.D., seeks reimbursement from the Carrier for $174.00 in medical services associated with three office visits by the Claimant on November 12, 1999, January 12, 2000, and February 4, 2000, and the preparation of a required report.
  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 May 31, 2001, concluding that the disputed expenses should be denied, and Petitioner timely appealed this decision.
  7. The Claimant suffers from two herniated discs incurred in ____ in a compensable injury while working for ___________. The injury was covered by worker’s compensation insurance written for Claimant’s employer by Western Indemnity Insurance Company. The injury was exacerbated by an additional compensable injury that occurred on _________, while the Claimant remained employed by the same employer that remained covered by the same Carrier.
  8. The continuing office visits and the report at issue in this proceeding were reasonable and necessary elements of a conservative plan of care for the Claimant. The Claimant continued to experience pain, requiring pain medication for his injury, and Dr. Neustein needed to monitor these symptoms and medications.

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.

  1. 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.
  2. The Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 Tex. Admin. Code § 148.21(h).
  3. The treatment provided to the Claimant was reasonably required by Tex. Lab. Code Ann. §408.021.
  4. The Petitioner should be reimbursed for the fees charged in providing treatment to the Claimant in the amount of $174.00.

ORDER

IT IS THEREFORE, ORDERED that Western Indemnity Insurance Company reimburse Petitioner in the amount of $174.00 for the fees charged in providing treatment to the Claimant on November 12, 1999, January 12, 2000, and February 4, 2000.

Issued May 28th, 2002.

Kerry D. Sullivan
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
Top