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At a Glance:
Title:
453-01-3721-m5
Date:
August 1, 2002
Status:
Retrospective Medical Necessity

453-01-3721-m5

August 1, 2002

DECISION AND ORDER

Truman Andrew Davidson, D.C. (Petitioner or Provider) appealed the Findings and Decision in Docket No. M5-00-0679-01 of the Medical Review Division (MRD) of the Texas Workers' Compensation Commission (Commission). The decision ordered payment of $315.00 of the claimed amount of $9,238.00 for the Provider’s services because the documentation submitted did not substantiate the medical necessity of the services. The Administrative Law Judge (ALJ) finds that the documentation submitted by the Provider substantiated medical necessity, and the Provider is entitled to reimbursement of $8,064.00[1] from Old Republic Insurance Company (Carrier).

I.PROCEDURAL HISTORY, JURISDICTION, AND NOTICE

On July 18, 2002, Michael J. Borkland, ALJ, convened the hearing at the William P. Clements Building, 300 West 15th Street, Austin, Texas. Petitioner appeared pro se. The Carrier was represented by Rhett Robinson, attorney. Following the presentation of evidence, the hearing was closed on the same day. Notice and jurisdiction were not contested and will be addressed in the findings of fact and conclusions of law.

II.EVIDENCE AND BASIS FOR DECISION

On______________, (Claimant) sustained a compensable workers’ compensation injury to his back while unloading water heaters from a trailer. Following treatment, the Claimant was released for light duty work, but light duty work was not available at his place of employment. The Claimant then entered a work hardening program designed to prepare him for return to his normal work duties. The dispute concerns reimbursement for the work hardening program provided from December 10, 1999, through January 15, 2000. After reviewing the records, the MRD found that the documentation submitted did not support the medical necessity of treatment rendered.

The issue to be determined is whether treatment rendered between December 10, 1999, and January 15, 2000, was medically necessary and whether the claim should be paid. The original amount in dispute was $9,238.00 of which the MRD ordered payment of $315.00, leaving the sum of $8,923.00 in dispute for CPT Codes 97545-WH (work hardening), 97546-WH (work hardening), 99212-52 (office visit), 99361 (case management), 97750 (testing), 99080-69 (special report), 99090 (analysis of data stored in computers), 99215 (office visit with reexamination), and 99371 (physician directed telephone calls). The evidence included a certified copy of the MRD's record (Exh. 1); the testimony of Dr. Davidson, who testified in his own behalf; and the testimony of Dr. Bill Timberlake, D.C., who appeared on behalf of the Carrier.

The amount of $8,064 is in dispute for the work hardening program (CPT Codes 97545-WH and 97546-WH). Contrary to the finding in the MRD Decision, there was documentation in the record which stated that the Claimant was released for regular work with no restrictions beginning January 17, 2000. (Exh 1, page 119, 125) Additionally, the Provider’s treatment notes contained in the record included weekly summaries, work simulation activities, cardiovascular conditioning activities, stretching activities, and forms documenting each day of the week and the number of hours that the Claimant performed the activities. (Exh 1, pages 44-53, 56-62, 64-71, 74-83, and 86-95) Dr. Davidson testified that the Claimant performed all the activities on the dates he attended the work hardening program. He further testified that the Claimant was successful because he returned to work and has not had further problems.

Dr. Timberlake, who has been a treating and consulting chiropractor for 38 years, testified that in his opinion the documentation was insufficient. Additionally, he stated that the Claimant could have performed his exercises at home, which is the least intensive setting. Dr. Davidson responded that the Claimant did not have the necessary equipment at home to perform the exercises.

The documentation submitted and contained in the MRD records substantiates medical necessity for the work hardening program (CPT Codes 97545-WH and 97546-WH). The Provider failed to carry his burden of proof on the other services in dispute.[2] In addition to the amount previously ordered to be reimbursed by the MRD, the ALJ finds that the Provider should be reimbursed a total of $8,064.00 for the disputed dates of service.

III.FINDINGS OF FACT

  1. On___________, (Claimant) suffered a work-related injury to his lower back while unloading water heaters from a trailer.
  2. At the time of the Claimant's injury, Old Republic Insurance Company (Carrier) provided workers' compensation insurance to the Claimant's employer.
  3. In October 1999, Truman A. Davidson, D.C. became the Claimant's treating doctor.
  4. Between December 10, 1999, and January 14, 2000, Dr. Davidson treated the Claimant’s back injury with a work hardening program, which was billed under CPT Codes 97545-WH and 97546-WH.
  5. Dr. Davidson also billed for services provided under CPT Codes 99212-52, 99361, 97750, 99080-69, 99090, 99215, and 99371.
  6. Dr. Davidson also billed for services provided under CPT Codes 99455-WP and 99080-64.
  7. The Claimant reached maximum medical improvement (MMI) on January 8, 2000, with a whole-body impairment rating of 6 percent.
  8. Dr. Davidson prepared notes documenting the treatment provided to the Claimant referred to in Finding of Fact No. 4.
  9. The Claimant returned to regular work with no restrictions on January 17, 2000.
  10. Dr. Davidson submitted claims to the Carrier for the treatment referred to in Findings of Fact Nos. 4 - 6.
  11. The Carrier denied payment of Dr. Davidson’s claims for the treatment referred to in Findings of Fact Nos. 4 - 6.
  12. On March 17, 2000, Dr. Davidson appealed the decision of the Carrier to the Medical Review Division (MRD) of the Texas Workers' Compensation Commission (Commission).
  13. On June 8, 2001, the MRD issued its decision that Dr. Davidson was entitled to reimbursement of $315.00 for the treatment referred to in Finding of Fact No. 6.
  14. The MRD decision referred to in Finding of Fact No. 13 denied reimbursement for the treatment referred to in Findings of Fact Nos. 4 and 5.
  15. On June 18, 2001, the Petitioner filed a request for hearing on the MRD’s decision denying reimbursement.
  16. The Commission sent notice of the hearing to the parties on August 7, 2001. The hearing notice and the statement of matters asserted informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  17. Dr. Davidson appeared pro se and the Carrier appeared through it representative, Rhett Robinson, at the hearing on July 18, 2001.
  18. The treatment provided by Dr. Davidson referred to in Finding of Fact No. 4 was reasonable and medically necessary for the treatment of the Claimant’s compensable injury.
  19. The Claimant was released for light duty work on October 4, 1999.
  20. Light duty work was not available at Claimant’s job.
  21. A work hardening program is designed to return an injured worker to regular job duties with less risk of re-injury.
  22. Following completion of the work hardening program, the Claimant was returned to regular work duties without restriction.
  23. The Claimant has not been re-injured on the job.
  24. Dr. Davidson did not prove that the treatment referred to in Finding of Fact No. 5 was reasonable and medically necessary for the treatment of the Claimant’s compensable injury.

IV.CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented, pursuant to Tex. Lab. 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 Tex. Lab. Code Ann. § 402.073(b) and 413.031(d) and Tex. Gov’t. Code Ann. ch. 2003.
  3. The Petitioner timely requested a hearing pursuant to 28 Tex. Admin. Code (TAC) §148.3.
  4. The parties received proper and timely notice of the hearing pursuant Tex. Gov’t Code Ann. ch. 2001.
  5. The Petitioner had the burden of proving the case by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031.
  6. A treating physician is responsible for maintaining efficient utilization of health care for a claimant, pursuant to Tex. Lab. Code Ann. ' 408.025(c).
  7. Based on Finding of Fact No. 8, Dr. Davidson adequately documented treatment provided to the Claimant, as required by 28 TAC § 134.1002(e)(2)(A).
  8. Based on Findings of Fact Nos. 7 and 9, Dr. Davidson’s treatment was specific to the injury and provided for the Claimant’s potential restoration of function and improvement.
  9. Based on Conclusions of Law Nos. 8, 9 and 18, the treatment referred to in Finding of Fact No. 4 was reasonable and medically necessary for treatment of the Claimant’s compensable injury, as required by Tex. Lab. Code Ann. § 408.021.
  10. Based on the foregoing findings of fact and conclusions of law, the Carrier should reimburse Dr. Davidson the sum of $8,064.00 for services billed under CPT Codes 97545-WH and 97546-WH.

ORDER

It is hereby ordered that Old Republic Insurance Company shall reimburse Dr. Truman A. Davidson, D.C., the sum of $8,064.00.

Signed this 1st day of August, 2002.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The amount of $8,064.00 does not include the sum $315.00 ordered to be paid by the MRD.
  2. The Provider did not specifically address the other disputed services by presenting evidence and argument on those issues.
End of Document
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