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At a Glance:
Title:
453-01-3892-m5
Date:
November 7, 2002
Status:
Retrospective Medical Necessity

453-01-3892-m5

November 7, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner, ____________Carrier), appealed the findings and decision of the Texas Worker’s Compensation Commission’s (Commission) Medical Review Division (MRD) which ordered it to reimburse Dr. Bradley Sikes (Provider) for chiropractic manipulations in the amount of $1,680.00. The manipulations were administered by the Provider to Claimant_____. from July 15, 1999, through June 5, 2000. This decision finds that Carrier is not liable to pay Provider additional reimbursement.

Administrative Law Judge Suzanne Marshall convened the hearing on these issues on September 12, 2002. The hearing concluded and the record closed on the same date. Assistant Attorney General Paige Duncan represented the Carrier. Attorney Richard Pena represented the Provider.

II. EVIDENCE AND BASIS FOR DECISION

The issue in this case is whether the chiropractic manipulations performed by Dr. Bradley Sikes (Provider) on _____(Claimant) during July 15, 1999, through June 5, 2000, were properly documented and, therefore, reimbursable as medically necessary.

The documentary evidence in the case consists of the 143-page certified record of the Medical Review Division proceeding.[1] One witness, Joyce Maxam, R.N., testified by telephone on behalf of ____________(Carrier).[2] Carrier denied reimbursement for the chiropractic manipulations performed by Provider during July 15, 1999, through June 5, 2000, under the denial code “Not appropriately documented” (“N”).

Based on the evidence, the Administrative Law Judge concludes that the Carrier met its burden of proof that there was insufficient documentation which could support a finding that the manipulations were reasonable and necessary medical treatment of Claimant and, consequently, reimbursement to the Provider should be denied. The particular facts and reasoning in support of this decision are set forth below in the Findings of Fact, and the legal conclusions derived from those facts appear in the Conclusions of Law.

III. FINDINGS OF FACT

  1. On ____________(Claimant), a truck driver for ___________, suffered a compensable injury when he slipped on soap on the floor of the linen room at work, causing him to jerk, twist, and grab for the sink. This resulted in cervical, lumbar, and thoracic abnormalities.
  2. ____________carried workers’ compensation coverage through the ___________.
  3. Claimant saw his treating chiropractor, Bradley Sikes, D.C. (Provider) on the date of his injury, __________, who noted that Claimant had a previous history of back surgery. Provider’s treatment plan at the time of injury recommends: “spinal manipulation, ice, myofascial release, traction, therapeutic exercise as appropriate to reduce pain [and] rehabilitate the injured structures. Home care stretches.”
  4. During the course of Claimant’s treatment, Provider prepared the following treatment plans:
    1. November 16, 1998 – “CMT for pain relief [and] improved biomechanical function. Patient is involved in home care stretches [and] exercises in addition to his job.” Provider recommended that treatment should be given three times per week, decreasing to one time per week, and lasting for eight weeks. Expected clinical response to the treatment was “slow, steady continued improvement w [ith] little or no residual symptoms.”
    2. January 30, 1999 - Provider’s follow-up treatment plan states, “Continued care as long as progress continues.” Prognosis at this time is “fair,” with expected improvement but not total resolution.
    3. March 30, 1999 - Provider’s treatment plan states that Claimant “will be scheduled for an impairment rating” and “care will be provided as needed for pain relief.”
  5. On April 14, 1999, a permanent impairment evaluation was performed on Claimant by Provider, who concluded that the Claimant had attained maximum medical improvement with some “permanencies and impairments.” Provider also notes in the treatment portion that further treatment is “indicated on an as needed basis.”[3]
  6. On August 20, 1999, Provider referred Claimant to Neal H. Blauzvern, D.O., of Central Texas Spine Institute for pain management and medication.[4]
  7. A Subsequent Medical Report (TWCC-64) from Provider, dated September 27, 1999, notes the unexplained exacerbation of Claimant’s back injury and contains a treatment plan of “frequent care, 3x/wk, progressing to as needed, as patient’s condition improves.”The report also states that Claimant’s prognosis is “fair,” with his condition “chronic and recurrent.”[5]
  8. Provider submitted its charges to the Carrier for the manipulations performed from July 15, 1999 through June 5, 2000.[6]
  9. The only documentation in the record for the manipulations administered to Claimant by the Provider is a single-page chart with a list of visits by Claimant commencing on July 15, 1999, and ending on June 5, 2000, containing one-line comments for each of 38 office visits. (E.g., “Quite a bit better today”; “Not totally P[ain] free”; and “Slow, steady improvement.”)[7]
  10. Carrier denied payment for the manipulations on the grounds that they were not sufficiently documented.
  11. Provider requested dispute resolution by the Texas Workers’ Compensation Medical Review Division (MRD) on July 14, 2000.
  12. The MRD issued its findings and decision on July 20, 2001, concluding that the Provider was entitled to reimbursement of $1,680.00 for the manipulations performed on Claimant during July 15, 1999, to June 5, 2000.
  13. On July 27, 2001, Carrier appealed the MRD’s decision.
  14. On August 21, 2001, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place 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.
  15. The hearing was held on September 11, 2002, before Administrative Law Judge Suzanne Marshall. Assistant Attorney General Paige Duncan represented the Carrier. Attorney Richard Pena represented the Provider. The hearing concluded and the record closed on the same date.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (Act), 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 §413.031(d) of the Act; Tex. Gov’t Code Ann. ch. 2003; and 28 Tex. Admin. Code chs. 148-49.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Gov’t Code Ann. § 2001.052 and 28 Tex. Admin. Code §148.4(b).
  4. Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code Ann. §413.031.
  5. The Spine Treatment Guidelines (Guidelines), effective June 1, 1995, apply to the dates of service from July 15, 1999, to January 28, 2000. 28 Tex. Admin. Code §134.1001. The 1995 Guidelines indicate that documentation “should” be provided by the provider to determine the level of care and the necessity for that care. 28 Tex. Admin. Code §134.1001(e)(3)(B).[8]
  6. The Spine Treatment Guidelines (Guidelines), effective February 1, 2000, apply to the dates of service from February 1, 2000, to June 5, 2000. 28 Tex. Admin. Code § 134.1001. The 2000 Guidelines indicate that documentation “shall” be provided by the provider to determine the phase of care and the necessity for that care. 28 Tex. Admin. Code §134.1001(e)(3)(B).
  7. The 2000 Guidelines add specific language concerning manipulation: “Documentation for manipulation should show objective/qualified substantive and continued measures of improvement over time.” 28 Tex. Admin. Code § 134.1001(e)(3)(E).[9]
  8. Carrier proved by a preponderance of the evidence that the manipulations administered to Claimant by Provider during July 15, 1999, to June 5, 2000, were not sufficiently documented under either the 1995 or 2000 Spine Treatment Guidelines.
  9. Provider is not entitled to reimbursement.

ORDER

It is hereby ordered that the appeal of _________ is granted and reimbursement to Dr. Bradley Sikes is denied due to the lack of sufficient documentation of the manipulations performed during July 15, 1999, through June 5, 2000.

Signed this 7th day of November, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

SUZANNE MARSHALL
Administrative Law Judge

  1. At the hearing, Carrier presented two missing pages of the certified record (C.R. 117-18). These pages were appropriately numbered and contained the same date stamp as the remainder of the certified record. No objection was raised as to their authenticity or subsequent admittance.
  2. Although Ms. Maxam testified for the Carrier, no predicate was laid for her testimony, nor was she qualified as an expert witness.
  3. No specific treatment plan was mentioned in this report.
  4. The visits to Dr. Blauzvern are well-documented in the certified record, but contain no information relating to the chiropractic manipulations. Each progress note from Dr. Blauzvern relates only to pain management and medications. The notes and treatment of Claimant by Dr. Blauzvern are not relevant to the treatment or manipulations administered by the Provider.
  5. The September 27, 1999, Subsequent Medical Report is the last treatment plan submitted to Carrier by Provider.
  6. The record contains a discrepancy in the claimed service dates. Provider lists the eligible dates of service from July 15, 1999, to April 18, 2000. The MRD lists the dates eligible for review as July 15, 1999, to June 5, 2000. Ex. 1, pp. 3-4. The MRD decision notes that no EOB’s were admitted for the following dates of service: August 30, 1999; October 8, 1999; October 11, 1999; October 13, 1999; and May 12, 2000. The discrepancy in the dates of service does not make a difference in the case’s outcome, however, since the documentation for all the manipulations is found to be insufficient to meet the requirements of the Spine Treatment Guidelines.
  7. Ex.1, p. 13.
  8. The 1995 Guidelines continue, “The elements of that documentation may include: . . . (iii) A plan of treatment, including proposed methods of treatment, expected outcomes, and probable duration of treatment; (iv) Updates to the plan of treatment as needed, including the clinical progress of the injured worker, and any revisions needed to the treatment plan in light of the injured worker’s response to treatment.” 28 Tex. Admin Code ''134.1001(e)(3)(B)(iii) and (iv) (West 1995).
  9. Subsection 134.1001(e)(3)(E) also cross-references § 134.1001(e)(3)(C), which states, “Documentation for physical medicine treatment should be objective and illustrate compliance and substantive and continued improvement over time.” 28 Tex. Admin Code §§ 134.1001(e)(3)(C)(listing examples (i) - (xii)).
End of Document
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