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At a Glance:
Title:
453-01-3982-m5
Date:
August 6, 2002
Status:
Retrospective Medical Necessity

453-01-3982-m5

August 6, 2002

DECISION AND ORDER

I. Summary

The Petitioner Suhail Al-Sahli, D.C., sought reimbursement from the Respondent the University of Texas System in the amount of $4,006.00 for various services he provided to the claimant M.F. from June 9, 1999, to March 3, 2000. The Respondent denied reimbursement, and the Petitioner requested medical dispute resolution from the Division of Medical Review (the Division) of the Texas Workers’ Compensation Commission (the Commission). In its Findings and Decision, the Division denied reimbursement because the services the Petitioner rendered to M.F. were not adequately documented, they were not preauthorized, they did not seem to be resulting in functional gains for the claimant, and they were treatments to an area other than the one that was injured. The Petitioner appealed the Division’s decision.

The hearing on the Petitioner’s appeal was held on June 26, 2002. The Petitioner appeared pro se. The Respondent was represented by its counsel, Jason Itkin and Brad McClellan, Assistant Attorneys General. The Commission’s staff did not appear. The record closed on June 26, 2002.

The Administrative Law Judge (ALJ) finds that the Division’s decision should be upheld.

II. Discussion

A. Background and Parties’ Arguments. ________ at the time an employee of the ______________ was injured on__________, when a television fell from either a wall or its cart (the evidence is not clear) and hit her on the head. She suffered contusions to her head, neck, back, and shoulders. She first went to a Dr. Kuncharapu with UTMB for treatment, where she was diagnosed with an abrasion on her right cheek and a bruise on her right shoulder. She was returned to work at light duty on April 28, 1999, with instructions to do graduated exercises. In early May, another doctor with UTMB took x-rays that were in essence normal. On May 21, 1999, Dr. Kuncharapu diagnosed M.F. with musculoskeletal strain that was improving with exercise, and he referred her to physical therapy at her request.

On June 4, 1999, ______ requested to change her treating doctor to the Petitioner. He began treating her on June 9, 1999, and her request that he be her treating doctor was approved on June 10, 1999. Over the next ten months, on approximately ninety dates of service, the Petitioner treated M.F. with procedures explained in his notes only as cryotherapy, adjustments, electric stimulation, rehabilitative exercise, theratubing exercises, and treadmill exercise, and there is no indication in the notes which body part the treatments were to treat. In September _______, ______ had arthroscopic surgery on her left shoulder, ostensibly to remove a bone fragment.

The Respondent denied reimbursement because the medical records did not properly document the treatments; preauthorization was required after eight weeks of physical therapy, and it was not sought or obtained; the treatments did not result in functional gains on ________ part; and the Respondent’s records rarely reflected that he treated her shoulder after her shoulder surgery.

The Petitioner disputed all of those arguments, contending at the hearing that his notes were sufficient to establish proper documentation, that they reflected improvement in ________ condition, and that her back had been injured in her original injury and he treated her back as well as her shoulder. He admitted he had not gotten preauthorization for certain treatments, but he claimed the Respondent had not followed the rules itself, and that it consistently manufactured excuses for why it would not pay his claims. The Petitioner also made broad assertions of bias on the part of the Respondent.

B. Applicable Rules and Guidelines. The Commission’s rule in effect at the time required that physical therapy beyond eight weeks of treatment be preauthorized.[1] In addition, the Ground Rules of the Commission’s Medical Fee Guidelines provide in pertinent part that, in order for physical medicine treatment to qualify for reimbursement,

  • the patient’s condition shall have the potential for the restoration of function;
  • the treatment shall be specific to the injury and provide for potential improvement of the patient’s condition;
  • the treatment plan for the patient must set out the type of treatment modality, the frequency of treatment, the expected duration of treatment, the expected clinical response to treatment, and the specification of a re-evaluation time frame; and
  • the treatment plan must be updated to reflect any changes in the patient’s condition, as well as her response to treatment.[2]

C. Analysis. The ALJ finds that the Petitioner did not prove he should be reimbursed for the services he provided to _______. The Petitioner stated several times at the hearing that the documentation was sufficient, but he never established why. An examination of the records themselves offers no illumination of the point. Typed notes, presumably transcriptions of the handwritten notes (most of which are illegible) from numerous office visits, are in the record, but with the exception of the explanation about why rehabilitative exercises are being done, they give no hint why the treatments were being rendered, to what area of the body they were administered, the frequency they were given, or why they would help _____ improve. There is also no explanation about what the therapy actually consisted of. In other words, the Petitioner did not explain, either in his testimony or in the documentation, what cryotherapy or theratubing is or what comprises rehabilitative exercises and why they were helpful to _______ or required by her condition. About the rehabilitative exercises, the records state they were performed to help increase endurance and strength.[3] That explanation appears innumerable times, almost verbatim each time, and one must wonder about its validity, much less its medical import.

Likewise, there is also no indication in the records that _______ improved with all the treatments, from the first to the last. The Petitioner testified that she showed improvement in her sleep patterns, had decreased pain, and was able to more easily perform the activities of daily living, and, the Petitioner asserted, the documentation showed as much. The ALJ is unable to find any documentary corroboration for the Petitioner’s claim about ________ improvement.

Moreover, there is no indication that the Petitioner’s treatment plan was changed to address ________ lack of improvement. In June 1999, the Petitioner’s plan was to provide eight weeks of physical therapy to _____ with the frequency to be determined. In August 1999, he referred ____ for an MRI of her cervical and lumbar spine and her left shoulder. According to his notes, the MRI showed that ____ had protruded and bulging discs at C4-5 and C5-6; mild dessication at L4-S1, and a grade 1 rotator cuff tear and spurs in her shoulder. Whatever his conclusion about the MRI’s findings, the treatment plan remained eight weeks of physical therapy modalities, with the frequency based on _____ needs and prognosis. In October 1999, the treatment plan was physical therapy three times a week for six weeks. In December 1999, the treatment plan was physical therapy daily for one week, then three times a week for three weeks. In February 2000, the treatment plan was still physical therapy daily for one week, then three times a week for three weeks. And, as noted earlier, the physical therapy provided to her consisted, virtually every time and without variation, of cryotherapy, adjustments, electrical stimulation, rehabilitative exercises, and theratubing, with the occasional reference to exercise on a treadmill. Furthermore, range of motion testing of the cervical spine and both shoulders was the same on June 8 and August 11, 1999. Range of motion testing was also the same for the shoulders on February 10, 2000, a date included in the dates of service under review, and April 24, 2000, a date outside the review. The Petitioner did not offer any explanation for that. This much is clear, however: The treatment never changed, the plan never changed, and _________ condition never changed.

In response to the Respondent’s assertion that the Petitioner rarely treated _______ shoulder, the Petitioner claimed that ______ back was injured as well and he had to treat her back. He also stated that her neck and lower back needed rehabilitation after the arthroscopic surgery of September 1999, but he gave no reason why. Even if either or both of those things is so (and the ALJ is not persuaded that they are), there is still no evidence in the record establishing on which occasions the Petitioner treated _________ back and the precise treatments he rendered for her back.

Finally, the Petitioner admitted he did not seek preauthorization at the appropriate points in his care of ______ Apparently the only request for preauthorization he made was on approximately September 30, 1999, seeking preauthorization for more physical therapy. Although the ALJ is unable to locate in the record the precise outcome of that request, it was denied, presumably, and the Petitioner offered no evidence to establish that preauthorization should have been granted.

The Petitioner’s case consisted in large measure of complaints that the Respondent had not been fair in its disposition of his claims, that it had given him no reasons for the actions it took, that it operated by its own set of rules and therefore could not complain because he had not always followed the rules with regard to preauthorization, and that the documentation of his treatment was adequate. He offered nothing in the way of evidence to support any of his arguments, and he offered no evidence in support of his claims about the merits of his treatment of the claimant. The ALJ recommends that his appeal be denied and that the Division’s findings and decision denying reimbursement to the Petitioner be upheld.

III. Findings of Fact

  1. ____, at the time an employee of the _______________ was injured on_________, when a television fell from its position and hit her on the head.
  2. ____ suffered contusions to her head, neck, back, and shoulders.
  3. ____ first went to a Dr. Kuncharapu with UTMB for treatment, where she was diagnosed with an abrasion on her right cheek and a bruise on her right shoulder. He returned _____ to light-duty work on April 28, 1999, with instructions to do graduated exercises.
  4. X-rays taken in early May of _____ were normal.
  5. On May 21, 1999, Dr. Kuncharapu diagnosed ______ with musculoskeletal strain that was improving with exercise, and he referred her to physical therapy at her request.
  6. On June 4, 1999, ______ requested to change her treating doctor to the Petitioner, Suhail Al-Sahli, D.C., and on June 10, 1999, her request was approved.
  7. The Petitioner began treating ________ on June 9, 1999.
  8. On ninety dates of service from June 9, 1999, until March 3, 2000, the Petitioner treated _______ with cryotherapy, adjustments, electric stimulation, rehabilitative exercise, theratubing exercises, and occasionally treadmill exercise.
  9. There is no evidence establishing what the treatments described in Finding of Fact No. 8 consisted of.
  10. There is no evidence establishing what the treatments described in Finding of Fact No. 8 were designed to treat, which areas of ______ body they were directed to and why, or the frequency at which they were given.
  11. There is no evidence ______ improved with the treatments provided to her by the Petitioner.
  12. The Petitioner’s treatment of ________ did not change over the ten months he treated her, despite her lack of improvement.
  13. The Petitioner’s treatment plan for _______ did not change over the ten months he treated her, despite her lack of improvement.
  14. The Petitioner did not seek preauthorization for the treatment he was providing to _______ after the first eight weeks of service.
  15. There is no evidence the treatments should have been preauthorized after the first eight weeks of service.
  16. The Petitioner sought reimbursement in the amount of $4,006.00 for the treatment he provided to _______ between June 9, 1999, and March 3, 2000.
  17. The University of Texas System (UT) denied reimbursement.
  18. The Petitioner appealed UT’s denial of reimbursement to the Medical Review Division (the Division) of the Texas Workers’ Compensation Commission (the Commission).
  19. The Division found that the Petitioner should not be reimbursed.
  20. The Petitioner appealed the Division’s decision.
  21. The staff of the Commission issued a notice of hearing on September 6, 2001, notifying the Petitioner and UT of a hearing on the Petitioner’s appeal.
  22. The hearing was held on June 26, 2002. The Petitioner and UT appeared and participated in the hearing.

IV. Conclusions of Law

  1. The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over the issue presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over all matters related to the hearing in this case, including the issuance of this decision and order, pursuant to Tex. Gov’t Code Ann. ch. 2003 and pursuant to §413.031(d) of the Act.
  3. Notice of the hearing was proper and timely, as required by the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001.
  4. The Petitioner did not adequately document the treatment he provided to _______, nor did he adequately document a treatment plan for her.
  5. The Petitioner did not adequately comply with the Medicine Ground Rules of the Medical Fee Guidelines in his treatment of ______.
  6. The Petitioner did not comply with 28 Tex. Admin. Code §134.600(h)(10) by seeking preauthorization for physical therapy services beyond eight weeks of treatment.
  7. Reimbursement to Suhail Al-Sahli for treatment provided to ________ between June 9, 1999, and March 3, 2000, should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the appeal of Suhail Al-Sahli for reimbursement in the amount of $4,006.00 for treatment he provided to ______ between June 9, 1999, and March 3, 2000, is denied.

Signed August 6th, 2002.

CATHLEEN PARSLEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. 28 Tex. Admin. Code §134.600(h)(10).
  2. Medicine Ground Rules, Physical Medicine I.A.
  3. See e.g. Exh. 1, pp. 18 and 19.
  4. As for Exhibit 1, the ALJ would note that the metal brad used to bind the two and one-half inch record was insufficient to the task. The prongs were simply not long enough to hold it together as the ALJ reviewed it.

End of Document
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