Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-02-0014-m5
Date:
November 6, 2002
Status:
Retrospective Medical Necessity

453-02-0014-m5

November 6, 2002

DECISION AND ORDER

PRIDE (Petitioner) has appealed the findings of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which denied its request for reimbursement of $14,886 for a chronic pain management program provided to workers’ compensation Claimant__. This decision reverses the decision of the MRD and orders the Insurance Company of the State of Pennsylvania (Carrier) to reimburse the Petitioner $14,886 for the program, which the Carrier preauthorized.

I.NOTICE AND HEARING

There were no contested issues regarding notice of the hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened September 12, 2002, at the hearings facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) Kerry D. Sullivan. The Petitioner was represented by Peter N. Rogers, who appeared by telephone; the Carrier was represented by Steven M. Tipton. After receipt of evidence, the record was closed the same day.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consists of the 442-page MRD record and supplemental documentation provided by the Petitioner. Additionally, Dr. Tracey Adams and Dr. Tom Mayer testified on behalf of the Petitioner and Dr. Michael Walter testified on behalf of the Carrier.

A. Key Facts

The Claimant is a 53-year old male who sustained a groin injury and hernia on_______, ____, while employed as a laborer moving carrying a heavy load. The Carrier contested the compensability of this injury, and a Commission hearing officer held a Benefits Contested hearing on August 28, 1998. The Decision and order rendered in that proceeding finds, “The Claimant’s injuries sustained on ______include (compensable) injuries to his groin, as well as a hernia,” but that the Claimant did not suffer a compensable lower back injury.[1] The Carrier did not appeal this decision, and it has become final. Additionally, on July 22, 1999, the Carrier preauthorized the chronic pain management program at issue in this proceeding.

B. Analysis.

The ALJ concurs with and follows prior SOAH precedent holding that the Carrier cannot challenge the medical necessity of services that it has preauthorized. See SOAH Docket Nos. 453-97-0912.M4, 453-97-0915.M4, 453-97-0626.M4, and 453-96-1070 (holding that preauthorization serves as the Carrier’s acknowledgment that the services are medically necessary and that any retrospective review of preauthorized treatment should focus on the necessity of the costs of treatment, rather than on the necessity of the treatment itself). Neither the Carrier nor the MRD questioned the costs of the treatment or the manner in which treatment was provided. Instead they believed the program was medically unnecessary to treat the compensable injury. Given the earlier final decision in the Benefits contested hearing (See Footnote 1, above) and the proscription against retrospectively challenging the medical necessity of preauthorized treatment, the ALJ finds that the Carrier cannot now deny payment on the basis of medical necessity or extent of injury. In any event, it is clear that Dr. Adams, the Claimant’s treating physician, was aware of the limited nature of the compensable injury as determined in the Benefits hearing, and implemented the program to address the pain pattern associated with the compensable injury.[2]

Based on these circumstances, the ALJ concludes that the Carrier should be required to reimburse the Petitioner $14,886 for the chronic pain management program provided to the Claimant.

III. FINDINGS OF FACT

  1. On________________, Claimant____. sustained a compensable injury to his groin and a hernia while employed as a laborer.
  2. At the time of the Claimant’s compensable injury, the Insurance Company of the State of Pennsylvania was the workers’ compensation insurer for Claimant’s employer.
  3. The Carrier disputed the compensability and extent of the Claimant’s injury, and a Texas Workers’ Compensation Commission hearing officer held a Benefits Contested hearing on August 28, 1998.
  4. The Decision and Order rendered in the Benefits Contested hearing on September 3, 1998, finds, “The Claimant’s injuries sustained on _____include (compensable) injuries to his groin, as well as a hernia” but that the Claimant did not suffer a compensable lower back injury. The Decision and Order also separately states, “Regarding the extent of injury, based on the medical documents there is more than sufficient evidence that the Claimant sustained a groin strain, and a hernia.”
  5. The Carrier did not appeal the Benefits decision, and that decision has become final.
  6. On July 22, 1999, the Carrier preauthorized the chronic pain management program in dispute in this proceeding.
  7. Neither the Carrier nor the MRD denied payment based on the costs of the treatment or the manner in which treatment was provided.
  8. On July 30, 2001, the MRD denied the Petitioner’s request for reimbursement of $14, 886 for the chronic pain management program in dispute in this proceeding; Petitioner timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter 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 matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031 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.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  5. The compensability and extent of the Claimant’s ________injury were determined in the Decision and Order issued in the Benefits contested hearing on September 3, 1998.
  6. Pursuant to TEX. LAB. CODE ANN. 413.014 and 28 TAC §134.600, the Carrier’s preauthorization of the chronic pain management program in dispute in this proceeding precludes it from challenging the medical necessity for that program after it has been provided.

ORDER

IT IS, THEREFORE, ORDERED that the Insurance Company of the State of Pennsylvania pay PRIDE $14,886.00 for the chronic pain management program provided to workers’ compensation Claimant ___

Signed this 6TH day of November, 2002.

KERRY D. SULLIVAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Decision and Order, Findings of Fact Nos. 3 and 4. (MRD record at 37, 199) At hearing, the Carrier urged that unresolved objections remain regarding the extent of the Claimant’s injury, and that this issue must be decided by a Commission hearing officer rather than at SOAH. It is clear, however, that the Commission hearing officer intended to address the extent of the injury in these findings. In the discussion section of his decision, the hearing officer stated, “Regarding the extent of injury, based on the medical documents there is more than sufficient evidence that the Claimant sustained a groin strain, and a hernia.” (MRD Record at 35, 197). Based on this decision, the ALJ concludes the issue of reimbursement for the chronic pain management program is appropriately before that ALJ in this proceeding and that SOAH has jurisdiction to address the issue.
  2. (MRD record at 81). The pain management program treats the whole person, including the typically deconditioned state of the individual attributable to inactivity following the compensable injury. Accordingly, PRIDE did not artificially restrict the program to avoid incidental therapy to a separate non-compensable injury-nor should it have.
End of Document
Top