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Title:
453-02-0179-m5
Date:
September 26, 2002

453-02-0179-m5

September 26, 2002

DECISION AND ORDER

America Home Assurance Co. (Carrier) seeks reversal of a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) awarding Respondent Christopher Buckley, D.C., $9,626.80 for testing, counselling, and a work hardening program provided to workers’ compensation Claimant _____ between July 19, 2000 and September 6, 2000. The Carrier had denied payment on the basis that the services provided were not medically necessary. This decision finds that reimbursement should be denied.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

Notice of the hearing was provided to the parties on September 19, 2001. The hearing convened July 31, 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 Mark Sickles. Respondent Christopher Buckley did not appear at the hearing. The Commission also did not participate in the hearing. Respondent Buckley filed no motion for continuance or other correspondence with SOAH. In accordance with 1 Tex. Admin Code §155.55, the hearing proceeding in Dr. Sickles’ absence. 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 294-page MRD record and supplemental documentation provided by the Carrier. In view of the Respondent’s non-appearance, the Carrier called no witnesses and presented argument based on the MRD record.

The ALJ accepts the evidence relied upon by the Carrier as persuasive in this proceeding. The Carrier showed that the Claimant’s compensable injury was carpal tunnel syndrome which she reported about______. Jane Duncan, D. C., conducted a peer review regarding the necessity for the work hardening program in dispute on September 8, 2000. She observed that the Claimant had previously received treatment consisting of manipulation, electrical stimulation, and biofreeze. Subsequently, the Claimant was diagnosed with a cervical radiculopathy. According to Dr. Duncan, the particular study used to diagnose the cervical radiculopathy is invalid for this purpose. In her view a needle EMG would have to be performed to confirm the diagnosis.

According to Dr. Duncan, the carpal tunnel syndrome has also not been objectively established, although she was willing to concede a mild case with appropriate treatment extending up to three months after the injury. In her view, treatment beyond June 9, 2000 should have been limited to an at-home rehabilitation program and a return to work with splints. In any event, Dr. Duncan concluded that a work hardening program was unnecessary to return this patient with mild carpal tunnel syndrome to her light physical demand job.

The ALJ accepts Dr. Duncan’s findings, which are the most detailed and specific assessment contained in the record regarding the need for a work hardening program and associated testing and counselling. Accordingly, the ALJ concludes that the Carrier should not be required to reimburse Dr. Buckley for these services.

III. FINDINGS OF FACT

  1. On_______, Claimant_____ sustained a compensable carpal tunnel syndrome injury.
  2. At the time of the Claimant’s compensable injury, American Home Assurance Co. (the Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. The Claimant received treatment consisting of manipulation, electrical stimulation, and biofreeze.
  4. Subsequently, the Claimant was diagnosed with cervical radiculopathy.
  5. The study used to diagnose the cervical radiculopathy is invalid for this purpose. A needle EMG would have to be performed to confirm the diagnosis.
  6. Beyond June 9, 2000, treatment for the Claimant’s mild carpal tunnel syndrome should have been limited to an at-home rehabilitation program and a return to work with splints.
  7. A work hardening program was unnecessary to return the Claimant to her light physical

demand job.

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(k) 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 Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i).
  6. The disputed services were not medically necessary health care for Claimant.
  7. Based on the foregoing, the Respondent Christopher Buckley’s claim for reimbursement from the Carrier for the disputed work hardening program, testing, and counseling should be denied.

ORDER

Theclaim by Respondent Christopher Buckley, D.C., is denied.

Signed this 26TH day of September, 2002.

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

End of Document
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