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At a Glance:
Title:
453-02-0540-m5
Date:
February 5, 2002
Status:
Retrospective Medical Necessity

453-02-0540-m5

February 5, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Electric Insurance Company (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC) ordering reimbursement to Respondent West Belt Medical (Provider) for medical services provided to ____ Claimant. This decision concludes that West Belt Medical is not entitled to reimbursement.

The Administrative Law Judge convened a hearing on January 10, 2002. The hearing was concluded and the record closed that date. The Carrier was represented James M. Loughlin, attorney. The Provider appeared through Dr. Robert Morrow, D.C.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this preceding is whether the Carrier should reimburse the Provider $3,410.00 plus interest for medical services provided between April 19, 2000, and November 1, 2000, and billed under CPT Codes 99213-MP (office visit with manipulation), 97250 (myofascial release), 97261 (additional manipulation), 97265 (joint mobilization), 99080 (special reports), 99214 (office visit for established patient), and 97032 (manually applied electrical stimulation).

The Carrier argued that the medical services provided to the Claimant were not medically necessary and reasonably required because the services were provided after the Claimant had reached maximum medical improvement (MMI), which is defined as the earliest date after which further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.[1] Medicine Ground Rule I.A of the Medical Fee Guideline provides that the “patient’s condition shall have the potential for restoration of function” for physical medicine treatment to qualify for reimbursement.

The documentary record in this case consisted of the 479-page certified record of the MRD proceeding (Exh. 1). The record reflects that the Claimant was examined by Gary C. Freeman, M.D. on January 31, 2000, was found to have reached MMI, and was given a 0% impairment rating. (Exh. 1, pp. 394-397). The Provider disputed the findings of Dr. Freeman, and the Claimant was then examined by a TWCC designated doctor, Dennis J. Roberts, D.C. Dr. Roberts found that the Claimant had reached MMI and assigned him an impairment rating of 0%. (Exh 1, pp.368-373). The record also contains the Provider’s notes documenting office visits and treatment for the contested services. (Exh. 1, pp. 74-95).

Based on the evidence, the ALJ concludes that Petitioner’s appeal should be granted. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On________, ____ (Claimant) suffered a compensable injury to his back while wiring a cubicle.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Electric Insurance Company (Carrier).
  3. Respondent West Belt Medical (Provider) treated the Claimant’s injury during 37 office visits from April 19, 2000, through November 1, 2000.
  4. The Provider treated the Claimant’s back injury with manipulation, myofascial release, joint mobilization, and electrical stimulation during the office visits referenced in Finding of Fact No. 3.
  5. Following an examination on January 31, 2000, Gary C. Freeman, M.D. determined that the Claimant had reached maximum medical improvement (MMI) and certified him with 0% whole body impairment.
  6. Following an examination on April 6, 2000, Dennis J. Roberts, D.C., the Texas Workers’Compensation Commission’s designated doctor, determined that the Claimant had reached MMI and certified him with 0% whole body impairment.
  7. The examinations referenced in Findings of Fact Nos. 5 and 6 showed that the Claimant’s condition did not have the potential for restoration of function.
  8. The Provider timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  9. The MRD issued its findings and decision on June 12, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to 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 Tex. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §2001.052 in that it contained a statement of the time, place and nature 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.
  4. The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. The Medicine Ground Rules of the Medical Fee Guideline provide that a patient’s condition shall have the potential for restoration of function for physical medicine treatment to qualify for reimbursement.
  6. Based on Findings of Fact Nos. 5 - 7, the Carrier proved that the Claimant’s condition did not have the potential for restoration of function.
  7. Based on Conclusions of Law Nos. 5 and 6, West Belt Medical is not entitled to reimbursement for the services provided on the disputed dates of service between April 19, 2000, and November 1, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Electric Insurance Company shall not reimburse West Belt Medical for the amount claimed.

Issued this 5th day of February 2002.

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

  1. Tex. Labor Code Ann. § 401.011 (30).
End of Document
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