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At a Glance:
Title:
453-02-0722-m5
Date:
June 7, 2002
Status:
Retrospective Medical Necessity

453-02-0722-m5

June 7, 2002

DECISION AND ORDER

This case involves a dispute over the decision by Texas Mutual Insurance Company (Carrier)[1] to not reimburse Accidental Injury Treatment Center (Provider) for treatment provided to___, an injured employee. After considering the evidence and legal arguments, the Administrative Law Judge (ALJ) finds that Carrier is not liable to reimburse Provider for the treatment in issue for the following reasons: (1) the steroidal injections given were not medically necessary; (2) the office visits billed were global to the steroidal injections and should not have been billed separately; and (3) Provider failed to adequately document treatment that would justify billing the office visits under CPT code 99214-22.

I. Discussion

The ALJ notes that nine office visits are in dispute for the following dates in 1999: 3/30, 4/27, 5/26, 6/22, 7/13, 8/10, 9/14, 10/12, and 11/9. During each office visit, Provider gave steroidal injections[2] to___ to help alleviate pain resulting from a compensable injury. After considering the evidentiary record, the ALJ concludes that Provider has not shown by a preponderance of the evidence that the steroidal injections were reasonable and necessary medical treatment for__.

Dr. Derald R. Morris, the physician providing the treatment on behalf of Provider, testified that the injections were a proper course of treatment and helped alleviate __ pain. The treatment notes reflect that __’s pain was alleviated for short periods of time (up to a week, in general) after the injections. In response, Carrier presented the peer review report of Dr. Samuel Bierner who concluded that the injections were not having any meaningful benefit to___ and should be discontinued because they posed a risk of harm. Dr. Bierner’s report clearly states his conclusion that the injections were not medically necessary. Carrier also presented the deposition testimony of Dr. Nicholas Tsourmas, who testified that the injections could not have been paravertebral because of the size of the needle involved, but were actually trigger-point injections. Further, Dr. Tsourmas contends that the treatment notes support the conclusion that the injections were not paravertebral, but only trigger-point injections.[3] Finally, Dr. Tsourmas concurred with Dr. Bierner’s conclusion that the injections were not medically necessary, pointing out that the injections did not result in long-lasting improvement to__’ s pain levels.

While Dr. Morris strongly disagreed with Dr. Tsourmas’s conclusions that the injections were not paravertebral, he did not refute the detailed reasons given by Dr. Tsourmas. Nor did Dr. Morris address in detail why the continued injections were medically necessary in light of the limited pain relief that __appeared to receive from them. After considering all of the testimony, the ALJ finds Dr. Bierner’s report and Dr. Tsourmas’s detailed testimony to be more persuasive than Dr. Morris’s summary conclusions. Therefore, the ALJ concludes that the steroidal injections were not medically necessary treatment and did not provide ___with significant medical benefit.

The evidence also does not establish that___’s condition warranted office visits that could be billed distinctly and separately from paravertebral injections. Rather, because the injections were the main service provided at the office visits, the Commission’s rules dictate that the office visits are global to the injections and should not have been billed separately. Moreover, Provider billed the office visits under CPT code 99214-22, which is the code for moderately complex office visits involving at least two of the following components: a detailed history, a detailed examination, and medical decision-making of moderate complexity. Provider’s documentation does not support the conclusion that at least two of these three components were present. The office visits were fairly routine follow-up visits to check on___’s status and pain levels. Provider’s documentation contains no detailed history nor indication of a detailed examination. Also, the modifier “-22”added to the CPT code is for examinations that are unusually difficult in nature; however, the documentation indicates nothing unusual, difficult or complex about the examinations.

For the reasons identified above, and as set forth in the findings of fact and conclusions of law below, Provider has not shown by a preponderance of the evidence that the treatments in issue were medically reasonable and necessary, nor properly provided and documented according to the Commission’s rules. Therefore, reimbursement is denied as to all amounts sought.

II. Findings of Fact

  1. ___ suffered a compensable injury to his neck on or about___. At all times relevant herein, Texas Mutual Insurance Company (Carrier) was the workers’ compensation insurance carrier for__.
  2. For his injury, __ underwent surgery in 1997. After his surgery, ___was seen by Derald R. Morris, D.O., with Accidental Injury Treatment Center (Provider) for post-operative therapeutic care. Primarily, Provider’s treatment of ___was focused on providing pain relief and management for ___’s injury.
  3. ___saw Provider on the following dates in issue in 1999: 3/30, 4/27, 5/26, 6/22, 7/13, 8/10, 9/14, 10/12, and 11/9. On each of those dates, ___was already an established patient of Provider. On each date, Provider saw ___for an office visit and provided four steroidal injections to ___.The injections were the major service provided at the office visit. The injections were similar to injections given by Provider to ___in 1997 and 1998, with similar results.
  4. Given___’s condition, and the previous steroidal injections given by Provider to___, it was not medically reasonable and necessary for___ to be seen by Provider on each of the nine occasions for steroidal injections to treat the ongoing pain from his compensable injury. ___did not achieve any significant relief from pain as a result of the injections.
  5. For each office visit, Provider failed to document a detailed history for___, a detailed examination of___, or medical decision-making of moderate complexity. Moreover, Provider did not document anything unusual or difficult regarding any of the office visits.
  6. Provider billed Carrier the total sum of $675 for the nine office visits, with each visit billed under CPT code 99214-22. This CPT code reflects a billing of a medical examination of moderate complexity. The modifier of “-22” indicates an examination of an unusually difficult nature.
  7. Provider billed Carrier the total sum of $5,580 for 36 paravertebral injections provided to ___during the nine office visits (four injections per visit, with nine total visits). Each of the four injections at each office visit were given at different vertebral levels (i.e., the level between two specific vertebrae of the spine) of___.’s spine.
  8. Carrier denied reimbursement for the office visits on the grounds that they were not adequately documented, not medically necessary, and were global to the paravertebral injections. Carrier denied reimbursement for the injections on the basis that they were not medically necessary.
  9. Provider filed a Request for Medical Dispute Resolution with the Commission, seeking reimbursement for the treatment of___.
  10. On August 29, 2001, the Commission’s Medical Review Division (MRD) determined that Provider was not entitled to any reimbursement.
  11. On September 18, 2001, Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  12. Notice of the hearing was sent on November 13, 2001.
  13. The notice 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 sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  14. The hearing was continued and all parties were notified of the new setting.
  15. The hearing was held on May 21, 2002, with Administrative Law Judge Craig R. Bennett presiding and representatives of the Carrier and Provider participating. The hearing was adjourned and the record closed the same day.

III. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann.§413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
  3. The Provider timely filed its notice of appeal, as specified in 28 Tex. Admin. Code §148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code Ann.§2001.052 and 28 Tex. Admin. Code § 148.4.
  5. The Provider has the burden of proof on its appeal by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code §148.21(h).
  6. Under the Spine Treatment Guideline, treatment of a work-related injury must be adequately documented and consistent with the guideline. 28 Tex. Admin. Code §134.1001(e)(2)(A) and (e)(3).
  7. Provider has not adequately documented, within the requirements of the Spine Treatment Guideline, that a medical examination of moderate complexity and an unusually difficult nature was provided to___ on the office visit dates in issue.
  8. Because the steroidal injection was the major service at the office visits in issue, the office visits may not be billed separately.
  9. Provider is not entitled to be reimbursed for the steroidal injections given between March 30, 1999 and November 9, 1999, because such injections were not medically necessary.
  10. Provider is not entitled to reimbursement for any office visits during March 30, 1999 and November 9, 1999, because they were not properly documented and were global to the paravertebral injections that were billed.

ORDER

IT IS ORDERED that the appeal by Accidental Injury Treatment Center is DENIED. Texas Mutual Insurance Company is not required to reimburse Accidental Injury Treatment Center for any of the services in issue in this proceeding.

Signed June 7th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CRAIG R. BENNETT
Administrative Law Judge

  1. Texas Mutual Insurance Company has gone by numerous different names in the past few years. It was operating under a different name at the time it was the carrier for __’s employer, however, the principal entity is the same.
  2. Provider billed the injections as paravertebral injections, although the evidence is conflicting on whether they were trigger-point injections instead of paravertebral injections. There is no dispute that the injections were of a steroid.
  3. While not dispositive in this case, this distinction is important because paravertebral injections do not require preauthorization and are reimbursed at $152. Trigger-point injections require preauthorization and are reimbursed at only $40.
End of Document
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