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At a Glance:
Title:
453-02-1000-m5
Date:
April 17, 2002
Status:
Retrospective Medical Necessity

453-02-1000-m5

April 17, 2002

DECISION AND ORDER

Scientific Therapy and Advanced Treatment (STAT) appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in MDR Docket No. M5-01-1817-01, which denied reimbursement to STAT for rental of a neuromuscular stimulator device to (Claimant). The MRD decision, issued September 27, 2001, upheld Zenith Insurance Company’s (Carrier) denial of reimbursement of $535.00 for the device rental and accompanying supplies. STAT asserted that the device was medically necessary for Claimant. This decision agrees with the MRD and finds reimbursement should be denied due to lack of documentation of medical necessity and the failure to obtain preauthorization for durable medical equipment.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing in this matter was held February 14, 2002, at the Hearings Facility of the State Office of Administrative Hearings, Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas, with Administrative Law Judge (ALJ) Stephen J. Pacey presiding. Carrier appeared through its attorney, James Laughlin. STAT’s employee, Randy Burgett, appeared telephonically and represented the company. Respondent Commission did not participate. After allowing three days for additional evidence, the record closed February 17, 2002.

II. DISCUSSION

A. Background Facts

On _____, Claimant suffered a compensable injury to her back. At the time of her compensable injury, Carrier was the workers’ compensation insurer for Claimant’s employer. Claimant is under the care of Dr. Salvador Baylan, M.D., for continuing pain and muscle spasms in her cervical area radiating to her lower back. On May 5, 2000, Dr. Baylan prescribed a neuromuscular stimulator device for Claimant to relieve chronic back muscle spasms and pain . The prescription was for rental of STAT’s BMR NT2000 device (NT2000). Carrier declined to pay for the rental.

The issues are whether there was sufficient documented clinical rationale to justify the use of the electrical stimulator over five years post-injury, and whether preauthorization was required for the July 2000, stimulator application.[1]

Under the Spine Treatment Guideline (STG), use of a TENS unit (the category into which the NT2000 falls) beyond the secondary level of care requires objective/quantified measures of substantive and continued improvement over time, which may include but are not limited to: decreased use of medication; increased function due to pain reduction; and enhanced ability to return to or retain employment. 28 Tex. Admin. Code (TAC) 134.1001 (e)(2)(G); 28 TAC 134.1001(e)(3)(F). STAT did not provide Carrier with any information regarding the objective measurements. Given the sparseness of documentation provided to Carrier to justify the medical necessity, even after STAT submitted additional information for reconsideration of the claim, Carrier was justified in denying the claim.

Under 28 TAC 134.600(h)(13) preauthorization is required for all durable medical equipment in excess of $500.00 per item. The May and June rentals exceeded the $500.00 limit; therefore, preauthorization was required for the July rental and Carrier was justified in denying the claim.

III. FINDINGS OF FACT

  1. On _____, ___(Claimant) suffered a compensable injury to her back.
  2. At the time of Claimant’s compensable injury, Zenith Insurance Company (Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. The NT2000 is a type of TENS unit in that it stimulates muscles via electric shocks.
  4. Claimant suffers from muscle spasms and pain in her cervical area radiating to her lower back.
  5. To treat her muscle spasms and reduce pain, Claimant’s doctor, Dr. Salvador Baylan, prescribed a neuromuscular stimulator medical device.
  6. In May 2000, Scientific Therapy and Advanced Treatment (STAT) rented a neuromuscular stimulator device, the NT2000, to Claimant.
  7. The Commission’s Spine Treatment Guideline (STG) approves use of a TENS unit for claimants at the primary or secondary level of care only for short-term (four to six weeks) of treatment of acute pain.
  8. Five years after her injury, Claimant was in the post-tertiary level of care under the Texas Workers’ Compensation Commission’s (Commission) STG.
  9. In a decision issued September 27, 2001, the Commission’s Medical Review Division denied STAT’s claim for reimbursement of $535.00 from Carrier for the rental of the NT2000.
  10. STAT appealed the MRD’s order.
  11. All parties were represented at the hearing in this matter.
  12. STAT failed to provide Carrier with adequate documentation to justify rental of the device because there was no documentation showing: Claimant’s treatment plan; the efficacy of the treatment; the use was for acute, not chronic, pain; or the need to deviate from the STG’s recommended treatments.
  13. STAT failed to request preauthorization for the July stimulator application.

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. LABOR 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(d) 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. STAT had the burden of proof in this case. 28 TAC § 148.21(h) and (i).
  6. The Commission’s Spine Treatment Guideline (STG) specifically recommends TENS units only for the primary and secondary levels of non-operative care. 28 TAC § 134.1001 (g)(7)(A-B).
  7. Under the STG, TENS units are for acute pain and usually used for no longer than four to six weeks. 28 TAC 134.1001 (e)(2)(G).
  8. The STG requires a documented treatment plan (including proposed methods, expected outcomes, and probable duration) and documentation substantiating any need to deviate from the STG. 28 TAC §134.1001 (e)(3)(B)(iii). The treating doctor must demonstrate the appropriateness of all services and the relatedness of all services to the compensable injury. 28 TAC §§ 134.1001(c) (2) (A) (ii) and (iii).
  9. Preauthorization is required for durable equipment in excess of $500.00.
  10. Based on the foregoing Findings of Fact and Conclusions of Law, STAT failed to provide sufficient documentation to meet the STG’s requirements to establish the medical necessity of the rental of the NT2000 for Claimant.
  11. Based on the foregoing Findings of Fact and Conclusions of Law, STAT failed to obtain preauthorization for the July stimulator application.
  12. Based on the foregoing, Carrier is not required to reimburse STAT for the rental of the NT2000 for Claimant.

ORDER

IT IS ORDERED that Zenith Insurance Company is not required to reimburse the rental cost of a neuromuscular stimulator from Scientific Therapy & Advanced Treatment for claimant ____.

Signed this 17th day of April 2002.

STEPHEN J. PACEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. This case only applies to the June and July, 2000, applications, even though the applications began in May, 2000,
End of Document
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