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At a Glance:
Title:
453-02-1054-m5
Date:
February 15, 2002
Status:
Retrospective Medical Necessity

453-02-1054-m5

February 15, 2002

DECISION AND ORDER

This case is a dispute over the decision by Connecticut Indemnity Company (Carrier) not to reimburse Albert M. Daniel, III, D.C. (Provider) for treatment provided to____, an injured employee.[1] After considering the evidence and legal arguments, the Administrative Law Judge (ALJ) finds that Carrier is liable to reimburse Provider the amount of $216 for four office visits by____. The ALJ finds that Provider is not entitled to reimbursement for all other amounts in issue for the following reasons: (1) the remaining office visits were not medically necessary nor reasonable; and (2) Provider failed to adequately document the work conditioning that was purportedly provided to____.

As to the office visits, the ALJ notes that 14 are in dispute, for the following dates in 2000: 10/18, 10/19, 10/20, 11/7, 11/8, 11/13, 11/15, 11/16, 11/29, 12/1, 12/4, 12/5, 12/20, and 12/22. Based on Carrier’s evidence, the ALJ concludes that office visits were medically necessary and reasonable on a weekly, not daily, basis only up until 11/29/00. Therefore, the ALJ finds that only four of the office visits in question were medically necessary and reasonable.

As to the work conditioning, the ALJ finds that Provider did not properly document the treatment under the rules of the Texas Workers’ Compensation Commission (Commission) and, therefore, is not entitled to reimbursement. Work conditioning is “a highly structured, goal-oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks.”[2] The Commission’s rules require that documentationfor programs such aswork conditioning show objective substantive and continued improvement over time that correlates to the job description the injured employee will most likely enter upon completion of the program.[3]

Given the nature of work conditioning, the medical records should contain some indication of inability to return to work or impairment of the injured worker’s ability to perform some or all of the functions of the job before work conditioning is deemed necessary. Here, there is no such documentation. Further, the medical treatment records themselves do not establish that work conditioning was properly provided. Of primary importance, none of the medical records contain adequate documentation of any actual or simulated work activities. Nor is there any record of improvement in work skills or a discussion of ____’s ongoing performance in work simulation activities. Without an emphasis on work simulation activities and an employee’s ability to perform work duties, the treatment can hardly be considered work conditioning. Given that the sole purpose of work conditioning is to enable an employee to return to work, it is glaring when the medical records contain virtually no discussion of____’s job requirements, his ability to perform work-related tasks or his ultimate ability to return to his job.

For the reasons identified above, and as set forth in the findings of fact and conclusions of law below, Carrier has shown by a preponderance of the evidence that most of the treatments in issue were not medically necessary nor shown to have been properly provided and documented according to the Commission’s rules. So, except as to the sum of $216, reimbursement is denied.

I. Findings of Fact

  1. ____suffered an injury to his right shoulder and cervical spine on or about_______. At all times relevant herein, Connecticut Indemnity Company (Carrier) was the workers’ compensation insurance carrier for ___.
  2. For his injury, ____ underwent surgery in 1999 and 2000. After surgery on August 23, 2000,____ was seen by Albert M. Daniel, III, D.C. (Provider) for post-operative therapeutic care.
  3. Beginning on October 18, 2000, Provider implemented a treatment plan which required ___ to be seen in office three times a week and to begin a work conditioning program.
  4. Given___’s condition, it was not medically reasonable and necessary for____ to be seen by Provider for office visits three times a week. Rather, it was only medically reasonable and necessary for ____ to be seen by Provider for office visits one day a week between October 18, 2000, and November 29, 2000.
  5. Provider did not document____’s inability to return to work or an impairment of____’s ability to perform some or all of the functions of his job before work conditioning was started.
  6. ____ was seen by Provider numerous times between October 18, 2000, and December 22, 2000. In the treatment records, Provider did not document ___’s work activities or job functions. Provider also did not document any actual or simulated work activities performed during work conditioning, nor any improvement in____’s work skills, ongoing performance in work simulation activities, or his ultimate ability to return to his job.
  7. Provider billed Carrier the sum of $3,436 for numerous office visits and work conditioning treatments between October 18, 2000 and December 22, 2000.
  8. Carrier denied reimbursement on the grounds that office visits were not needed three times per week to provide reasonable and necessary medical treatment to ___.Further, Carrier contended that work conditioning was not shown to be medically necessary, nor was it adequately documented by the Provider.
  9. Provider filed a Request for Medical Dispute Resolution with the Commission, seeking reimbursement for the unreimbursed treatment of ____.
  10. On October 18, 2001, the Commission’s Medical Review Division (MRD) determined that Provider was entitled to reimbursement in the amount of $1,472.
  11. On November 7, 2001, Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  12. Notice of the hearing was sent on December 6, 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 held January 29, 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.

II. 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 Carrier 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 §2001.052 and 28 Tex. Admin. Code § 148.4.
  5. The Carrier had 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. Provider is only entitled to be reimbursed for four office visits between October 18, 2000 and November 29, 2000, and not entitled to reimbursement on any other office visits because they were not medically reasonable and necessary.
  7. Provider is entitled to reimbursement in the total amount of $216 for office visits and manipulations on October 18, 2000 ($56); November 7, 2000 ($48); November 15, 2000 ($56); and November 29, 2000 ($56).
  8. Under the Upper Extremities Treatment Guideline, treatment of a work-related injury must be adequately documented and consistent with the guideline. 28 Tex. Admin. Code §134.1002(e)(2)(A).
  9. Work conditioning is a highly structured, goal-oriented, individualized treatment program using real or simulated work activities in conjunction with conditioning tasks. 28 Tex. Admin. Code § 134.1002(h)(55).
  10. Documentation for rehabilitation programs such as work conditioning should show objective substantive and continued improvement over time that correlates to the job description the injured employee will most likely enter upon completion of theprogram. 28 Tex. Admin. Code § 134.1001(e)(3)(D).
  11. Provider has not adequately documented that work conditioning treatment was provided to I.H. consistent with the Commission’s rules.
  12. Provider is not entitled to reimbursement for work conditioning treatment for I.H. for dates of service between October 18, 2000 and December 22, 2000.

ORDER

IT IS ORDERED that the appeal by Connecticut Indemnity Company is GRANTED in part. The decision by the Commission’s Medical Review Division ordering reimbursement to Albert M. Daniel, III, D.C., in the amount of $1,472 is reversed. Instead, Connecticut Indemnity Company is ordered to pay the sum of $216 to Albert M. Daniel, III, D.C., pursuant to this order.

Signed February 15th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CRAIG R. BENNETT
Administrative Law Judge

  1. The amount in dispute is $1,472. The amount billed was $3,436, but the Commission’s Medical Review Division denied reimbursement for some items, and Provider did not request a hearing on that determination.
  2. 28 Tex. Admin. Code § 134.1002(h)(55) (emphasis added).
  3. 28 Tex. Admin. Code § 134.1001(e)(3)(D) (emphasis added)
End of Document
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