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At a Glance:
Title:
453-02-1058-m5
Date:
February 27, 2002
Status:
Retrospective Medical Necessity

453-02-1058-m5

February 27, 2002

DECISION AND ORDER

This case is a dispute over whether Twin City Fire Insurance Company (Respondent) should reimburse Mega Rehab (Petitioner) for work hardening services provided to____ (Claimant) from February 5, 2001, through March 7, 2001, and for Functional Capacity Evaluations (FCEs) performed on Claimant on January 2, 2001, and on January 31, 2001. The amount in controversy is $5,205.60, as stated in the Agreed Clarification of Outstanding Charges submitted to the Administrative Law Judge (ALJ) by the parties on February 4, 2002.[1]

The ALJ concludes the Petitioner met its burden of proving the work hardening services and FCEs meet the requirements of the Medical Fee Guidelines (MFG). Therefore, reimbursement of $5,205.60 is ordered.

Findings of Fact

  1. ________ (Claimant) suffered a compensable injury on________, when she developed pain in her left wrist and tingling in her left little finger while doing repetitive typing at work.
  2. Treatment for Claimant’s compensable injury included pain medication, cortisone injections, approximately three weeks of physical therapy, and an MRI of her cervical spine. The treatment did not alleviate Claimant’s pain. (Pet. Ex. 1, 241).
  3. Claimant’s treating physician Joseph Viernow, D.C. referred her to Alan B. Hurschman, M.D., P.A. for consultation and possible treatment. (Pet. Ex. 1, 241).
  4. On September 7, 2000, Dr. Hurschman consulted with Claimant and reported her diagnosis to be clinical left carpal tunnel syndrome, left shoulder tendinitis,[2] C3 through C7 disc bulges as evidenced by the cervical MRI, associated with myofascial pain, and left de Quervain’s tenosynovitis,[3] all secondary to Claimant’s repetitive typing at work. (Pet. 1, 241-243).
  5. Dr. Viernow referred Claimant to Mega Rehab (Petitioner) for work hardening on December 21, 2000. (Pet. Ex. 1, 90).
  6. Petitioner conducted an FCE on Claimant on January 2, 2001, under the supervision of Stephen Dudas, D.C.
  7. Petitioner prepared a summary report of the FCE. (Pet. Ex. 1, 179-188).
  8. The start and stop times of the FCE are documented on a time card. (Pet. Ex. 1, 188).
  9. The FCE included a physical examination and neurological evaluation of Claimant,including her appearance, flexibility of the extremity joint or spinal region, posture and deformities, vascular integrity, neurological tests to determine sensory deficit, myotomal strength to detect gross motor deficit, and reflexes to detect neurological reflex symmetry. (Pet. Ex. 1, 223-240).
  10. The FCE documented a physical capacity evaluation of the injured area which includedrange of motion of the injured joint or region, and strength/endurance with comparison to contralateral side or normative data base. (Pet. Ex. 1, 180 and 182-187)
  11. The FCE should have included functional abilities tests which included activities of daily living such as pushing, pulling, kneeling, squatting, carrying and climbing, but due to hernia surgery, Claimant could not perform those tests.
  12. The FCE measured Claimant’s grip strength; aerobic capacity by having Claimant perform a cardiovascular endurance test using stationary bicycle or treadmill; and her static positional tolerance (observational determination of tolerance for sitting or standing.) (Pet. Ex. 1, 179-180, 225, 227)
  13. The computer print-out of the FCE is fully legible. (Pet. Ex. 1, pp. 179-187).
  14. h.The psychological component of the FCE is presented in the written data sheet. (Pet. Ex. 1, 223-239).
  15. Petitioner conducted an FCE on Claimant on January 31, 2001, under the supervision of Dr. Dudas.[4]
  16. Petitioner prepared a summary report of the FCE. (Pet. Ex. 1, 189-202).
  17. The start and stop times of the FCE are documented on a time card. (Pet. Ex. 1, 202).
  18. The FCE included a physical examination and neurological evaluation of Claimant,including her appearance, flexibility of the extremity joint or spinal region, posture and deformities, vascular integrity, neurological tests to determine sensory deficit, myotomal strength to detect gross motor deficit; and reflexes to detect neurological reflex symmetry. (Pet. Ex. 1, 223-227).
  19. The FCE included a physical capacity evaluation of the injured area which included range of motion of the injured joint or region and strength/endurance with comparison to contralateral side or normative data base.(Pet. Ex. 1, 190 and 193-201).
  20. The FCE included functional abilities tests which included activities of daily living such as pushing, pulling, kneeling, squatting, carrying and climbing;a grip strength test,a submaximal cardiovascular endurance test which measures aerobic capacity using a stationary bicycle or treadmill;and a static positional tolerance test. (observational determination of tolerance for sitting or standing.) (Pet. Ex. 1, 189-190, 225, 227).
  21. The FCE showed Claimant had improved since the initial FCE conducted January 2, 2001. The computer generated report dated January 31, 2001 (Pet. Ex. 1, 196) shows a 52.9% improvement in leg lift strength, 57.6% improvement in pull down strength, 61.8% improvement in push down strength, 200% improvement in high far lift strength, and a 247% improvement in high near lift strength. Grip strength in the patient’s left hand increased from 15 pounds of force (Pet. Ex. 1, 179) on January 2, 2001 to 30 pounds of force on January 31, 2001 (Pet. Ex. 1, 189). Resting pulse rate decreased from108 beats per minute on January 2, 2001 to 88 beats per minute on January 31, 2001, and she dropped her weight from 225 pounds to 221 pounds over the same time period. (Pet. Ex. 1, 179 and 189) Furthermore, during the initial FCE, Claimant was unable to push, pull or carry any significant weight. During the FCE dated January 31, 2001, she was able to perform these tasks. Progress bar graphs depict the increases in strength the patient displayed during the work hardening program. (Pet. Ex. 1, 214-215).
  22. Activity summaries for the arm lift, leg lift, high far lift, high near lift, push down, and pull down as performed on January 2, 2001 and January 31, 2001, and recorded in the FCE conducted April 19, 2001, show Claimant’s gradual advancement. (Pet Ex. 1, 433-434).
  23. The computer-generated data is legible. (Pet. Ex. 1, 193-196).
  24. Mega Rehab (Petitioner) provided work hardening for Claimant from February 5, 2001, through March 7, 2001.
  25. Claimant was likely to benefit from the program, in that her current levels of functioning due to injury interfered with her ability to carry out specific tasks required in the workplace;her medical, psychological and other conditions did not prohibit participation in the program; and she was capable of attaining specific employment upon completion of the program.(Pet. Ex. 1, 241-243, 401-403, 412, 425, testimony of Dr. Dudas)
  26. Claimant participated in work hardening a minimum of four hours per day except for the first week due to her inability to tolerate the full session, but attended at least two hours per day during the initial week. (Pet. Ex. 1, 127, 135, 140, 145).
  27. Claimant’s individualized plan of treatment was supervised by a licensed physical or occupational therapist or doctor within a therapeutic environment. More than half the time was self-monitored under the supervision of a licensed member of the interdisciplinary team. (Pet. Ex. 1, 336-352).
  28. The program supervisor provided direct on-site supervision of work hardening activities; participated in the initial and final evaluation of the patient; wrote the treatment plan for the patient and wrote changes to the plan based on documented changes in the patient’s condition; directed the interdisciplinary team when providing treatment and services; and reviewed the patient’s program on a systemic basis. Dr. Dudas signed each progress note. (Pet. Ex. 1, 120-126, 128-134, 136-139 and 141-144, 166, 168, 170-172).
  29. Daily treatment and patient response to treatment were documented and reviewed to ensure continued progress. (Pet. Ex. 1, 120-126, 128-134, 136-139 and 141-144).
  30. The weekly team conference notes dated February 8, 2001, February 15, 2001, February 22, 2001, March 1, 2001, and March 8, 2001, all contain appropriate comprehensive notes regarding the Clamant; detail specific names and credentials of the psychologist, exercise physiologist, master in physical therapy, chiropractor and other assistants who compose the team; and are all individually signed and dated on the weekly team meeting. (Pet. Ex. 1, 166, 170-172, 449, 452, 454, 456, 465, 467 and 469-470).
  31. Work simulation began on February 12, 2001, the second week of Claimant’s work hardening program. (Pet. Ex. 1, 129).
  32. Work simulation in the form of data entry and typing is documented in the work hardening daily SOAP notes dated February12-16, 2001, and the work hardening exercise flow sheets for February 19-21, 2001 and for March 5-7, 2001. (Pet. Ex. 1, 129-133, and 136).
  33. The work hardening exercise flow sheets, under the heading “Work Simulation,” document exercise activity such as several shoulder range-of-motion exercises and wrist exercises, and document the exact weight and repetition activity. The work flow sheets are signed and documented for individual dates of therapy either by a physical therapist or Dr. Dudas. (Pet. Ex. 1, 120, 128, 136 and 141).
  34. The work hardening documentation notes that Claimant’s job duties consist of constant data entry and typing, and is sedentary in nature, so work specific training was directed toward typing and data entry.
  35. Claimant’s typing during work simulation began at 20 minutes per session the week of February 5, 2001 (Pet. Ex. 1, 141); increased from 30 minutes per session to 45 minutes session as of February 16, 2001 (Pet. Ex. 1, 133); and progressed to one hour per session by the week of April 17, 2001. (Pet. Ex. 1, 153).
  36. The documentation supports a highly structured, goal oriented program, with individualized treatment involving sitting and typing, designed to maximize the ability of the person to return to work.
  37. Claimant returned to work following the work hardening program. (Testimony of Dr. Dudas).
  38. In April 2001 Twin City Insurance Company (Respondent) denied payment for the FCEs conducted January 2, 2001 and January 31, 2001 on the grounds that they was not medically necessary (Pet. Ex. 1, 53 and 69-70); and for the work hardening provided February 5 - March 7, 2001, on the grounds that it was not medically necessary (Pet. Ex. 1, 71-86)
  39. On May 10, 2001, Petitioner filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking $8,235.80 in reimbursement.
  40. On October 5, 2001, the Commission’s Medical Review Division (MRD) denied the request for reimbursement.
  41. Petitioner agreed with the portion of the MRD decision denying reimbursement for work conditioning, but appealed the denial of reimbursement for work hardening provided February 5 - March 7, 2001, and for FCEs conducted January 2, 2001, and January 31, 2001, resulting in a revised disputed amount of $5,205.60.
  42. Petitioner filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  43. Notice of the hearing was sent December 6, 2001.
  44. 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.
  45. The hearing was held January 31, 2002, with ALJ Sharon Cloninger presiding and representatives of Mega Rehab and Twin City Fire Insurance Company participating. The hearing adjourned the same day. The record closed February 4, 2002.

Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation 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. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Mega Rehab met its burden of proving it was entitled to reimbursement.
  6. Pursuant to Findings of Fact Nos. 6 and 7, Petitioner met the requirements of Medical Ground Rule I(E)(2) related to functional capacity evaluations.
  7. The requirements of the work hardening program pursuant to Medicine Ground Rule II. E. were met as listed in Finding of Fact No. 8.
  8. Mega Rehab’s request for reimbursement should be granted.

ORDER

IT IS, THEREFORE, ORDERED that Twin City Insurance Company pay $5,205.60 to Mega Rehab for work hardening provided to Claimant from February 5, 2001, through March 7, 2001, and for Functional Capacity Evaluations performed on January 2, 2001, and January 31, 2001.

Signed February 27, 2002.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Petitioner had also asked the MRD to approve reimbursement for work conditioning. The MRD decided the charges for work conditioning were not reimbursable. Petitioner subsequently agreed with the MRD decision regarding work conditioning, and is not appealing that portion of the MRD decision, thus reducing the amount in dispute from the original $8,235.80 to the current $5,205.60.
  2. Tendinitis is inflammation of a tendon. Merriam-Webster’s Medical Dictionary, 1995, Merriam-Webster Incorporated, Springfield Massachusetts, p. 691.
  3. de Quervain’s disease is inflammation of tendons and their sheaths at the styloid process of the radius that often causes pain in the thumb side of the wrist. Merriam-Webster’s Medical Dictionary, 1995, Merriam-Webster Incorporated, Springfield, Massachusetts, p. 169.
  4. The MRD did not consider the FCE performed on January 31, 2001, because when Petitioner filed its dispute with the MRD, the date of the FCE was listed as occurring in 2000, not in 2001, so appeared to be more than a year old, putting it outside MRD jurisdiction. At the hearing, the parties agreed that a clerical error had been made when Petitioner submitted the January 31st date to the MRD, and the FCE occurred in 2001. The ALJ decided reimbursement for the January 31, 2001, FCE would be considered.
End of Document
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