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At a Glance:
Title:
453-02-1060-m5
Date:
March 5, 2002
Status:
Retrospective Medical Necessity

453-02-1060-m5

March 5, 2002

DECISION AND ORDER

This case is a dispute over whether Liberty Insurance Corporation should reimburse Rehab 2112 for work hardening services provided to ___ from February 5-22, 2001.The amount in controversy is $4,992.00.

The Administrative Law Judge concludes Rehab 2112met its burden of proving the work hardening services met the requirements of the Medical Fee Guidelines (MFG). Therefore, reimbursement of $4,992.00 is ordered.

Findings of Fact

  1. ____ (Claimant) suffered a compensable injury on______, when she pulled a muscle in her back.
  2. Claimant was not physically or emotionally capable of returning to work after, _________. (Pet. Ex. 1, 10 and 133).
  3. Claimant’s family physician David Carson treated Claimant conservatively with two injections to include pain relief and muscle relaxant. (Pet. Ex. 1, 17).
  4. An MRI[1] performed on October 30, 2000, revealed a mild disk bulge and desiccation[2] at the L5-S1 level of Claimant’s spine. (Pet. Ex. 1, 17).
  5. Dr. Carson referred Claimant to Jon Reynolds, D.C., who treated patient conservatively with manipulation and therapy. (Pet. 1, 17).
  6. On November 16, 2000, Dr. Reynolds referred Claimant to Rehab 2112 (Petitioner) for a functional capacity evaluation (FCE) and work hardening five times per week for six to eight weeks.(Pet. Ex. 1, 16).
  7. Petitioner conducted an FCE on Claimant on January 22, 2001. (Pet. Ex. 1, 34 - 45).
  8. The FCE demonstrated the necessity for a work hardening program due to Claimant’s decreased range of motion, endurance deficiencies, positive orthopedic test, psychological deficit, potential to improve, and access to gain full employment upon completion of the program. (Pet. Ex. 1, 10 and 34).
  9. Petitioner provided work hardening for Claimant from January 23, 2001, through February 22, 2001, under the supervision of Michael Smith, D.C.
  10. Claimant’s job is sedentary and involves computer work, and requires her to lift less than 10 pounds. (Pet. Ex. 1, 19).
  11. Claimant showed progress from January 22, 2001, through February 22, 2001, as indicated by a comparison of the FCEs conducted January 22, 2001 and February 28, 2001. (Pet. Ex. 1, 32-45 and 77 - 87).
  12. From the January 22, 2001, FCE to the February 28, 2001, FCE Claimant’s range of motion[3] improved from 95% of normal to 101% of normal on true lumbar flexion, from 56% of normal to 60% of normal on true lumbar extension, dropped from 116% of normal to 97% of normal on left lateral flexion, increased from 137% of normal to 145% of normal on right lateral flexion, jumped from 42% of normal to 75% of normal on left straight leg raise, and dropped from 103% of normal to 97% of normal on right straight leg flexion.
  13. Claimant’s walking, sitting, and standing tolerances remained unchanged at 30 minutes for both FCEs.
  14. Claimant’s standard hand grip leapt from an average of 10.9 pounds to 41.6 pounds for her left hand, and from 30 pounds to 40.9 pounds for her right hand.
  15. Claimant’s leg lift average increased from 30.2 pounds to 35.2 pounds; her torso lift improved from 20 pounds to 34.3 pounds; her arm lift changed from 22.8 pounds to 30.3 pounds; and her high near lift improved slightly from 26.4 pounds to 28.9 pounds.
  16. Claimant’s sustained crouching reach standard score improved from 129% to 148%.
  17. Claimant’s cardiovascular testing remained virtually unchanged, with a resting pulse rate of 70 on both FCEs, systolic pressure of 120 on both dates, and diastolic pressure that dropped from 78 on the first FCE to 68 on the second one.
  18. On January 23, 2001, Claimant spent 20 minutes on job readiness. (Pet. Ex. 1, 47).
  19. On February 2, 2001, Claimant spent 30 minutes on job readiness. (Pet. Ex. 1, 50).
  20. On February 28, 2001, Claimant spent 60 minutes on job readiness. (Pet. Ex. 1, 60).
  21. Claimant showed progress in job readiness between January 23, 2001 and February 28, 2001.
  22. Claimant’s physical conditioning improved between January 23, 2001, and February 22, 2001.

a. On January 23, 2001, Claimant stretched for 30 minutes, and spent 60 minutes on the treadmill and 30 minutes on the stationary bicycle. For strengthening, Claimant used 10 pound weights for her upper extremities and 20 pound weights on her lower extremities. She used 10 pound weights for work simulation. (Pet. Ex. 1, 49).

  1. On February 2, 2001, Claimant stretched for 30 minutes, and spent 60 minutes on the treadmill and 30 minutes on the stationary bicycle. She added 30 minutes of stabilization exercises. She used 30 pound weights for body strengthening, and used 15 pound weights for the work simulation exercises. (Pet. Ex. 1, 52).
  2. On February 22, Claimant stretched for 40 minutes, spent 60 minutes on the treadmill, 30 minutes on the stationary bicycle and practiced 30 minutes of stabilization exercises. She used 30 pound weights for strengthening and 12 pound weights for work simulation. (Pet. 1, 60.)
  3. In March 2001 Liberty Insurance Corporation (Respondent) denied payment for the work hardening provided January 23, 2001 through February 22, 2001.
  4. On June 7, 2001, Petitioner filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission),seeking $8,064.00 in reimbursement.
  5. On October 30, 2001, the Commission’s Medical Review Division (MRD) ordered Respondent to pay Petitioner $3,072.00 for work hardening provided January 23, 2001, through February 2, 2001, but denied the request for $4,992.00 in reimbursement for work hardening provided February 5-22, 2001.
  6. Petitioner appealed the denial of reimbursement for work hardening provided February 5-22, 2001, seeking reimbursement of $4,992.00.
  7. Petitioner filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  8. Notice of the hearing was sent December 6, 2001.
  9. 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.
  10. The hearing was held January 31, 2002, with Administrative Law Judge Sharon Cloninger presiding and representatives of Rehab 2112 and Liberty Insurance Corporation participating. The record closed the same day.

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. §2001.052.
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Pursuant to Findings of Fact Nos.7 - 13, Petitioner met its burden of proving it was entitled to reimbursement.
  6. Rehab 2112’s request for reimbursement should be granted.

ORDER

IT IS, THEREFORE, ORDERED thatLiberty Insurance Corporationshall pay $4,992.00 to Rehab 2112 for work hardening provided to Claimant from February 5 - 22, 2001.

Signed March 5, 2002.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Magnetic resonance imaging is a non-invasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves. Merriam-Webster Medical Dictionary, Merriam-Webster Incorporated, Springfield Massachusetts, 1995, p. 389.
  2. Desiccation is a complete or nearly complete deprivation of moisture, or dehydration. Id. at 171.
  3. The “normals” are specified in the American Medical Association Guide to the Evaluation of Permanent Impairment, Third Edition (Pet. Ex. 1, 37).
End of Document
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