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At a Glance:
Title:
453-02-1061-m5
Date:
April 4, 2002
Status:
Retrospective Medical Necessity

453-02-1061-m5

April 4, 2002

DECISION AND ORDER

Scientific Therapy and Advanced Treatment (STAT) seeks reimbursement of $396.50 from Liberty Mutual Insurance Company (Liberty) for a massager and hot/cold flex pad provided to ___ (Claimant), a worker who had strained her neck and back. The Texas Workers’ Compensation Commission, Medical Review Division, in its Medical Dispute Resolution Findings and Decision, agreed with Liberty’s denial of reimbursement. Based on evidence and arguments of the parties, the Administrative Law Judge concludes STAT failed to meet its burden of proving the equipment met the medical necessity requirements of the Commission’s Medical Fee Guideline (MFG). Therefore, reimbursement is denied.

I. Statement of the Case

Administrative Law Judge Gary Elkins convened and closed a hearing on February 5, 2002. STAT was represented by Randy Burgett, and Liberty was represented by Mahon Garry. Neither jurisdiction nor notices were disputed.

II. Discussion

In support of its reimbursement claim for the massager and hot/cold flex pad provided to Claimant approximately sixteen months after her injury, STAT argued that a treating doctor had seen Claimant, had observed chronic pain and muscle spasms experienced by her, and prescribed the treatment as part of an effort to avoid the use of drugs and to get her back to work. A paper review by another doctor such as Liberty’s witness, who had not personally examined the patient, would not be sufficient to overcome the treating doctor’s observations and findings, STAT contended.

Liberty maintained that STAT’s reimbursement claim should fail because the particular treatment was not appropriate for a neck and back strain under the facts of this case. Specifically, Liberty argued the following:

  • The record did not support the use of hot/cold packs at 16 months post-injury, when Claimant received such treatment.
  • Hot/cold packs and massagers fall within the category of physical medicine modalities under section I.A.9. of the Commission’s Medicine Ground Rules. These ground rules require a treatment plan to be on file with the health care provider.
  • Paragraph (e)(2) of the Commission’s Spine Treatment Guideline, requires the medical treatment to be of positive benefit to the injured worker, and STAT failed to produce evidence of such benefits.
  • Paragraph (e)(3)(B) of the Spine Treatment Guideline, which addresses the nature of documentation required to support a particular medical treatment, requires a description of the injury and treatment plan, but there is no such plan in the record.
  • Medicine Ground Rule (e)(2)(A)(v) requires a documented clinical rationale for any deviation from the Spine Treatment Guideline, which occurred in this case, but the evidence contained no such rationale.

III. Analysis and Conclusion

The Administrative Law Judge agrees with Liberty that the evidentiary record does not support the treatment administered to Claimant as medically necessary. The record also reflects several shortcomings in documentation required by the Medical Fee Guideline for the type of care administered to Claimant. Even though Claimant may have benefited from the medical equipment, for example, there was no documentation revealing a treatment plan for her. Furthermore, the evidence failed to reflect a clinical indication that the treatment administered resulted in progress in her recovery; there was no clinical evidence of Claimant’s medical condition before, during, or after the medical equipment was prescribed. Consequently, STAT’s claim is denied.

IV. Findings of Fact

  1. ___ (Claimant) suffered a compensable injury when she suffered neck and back strains in_______.
  2. At the time of Claimant’s injury, her employer held workers’ compensation insurance coverage through Liberty Mutual Insurance Company (Liberty).
  3. On January 8, 2001, Scientific Therapy and Advanced Treatment (STAT) billed Liberty $396.50 under CPT Code E1399 for hot/cold packs, a Genie massager, and an accessory kit for the massager.
  4. On February 28, 2001, Liberty refused reimbursement for the three pieces of medical equipment as medically unnecessary.
  5. On April 23, 2001, STAT sought reconsideration of Liberty’s denial of reimbursement.
  6. On April 25, 2001, Liberty confirmed its denial of reimbursement.
  7. In May 2001, STAT requested medical dispute resolution from the Texas Workers’ Compensation Commission’s Medical Review Division.
  8. Upon receipt of the Medical Review Division’s Medical Dispute Resolution Findings and Decision denying reimbursement, STAT timely filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  9. Notice of the hearing was sent to the parties on December 7, 2001. The notice informed the parties of the date, time, and location of the hearing, a statement of the matters to be considered, the legal authority under which the hearing would be held, and the statutory provisions applicable to the matters to be considered.
  10. The hearing was held on February 5, 2002.
  11. The equipment was prescribed approximately sixteen months after Claimant’s injury, when she was at the post-tertiary phase of care.
  12. There is no clinical evidence of Claimant’s medical condition before, during, or after the medical equipment was prescribed.
  13. There was no plan of treatment from the treating physician relating to the medical equipment.

V. 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. As Petitioner, STAT has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Section (e)(2) of the Commission’s Spine Treatment Guideline requires that medical treatment be of positive benefit to an injured worker.
  6. Section (e)(3)(B) of the Spine Treatment Guideline requires a description of the compensable injury and treatment plan.
  7. Based on the foregoing Findings of Fact and Conclusions of Law, STAT failed to meet its burden of proving it was entitled to reimbursement.
  8. STAT’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED thatclaim of Scientific Therapy and Advanced Treatment for reimbursement from Liberty Mutual Insurance Company is denied.

Signed this 4th day of April 2002.

GARY W. ELKINS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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