DECISION AND ORDER

The Texas Guaranty Fund (Carrier) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) directing its predecessor in interest, United Pacific Insurance Company (UPIC), to pay the Work and Accident Clinic (Provider) $2,962 for chiropractic services provided between August 28, 2000, and June 12, 2001, to L.G. (Claimant). The only disputed issue is whether the services were medically necessary to treat the compensable injury.

As set out below, the Administrative Law Judge (ALJ) finds that the provided services were not medically necessary to treat the compensable injury and denies the Provider’s request for reimbursement.

I. FINDINGS OF FACT

1. The Claimant sustained a work-related compensable injury, a sprain or strain to his left shoulder including surrounding ligaments and muscles, on_____, while his employer was_______ and its workers’ compensation insurance carrier was UPIC.
2. UPIC is an impaired insurer, and its obligations regarding this matter have been assumed by the Carrier.
3. As a result of the compensable injury to his left shoulder, the Claimant experienced left shoulder pain.
4. Between August 28, 2000, and June 12, 2001, the Provider furnished chiropractic office visits and thoracic spinal manipulations to correct misalignment of and pain in the thoracic region of the Claimant’s spine.
5. The Claimant did not suffer a compensable injury to either his cervical or thoracic spine.
6. There is no evidence that clearly explains how the provided services were related to the compensable left shoulder injury.
7. The Provider timely sought reimbursement of $3106 from the Carrier for the above described services.
8. The Carrier denied the requested payment.
9. The Provider filed a request for medical dispute resolution with TWCC.
10. MRD reviewed the dispute and ordered UPIC to pay the Provider $2,962 for the above described services.
11. The Carrier appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
12. Notice of a February 26, 2002 hearing in this case was mailed to the Carrier, the Provider, and the TWCC Staff on December 10, 2001.
13. On February 26, 2002, William G. Newchurch, an Administrative Law Judge (ALJ) with SOAH, held a hearing on the Carrier’s appeal at the Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas. Representatives of the Carrier and the Provider attended that hearing. The hearing concluded and the record closed on that same day.

II. CONCLUSIONS OF LAW

1. 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 Tex. Labor Code Ann. §§ 402.073(b) and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003. (Vernon 2001).
2. Adequate and timely notice of the hearing was provided in accordance with Tex Gov’t. Code Ann. §§ 2001.051 and 2001.052 (Vernon 2001).
3. As the party appealing the MRD’s decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
4. Under Tex. Labor Code § 408.021 (a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
5. The Commission’s Upper Extremities Treatment Guideline generally requires the Provider to furnish documentation that clearly explains how the provided treatment is related to the compensable injury. 28 Tex. Admin. Code §§134.1002 (d)(1)(D).
6. Based on the above Findings of Fact and Conclusions of Law, there is no basis for concluding that the provided services were medically necessary to treat the compensable injury.
7. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for reimbursement of $3,106 for the chiropractic services provided to the Claimant between August 28, 2000, and June 12, 2001 should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request for reimbursement of $3,106 for the chiropractic services provided to the Claimant between August 28, 2000, and June 12, 2001, is denied.

Signed March 6, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge