DECISION AND ORDER

This case involves a dispute over payment for aquatic physical services, an item of durable medical equipment, and an associated office visit provided by Aquatic Care Programs, Inc. (the Provider) to Claimant_____ from January 12, 2001 to February 13, 2001. Harris County (Carrier) argues that it only preauthorized four weeks of aquatic physical therapy (CPT Code 97113) and, consequently, the services the Provider provided beyond the four-week period were not preauthorized and are ineligible for payment. The amount in controversy is $1,009.

The Administrative Law Judge (ALJ) finds that Carrier is liable to reimburse the Provider for the services rendered on February 5, 2001,in the amount of $416, and for serviced provided on February 12 and 13, 2001, that did not require preauthorization for $73. Carrier is not obligated to pay the Provider for the aquatic physical therapy provided on February 12 and 13, 2001, because these services were not preauthorized.

II. Discussion

Certain categories of health care identified by the Commission require preauthorization, which is dependent upon a prospective showing of medical necessity. Tex. Lab. Code Ann. §413.014; 28 Tex.Admin. Code (TAC) § 134.600. Under 28 TAC § 134.600(h)(10), preauthorization is required for physical therapy and under (h)(13) it is required for all durable medical equipment in excess of $500 per item.

Cynthia Villarreal, the Provider’s medical billing and collections officer, and Jean Bennett, the Provider’s facility administrator, testified that the Provider provided aquatic physical therapy as preauthorized by the Carrier. On January 4, 2001, the Provider received written preauthorization from Carrier allowing the Claimant to undergo “P.T. 3X A WK FOR 4 WEEKS “97113. The Provider noted that Carrier did not reference any ending date. On Friday, January 12, 2001, the Provider began physical therapy treatments for Claimant.

The Provider argued that Claimant underwent four weeks of treatment and therefore, it is entitled to be paid for all services provided through February 13, 2001.

Carrier argued that the preauthorized four weeks ended before February 5, 2001, and because it had not preauthorized any further treatment, all other claims should be denied. The Carrier provided no evidence beyond that contained in the Commission’s certified record admitted as Exhibit 1.

The ALJ finds that Carrier did preauthorize four weeks of aquatic physical therapy. The therapy began on January 12, 2001. The four weeks covered the following periods:

First week: Friday, January 12, 2001 to Thursday, January 18, 2001.

Second week Friday, January 19, 2001 to Thursday, January 25, 2001.

Third week Friday, January 26, 2001 to Thursday, February 1, 2001.

Fourth week Friday, February 2, 2001 to Thursday, February 8, 2001.

The fourth week ended on February 8, 2001. The physical therapy services provided after February 8, 2001 were not preauthorized and therefore are not recoverable. However, services that did not require preauthorization, the office visit (CPT Code 99213) and the lumbar roll (CPT Code 99070), were medically necessary and are recoverable. Carrier provided no credible evidence to establish these services were not medically necessary. Therefore, the Provider is entitled to recover $416 for the aquatic physical therapy provided on February 5, 2001, and $73 for the office visit and the lumbar roll. Provider is not entitled to recover reimbursement for the physical therapy provided beyond the preauthorized period of four weeks-the aquatic physical therapy provided on February 12 and 13, 2001.

III. Findings of Fact

1. Claimant, ____, suffered a compensable lower back injury on or about____.
2. At the time of Claimant’s compensable injury, Harris County (Carrier) was the workers’ compensation insurer for Claimant’s employer __________.
3. Claimant was referred by his primary treating physician to Aquatic Care Program, Inc. (the Provider) for aquatic physical therapy as part of pain and health management.
4. On January 9, 2001, Carrier preauthorized the Provider to provide Claimant aquatic physical therapy three times a week for four weeks under CPT code 97113.
5. On Friday, January 12, 2001, the Provider evaluated Claimant’s condition and began providing aquatic physical therapy to Claimant.
6. The fourth week of preauthorization ended on February 8, 2001.
7. Carrier paid the Provider for all services provided except those provided on February 5, 12, and 13, 2001, maintaining that the Provider had failed to secure preauthorization for these additional services and that the services were not medically necessary.
8. The treatment was medically reasonable and necessary and consistent with the Commission’s guidelines.
9. The Provider failed to obtain preauthorization for the aquatic physical therapy provided to Claimant on February 12 and 13, 2001.
10. The office visit and the lumbar roll provided to Claimant on February 12 were medically necessary.
11. The Provider charged a reasonable fee of $48 for the February 12, 2001 office visit provided to Claimant.
12. The lumbar roll is durable medical equipment and cost $25.
13. The Provider filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement of $1,009.
14. On October 18, 2001, the Commission’s Medical Review Division (MRD) determined that $1,009 was due the Provider.
15. Carrier filed a timely request for hearing before the State Office of Administrative Hearings (SOAH).
16. Notice of the hearing was sent December 21, 2001.
17. 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.
18. The hearing was held March 13, 2002, with SOAH Administrative Law Judge Catherine C. Egan presiding and representatives of the Carrier and Petitioner participating. The hearing was adjourned the same day.

IV. Conclusions of Law

1. 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. §13.031(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. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
5. Aquatic Care Programs, Inc., is not entitled to reimbursement for the aquatic physical therapy provided to Claimant on February 12 and 13, 2001 because Aquatic Care Programs, Inc, failed to obtain preauthorization for these services as required by 28 TAC § 134.600 (h)(10).
6. Aquatic Care Program, Inc. is entitled to reimbursement for the office visit costing $48, and for the durable medical equipment costing $25, because neither required preauthorization under 28 TAC § 134.600 (h) and (h)(13).
7. Aquatic Care Program, Inc. is entitled to recover reimbursement in the amount of $73 for the office visit ($48) and the lumbar roll ($25) provided on February 12, 2001.

ORDER

IT IS, THEREFORE, ORDERED that the request by Harris County to deny reimbursement to Aquatic Care Programs for aquatic physical therapy provided on February 12 and 13, 2001 is granted. It is further ORDERED that Harris County reimburse Aquatic Care Programs, Inc. for the aquatic physical therapy services provided on February 5, 2001, in the amount of $416, and for the office visit ($48) and the lumbar roll ($25) provided on February 12, 2001, in the amount of $73 for a total of $ 489.

Signed this 1^st day of April, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CATHERINE C. EGAN
Administrative Law Judge