DECISION AND ORDER

American Home Assurance Company (Petitioner or Carrier) is appealing the decision of the Texas Workers’ Compensation Commission’s (TWCC’s) Medical Review Division (MRD) in Medical Dispute Resolution Docket M4-02-0511-01 ordering reimbursement to First Rio Valley Medical (Respondent or Provider) for medical services provided to____., Claimant. This decision orders reimbursement of $421.00 because Petitioner failed to meet its burden of proof.

I. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

There are no contested issues of notice or jurisdiction in this proceeding. Therefore, these matters are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing convened on October 29, 2002. Petitioner appeared through its counsel, Steven M. Tipton. Respondent did not appear, and at the conclusion of the hearing, the record was closed.^[1]

II. DISCUSSION

A. Background.

Claimant, who is a 62 year old woman, worked for______, and suffered a compensable neck, shoulder, and back injury on_________ while lifting a mixing bowl weighing approximately 50 pounds. She complained of a sharp pain in her neck and lower back. The pain radiated from her neck down her right arm. Robert Howell, D.C., Claimant’s treating physician, prescribed one-on-one therapeutic exercises consisting of stretching, cardiovascular endurance exercises, and strength conditioning. (Exh. 1, pages 80-83) Dr. Howell obtained preauthorization for

CPT Code 97110 (therapeutic exercises) and billed the Petitioner for dates of service of April 30, 2001 (six units) and June 29, 2001 (4 units). Additionally, Dr. Howell billed the Carrier for an office visit, CPT Code 99214, on August 9, 2001. The Carrier denied payment with denial code “R – unrelated to the compensable injury.” The MRD ordered the Carrier to pay the Provider $350.00 for CPT Code 97110 and $71.00 for CPT Code 99214.

Issue

The issue is whether the Carrier should reimburse the Provider for CPT Codes 97110 and 99214. The Carrier argued that the compensable injury had resolved prior to the treatment provided by the Respondent, and that any additional treatment was thus unrelated to the compensable injury. The Carrier submitted TWCC Advisory 2001-03B, which provides that a carrier is still permitted to contest the amount of reimbursement even though treatment has been preauthorized. The Advisory further provides that preauthorization does not guarantee payment for treatment provided for a condition unrelated to the compensable injury.

The Certified Record

Oral testimony was not given at the hearing, but the TWCC Certified Record was submitted. The records showed that the Provider examined the Claimant on March 21, 2001. The examination revealed that the Claimant continued to suffer from moderate and constant pain in the neck and lower back, and was slowly continuing to improve. (Exh. 1, pages 77-79, and 134) The Claimant was again examined on April 30, 2001, and she continued to have moderate and constant pain in the back, neck, and shoulder. The Provider stated that the Claimant was continuing to improve slowly, and therapeutic exercises were performed by the Claimant. The Provider examined the Claimant again on June 29, 2001, and found that the Claimant continued to have moderate and constant low back pain, and minimal and occasional neck pain. The Provider noted that the Claimant was continuing to improve slowly, and the Claimant again performed therapeutic exercises. (Exh. 1, pages 90-92)

A peer review was performed by Dr. Jaime J. Rivera, D.C., on July 10, 2001. Dr. Rivera granted the Claimant 0% whole person impairment. Additionally, it was his opinion that the Claimant suffered from normal degenerative changes in the cervical and lumbar spine, and from common arthritic pain, which was worse after getting out of bed in the morning, but improved as the day progressed. Dr Rivera concluded that continued treatment was unnecessary. (Exh. 1, pages 125-130)

The Claimant was seen by the Provider on August 9, 2001, and an interim assessment report was prepared. The Claimant continued to complain of slight and frequent pain in the neck and low back. The Claimant’s condition was aggravated by driving, sitting, standing, or walking for more than one hour; bending at the waist; lifting; and performing usual household tasks and other daily living activities. The Provider believed that a treatment plan consisting of joint mobilization, physical medicine modalities, and rehabilitation three times weekly for four weeks would allow the Claimant to return to work full duty without restrictions at the start of the new school year. (Exh. 1, pages 55-76)

III. ANALYSIS AND CONCLUSION

The issue in this case is whether the compensable injury had resolved making additional treatment unrelated. The evidence shows that the Claimant suffered a compensable injury to the neck, shoulder and back. The Provider obtained preauthorization for treatment, but the Carrier now states that treatment provided was unrelated to the compensable injury. The specific treatment complained of is 10 units of therapeutic exercises provided on April 30, 2001, and June 29, 2001. The Carrier is also complaining of an extended office visit on August 9, 2001, which resulted in preparation of an interim assessment report.

The Carrier’s peer review was completed on July 10, 2001, after the 10 units of therapeutic exercise had already been completed, but before the office visit on August 9, 2001. The peer review concluded that additional treatment was unnecessary, but did not speak to prior treatment. Further, a conclusion cannot be drawn from the peer review that the treatment complained of was unrelated to the compensable injury. The exercises and the office visit specifically dealt with treatment of the compensable injury.

The ALJ concludes that the Carrier’s appeal should be denied. The Carrier should reimburse the Provider $421.00 for treatment provided on the disputed dates of service.

IV. FINDINGS OF FACT

1. On January 24, 2002, a notice of hearing was issued by the staff of the Texas Workers’ Compensation Commission (Commission) to all parties in this matter regarding the appeal by Petitioner, American Home Assurance Company (Carrier), of the Commission’s decision ordering payment for the disputed services to First Rio Valley Medical (Provider).
2. The hearing on the merits convened on October 29, 2002. The Carrier appeared through its counsel. The Commission waived its right to participate in the hearing, and the Provider did not appear.
3. The Claimant suffered a neck, shoulder, and back injury compensable under the Texas Workers’ Compensation Act (the Act) on______, while lifting a mixing bowl weighing approximately 50 pounds.
4. The Provider obtained preauthorization to treat the Claimant’s compensable injury.
5. Treatment included 10 units of therapeutic exercises performed on April 30, 2001, and June 29, 2001, and an office visit on August 9, 2001.
6. The treatment referred to in Finding of Fact No. 5 was related to the compensable injury.

V. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission (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. 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. Lab. Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
3. Notice was provided in this matter as required by the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001.
4. The Carrier had the burden of proving the case by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code §148.21 (h) and (I).
5. Based on Findings of Fact Nos. 4 and 6, and Conclusion of Law No. 4, the Carrier should reimburse the Provider the sum of $421.00.

ORDER

IT IS, THEREFORE, ORDERED, that American Home Assurance Company reimburse First Rio Valley Medical the sum of $421.00.

Signed this 19^th day of November, 2002.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The Respondent’ attorney filed a Notice of Withdrawal of Authority of Counsel and Motion to Withdraw as Counsel on October 28, 2002, at 5:34 p.m.↑