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At a Glance:
Title:
453-02-1694-m5
Date:
April 19, 2002
Status:
Retrospective Medical Necessity

453-02-1694-m5

April 19, 2002

DECISION AND ORDER

This case is an appeal by Marcy Halterman, D.C. (“Petitioner”) from the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (“MRD”in a medical fee dispute. The MRD denied Petitioner reimbursement for medical service provided to an injured claimant (i.e., a series of chiropractic manipulations) on the basis that such service had not been shown to be consistent with Commission rules and guidelines.

This decision affirms the MRD’s decision, finding that reimbursement for the disputed service should be denied, because Petitioner failed to document adequately the medical necessity of that service.

JURISDICTION AND VENUE

The Texas Workers’ Compensation Commission (“the Commission”) has jurisdiction to consider appeals from decisions of its Medical Review Division pursuant to § 413.031 of the Act. The State Office of Administrative Hearings (“SOAH”) has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003.

STATEMENT OF THE CASE

The hearing in this docket was convened on April 1, 2002, at SOAH facilities in the William P. Clements Building, 300 W. 15 St., Austin, Texas. Administrative Law Judge (“ALJ”) Mike Rogan presided over the hearing. Respondent Liberty Mutual Fire Insurance Company (“Respondent”) was represented by Mahon B. Garry, Jr., attorney. Petitioner represented herself and appeared via telephone. After presentation of evidence and argument, the hearing was adjourned on April 1, 2002, and the record closed on that date.

The record developed at the hearing revealed that the claimant sustained a compensable injury to the thoracic spine on _____, and has experienced chronic stiffness and pain ever since. After treatment from several other providers, the claimant made a series of office visits to Petitioner, who performed chiropractic manipulations to address the continuing pain. The dispute in this case involves such therapy that was rendered from April 8 through April 30, 1999. Respondent, the insurance carrier for claimant’s former employer, denied Petitioner’s request for reimbursement of these services in the amount of $250.00, asserting that the services were unnecessary for the treatment of the claimant’s compensable injury. Petitioner then sought medical dispute resolution with respect to this issue from the Commission’s MRD.

The MRD issued a decision on December 3, 2001, finding that Petitioner was not entitled to reimbursement, because she had failed to establish that her performance was consistent with Commission rules, including the Spine Treatment Guideline (“STG”)[1] and the Medical Fee Guideline (“MFG”).[2] In particular, the MRD found that the clinical records produced by Petitioner failed to support the medical necessity of the disputed treatment because “subjective findings of pain were not supported by objective findings,” in accordance with § 134.1001(e) (2) (A) of the STG.

EVIDENCE AND BASIS FOR DECISION

Petitioner contended that she was not given the opportunity to continue her regimen of manipulations upon the claimant long enough for the patient to show noticeable improvement.

Respondent asserted, on the other hand, that the medical records in this case show no objective basis for the subjective complaints of pain made by the claimant-and thus provide no reliable indication that the treatment by Petitioner would address such pain. By Respondent’s analysis, Petitioner’s documentation is deficient in failing to show “objectively measured and demonstrated functional gains,” as required by § 134.1001(e)(2)(A)(vi) of the STG; in failing to satisfy requirements related to manipulations in § 134.1001(e)(2)(E); and in failing to address specific documentation requirements in § 134.1001(e)(3).

The ALJ concludes that the documentation provided by Petitioner in this case is too perfunctory to allow real assessment of the necessity for the care in question. Petitioner’s five nearly identical reports regarding the claimant’s treatment are quite general and conclusory. The information within them relating to the claimant’s pain consists entirely of the claimant’s own subjective assessments of his condition. While § 134.1001(e) (3) (B) and (C) of the STG do not mandate specific elements of documentation, Petitioner’s reports do not appear to satisfy any of the potentially relevant categories of information listed in those subsections. By failing to address properly the elements listed in § 134.1001(e)(3)(B) and (C), Petitioner has failed, as well, to satisfy the general requirement of § 134.1001(e)(2)(A)(i) that treatment of a work-related injury be “adequately documented.”

The ALJ disagrees, however, with the position of Respondent and the implied position of MRD that §134.1001(e)(2)(A)(vi) of the STG applies to this case, thus requiring that the treatment in issue be shown to provide “objectively measured and demonstrated functional gains.”[3] Intuitively, such a requirement appears anomalous, if not perverse, for a patient who has reached MMI and is primarily seeking relief from chronic pain that cannot be permanently eliminated. More concretely, however, § 134.1001(g)(6) appears to provide a clear exception to the requirements of § 134.1001(e)(2)(A)(vi), noting that some claimants “will require treatment after they have reached MMI” and that these claimants should be provided treatment “to control pain or other symptom logy, maintain function, and/or to help the injured employee remain at work.”

Additionally, § 134.1001(e)(3)(C) of the STG explicitly mandates objective documentation of a patient’s pain levels and continued improvement in cases involving physical medicine, such as this one. This requirement is specifically reiterated with respect to manipulations in § 134.1001(e)(2)(E).

Accordingly, the ALJ must conclude that Petitioner has failed to satisfy the STG in documenting that the treatment in dispute is medically reasonable and necessary within the meaning of §§ 408.021 and 401.011(19) of the Texas Workers’ Compensation Act, TEX. LABOR CODE ANN. ch. 401 et seq.

CONCLUSION

The ALJ finds that, under the record provided in this case, reimbursement sought by Petitioner for medical services provided from April 8 through April 30, 1999, in the amount of $250.00, should be denied for lack of documentation that such treatment was medically necessary. The ALJ thus generally concurs with the MRD decision of December 3, 2001, in this matter.

FINDINGS OF FACT

  1. On _____, the Petitioner’s claimant suffered an injury to the thoracic spine that was a compensable injury under the Texas Workers’ Compensation Act (“the Act”), TEX. LABOR CODE ANN. § 401.001et seq. Subsequent to the injury, the claimant has suffered chronic stiffness and pain in his back.
  2. Treatment provided by Petitioner, Marcy Halterman, D.C., included chiropractic manipulations on five office visits by the claimant from April 20, 2000, and April 2, 2001.
  3. Primary documentation provided by Petitioner for the services noted in Finding of Fact No. 2 consists of the medical reports on the claimant’s five office visits to Petitioner. All of the reports are very similar and are general and conclusory. The information within the reports relating to the claimant’s pain consists entirely of the claimant’s own subjective assessments of his condition.
  4. Petitioner sought reimbursement of $250.00 from Respondent Liberty Mutual Fire Insurance Company (the insurance carrier for the claimant’s former employer) for the services noted in Finding of Fact No. 2.
  5. Respondent denied the request for reimbursement on the grounds that the treatment in question was medically unnecessary.
  6. Petitioner made a timely request to the Medical Review Division (“MRD”) of the Texas Workers’ Compensation Commission (“Commission”) for medical dispute resolution with respect to the requested reimbursement.
  7. The MRD declined to order reimbursement in a decision dated December 3, 2001, in dispute-resolution docket No. M5-00-0013-02. The MRD determined that medical services performed by Petitioner (CPT Code 99213-MP) were ineligible for reimbursement because Petitioner failed to comply with the Commission’s Medical Fee Guideline, 28 TEXAS ADMINISTRATIVE CODE (“TAC” § 134.201, Ground Rules (I)(B)(1)(b), and the Commission’s Spine Treatment Guideline (“STG”), 28 TAC §134.1001(e)(2)(A).
  8. Petitioner requested in timely manner a hearing with the State Office of Administrative Hearings, seeking review and reversal of the MRD decision regarding reimbursement.
  9. The Commission mailed notice of the hearing’s setting to the parties at their addresses on February 5, 2002.
  10. A hearing in this matter was convened on April 1, 2002, at the William P. Clements Building, 300 W. 15th St., Austin, Texas, before Mike Rogan, an Administrative Law Judge with the State Office of Administrative Hearings. All parties were represented.

CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented pursuant to the § 413.031 of the Act.
  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 § 413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV’T CODE ANN. ch. 2001, and the Commission’s rules, 28 TAC § 133.305(g) and §§ 148.001-148.028.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. Petitioner, the party seeking relief, bore the burden of proof in this case, pursuant to 28 TAC §148.21(h).
  6. Based upon the foregoing Findings of Fact, the Petitioner’s medical treatment of claimant (CPT Codes 99213-MP), as noted in Finding of Fact No. 2, is ineligible for reimbursement because Petitioner failed to comply with STG § 134.1001(e)(2)(A)(i), § 134.1001(e)(3)(C), and § 134.1001(e)(2)(E).
  7. Based upon the foregoing Findings of Fact and Conclusions of Law, the conclusion of the MRD that Petitioner is not entitled to requested reimbursement of $250.00 for medical services to the claimant, as stated in the MRD’s decision issued in this matter on December 3, 2001, is affirmed.

ORDER

IT IS THEREFORE, ORDERED that the Petitioner’s request for reimbursement from Liberty Mutual Fire Insurance Company of $250.00 for medical services rendered to Petitioner’s claimant, as well as Petitioner’s appeal from the decision of the Medical Review Division of the Texas Workers’ Compensation Commission in this matter, issued on December 3, 2001, are denied.

Signed this 19th day of April, 2002.

MIKE ROGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. 28 TEXAS ADMINISTRATIVE CODE (“TAC”) §134.1001.
  2. 28 TAC§ 134.201.
  3. It should be noted that this apparently is the commonly extrapolated meaning of this somewhat garbled portion of the STG. Literally, § 134.1001(e)(2)(A)(vi) reads,A. . treatment of a work related injury must be: (vi) objectively measured and demonstrated functional gains-which is nonsensical phraseology.
End of Document
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