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At a Glance:
Title:
453-02-1721-m5
Date:
May 31, 2002
Status:
Retrospective Medical Necessity

453-02-1721-m5

May 31, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Jack P. Mitchell, D.C. (Provider) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC) denying reimbursement from Respondent, Continental Casualty Company (Carrier), for medical services provided to__, Claimant. This decision concludes that the Provider is not entitled to reimbursement.

The Administrative Law Judge convened a hearing on April 16, 2002. The hearing was concluded and the record closed that date. The Provider appeared pro se. The Carrier was represented by Shannon Simmons, attorney.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this preceding is whether the Carrier should reimburse the Provider $2,219.00 plus interest for medical services provided between November 3, 1999, and April 5, 2000, and billed under CPT Codes 99213-MP (office visit with manipulation), 99214-MP (office visit with higher level of manipulation), 99371 (telephone call).

The Carrier argued that the medical services provided to the Claimant were not medically necessary and reasonably required because the services were provided after the Claimant had reached maximum medical improvement (MMI), which is defined as the earliest date after which further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.[1] Medicine Ground Rule I.A of the Medical Fee Guideline provides that the “patient’s condition shall have the potential for restoration of function” for physical medicine treatment to qualify for reimbursement. Additionally, the Carrier argued that the Claimant did not show improvement, which is required for continued treatment.

The documentary record in this case consisted of the 326-page certified record of the MRD proceeding (Exh. 1). The record reflects that the Claimant was examined by William X. Bratcher, D.C. on July 26, 1999. Dr. Bratcher determined that the Claimant had reached MMI and he certified her with a 9% impairment rating. (Exh. 1, pp. 251-255). Further, the Claimant was again examined on August 6, 1999, by James E. Swink, M.D. He found that the Claimant had reached MMI and he certified her with a 5% impairment rating.

Bill Defoyd, D.C., a board certified chiropractor, reviewed the records at the request of the Carrier. He testified that the continued use of manipulation was not medically necessary because the pain scale testing chart prepared by the Provider indicated that the Claimant had not improved, and had perhaps worsened.

Based on the evidence, the ALJ concludes that Petitioner’s appeal should be denied. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On _______, ___ (Claimant) suffered a compensable injury to her lower back while attempting to put a patient in bed.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Continental Casualty Company (Carrier).
  3. Petitioner Jack P. Mitchell, D.C. (Provider) treated the Claimant’s injury during 45 office visits from November 3, 1999, through April 5, 2000.
  4. The Provider treated the Claimant’s back injury with manipulation during the office visits referenced in Finding of Fact No. 3.
  5. Following an examination on July 26, 1999, William X. Bratcher D.C. determined that the Claimant had reached maximum medical improvement (MMI) and certified her with 9% whole body impairment.
  6. Following an examination on August 6, 1999, James E. Swink, M.D. determined that the Claimant had reached MMI and certified her with 5% whole body impairment.
  7. The treatment provided by the Provider did not reduce the Claimant’s pain.
  8. The examinations referenced in Findings of Fact Nos. 5 and 6 showed that the Claimant’s condition did not have the potential for restoration of function.
  9. The Provider timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  10. The MRD issued its findings and decision on December 3, 2001, concluding that the disputed expenses should not be paid, and the Provider timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  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. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. The Provider has the burden of proving by a preponderance of the evidence that he should prevail in this matter. Tex. Labor Code §413.031.
  5. The Medicine Ground Rules of the Medical Fee Guideline provide that a patient’s condition shall have the potential for restoration of function for physical medicine treatment to qualify for reimbursement.
  6. Based on Findings of Fact Nos. 5 - 8, the Carrier proved that the Claimant’s condition did not have the potential for restoration of function.
  7. Based on Conclusions of Law Nos. 5 and 6, Jack P. Mitchell, D.C. is not entitled to reimbursement for the services provided on the disputed dates of service between November 3, 1999, and April 5, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Continental Casualty Company shall not reimburse Jack P. Mitchell, D.C. for the amount claimed.

Issued this 31st day of May, 2002.

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

  1. Tex. Labor Code Ann. § 401.011 (30).
End of Document
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