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At a Glance:
Title:
453-02-1723-m5
Date:
October 18, 2002
Status:
Retrospective Medical Necessity

453-02-1723-m5

October 18, 2002

DECISION AND ORDER

This case involves a dispute over whether Petitioner, SCD Back & Joint Clinic (BJC), should be reimbursed $3,469.00 for various physical medicine procedures provided between September 25, 2000, and January 12, 2001. Respondent American Home Assurance Company (AHAC) denied payment for these and other services totaling $4,801.00. Petitioner appealed all the denials to the Commission’s Medical Review Division (MRD), which ordered partial reimbursement, but denied payment for the services involved in this proceeding. MRD based its decision on lack of medical necessity, lack of documentation of one-on-one supervision for certain procedures, physical medicine sessions lasting longer than two hours, and for other reasons. AHAC continues to deny liability based on the reasons stated by MRD.

Petitioner complains that AHAC never asserted the reasons for denial relied upon by MRD. Instead, MRD raised these issues sua sponte. In addition, Petitioner argues that medical necessity cannot be raised by AHAC retrospectively for preauthorized procedures, that one-on-one supervision was provided, and that the 2-hour limitation for physical medicine sessions does not apply to the untimed procedures involved in this appeal.

The Administrative Law Judge (ALJ) concludes that BJC is entitled to additional reimbursement of $3,409.00.

I. Procedural History

The hearing in this case was held August 19, 2002. There were no contested issues of jurisdiction or notice. Attorney Scott Hilliard represented SCD Back and Joint Clinic, and attorney Steven Tipton represented American Home Assurance Company. The hearing concluded and the record closed the same day.

II. Discussion

A. Introduction

The Claimant sustained a compensable injury on______, in the course of her employment with_____. On October 27, 2000, Claimant sent a preauthorization request to AHAC’s representative that stated the following:

This office is requesting 18 sessions of PHYSICAL MEDICINE CARE, as defined in the TWCC Medical Fee Guidelines, pages 31-32, for the compensable injury of the injured worker cited above [Claimant]. This office is requesting specifically that each of these 18 sessions are to include the services identified by CPT codes 97110 (8 units), and one unit each of 97250, 97265, 97024, and/or 97014.[1]

On November 1, 2000, HDI Disability Management provided Petitioner with written preauthorization to provide these services:

“Your chiropractic plan for the claimant . . . has been reviewed and recommended as medically necessary. At this time, 18 units are being certified as curative, at the frequency of 3 per week for 6 weeks.”[2]

And on January 4, 2001, HDI extended the preauthorization for Petitioner to provide additional services:

Your physical medicine treatment plan has been reviewed, and recommended as medically necessary. At this time, 6 visits are being certified as curative.[3]

The dates of service and the CPT Codes now in dispute are:

DateCPT CodesAmt. BilledAmt. PaidEOB Denial Code

9/25/00 97110 $280.00 $ 0.00 No EOB

9/25/0097265 $ 43.00 $ 0.00

9/25/0097250 $ 43.00 $ 0.00

9/25/0097014 $ 17.00 $ 0.00

9/27/00 97110 $280.00 $ 0.00 No EOB

9/27/0097014 $ 17.00 $ 0.00

9/29/00 97110 $245.00 $ 0.00 No EOB

9/29/0097265 $ 43.00 $ 0.00

9/29/0097250 $ 43.00 $ 0.00

9/29/0097014 $ 17.00 $ 0.00

10/12/00 97250 $ 43.00 $ 0.00 U [Unnecessary]

10/12/0097014 $ 17.00 $ 0.00

11/27/00 97265 $ 43.00 $ 0.00 U

11/27/0097250 $ 43.00 $ 0.00

11/27/0097014 $ 17.00 $ 0.00

11/29/00 97265 $ 43.00 $ 0.00 U

11/29/0097250 $ 43.00 $ 0.00

11/29/0097014 $ 17.00 $ 0.00

12/1/00 97265 $ 43.00 $ 0.00 U

12/1/0097250 $ 43.00 $ 0.00

12/1/0097014 $ 17.00 $ 0.00

  1. 12/4/00 97110 $280.00 $ 0.00 A [No Preauthorization]
  2. 12/6/00 97110 $280.00 $ 0.00 A
  3. 12/8/00 97110 $280.00 $ 0.00 A
  4. 1/4/01 97250 $ 43.00 $ 0.00 U

1/4/0197024 $ 17.00 $ 0.00

1/5/01 97250 $ 43.00 $ 0.00 U

1/5/0197014 $ 17.00 $ 0.00

1/8/01 97110 $245.00 $ 0.00 U

1/8/0197265 $ 43.00 $ 0.00

1/8/0197250 $ 43.00 $ 0.00

1/8/0197014 $ 17.00 $ 0.00

1/8/0199070 $ 8.00 $ 0.00

1/9/01 97110 $175.00 $ 0.00 U

1/9/0197014 $ 17.00 $ 0.00

1/10/01 97110 $140.00 $ 0.00 U

1/10/0197265 $ 43.00 $ 0.00

1/10/0197250 $ 43.00 $ 0.00

1/10/0197014 $ 17.00 $ 0.00

1/12/01 97110 $210.00 $ 0.00 U

1/12/0197265 $ 43.00 $ 0.00

1/12/0197250 $ 43.00 $ 0.00

1/12/0197014$ 17.00$ 0.00

Total $3,469.00

B. Petitioner’s Evidence and Arguments

David N. Bailey, D.C., testified on behalf of Petitioner. He has practiced chiropractic in Bryan, Texas, since 1985 and has been Board Certified in Chiropractic Orthopedics since 1988. Dr. Bailey stated that the Claimant was first seen at his clinic on September 14, 2000. She complained of neck and low back pain, numbness in her feet, and other complaints. He diagnosed her condition as lumbar and neck sprain/strain and myofascial pain syndrome.

One-on-One Supervision: Dr. Bailey stated that CPT Code 97110 is for therapeutic procedures and exercises to develop strength and endurance, range of motion, and flexibility. As noted in the chart above, MRD denied ten sessions under 97110, totaling $2,415.00, for lack of documentation of one-on-one supervision. In response to this, Dr. Bailey pointed to the 9/25/00 SOAP notes in the certified record that state:

The following therapy modalities and procedures were ordered by the doctor after the doctor’s evaluation of this patient today. THERAPEUTIC PROCEDURES: (97110, per TWCC MFG, p. 32. Not Group Setting): CERVICAL AND LUMBAR SPINE. DURATION 2 hours. . . .[4]

This same “Not Group Setting” statement is contained in the SOAP notes for December 4, 6, and 8, 2000; and January 8, 9, 10, and 12, 2001.[5] Dr. Bailey testified that a change in procedures was implemented by TWCC to require one-on-one supervision for CPT Code 97110, and that his clinic changed to exclusive-and-continuous supervision in late 1999 in order to comply with this requirement. And Dr. Bailey testified that continuous, exclusive supervision was actually provided to the Claimant on all the dates in question.

Preauthorization: Dr. Bailey also pointed to his Preauthorization Request, dated October 27, 2000, which stated:

This office is requesting 18 sessions of PHYSICAL MEDICINE CARE, as defined in the TWCC Medical Fee Guidelines, pages 31-32, for the compensable injury of the injured worker cited above [Claimant]. This office is requesting specifically that each of these 18 sessions are to include the services identified by CPT codes 97110 (8 units), and one unit each of 97250, 97265, 97024, and/or 97014.[6]

In response, HDI Disability Management sent Dr. Bailey a letter dated November 1, 2000, approving the request for the period October 30 through December 13, 2000:

Your chiropractic plan for the claimant indicated above has been reviewed and recommended as medically necessary. At this time, 18 units are being certified as curative, at the frequency of 3 per week for 6 weeks.[7]

Due to the holidays, Dr. Bailey requested an extension of time to complete the treatment. HDI agreed and extended the treatment period until February 15, 2001.[8]

Two-hour time limit: MRD also denied reimbursement for services in addition to 97110 on the dates when the total services exceeded the two-hour limit contained in the Medical Fee Guideline (Medicine) § I.A.10.a. These dates were September 25, 27, and 29; October 12; November 27 and 29, 2000; and January 4, 5, 8, 9 and 10, 2001. Dr. Bailey complains that MRD has not applied the two-hour time limit consistently. In particular, he pointed out that MRD ordered reimbursement for these same services on December 4, 6, and 8, but denied them on the other dates previously noted.

Carrier’s EOBs and denial codes: Dr. Bailey testified that the Carrier did not provide EOBs for September 25, 27, and 29, 2000. In addition, the Carrier used denial code A [lack of preauthorization] for dates of service December 4, 6, and 8, 2000, and denial code U [unnecessary] for dates of service January 8, 9, 10, and 12, 2001. But because these dates were covered by the preauthorization discussed above, Dr. Bailey states that denial code A was incorrect and that the Carrier is precluded by TWCC rules from retrospectively challenging the medical necessity of the services it preauthorized. Further, Dr. Bailey testified that the Carrier is not allowed to assert new reasons for denial that it did not assert at the MRD. In particular, Dr. Bailey complains that the Carrier never asserted lack of one-on-one supervision as a reason for denial when the case was pending at MRD.

Cross examination: On cross examination, Dr. Bailey agreed that preauthorization does not relieve the provider from the TWCC documentation requirements. He also agreed that on the dates he provided two hours of service under CPT Code 97110, the other services provided that date took some amount of time in excess of the two hours “clock time” spent on Code 97110. Dr. Bailey stated that the SOAP notes are pre-written and inserted on a patient’s records with a computer key stroke. However, he emphasized that all the services were performed as stated, and he said it is a common practice for providers to use computers in this manner for increased efficiency. Dr. Bailey also agreed that CPT Code 97110 currently requires continuous, exclusive one-on-one supervision, although this is a fairly new requirement. Under the prior 1995 guidelines, 97110 required supervision, but not one-on-one supervision. In other words, under the prior guidelines, the provider could supervise more than one patient at a time.

Arguments: Based on this testimony and the certified record, Dr. Bailey’s counsel argues that the carrier should pay for all the disputed services. He emphasizes that the Carrier preauthorized the one-on-one therapy under CPT Code 97110 and argues that the Carrier cannot retrospectively review the medical necessity of services it has preauthorized. Further, he notes, the Carrier only used denial code A - lack of preauthorization - and did not deny the 97110 services based on medical necessity or lack of documentation of one-on-one supervision until after MRD issued its decision.

Concerning the two-hour time limit contained in §I.A.10.a., counsel for Dr. Bailey argues that the time limit applies only to timed services and not to the untimed services. In this case, however, MRD used the two-hour time limit to deny untimed services (services other than CPT Code 97110), which Dr. Bailey’s counsel argues was improper. He cited several SOAH decisions to support this argument.

C. Carrier’s Evidence and Arguments

Medical necessity: The Carrier called Dr. Jane C. Duncan as a witness. She did not see or treat the Claimant, but instead did a retrospective medical peer review based on medical records. Dr. Duncan noted that Claimant first saw Dr. Julico Cadenas, a company doctor. Dr. Cadenas released Claimant at Maximum Medical Improvement (MMI), with zero impairment, on December 21, 1999, just two days after the date of injury.

Claimant next saw a Dr. Chenault on December 30, 1999. He noted urine incontinence and neck pain and made a diagnosis of unspecified back sprain/strain. Dr. Chenault prescribed medications and ordered an MRI. The MRI suggested a degenerative lumbar spine. Claimant was given three weeks of therapy in March 2000. Then, on March 16, 2000, Dr. Chenault released Claimant to return to sedentary work.

In September 2000, Claimant was seen by Dr. Swena, a designated doctor. Dr. Swena reported that Claimant reached MMI on September 11, 2000, with zero impairment.

Based on this review of medical records, Dr. Duncan rendered an opinion that the one-on-one therapy provided by Dr. Bailey’s office under CPT Code 97110 was not medically necessary for Claimant. In her opinion, one-on-one physical therapy is designed for patients who have severe neurological or mental handicaps, or who could injure themselves while exercising. But in the present case, Claimant had already seen several doctors who found zero impairment, and she had no neurological deficits, muscle wasting, or any other serious condition that required one-on-one therapy. Therefore, Dr. Duncan stated that she did not believe any of the disputed services provided to Claimant by Dr. Bailey were medically necessary.

Argument: Counsel for the Carrier argues that preauthorization is not a guarantee of payment. Even with preauthorization, a provider must provide and properly document the appropriate services. He further argues that MRD must review each case based on all the TWCC rules and guidelines, regardless of which denial codes a carrier uses. In the Carrier’s view, one-on-one supervised physical therapy was not medically necessary for Claimant and the preauthorization is irrelevant.

Carrier also argues that the two-hour time limit contained in § I.A.10.a. of the Medical Fee Guidelines applies to all services provided during a physical therapy session, not just to timed services. It states that the rule clearly refers to a “physical therapy session” and is not limited to timed-procedures. Further, Carrier emphasizes that the purpose of the rule is to control utilization rather than expand utilization, which would be the result if the time limit does not apply to all services provided during a physical therapy session.

IV. ALJ’s Analysis

The ALJ grants most of Bone and Joint Clinic’s appeal and orders that AHAC reimburse the clinic $3,409.00. This case is troubling in that the MRD rejected all the denial codes asserted by AHAC but then denied reimbursement based on other reasons never asserted by AHAC. In each case where AHAC used denial code “A” for lack of preauthorization, MRD found: “This service was preauthorized per documentation.” Yet, MRD then denied reimbursement for these claims based on lack of documentation of one-on-one supervision. Likewise, in each case where AHAC used denial code “U” for unnecessary services, MRD found: “The preauthorization of this service supports medical necessity.” Yet, MRD then denied reimbursement for these claims based on lack of DOP to support delivery beyond the two-hour limit.

In addition to the EOBs, the official record contains a position statement submitted by AHAC’s counsel to MRD dated August 8, 2001. This statement argued for denial of BJC’s claim due to its failure to file EOBs for services on September 25, 27, and 29, 2000. It also complained of BJC exceeding the two-hour time limit under § I.A.10.a. for many of the services, and it generally stated that the services were not medically necessary. But even in this statement, Carrier did not assert lack of documentation of one-on-one supervision for CPT Code 97110.

Failure to provide EOBs: In its position statement filed with MRD, AHAC denied liability for services rendered on September 25, 27, and 29, 2000, because BJC did not file EOBs with MRD. But BJC established that AHAC failed to provide BJC any EOBs for those dates. Thus, the ALJ concludes that AHAC cannot use its own failure to provide EOBs to BJC as a reason to deny BJC’s claims for these dates.

One-on-One supervision for CPT Code 97110: The largest monetary items in this case are for CPT Code 97110. MRD denied reimbursement for this CPT code based on lack of documentation of one-on-one supervision for the following dates: September 25, 27 and 29, 2000; December 4, 6, and 8, 2000; and January 8, 9, 10, and 12, 2001. BJC’s office notes in the official record suggest one-on-one supervision by the comment “Not in Group Setting.” But the ALJ finds that this documentation is vague and does not expressly state that one-on-one supervision was provided. However, Dr. Bailey testified at hearing that exclusive one-on-one supervision was, in fact, provided and no evidence was offered to contradict his testimony.

Further, the ALJ finds that AHAC never raised lack of documentation of one-on-one supervision as a defense when the case was pending at MRD. Rather, MRD raised this issue sua sponte. In light of AHAC’s failure to raise documentation of one-on-one supervision as an issue at MRD, and in light of Dr. Bailey’s testimony that one-on-one supervision was actually provided, the ALJ finds that BJC has established its entitlement to reimbursement for the services provided under CPT Code 97110.

Preauthorization / Medical Necessity: For the dates where AHAC asserted at MRD either lack of preauthorization or lack medical necessity, BJC has established that AHAC did preauthorize the services rendered after October 30, 2000.[9] This both defeats AHAC’s defense of lack of preauthorization and precludes AHAC from making a retrospective review of medical necessity for these dates of service. Indeed, AHAC’s preauthorization specifically stated: “Your chiropractic plan for the claimant indicated above has been reviewed and recommended as medically necessary.” Based on AHAC’s preauthorization, the MRD found that medical necessity was established. Therefore, under this state of the record, the ALJ also finds that the services were preauthorized and that AHAC is precluded from raising a medical necessity challenge.

October 12, 2001, is one of the dates that AHAC challenged for lack of medical necessity, and this date of service is prior to the October 30, 2001, preauthorization. Because BJC offered no evidence of medical necessity other than the preauthorization, which did not cover this date of service, the ALJ denies BJC’s request for reimbursement of $60.00 for these services.

Two-hour time limit: The final issue concerns the two-hour time limit for physical therapy procedures contained in the Medicine Medical Fee Guidelines § I.A.10.a. BJC argues that the time limit applies only to timed procedures and does not apply to untimed procedures. It cites several SOAH decisions that adopt this position, although most of those decisions simply cite one earlier decision and contain little or no analysis. In response, AHAC argues that the section unambiguously imposes a two hour limit to each physical therapy session, regardless of whether it is a timed or untimed procedure. It also cites one SOAH decision that supports its position, and it emphasizes that the purpose of the rule is to control utilization rather than expand utilization.

But under the facts of this case, the ALJ does not find it necessary to decide whether the time limit applies to untimed procedures, because AHAC preauthorized all the procedures at issue. In its request for preauthorization, BJC specifically stated the following:” This office is requesting that each of these 18 sessions are to include the services identified by CPT Codes 97110 (8 units), and one unit each of 97250, 97165, 97024, and/or 97014.” Thus, when AHAC granted preauthorization, it knew that each session would exceed two clock hours because eight units of 97110 alone equaled two hours, yet AHAC preauthorized services in addition to the two-hour 97110 timed service. Further, the rule itself allows these services to last up to three hours when necessary to complete a session.[10] Therefore, the ALJ concludes that AHAC preauthorized BJC to exceed two hours of treatment per session and may not now challenge those services, even assuming that the two-hour limit applies to both timed and untimed procedures.

In conclusion, and for the reasons stated, the ALJ grants BJC’s appeal and orders AHAC to pay BJC reimbursement in the amount of $3,409.00.

V. Findings of Fact

  1. The Claimant sustained a compensable injury on_____, in the course of her employment with_____.
  2. Respondent American Home Assurance Company (AHAC) was the workers’ compensation insurance carrier for Claimant’s employer and provides coverage for Claimant’s injury.
  3. On November 1, 2000, AHAC gave written preauthorization for Petitioner The Back and Joint Clinic (BJC) to provide 18 sessions of physical medicine to Claimant during the period October 30, 2000, to December 13, 2000, including the following services for each session: CPT Codes 97110 (8 units), and one unit each of 97250, 97265, 97024, and/or 97014.
  4. On January 4, 2001, AHAC extended the time to complete the services described in Finding of Fact No. 3 to include the period January 2, 2001, to February 15, 2001.
  5. BJC provided the preauthorized physical medicine services described in Findings of Fact Nos. 3 and 4 to Claimant on the following dates: November 27 and 29, 2000; December 1, 4, and 8, 2000; and January 4, 5, 8, 9, 10, and 12, 2001.
  6. BJC also provided physical medicine services to Claimant on September 25, 27, and 29, 2000, and October 12, 2000. These services were provided before the effective date of the preauthorization described in Finding of Fact No. 3.
  7. AHAC denied payment to BJC for the services described in Findings of Fact Nos. 5 and 6.
  8. For the services provided by BJC on December 4, 6, and 8, 2000, AHAC used denial code “A” - services not preauthorized.
  9. For the services provided by BJC on October 12, November 27 and 29, and December 1, 2000; and January 4, 5, 8, 9, 10, and 12, 2001, AHAC used denial code “U” - services not medically necessary.
  10. For the services provided by BJC on September 25, 27, and 29, 2000, AHAC did not provide BJC an Explanation of Benefits (EOB).
  11. In its response filed with MRD on August 8, 2001, AHAC denied liability for the services BJC provided on September 25, 27, and 29, 2000, due to BJC’s failure to file EOBs with MRD.
  12. In its response filed with MRD on August 8, 2001, AHAC denied liability for services provided October 12, November 27 and 28, and December 1, 2000, on the ground that the services exceeded the two-hour time limit contained in Medical Ground Rule I.A.10.a.
  13. In its response filed with MRD on August 8, 2001, AHAC denied liability for services provided December 4, 5, 6, and 8, 2000, and January 4, 5, 8, 9, 10, and 12, 2001, based on lack of preauthorization and because the services exceeded the two-hour time limit contained in Medical Ground Rule I.A.10.a.
  14. In its response filed with MRD on August 8, 2001, AHAC also denied liability for all services rendered by BJC on the grounds that they were not medically necessary.
  15. While this case was pending before MRD, AHAC never contended that BJC failed to document one-on-one supervision for services provided under CPT Code 97110.
  16. MRD rejected the reasons for denial stated by AHAC in its EOBs, but denied BJC reimbursement for all the disputed services based on either lack of documentation of one-on-one supervision for services provided under CPT Code 97110, or for exceeding the two-hour time limit for physical medicine sessions contained in Medical Ground Rule I.A.10.a.
  17. All services in dispute in this case provided by BJC between November 27, 2000, and January 12, 2001, were preauthorized by AHAC as medically reasonable and necessary.
  18. BJC provided one-on-one supervision for the disputed physical therapy services provided to Claimant under CPT Code 97110.
  19. BJC did not adequately document one-on-one supervision for the disputed physical therapy services provided to Claimant under CPT Code 97110. However, AHAC never asserted this defense of lack of documentation while this case was pending at MRD.
  20. Based on AHAC’s preauthorization, the services provided by BJC to Claimant between November 1, 2000, and January 12, 2001, were medically reasonable.
  21. At the time AHAC gave BJC preauthorization in this case, AHAC was aware that the authorized services to be provided could exceed two hours in duration per session. Based on AHAC’s preauthorization, AHAC may not raise the two-hour time limit contained in Medicine Medical Fee Guideline §I.A.10.a. as a defense in this proceeding to the services provided by BJC to Claimant between November 1, 2000, and January 12, 2001.
  22. The services provided by BJC to Claimant on October 12, 2000, were not preauthorized and were not shown by BJC to be medically necessary.
  23. BJC timely appealed AHAC’s denial of payment to the Commissions Medical Review Division (MRD).
  24. MRD found in favor of AHAC and denied additional reimbursement for the services at issue in this proceeding.
  25. Petitioner timely appealed of the MRD decision.
  26. Notice of the hearing was sent February 6, 2002. 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.
  27. The hearing was held August 19, 2002, with Administrative Law Judge (ALJ) Thomas H. Walston presiding, and representatives of BJC and AHAC participating. The hearing adjourned and the record closed the same day.

VI. Conclusions of Law

  1. The 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. §413.031(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. SCD Back and Joint Clinic (BJC), has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. Based on AHAC’s preauthorization, AHAC may not raise medical necessity as a defense in this proceeding to the services provided by BJC to Claimant between November 1, 2000, and January 12, 2001.
  6. Because AHAC failed to provide BJC with EOBs for dates of service September 25, 27, and 29, 2000, AHAC may not raise as a defense in this proceeding BJC’s failure to file EOBs with the MRD for these dates of service.
  7. BJC, established that it is entitled to additional reimbursement from AHAC in the amount of $3,409.00 for services provided to Claimant on September 25, 27, and 29, 2000; November 27 and 29, 2000; December 1, 4, 6, and 8, 2000; and January 4, 5, 8, 9, 10, and 12, 2001.

ORDER

IT IS, THEREFORE, ORDERED that SCD Back and Joint Clinic’s request for reimbursement of $3,409.00 from American Home Assurance Company for services provided on September 25, 27, and 29, 2000; November 27 and 29, 2000; December 1, 4, 6, and 8, 2000; and January 4, 5, 8, 9, 10, and 12, 2001, is GRANTED, and SCD Back and Joint Clinic, shall have and recover $3,409.00 of and from American Home Assurance Company for the claims brought in this proceeding, plus interest at the rate and for the time as provided by law.

Signed October 18, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

THOMAS H. WALSTON
Administrative Law Judge

  1. Certified Record at 46 (emphasis in original).
  2. Certified Record at 45.
  3. Certified Record at 51.
  4. Certified Record at 87 (emphasis added).
  5. Certified Record at 94, 95, 96, 104, 105, 106, and 107. No such notes are contained in the Certified Record for September 27 and 29, 2000.
  6. Certified Record at 46.
  7. Certified Record at 45.
  8. Certified Record at 51.
  9. In its denial codes and/or in its position statement at MRD, AHAC raised lack of preauthorization and lack of medical necessity for the following dates of service: October 12, November 27 and 29, and December 4, 6, and 8, 2000; and January 4, 8, 9, 10, and 12, 2001.
  10. The rule provides” . . The maximum amount of time allowed per session is two hours. If additional time is required to complete the treatment rendered in a session, a maximum of one additional hour may be allowed.” .
End of Document
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