DECISION AND ORDER
_____, an injured worker (Petitioner), has appealed a decision of the Medical Review Division (MRD) of the Texas Workers Compensation Commission (Commission). MRD denied preauthorization for the reasonable and necessary costs for outpatient carpal tunnel release surgery on Petitioner. In this decision, the Administrative Law Judge finds that Petitioner has shown that the requested surgery is medically reasonable and necessary and should be approved. Therefore, the MRD decision is overruled and the Insurance Company of the State of Pennsylvania (Carrier) is ordered to authorize and reimburse the reasonable and necessary costs associated with the surgery.
It is uncontroverted that Petitioner still has pain in her wrists as a result of a ____ compensable injury diagnosed as carpal tunnel syndrome. Carrier relies on an independent medical examination performed at the direction of the Commission. Dr. Mark Huff, the physician performing that examination, concluded that Petitioner did not still exhibit symptoms of carpal tunnel syndrome and that surgery was not necessary. Petitioner, however, relies on the opinions of Dr. Danny Bartel, Dr. Sanjoy Sundaresan, and Dr. Quentin Kramer, all of whom concluded that carpal tunnel release surgery was medically necessary treatment for Petitioner.
After reviewing the evidentiary record, the ALJ finds that the preponderance of the evidence supports Petitioner’s position that the requested surgery is medically reasonable and necessary treatment for Petitioner’s compensable ____ injury. Particularly, the ALJ notes that Dr. Kramer originally concluded that surgery was necessary in 1997, but Petitioner sought more conservative treatment from Dr. Bartel. After attempting conservative treatment, Dr. Bartel eventually concluded that Petitioner’s condition, which worsened when she more strenuously used her hands and wrists, would require surgery to fully resolve it. After examining Petitioner, Dr. Sundaresan agreed with Dr. Bartel’s recommendation. Only Dr. Huff disagrees, but Dr. Huff’s opinion was rendered after a period of relative inactivity on the part of Petitioner, when her condition was in a milder state. Dr. Huff did not dispute that the 2000 EMG revealed bilateral carpal tunnel syndrome, but simply did not observe similar findings clinically when he examined Petitioner. Dr. Bartel testified that another EMG in the Fall of 2001 also revealed a diagnosis of bilateral carpal tunnel syndrome. Dr. Huff apparently did not consider this EMG, or simply found it unpersuasive. Given this evidence, and the recommendations of Drs. Kramer, Bartel, and Sundaresan, the ALJ concludes that Petitioner has carpal tunnel syndrome and that the proposed surgery is medically reasonable and necessary treatment.
II. FINDINGS of Fact
- Petitioner sustained a compensable work-related injury on______, at which time her employer’s workers compensation carrier was the Insurance Company of the State of Pennsylvania.
- As a result of the compensable injury, Petitioner suffered pain in her wrists and hands, which was later diagnosed as bilateral carpal tunnel syndrome.
- Petitioner was seen by Dr. Quentin Kramer in July 1997 and Dr. Kramer recommended that Petitioner have an EMG and a nerve conduction study to determine if Petitioner’s injury was carpal tunnel syndrome.
- The EMG and nerve conduction studies were performed and Dr. Kramer concluded that Petitioner had carpal tunnel syndrome. Dr. Kramer recommended surgery as treatment of her condition.
- Petitioner did not undergo surgery but was treated by Dr. Danny Bartel in a more conservative manner. Petitioner continued to be treated by Dr. Bartel in a more conservative manner, including the use of therapy and medication, until May 2001.
- In March 2000, Dr. Bartel performed another EMG which also indicated carpal tunnel syndrome. On May 21, 2001, Dr. Bartel examined Petitioner and concluded it was appropriate to refer her to Dr. Sanjoy Sundaresan for a surgical evaluation.
- On August 10, 2001, Dr. Sundaresan examined Petitioner and concluded that she had carpal tunnel syndrome and that carpal tunnel release surgery was the appropriate treatment.
- Both Dr. Sundaresan and Dr. Bartel prescribed carpal tunnel release surgery as appropriate treatment for Petitioner.
- Dr. Sundaresan sought preauthorization from the Carrier for the surgery.
- The Carrier denied preauthorization on two occasions, maintaining that the surgery was not medically necessary and appropriate treatment for Petitioner’s injury, because of the period of time between the injury and requested treatment, and the alleged improved state of Petitioner’s injury.
- Petitioner requested medical dispute resolution through the Commission’s MRD. The Commission ordered Petitioner to attend a required medical examination under the direction of Dr. Mark Huff, an independent health care provider. Dr. Huff concluded that, while the EMGs established carpal tunnel syndrome, clinical evaluation did not support this same finding. Dr. Huff’s review, however, was conducted after Petitioner had gone an extended period of time without the strenuous use of her hands or wrists.
- Petitioner has bilateral carpal tunnel syndrome. Petitioner’s condition worsens when she engages in extended and/or repetitive use of her hands and wrists. Conservative treatment, such as therapy and medication, has not cured Petitioner’s condition nor allowed her to fully return to work. Carpal tunnel release surgery has a better likelihood of allowing Petitioner to return to work and function more normally.
- MRD reviewed the dispute and issued a decision on January 4, 2002, finding that carpal tunnel release surgery was not medically necessary and declining to order the Carrier to authorize and pay for the treatment.
- On January 21, 2002, Petitioner appealed the MRD decision to the State Office of Administrative Hearings (SOAH).
- Notice of the hearing in this case was mailed to the parties on February 19, 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. In the notice, the Commission’s staff indicated that it would not participate in the hearing.
- The hearing was held on March 20, 2002, with Administrative Law Judge Craig R. Bennett presiding. The Carrier was represented by Jeffrey Hill, attorney. Petitioner represented herself and was assisted by ombudsman Anthony Walker. The hearing was adjourned and the record closed the same day.
III. CONCLUSIONS of Law
- 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.
- 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.
- Petitioner timely filed her notice of appeal, as specified in 28 Tex. Admin. Code § 148.3.
- Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code §2001.052 and 28 Tex. Admin. Code § 148.4.
- Petitioner had the burden of proof on her appeal by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code §148.21(h).
- Under Tex. Labor Code § 408.021 (a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
- Based on the above Findings of Fact and Conclusions of Law, Petitioner has shown that the prescribed carpal tunnel release surgery is medically reasonable and necessary treatment for her compensable injury.
- Based on the above Findings of Fact and Conclusions of Law, Petitioner’s appeal and request for preauthorization should be granted.
IT IS ORDERED THAT the Petitioner’s appeal and request for preauthorization for carpal tunnel release surgery is granted and Carrier is ordered to reimburse all reasonable and necessary covered expenses associated with such treatment.
Signed April 2, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
CRAIG R. BENNETT
Administrative Law Judge