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At a Glance:
Title:
453-02-1902-m5
Date:
August 14, 2002
Status:
Retrospective Medical Necessity

453-02-1902-m5

August 14, 2002

DECISION AND ORDER

I. SUMMARY

Adom Rehab & Physical Medicine (Petitioner), the provider of services in this case, seeks reimbursement for work hardening services provided an injured worker, ___ Hartford Casualty Insurance Company (Carrier) denied payment indicating the services were not medically necessary. Subsequently, the Medical Review Division (MRD) of the Texas Workers' Compensation Commission (Commission) considered Petitioner’s claim of $14,848.00 and recommended no reimbursement. Petitioner appealed the MRD’s order, arguing that full reimbursement should be ordered.

The Administrative Law Judge (ALJ) concludes that Petitioner did not meet its burden of proving that the work hardening program was medically necessary and is, therefore, not entitled to reimbursement.

II. JURISDICTION, NOTICE AND PROCEDURAL HISTORY

On July 17, 2002, ALJ Michael J. O’Malley convened the hearing on the merits at the William P. Clements Building, 300 West 15th Street, Austin, Texas. Carrier appeared through its attorney, James M. Loughlin. Petitioner appeared through its representative, Diana A. Hodge. After the evidence was presented, the record of the hearing closed on July 31, 2002, when the last closing argument was filed.

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

III. BACKGROUND, EVIDENCE, AND DISCUSSION

Background

Claimant, ___, suffered a compensable back injury on_________, while working for __________ as a file clerk. She complained of pain in her neck and thoracic and lumbar spine. She also complained of memory loss, stiffness, and depression. Tina Collins, D.C. began providing chiropractic services to Claimant, and she became Claimant’s treating doctor. On December 4, 2000, Claimant’s employer completed a Job Demand Analysis, listing her job as a file clerk. The employer indicated it could accommodate transitional duty and could meet all job restrictions. An MRI was performed, and it showed no significant findings in the lumbar spine and minimal degenerative findings in the cervical spine. On January 11, 2001, Claimant underwent a Functional Capacity Evaluation (FCE). The FCE indicated that Claimant qualified for the medium work category with restrictions and the light category without restrictions. On January 16, 2001, Claimant began the work hardening. The program continued until February 23, 2001.

Because of the lack of sufficient documentation, the MRD was unable to establish the medical necessity of the work hardening program. The issue in this case is whether Petitioner’s work hardening program provided between January 16 and February 23, 2001, was medically necessary, substantiating reimbursement of $14,848.00.

  1. Parties’ Positions and Evidence
  2. Petitioner’s Position and Evidence

Petitioner relies on a May 9, 2001, letter written by Richard J. Kondejewski, M.D. Dr. Kondejewski is the Medical Director for Petitioner. The letter was addressed to the Carrier to explain the initial determination that work hardening was appropriate for Claimant. Dr. Kondejewski emphasized to Carrier that the decision to place Claimant in the work hardening program had a lot to do with her mental condition at the time. He stated that Petitioner informed Claimant that her physical condition would not prevent her from returning to work, but she stated that she did not feel like she could return to work. Because of Claimant’s inability to cope on a day‑to-day basis, Petitioner believed a work hardening program would be appropriate for her. Petitioner’s Ex. 1, Certified Record at 28-29.

Also part of the certified record and relied on by Petitioner is the evaluation performed by Lourdes M. Valdes, Ph.D. of Behavioral Healthcare Associates. Dr. Valdes performed the psychological test to make additional recommendations that would assist Claimant in coping with her pain and injury related stress. Because of Claimant’s degree of somatic focus and her ineffective coping strategies, Dr. Valdez recommended a psychophysiological profile assessment to determine whether Claimant’s muscle activity might be contributing to her pain; the degree to which Claimant is capable of achieving a relaxed state; and the extent relaxation training could be beneficial for pain management. Petitioner’s Ex. 1, Certified Record at 30-31.

Petitioner also asserts that the Daily Progress Notes document the medical necessity of the work hardening program.

Carrier’s Position and Evidence

Zvi Kalisky, M.D. testified on behalf of Carrier. Dr. Kalisky testified that the purpose of a work hardening program is to return the patient to work by correcting disparities between the patient’s current abilities and those required by her job. He further testified that, in this case, there was no disparity to be corrected. At the time Claimant began the work hardening program, she was exceeding her job skills and was able to return to work.

Dorothy Ann Leong, M.D. first reviewed the necessity of the work hardening program on April 5, 2001. In her report, she stated that given that Claimant’s job requirements were at a sedentary physical demand level and she was functional at the light physical demand level as of January 11, 2001, there was no mismatch to support the work hardening program. Petitioner’s Ex. 1, Certified Record at 20-23.

Carrier argued that the fact that Claimant may have needed psychological counseling does not justify placing her in an expensive work hardening program. Dr. Kalisky testified that the more sound approach would have been to have Claimant return to work and prescribe individual psychotherapy sessions several times per week. He noted that the best policy is to return patients to work as soon as possible because the longer they remain off work, the more difficult it becomes for them to return to work.

Carrier further contends that there is no treatment plan for Claimant’s work hardening program, which is required under the Medical Fee Guideline. Carrier also notes that the Daily Progress Notes are missing from January 16, 2001, through January 26, 2001. In addition to the missing notes, Carrier claims that the Daily Progress Notes did not document Claimant’s response to treatment to ensure continued progress. Also, most of the Daily Progress Notes are sketchy or illegible according to Carrier. Carrier further claims that the Weekly Progress Notes are inadequate because they do not document important activities for certain days. Carrier also asserts that there is no documentation that Claimant was engaging in simulated work activities, and according to Dr. Kalisky, work simulation is the hallmark of a work hardening program. Finally, Carrier contends that Petitioner billed for eight hours a day for the work hardening program, but according to the documentation, the program lasted only five hours. See Petitioner’s Ex. 1, Certified Record at 32-62.

ALJ’s Analysis

In this case, Petitioner did not meet its burden of proof that the work hardening program was medically necessary and should be reimbursed.

Work hardening is an individualized, highly structured, goal-oriented treatment program designed to maximize the ability of the person receiving the treatment to return to work. Work hardening programs are interdisciplinary, intended to address the functional, physical, behavioral, and vocational needs of the Claimant. The Commission has adopted rules governing work hardening programs. The rules, found in the Medical Fee Guideline, relate to, among other things, when work hardening is appropriate, how such programs are to be administered and billed, and what documentation is required of work hardening programs.[1] In this case, Petitioner did not follow the requirements of the Medical Fee Guideline. First, Petitioner did not develop a treatment plan for Claimant’s work hardening program. Second, the Daily Progress Notes were missing from January 16, 2001, through January 26, 2001. Third, it was difficult to determine the clinical progress of Claimant because the Daily Progress Notes were often illegible. Fourth, the documentation in general did not document activities that Claimant participated in. For example, Petitioner did not indicate that Claimant participated in work simulation activities, which is an important component of a work hardening program. Finally, the records indicate that Claimant’s work hardening program lasted five hours a day instead of eight hours as billed by Petitioner. See Petitioner’s Ex. 1, Certified Record at 32-62.

In addition, at the time Claimant began her work hardening program, she was capable of returning to work. The FCE conducted on January 11, 2001, indicated that Claimant qualified for the medium work category with restrictions and the light category with no restrictions. Therefore, Claimant exceeded her job requirements before starting the work hardening program. Respondent’s Ex. 1, Functional Capacity Evaluation.

Furthermore, the work hardening program was not an effective tool for treating Claimant’s psychological problems. It would have been more appropriate, given the nature of her problems, to recommend individual counseling sessions. Not only would the individual sessions have been more effective in treating Claimant’s psychological problems, they also would have been less costly than the work hardening program. Further, the notes from the group sessions indicate that the discussions did not focus on Claimant’s problems, such as her marginal living status and her parenting problems. According to the notes, the group sessions focused on assertive versus aggressive and passive responses, the importance of not overworking the injured area, improving sleep habits, and autogenic relaxation. Petitioner’s Ex. 1, Certified Record at 63-66. In addition, the ALJ did not find that Dr. Kondejewski adequately justified the work hardening program in his May 9, 2001, letter to Carrier. In that letter, Dr. Kondejewski agreed that Claimant’s physical condition did not prevent her from returning to work; however, her psychological problems did. Petitioner’s Ex. 1, Certified Record at 28-29. As discussed above, however, the work hardening program did not address Claimant’s psychological problems.

For the reasons indicated above, Petitioner did not prove that the work hardening program for Claimant was medically necessary. Accordingly, reimbursement is denied.

IV. FINDINGS OF FACT

  1. Claimant ___, employed as a ___ for _______, sustained an injury to her back on _________.
  2. At the time of the injury, Claimant’s employer had workers’ compensation insurance through Hartford Casualty Insurance Company (Carrier).
  3. Tina Collins, the treating doctor, referred Claimant to MedTest for a functional capacity evaluation (FCE), which was completed on January 11, 2001.
  4. The FCE established that Claimant qualified for the medium work category with restrictions and the light work category without restrictions.
  5. Claimant enrolled in a six-week work hardening program provided by Adom Rehab & Physical Medicine (Petitioner) from January 16, 2001, through February 23, 2001.
  6. One of the primary goals of work hardening is to correct disparities between the patient’s current abilities and those required to return to work.
  7. In this case, there was no disparity to be corrected because Claimant’s FCE indicated that she was able to return to work.
  8. Given that Claimant’s job requirements were a sedentary physical demand level and she was functional at the light physical demand level as of January 11, 2001, there was no disparity to support the work hardening program.
  9. The work hardening program was not an effective tool in treating Claimant’s psychological problems.
  10. The group sessions did not focus on Claimant’s problems, which included her marginal living status and her parenting problems.
  11. The Daily Progress Notes were missing from January 16, 2001, through January 26, 2001.
  12. Petitioner did not have a treatment plan for Claimant.
  13. The Daily Progress Notes did not adequately document Claimant’s response to treatment to ensure continued progress.
  14. Most of Petitioner’s Daily Progress Notes are sketchy or illegible.
  15. The Daily Progress Notes do not reflect that Claimant engaged in simulated work activities.
  16. Petitioner billed eight hours a day for each day of service from January 16, 2001, to February 23, 2001, but the work hardening program lasted only five hours a day.
  17. Petitioner seeks reimbursement for Claimant’s work hardening in the amount of $14,848.00.
  18. Carrier denied reimbursement of the claim, indicating the services were not medically necessary.
  19. On July 27, 2001, Petitioner appealed the Carrier’s reimbursement denial to the Medical Review Division (MRD) of the Texas Workers' Compensation Commission (the Commission).
  20. On December 17, 2001, the MRD denied Petitioner reimbursement because it was unable to establish the medical necessity of the work hardening program.
  21. On January 11, 2002, Petitioner appealed the MRD’s decision.
  22. The Commission sent notice of the hearing to the parties on February 20, 2002. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
  23. The hearing was held on July 17, 2002. Carrier appeared through its attorney, James M. Loughlin. Petitioner appeared through its representative, Diana A. Hodge. After the evidence was presented, the record of the hearing closed on July 31, 2002, when the last closing argument was filed.

V. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers' Compensation Act, Tex. Lab. Code Ann. §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. Lab. Code Ann. §§ 402.073 and 413.031(d) and Tex. Gov't Code Ann. ch. 2003.
  3. The Petitioner timely filed notice of appeal of the MRD decision, as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov't Code Ann. ch. 2001 and 28 TAC §148.4(b).
  5. Pursuant to 28 TAC §148.21(h) and (i), Petitioner had the burden of proving by a preponderance of the evidence that it should receive total reimbursement of its claim.
  6. Petitioner failed to prove that the services rendered to Claimant from January 16, 2001, through February 23, 2001, met the requirements set out in the Medical Fee Guideline Medicine Ground Rule II. E. 6, 7 and 8.
  7. The Petitioner failed to meet the documentation requirements of Medical Fee Guideline Medicine Ground Rule II. E. 8.
  8. Based on the foregoing findings of fact and conclusions of law, Petitioner did not prove that its claim for $14,848.00 should be reimbursed.

ORDER

IT IS HEREBY ORDERED that the request for reimbursement of Adom Rehab & Physical Medicine is denied as it did not prove that the services provided Claimant ___ from January 16, 2001, through February 23, 2001, were medically necessary.

Signed this 14th day of August 2002.

MICHAEL J. O’MALLEY
Administrative Law Judge
State Office of Administrative Hearing

  1. See Medical Fee Guideline Medicine Ground Rule II. E. and 28 Tex. Admin. Code §134.201.
End of Document
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