DECISION AND ORDER
I. PROCEDURAL HISTORY
Petitioner Insurance Company of the State of Pennsylvania (the Carrier), seeks reversal of a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordering the Carrier to reimburse Waco Ortho Rehab $490 for medical services provided to workers’ compensation claimant ___from April 16, 2001 through April 20, 2001. The disputed services related to numerous billings for CPT Code 97110 (therapeutic procedures with a 15 minute duration).
The Administrative Law Judge convened a hearing on these issues on July 10, 2002. The hearing was concluded and the record closed that date. The Carrier was represented by Patricia Blackshear. Respondent Waco Ortho Rehab was represented by Scott Hilliard. The Commission did not participate in the hearing.
II. EVIDENCE AND BASIS FOR DECISION
The documentary record in this case consisted of the 121-page certified record of the MRD proceeding and several prior SOAH decisions that were Officially Noticed. Additionally, Dr. David N. Bailey testified on behalf of Respondent Waco Ortho Rehab. No additional evidence was offered during the hearing.
Based on this record, the ALJ concludes that the Carrier’s petition should be denied and that the Carrier should be required to reimburse Waco Ortho Rehab for the services in dispute. The Carrier’s main contention was that the services provided did not require one-on-one direct therapy and so should have been billed under a different CPT code at a cheaper rate. The disputed therapy involved resistance exercises with an elastic “T-band,” range of motion exercises on a “wobble board,” and exercises with a large exercise ball. The Claimant had suffered a work related injury to his right knee on___________, and the exercises were intended to decrease his pain and increase his range of motion.
The need for one-on-one continuous supervision of individuals undertaking these therapeutic exercises is not self evident. Nevertheless, Dr. Bailey testified unequivocally that one-on-one supervision is required for the exercises in dispute in order to benefit the patient and to prevent injury. He also testified that the current practice at Waco Ortho Rehab is to bill under CPT Code 97110 only when the patient is provided exclusive one-on-one treatment. The Carrier points to no evidence in the record disputing Dr. Bailey’s testimony. Under the circumstances, the Carrier has failed to satisfy its burden of proof. The particular facts, reasoning, and legal analysis in support of this decision are further set forth below in the Findings of Fact and Conclusions of Law.
III. FINDINGS OF FACT
- On___________, Claimant ___suffered a compensable injury to his left knee.
- The Claimant’s injury is covered by worker’s compensation insurance written for the Claimant’s employer by Insurance Company of the State of Pennsylvania (the Carrier).
- Service provider Waco Ortho Rehab seeks reimbursement from the Carrier for $490 in medical services provided to the Claimant from April 16, 2001 through April 20, 2001. The disputed services related to numerous billings for CPT Code 97110 (therapeutic procedures with a 15 minute duration).
- The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
- Waco Ortho Rehab timely requested dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
- The MRD issued its findings and decision on March 8, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.
- Waco Ortho Rehab provided continuous one-on-one therapy to the Claimant for the disputed bills.
- The Carrier failed to establish that the services provided did not require continuous one-on-one supervision by the care provider.
- The units billed for CPT Code 97110 were not shown to be unreasonable or unnecessary treatment for the Claimant’s condition.
IV. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
- 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.
- The Notice of Hearing issued by the Commission 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.
- The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
- The Carrier failed to establish that the treatment provided to the Claimant was not reasonably required by Tex. Lab. Code Ann. §408.021.
- Waco Ortho Rehab should be reimbursed $490 for medical services provided to workers’ compensation claimant ___for CPT Code 97110 (therapeutic procedures with a 15 minute duration), from April 16, 2001 through April 20, 2001.
IT IS THEREFORE, ORDERED that Petitioner Insurance Company of the State of Pennsylvania shall reimburse Respondent Waco Ortho Rehab $490 for the services that are the subject of this dispute.
Issued August 28, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
Kerry D. Sullivan
Administrative Law Judge
- The Carrier cites the Order issued in SOAH Docket No. 453-00-2051.M4 for the proposition that only one-on-one direct therapy may be billed under CPT Code 97110, which is billed at the rate of $35 per 15 minute unit.↑
- A Wobble Board is a piece of exercise equipment in the shape of a blunt disk with a rounded bottom. It is used in range of motion exercises.↑
- Dr. Bailey contrasted these exercises with exercises such as riding a stationary bicycle, which he bills under a group therapy code.↑