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At a Glance:
Title:
453-02-2845-m5
Date:
July 24, 2002
Status:
Retrospective Medical Necessity

453-02-2845-m5

July 24, 2002

DECISION AND ORDER

Pharr San Juan Alamo I.S.D. (Carrier) challenges a decision of the Texas Workers’ Compensation Commission’s Medical Review Division ordering reimbursement of $35.00 to Pain Institute of Texas (Provider) for manipulations billed under CPT Code 97260. This decision finds the manipulations were not medically necessary.

The parties were duly notified of the hearing in accordance with the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001. The hearing convened and closed on June 4, 2002, before Administrative Law Judge Gary Elkins. Attorney Don York appeared on behalf of Carrier. Provider did not appear.

I. DISCUSSION

A worker suffered a compensable injury in ___. As pertinent to this case, Provider performed cervical and lumbar manipulations on the worker on December 15, 2000. Carrier argued that the manipulations were not medically necessary because there were no quantified, objective, and substantive measures demonstrating improvement in the injured worker’s condition. In addition, Carrier argued that an orthopedist had concluded in November 2000, one month before the disputed manipulations, that they were no longer necessary. As reflected in the Findings of Fact and Conclusions of Law, the ALJ agrees with Carrier. Accordingly, reimbursement should be denied.

II. FINDINGS OF FACT

  1. An injured worker sustained a compensable injury in ___.
  2. At the time of the worker’s injury, her employer, Pharr San Juan Alamo I.S.D. (Carrier), was self-insured as a workers’ compensation insurance carrier.
  3. On December 15, 2000, Pain Institute of Texas (Provider) administered cervical and lumbar manipulations to the injured worker and billed Carrier $35.00 under CPT Code 97260.
  4. Carrier denied reimbursement for the manipulations as not being medically necessary.
  5. Notice of the hearing was sent to the parties on May 6, 2002.
  6. 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.
  7. At the time of the December 2000 manipulations, the injured worker was at the post-tertiary phase of care.
  8. Provider performed several other manipulations on the injured worker in 2000, prior to the December 2000 manipulations.
  9. There were no objective measures of improvement leading up to the December 2000 manipulations.
  10. As of July 2000, lumbar and cervical manipulations were no longer medically necessary.

III. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation 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. The State Office of Administrative Hearings 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. Carrier timely requested a hearing pursuant to 28 Tex. Admin. Code§148.3.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  5. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  6. Pursuant to 28 TAC §134.1001(g)(6), an injured employee is entitled to reasonable and necessary health care for the duration of the injury.
  7. The evidence demonstrated that the manipulations performed by Provider were not reasonable and necessary for the treatment of Claimant’s injury.
  8. Carrier met its burden of proof.
  9. Carrier is not required to reimburse Provider.

ORDER

IT IS ORDERED that Carrier, Pharr San Juan Alamo I.S.D., is not required to reimburse Provider, Pain Institute of Texas, for the December 15, 2000, manipulations billed under CPT Code 97260.

Signed this 24th day of July, 2002.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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