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At a Glance:
Title:
453-02-2939-m4
Date:
November 17, 2003
Status:
Medical Fees

453-02-2939-m4

November 17, 2003

DECISION AND ORDER

This case is a dispute over whether The Connecticut Indemnity Company (Carrier) should reimburse John Schmidt, D.C. (Provider) $5,529.60 for work hardening services provided to Claimant from November 14, 2000, through December 8, 2000. The Administrative Law Judge (ALJ) concludes Provider met his burden of proving the work hardening services meet the requirements found at Medicine Ground Rule II(E) of the Texas Workers’ Compensation Commission’s Medical Fee Guideline (MFG). Therefore, reimbursement of $5,529.60 is ordered.

I. FINDINGS OF FACT

  1. On_______, Claimant suffered a compensable work-related injury to his left shoulder while repetitively pushing boxes of meat weighing 60 pounds. (Pet. Ex. 1, 202).
  2. Claimant’s employer carries workers’ compensation insurance through The Connecticut Indemnity Company (Carrier).
  3. Claimant’s compensable injury was diagnosed as rotator cuff syndrome. (Pet. Ex. 1, 132).
  4. John Schmidt, D.C. (Provider) became Claimant’s treating doctor on September 14, 2000. (Pet. Ex. 1, 188).
  5. Planned treatment for Claimant’s compensable injury included ultrasound, myofascial release, electric muscle stimulation with heat compresses, and active exercises. (Pet. Ex. 1, 203).
  6. Claimant participated in a work hardening program under Provider’s direction from November 14, 2000, through December 8, 2000.
  7. Provider furnished Claimant with a highly structured, goal-oriented, individualized treatment program designed to maximize Claimant’s ability to return to work.

a. Claimant was likely to benefit from the program; his medical, psychological and other conditions did not prohibit participation in the program; and he was capable of attaining specific employment upon completion of the program.

b. The main job-related goal of Claimant’s work hardening program was to increase the strength and range of motion in his left shoulder. (Pet. Ex. 1, 303).

c. Claimant’s work hardening activities were overseen by Frank Neugebauer, a work hardening manager at Montgomery Physical Medicine Rehabilitation, with group therapy provided by a licensed professional counselor. (Pet. Ex. 1, 252, 266-268, 280-281, 297-298, 315, 326-327, 344-345).

d.Claimant’s daily treatment and response to that treatment were documented.

e. Claimant participated in the work hardening program at least four hours per day.

f. Over the course of the work hardening program, Claimant continued to complain of pain in his left shoulder, so Provider referred him to a medical doctor for further evaluation.

g. Linden Dillin, M.D., examined Claimant on December 4, 2000, and determined Claimant required further health care intervention in the form of left shoulder arthroscopic surgery.

h. Claimant was advised by Dr. Dillen to continue his rehabilitation with Provider until he decided whether to undergo the surgery. (Pet. Ex. 1, 238).

i. Claimant decided to go ahead with the recommended surgery and discontinued participation in the work hardening program after December 8, 2000. (Testimony of Kelly Schmidt).

(The treatment program documents Claimant’s objective substantive and continued improvement over time that correlates with Claimant’s job description. (Pet. Ex. 1, 253,303, 320, 332, and 350).

a. On November 14, 2000, Claimant performed the push and pull task 15 times, the wood stack task for 45 minutes, the shoulder range of motion task for 30 minutes and lift and carry task for 17 minutes, with weights ranging from 20-to-40 pounds.

b.On November 21, 2000, Claimant performed the push and pull task 15 times, the wood stack task for 45 minutes, the shoulder range of motion task for 45 minutes, and the lift and carry task for 30 minutes, with weights ranging from 20-to-40 pounds.

c.On November 28, 2000, Claimant performed the push and pull task 15 times, the wood stack task for 45 minutes, the shoulder range of motion task for 40 minutes, and the lift and carry task for 14 minutes, with weights ranging from 20-to-50 pounds.

d.On December 8, 2000, Claimant performed the push and pull task 15 times, the wood stack task for 45 minutes, the shoulder range of motion task for 45 minutes, and the lift and carry task for 30 minutes, using “all weights.” (Pet. Ex. 1, 343).

  1. Carrier denied reimbursement to Provider for the work hardening program provided to Claimant.
  2. On November 14, 2001, Provider filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  3. On April 5, 2002, the Commission’s Medical Review Division (MRD) denied Provider’s request for reimbursement as to the work hardening.
  4. On April 10, 2002, Provider filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  5. Notice of the hearing was sent to the parties on May 17, 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. The hearing convened before ALJ Sharon Cloninger on September 16, 2003. Provider was represented by his wife Kelly Schmidt. Carrier failed to appear. The hearing adjourned and the record closed that same day.

II. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation 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. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. Provider, as the petitioner, has the burden of proof in this matter, pursuant to 28 Tex. Admin. Code (TAC) § 148.21(h).
  5. Provider met his burden of proving reimbursement is warranted.
  6. Based on Finding of Fact No. 7, the requirements of the work hardening program pursuant to Medicine Ground Rule II. E. found in the Commission’s Medical Fee Guideline at 28 TAC §

134.201 were met.

  1. Based on Findings of Fact Nos. 7-8,the requirements of the Commission’s Upper Extremities Treatment Guideline rule found at 28 TAC § 134.1002 (e)(2)(A) was met in that the treatment was objectively measured, and demonstrated functional gains; and the treatment was consistent in demonstrating ongoing progress in the recovery process by appropriate re-evaluation of the treatment.
  2. Provider’s request for reimbursement should be granted.

ORDER

IT IS, THEREFORE, ORDERED that The Connecticut Indemnity Company is to pay $5,529.60 to John Schmidt, D.C., for work hardening provided to Claimant from November 14, 2000, through December 8, 2000.

Signed November 17, 2003.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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