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At a Glance:
Title:
453-02-3128-m5
Date:
September 12, 2002
Status:
Retrospective Medical Necessity

453-02-3128-m5

September 12, 2002

DECISION AND ORDER

This case was initially an appeal by St. Paul Insurance Company, (Petitioner) from the Findings and Decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) in a fee dispute. The MRD countermanded (in part) Petitioner’s denial of a request from Waco Ortho Rehab (Respondent) for reimbursement of $2,217.00, covering medical services to a claimant under the Texas Workers’ Compensation Act (the Act), TEX. LABOR CODE ANN. ch. 401 et seq. The MRD’s decision required Petitioner to reimburse Respondent $1,757.00 for a portion of the disputed services.

After Petitioner formally sought an administrative review of the MRD’s decision, Respondent also filed a “Request for Amended Decision,” challenging the same decision insofar as it failed to recommend reimbursement of the entire $2,217.00 initially requested by Respondent.

This decision affirms that of the MRD.

I. JURISDICTION AND VENUE

The Texas Workers’ Compensation Commission (Commission) has jurisdiction to consider appeals from decisions of its MRD pursuant to § 413.031 of the Act. The State Office of Administrative Hearings (SOAH) has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and TEX. GOV'T CODE ANN. ch. 2003.

II.STATEMENT OF THE CASE

The hearing in this docket was convened on August 28, 2002, at SOAH facilities in the William P. Clements Building, 1700 North Congress Avenue, Austin, Texas. Administrative Law Judge (ALJ) Mike Rogan presided over the hearing. The Commission, as Respondent, did not appear or participate.[1] Respondent Waco Ortho Rehab was represented by James Rainey, Attorney, who appeared by telephone. Petitioner was represented by Steve Tipton, Attorney. After presentation of evidence and argument, the hearing was adjourned and the record was closed on August 28, 2002.

The record developed at the hearing revealed that, on ___, the claimant suffered a compensable knee injury, which necessitated surgery on October 5, 2000. During the patient’s rehabilitative process, the treating physician referred her to Respondent for physical therapy. Respondent sought preauthorization from Petitioner for these services, which was initially denied. In a document dated December 29, 2000, Respondent reiterated the need for rehabilitation to increase the range of motion at the knee joint, increase the flexibility of musculature and other tissue around the joint, and strengthen that muscle and tissue. To address these objectives, Respondent requested 18 sessions of therapy, including eight units under CPT Code 97110 and one unit each under Codes 97250, 97265, 97024, and/or 97014.

In response, by letter dated January 3, 2001, Petitioner stated that the “requested treatment” had been reviewed and “recommended as medically necessary.” However, this document explicitly authorized only “12 visits” for ”therapy times 3 times 4,” starting on January 3, 2001, and ending on February 7, 2001.

Based upon this preauthorization, Respondent proceeded to provide therapy to the claimant on February 5, 6, 8, and 9, 2001. According to Respondent’s billings, on each of those dates the claimant participated in eight units of Code 97110 therapy and one unit each of Code 97024, 97250, and 97265 therapy. When Respondent requested reimbursement for this therapy (and for related office visits), Petitioner rejected the request with an explanation of review (dated February 28, 2001), categorizing the services as medically unnecessary. Similarly, Petitioner later denied reimbursement for other tests and examinations related to the therapy. Respondent then sought medical dispute resolution with respect to these issues from the Commission’s MRD.

The MRD issued a decision on April 30, 2002, finding that Respondent had submitted proper proof of preauthorization in accordance with Commission Rule 134.600, which (under Rule 133.301) precluded the carrier’s further retrospective review of the medical necessity for the treatments at issue. The MRD thus concluded that Petitioner could not object to the therapy provided by Respondent in this case as unnecessary. In addition, the MRD found that several ancillary tests performed upon the claimant had been adequately documented to be necessary. On the other hand, the MRD found that the necessity of a number of office visits and related services had not been established.

III. EVIDENCE, ARGUMENT, AND DISCUSSION

The certified record compiled by the Commission i.e., the MRD’s Findings and Decision, with accompanying documents, including materials offered by the Petitioner was admitted into evidence as Exhibit 1.

Petitioner contended that the therapy in this case was not insulated from challenge, even though preauthorized, because Respondent failed to provide that service in accordance with the specific parameters of Petitioner’s authorization. Respondent billed for only four visits, rather than the 12 preauthorized. All four sessions took place within one week, ignoring the authorization’s limit of three sessions per week. Two of the four sessions took place after the authorization’s deadline for completion of the therapy (February 7, 2001).

Respondent countered that the services it provided were substantially in accord with Petitioner’s preauthorization, that it obtained from an employee of Petitioner (by telephone) prior approval to extend the time period for the claimant’s therapy by two days, and that no Commission rules or guidelines authorize carriers to limit the timing of preauthorized services so specifically as Petitioner has done. Also, with respect to office visits that the MRD did not find reimbursable, Respondent contended that close, day-to-day assessment of the claimant’s condition was needed during and immediately after her participation in an intense program of rehabilitative therapy.

In the ALJ’s view, the parties have provided no evidence or argument sufficient to compel the reversal of any of the MRD’s findings or recommendations. The principal dispute, of course, relates to the preauthorized therapy sessions, which encompass $1,548.00 of the billings approved by the MRD. The ALJ agrees with Respondent that no cited authority provides for time limitations upon preauthorized treatment of the type asserted by Petitioner in this case. Such limitations”particularly when extremely precise or short-term”would severely impede care-providers in adjusting treatment to deal with changing circumstances.[2] Indeed, Petitioner’s preauthorization letter, while very brief and general on the whole, seems to imply that Respondent retains reasonable flexibility in administering the preauthorized treatment; the letter includes the following statement:

While the case manager and/or physician adviser may explore treatment alternatives with you, the final decision regarding medical treatment remains with the patient and you, the treating physician.

Petitioner sought to demonstrate at the hearing, however, that Respondent’s lack of adherence with the disputed time limitations represented not just a technical inconsistency between the treatment preauthorized and the treatment actually provided, but rather an actual failure to provide proper medical care. Petitioner presented a reviewing chiropractor who asserted that physical therapy of the type administered by Respondent in this case must be administered every other day “allowing a day for the body to rest and recover between sessions “rather than upon successive days, as Respondent scheduled it. Respondent, in turn, offered the testimony of a chiropractor who declared that every-other-day sessions, although widely practiced, are in no way obligatory. Neither practitioner cited any specific authority or provided any systematic explanation for his position. Nor would any other information in the record allow the ALJ to conclude that the therapy in question was improperly provided and thus unnecessary (even assuming that such preauthorized services were subject to retrospective review for necessity).

Similarly, the parties’ disputes about ancillary tests and examinations provided no definitive basis for changing the MRD’s determinations as to the proper reimbursement for those items.

IV. CONCLUSION

The ALJ finds that, under the record provided in this case, no basis exists for reversing the decision of the MRD with respect to Petitioner’s required reimbursement for medical services provided by Respondent.

V. FINDINGS OF FACT

  1. On___________, the claimant in this case suffered an injury to her knee that was a compensable injury under the Texas Worker's Compensation Act (the Act), TEX. LABOR CODE ANN. ch. 401 et seq. The injury necessitated surgery on October 5, 2000.
  2. During the claimant’s rehabilitative process, the treating physician referred her to Waco Ortho Rehab (Respondent) for physical therapy.
  3. Respondent sought preauthorization for therapy services from the insurance carrier for claimant’s employer, an affiliate of St. Paul Insurance Company (Petitioner). Preauthorization was initially denied.
  4. In a document dated December 29, 2000, Respondent reiterated the need for therapy to promote the claimant’s rehabilitation. To address this objective, Respondent requested 18 sessions of therapy, including (for each session) eight units under CPT Code 97110Bas listed in the Texas Workers’ Compensation Commission’s Medical Fee Guideline (MFG), 28 TEX. ADMINISTRATIVE CODE (TAC) §134.201Band one unit each under Codes 97250, 97265, 97024, and/or 97014.
  5. In a letter dated January 3, 2001, Petitioner preauthorized the requested treatment, as noted in Finding of Fact No. 4, but limited it to only 12 sessions, to occur three times a week for four weeks, starting on January 3, 2001, and ending on February 7, 2001.
  6. Respondent subsequently billed Petitioner $2,217.00 for the following services provided to the claimant:
  7. Therapy administered on February 5, 6, 8, and 9, 2001 including, for each date, eight units of Code 97110 therapy and one unit each of Code 97024, 97250, and 97265 therapy.
  8. Office visits (Code 99213) on February 5, 6, 8, 9, and 20, and April 24, 2001, as well as one office visit (Code 99215) on February 15, 2001.
  9. Services (Code 99080-73) on February 15, 2001.
  10. Services (Code 99080) on March 19, 2001.
  11. Testing procedures (Codes 95851 and 97750-MT) on February 15, 2001.
  12. Petitioner denied the requested reimbursement, issuing explanations of review that categorized the services noted in Finding of Fact No. 6 as medically unnecessary.
  13. By letter dated September 24, 2001, Respondent made a timely request to the Commission’s Medical Review Division (MRD) for medical dispute resolution with respect to the disputed reimbursements.
  14. The MRD, in a decision dated April 30, 2002, in dispute-resolution docket No. M5-02-0437-01, concluded that Petitioner should reimburse Respondent $1,757.00 for the services noted in Findings of Fact Nos. 6a, 6d, and 6e; the MRD found that reimbursement was not appropriate for the services noted in Findings of Fact Nos. 6b and 6c, for which Respondent has sought $440.00.
  15. Petitioner requested in timely manner a hearing with the State Office of Administrative Hearings, seeking review and reversal of the MRD decision insofar as it required reimbursement of Respondent. Respondent subsequently also filed a “Request for Amended Decision,” challenging the decision insofar as it failed to recommend reimbursement of the entire amount initially sought by Respondent.
  16. The Commission mailed notice of the hearing's setting to the parties at their addresses on May 31, 2002.
  17. A hearing in this matter was convened on August 28, 2002, at the William P. Clements State Office Building in Austin, Texas, before Mike Rogan, an Administrative Law Judge with the State Office of Administrative Hearings. All parties were represented.

VI. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issues presented pursuant to § 413.031 of the Act.
  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 ' 413.031(d) of the Act and TEX. GOV’T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001 (Vernon 1998) and the Commission’s rules, 28 TAC § 133.305(g) and §§ 148.001-148.028.
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. Pursuant to 28 TAC § 148.21(h), both parties, to the extent that they were seeking relief from the prior decision of the MRD, bore a burden of proof in this case.
  6. Based upon the foregoing Findings of Fact, Petitioner sought and obtained preauthorization for the therapy services noted Finding of Fact No. 6a, in accordance with 28 TAC § 134.600.
  7. Pursuant to 28 TAC § 133.301, retrospective review by Petitioner (as an insurance carrier) of the medical necessity of the preauthorized therapy services noted in Conclusion of Law No. 6 is not authorized.
  8. Based upon the foregoing Findings of Fact, the medical services for the claimant noted in Finding of Fact No. 6 (to the extent approved for reimbursement by the MRD, as noted in Finding of Fact No. 9) represent elements of health care medically necessary under § 408.021of the Act.
  9. Based upon the foregoing Findings of Fact and Conclusions of Law, the Findings and Decision of the Medical Review Division, issued in this matter on April 30, 2002, are affirmed. Reimbursement of $1,757.00 for the services noted in Conclusion of Law No. 8, to be paid for by the St. Paul Insurance Company, should be approved.

ORDER

IT IS THEREFORE, ORDERED that the St. Paul Insurance Company reimburse Waco Ortho Rehab $1,757.00, plus all accrued interest due at the time of payment, for physical therapy and related services, in accordance with the Findings and Decision of the Medical Review Division of the Texas Workers’ Compensation Commission, issued in this matter on April 30, 2002.

Signed this 12th day of September, 2002.

MIKE ROGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The staff of the Commission was initially designated as a Respondent in the proceeding but formally elected not to participate, although it filed a “Statement of Matters Asserted” that recommended upholding the MRD’s decision.
  2. Petitioner’s initial refusal to preauthorize treatment, followed by preauthorization prescribing a schedule that could have been satisfied only if the claimant began therapy almost immediately, clearly placed undesirable constraints on Respondent’s ability to manage the services and to accommodate any scheduling conflicts created by the patient, treating physician, or others involved in the case.
End of Document
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