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At a Glance:
Title:
453-02-3176-m5
Date:
June 9, 2003

453-02-3176-m5

June 9, 2003

DECISION AND ORDER

Petitioner CLC Chiropractic (Provider) seeks reimbursement from _____________ (Respondent) of approximately $10,000 for various services provided to claimant ____ from July 9, 1999, through May 31, 2000. Respondent denied reimbursement and the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) declined to order reimbursement. In this decision, the Administrative Law Judge (ALJ) finds that Provider has shown by a preponderance of the evidence that it is entitled to reimbursement for some of the services. Therefore, the ALJ orders reimbursement in part in the amount of $5,313.60.

I. Background Facts

Claimant____, a police officer for______________, was injured in an automobile accident on________. Claimant was diagnosed with cervical and lumbar strain and attendant cervical and lumbar lesions. After his accident, Claimant continued working, but took medications for pain related to his injury and received therapy and chiropractic manipulations from Dr. Myron Heimlich. Approximately 11 months after the injury, Claimant’s pain continued to be so significant that he visited Provider for additional treatment. Provider began performing physical therapy modalities on Claimant and ordered x-rays and an MRI of Claimant’s spine. The x-rays and MRI revealed significant abnormalities and degenerative conditions. Provider continued to treat Claimant with extensive conservative care. Although he continued working, Claimant was placed on restricted duty because of limitations related to his injury. Therefore, Provider determined that work hardening would be appropriate for Claimant. Work hardening was provided to Claimant from March 13, 2000, through April 19, 2000.

Provider billed Respondent for the medical treatment provided to Claimant. Respondent denied reimbursement for much of the treatment, contending it was not medically necessary, not preauthorized, or not properly documented. After Respondent reconsidered the reimbursement requests and maintained its denial of reimbursement, Provider sought medical dispute resolution through the Commission’s MRD. After conducting medical dispute resolution, MRD declined to order reimbursement. Provider then appealed, requesting a hearing before the State Office of Administrative Hearings.

II. Discussion and Analysis

At the hearing, Provider conceded that it had failed to obtain the necessary preauthorization for some of the treatment in issue. Therefore, Provider withdrew its request for reimbursement as to those services.[1] However, Provider contended that the remaining treatment was medically necessary and properly documented. Provider offered into evidence voluminous documents reflecting the treatment provided to Claimant. Provider also offered the testimony of Dr. Suhail Al-Sahli, the chiropractor who actually rendered the treatment to Claimant. Dr. Al-Sahli testified to the treatment provided, the basis for the treatment, the medical necessity of the treatment, and, to some degree, the documentation of the treatment. Dr. Al-Sahli also pointed out the documentary evidence containing the opinions of other physicians that the treatment was medically necessary. In response, Respondent relied on the Commission’s certified record and also presented the testimony of Joyce Maxim, a registered nurse who questioned the medical necessity of the treatment and the adequacy of the documentation for the treatment.

At the conclusion of the hearing on the merits, the ALJ advised the parties that the evidence presented appeared to establish the medical necessity of the treatment in issue, and that the only real issue in dispute appeared to be whether the documentation was adequate. However, the ALJ also advised the parties that they could argue the issues of medical necessity and documentation and the ALJ would give due consideration to their arguments. In its closing arguments, Respondent apparently concedes the issue of medical necessity, stating “[Respondent] and [Provider] do not have a dispute over medical necessity. The issue in dispute is whether [Respondent] should reimburse [Provider] based on the documentation [Provider] submitted.”[2] Moreover, in its reply brief, Respondent further states “[Provider] begins its closing statement by first arguing about medical necessity, which is not an issue in this dispute.”[3] The ALJ construes Respondents’ statements and failure to address the issue of medical necessity as a concession that medical necessity is no longer disputed by it. However, even if it were a disputed issue, the ALJ concludes the evidence clearly establishes the medical necessity of the treatment in issue. In particular, Dr. Al-Sahli testified as to the medical necessity of the treatment. Further, an independent medical examination of Claimant was conducted by Dr. Todd Bear on May 26, 2000, and Dr. Bear concluded that the treatment rendered by Provider, especially the work hardening program, was medically necessary.[4]

The sole issue remaining in dispute, then, is whether the treatment provided was adequately documented in a manner consistent with the Commission’s guidelines, so as to support the Provider’s claims for reimbursement. Respondent asserts that the documentation was not sufficient,

pointing to the Ground Rules of the Commission’s Medical Fee Guidelines which provide, in pertinent part, that in order for physical medicine treatment to qualify for reimbursement:

  • the patient’s condition shall have the potential for the restoration of function;
  • the treatment shall be specific to the injury and provide for potential improvement of the patient’s condition;
  • the treatment plan for the patient must set out the type of treatment modality, the frequency of treatment, the expected duration of treatment, the expected clinical response to treatment, and the specification of a re-evaluation time frame; and
  • the treatment plan must be updated to reflect any changes in the patient’s condition, as well as her response to treatment.[5]

Respondent contends that Provider has failed to meet these requirements. Moreover, Respondent points to the Commission’s Spine Treatment Guideline (STG) (in effect at the time) which required, among other things that “treatment of a work related injury must be (i) adequately documented; and (ii) evaluated for effectiveness and modified based on clinical changes.”[6] Further, the STG required that “documentation shall be provided by a health care provider sufficient to determine the level of care to be provided and the necessity of that care”and“documentation of manipulation should show objective/qualified substantive and continued measures of improvement over time.”[7] Respondent contends that Provider’s documentation does not meet these requirements either.

After considering the evidence presented, the ALJ finds that, except as to the work hardening program, Provider has failed to establish that the treatment was adequately documented in a manner consistent with the Commission’s rules. The Provider asserted at the hearing that the documentation was sufficient, but never established precisely how the documentation was adequate. While there is a volume of documentary evidence in the record (roughly 550 pages of documents), the ALJ cannot, from his mere review of the documents, determine how they all relate to the treatment in issue and how they establish compliance with the Commission’s requirements. While some documents are relatively self-explanatory, the bulk of the documents require an explanation by the medical professional preparing them to establish their relevance to the treatments in issue. Typed and handwritten notes from numerous office visits are in the record, but they generally give little hint as to why the treatments were being rendered, to what area of the body they were administered, the frequency with which they were given, or why they would help____’s condition. Moreover, many of the documents are illegible and the ALJ cannot determine what is recorded on them.

However, the ALJ does find that the services provided pursuant to the work hardening program were properly documented. For the work hardening program, Respondent denied reimbursement for most dates of service on the basis that the treatment was unnecessary.[8] However, Respondent denied reimbursement for dates of service of April 13, 19, and 20, 2000, on the basis that they were not adequately documented. Provider’s Exhibit 2 contained roughly 200 pages of documents, all related to the work hardening treatment provided to Claimant. From reviewing those documents, the ALJ found the relevant treatment notes for those dates and concludes that Provider adequately documented the treatment provided to Claimant on April 13, 19, and 20, 2000.

Accordingly, in light of the evidence and Respondent’s apparent waiver of the medical necessity ground for denial, the ALJ finds that Provider is entitled to reimbursement for all treatment in issue which was denied solely on the basis that it was not medically necessary.[9] Moreover, the ALJ finds that Provider is entitled to reimbursement for all of the work hardening treatment provided. Finally, the ALJ concludes that Provider is not entitled to reimbursement for any other services, all of which were denied for lack of documentation. The ALJ concludes that the Provider has failed to show by a preponderance of the evidence that such services were adequately documented consistent with the Commission’s rules.

Therefore, upon reviewing the maximum allowable reimbursements for the billed services for which Provider is entitled to be reimbursed, the ALJ finds it appropriate to order Respondent to reimburse Provider the sum of $5,313.60.

III. Findings of Fact

  1. Claimant____, a police officer for ___________ (a self-insured employer), was injured in an automobile accident on_________.
  2. Claimant was diagnosed with cervical and lumbar strain and attendant cervical and lumbar lesions.
  3. After his accident, Claimant continued working, but took medications for pain related to his injury and received therapy and related treatment.
  4. Approximately 11 months after the injury, Claimant’s pain continued to be so significant that he visited Provider for additional treatment.
  5. Provider began performing physical therapy modalities on Claimant and ordered x-rays and an MRI of Claimant’s neck and back. The x-rays and MRI revealed significant abnormalities and degenerative conditions.
  6. Provider continued to treat Claimant with extensive conservative care, including physical therapy. Although he continued working, Claimant was placed on restricted duty because of limitations related to his injury.
  7. Provider determined that work hardening would be appropriate for Claimant and work hardening was provided to him from March 13, 2000, through April 19, 2000.
  8. The medical treatment rendered to Claimant by Provider was medically necessary.
  9. Except for the work hardening program, Provider failed to document the treatment provided to Claimant in a manner consistent with the Commission’s guidelines.
  10. Provider sought reimbursement in the amount of $10,257.60 for the treatment he provided to ____ between July 9, 1999, and May 31, 2000.
  11. ____________ (Respondent) denied reimbursement.
  12. Provider appealed Respondent’s denial of reimbursement to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission).
  13. MRD found that the Provider was entitled to reimbursement in the amount of $500 for only the date of service of December 23, 1999. MRD declined to order reimbursement for any other services.
  14. MRD mailed a copy of the decision on May 2, 2002.
  15. On May 13, 2002, Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  16. Notice of the hearing was sent on June 11, 2002.
  17. The hearing was continued from its original setting and the parties received notice of the eventual hearing date.
  18. The hearing was conducted by SOAH, before Administrative Law Judge Craig R. Bennett, on April 22, 2003. Dr. Suhail Al-Sahli appeared on behalf of the Provider. Attorney Kevin Heyburn appeared on behalf of Respondent. The Commission did not appear. The hearing adjourned and the record closed on May 30, 2003, after the submission of written closing arguments and reply briefs.
  19. At the hearing, Provider withdrew its request for reimbursement for services billed under CPT Code 97110 for the following dates of service: 7/26, 7/28, 8/2, 8/4, 8/16, 8/20, 8/21, 8/27, 8/30, 9/1, and 9/20/99.
  20. In its final written briefing, Respondent conceded that it was not disputing the medical necessity of any treatment in issue, but rather was only disputing the adequacy of documentation for the services provided.

IV. Conclusions of Law

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issues presented pursuant to the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. §413.031.
  2. 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 of the Act and Tex. Gov’t Code Ann. ch. 2003.
  3. Provider timely filed its request for a hearing, as specified in 28 Tex. Admin. Code §148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code §2001.052 and 28 Tex. Admin. Code §148.4.
  5. Provider has the burden of proof in this matter by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. §413.031 and 28 Tex. Admin. Code §148.21(h).
  6. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
  7. Provider established, by a preponderance of the evidence, that the treatment rendered to Claimant between July 9, 1999, and May 31, 2000 was reasonably medically necessary treatment for Claimant.
  8. Except as to work hardening, Provider failed to establish by a preponderance of the evidence that it appropriately documented the treatment provided to Claimant between July 9, 1999, and May 31, 2000.
  9. Provider’s request for reimbursement should be granted for services billed under codes 97110 and 99213 on dates of service of 11/29, 12/1, 12/3, and 12/13/99; and services billed under code 99213 on dates of service of 3/10, 5/1, 5/3, 5/5, 5/19, 5/22, and 5/31/00. Carrier denied reimbursement for those services only on the basis of lack of medical necessity, which has been shown to be an unsustainable basis for denial.
  10. Provider’s request for reimbursement for work hardening treatment provided to Claimant between March 10, 2000, and April 19, 2000 should be granted.
  11. Except as set forth above, Provider’s request for reimbursement for all other services and dates of service in issue should be denied as Claimant did not adequately document the services and Carrier denied reimbursement for them on that basis.

ORDER

IT IS, THEREFORE, ORDERED that the request for reimbursement by CLC Chiropractic Center (Provider) is granted in part and ________________ is ordered to reimburse Provider the sum of $5,313.60.

Signed this 9th day of June 2003.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Accordingly, Provider no longer seeks reimbursement for services billed under CPT Code 97110 for the following dates of service: 7/26, 7/28, 8/2, 8/4, 8/16, 8/20, 8/21, 8/27, 8/30, 9/1, and 9/20/99.
  2. Respondent’s Closing Statement, at 4 (emphasis added).
  3. Respondent’s Response to Petitioner’s Closing Statement, at 2 (emphasis added).
  4. Ex. 1 at 70-73.
  5. Medicine Ground Rules, Physical Medicine I.A (in effect at all times relevant to this dispute).
  6. Spine Treatment Guideline (e)(2)(A).
  7. Id.
  8. On the EOBs, Respondent used the code “U” for “Unnecessary Medical Treatment or Service” but also explained that there was no documentation of relatedness to the compensable injury and insufficient documentation to support the work hardening program. See, e.g., Ex. 1 at 234. The ALJ construes this as purely a denial for lack of medical necessity, as Respondent essentially was stating that there was no documentation to show that the treatment was medically necessary, not that the treatment itself was not adequately documented consistent with the Commission’s rules.
  9. This encompasses services billed under codes 97110 and 99213 on dates of service of 11/29, 12/1, 12/3, and 12/13/99; and services billed under code 99213 on dates of service of 3/10, 5/1, 5/3, 5/5, 5/19, 5/22, and 5/31/00.
End of Document
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