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At a Glance:
Title:
453-02-3621-m5
Date:
January 8, 2003
Status:
Retrospective Medical Necessity

453-02-3621-m5

January 8, 2003

DECISION AND ORDER

This case is a dispute over whether______________ in San Antonio, Texas, should reimburse Rehab 2112 (Provider) for work hardening services provided to____ (Claimant) from June 14, 2001, through July 18, 2001.The amount in controversy is $8,768.00 plus interest.

Provider contends reimbursement is warranted because the criteria for Claimant’s entrance into the work hardening program were met, and work hardening was medically necessary. _____argues reimbursement should not be ordered because the work hardening entrance criteria were not met, and the work hardening was not medically necessary.

The Administrative Law Judge (ALJ) concludes Provider did not meet its burden of proving entrance into the work hardening program met the requirements of the Spine Treatment Guideline (STG) of the Texas Workers’ Compensation Commission (Commission). Therefore, reimbursement of $8,768.00 plus interest is denied.

I. BACKGROUND, APPLICABLE LAW,AND ANALYSIS

On______, while working as a custodian for_____, Claimant slipped and fell on her tailbone, which resulted in sacrococcygeal[1] sprain/strain. Because Claimant’s compensable injury was to her back, the STG, found at 28 Tex. Admin. Code (TAC) §134.1001, applies to her treatment.

On June 14, 2001, a little less than six weeks after her compensable injury occurred, Claimant began a work hardening program administered by Provider. Under the STG, the initial phase of care following an injury lasts up to eight weeks, so Claimant was in the initial phase of care when she began work hardening. 28 TAC § 134.1001(g)(7)(A). Under the STG, work hardening is not indicated until the intermediate phase of care. 28 TAC § 134.1001(g)(7)(B). However, deviation from the STG is permitted if necessary for a patient’s treatment. The STG states that “[D]ocumented failure to respond at any time to treatment may require additional. . . treatment consistent with a greater level of severity.” 28 TAC § 134.1001(g)(7)(A). The STG states in relevant part that “Documentation shall be provided by the health care provider to determine the phase of care to be provided and the necessity for that care. The elements of that documentation may include: . . . (vi) objective documentation substantiating the need for deviation from the guideline, if necessary.” 28 TAC § 134.1001(e)(3)(B)(vi).

Based on the above law, the ALJ concludes Provider should not be reimbursed for the work hardening provided to Claimant. Provider did not substantiate the need for providing work hardening to Claimant during the initial phase of care by providing documented failure of Claimant to respond to initial treatment or by establishing work hardening was medically necessary for Claimant. The medical records set out in Finding of Fact No. 2 below indicate Claimant was “progressing” under chiropractic treatment. There is not a preponderance of evidence in the medical records to indicate it was medically necessary for Claimant to enter a work hardening program less than six weeks after her compensable injury occurred, without first giving the chiropractic treatment up to eight weeks after her injury to be effective. Provider failed to provide adequate opinion evidence that the matters described under Findings of Fact No. 2, below, indicated a need for work hardening before the intermediate level of treatment.

II. FINDINGS OF FACT

  1. ___. (Claimant) suffered a compensable injury on______, when she slipped and fell while working as a custodian for_________________, which is self-insured. As a result of the fall, Claimant suffered sacrococcygeal sprain/strain, and bruised her ankles. (Petitioner’s Exhibit 1 at 29, 37 and 52).
  2. Claimant’s treatment for her compensable injury included the following:

a. On May 5, 2001, Claimant was treated at Texas MedClinic where X-rays of the coccyx[2] were reported as negative. Claimant was returned to work with restrictions. (Petitioner’s Exhibit 1 at 161).

b. On a return visit to Texas MedClinic on May 11, 2001, the exam results remained unchanged and Claimant again was returned to work with restrictions. (Petitioner’s Exhibit 1 at 161).

c. On May 17, 2001, Tom Larison, D.C., diagnosed Claimant to have sacroiliac[3] sprain/strain, sacroiliitis[4], and traumatic injury of the lumbar spine with tearing of the regional connective tissues. (Petitioner’s Exhibit 1 at 153 and 190).

  1. d.Claimant was treated at Accident & Injury Chiropractic (the clinic) from May 17, 2001, through June 26, 2001. (Petitioner’s Exhibit 1 at 190). She received extensive chiropractic management to include physical medicine modalities from May 18, 2001, through June 12, 2001. Clinical notes submitted by the clinic document no significant findings or functional limitations as evidenced by the results of Claimant’s May 30, 2001 office visit, in which her “L-spine was non-tender, range of motion WNL, and bilateral straight leg raises negative”; the results of her June 5, 2001 visit, in which she was “progressing”; and the results of her June 6, 2001 musculoskeletal exam which demonstrated motor strength 5/5, sensory WNL, negative orthopedic findings, thoraco-lumbar range of motion- flexion 70/90, extension 20/30, left and right rotation 30/30 and right and left lateral flexion 25/25, with the only functional limitation recorded as “Pt has trouble w/1st steps after waking up.” (Petitioner’s Exhibit 1 at 162).
  2. e.On May 23, 2001, Douglas M. Wood, D.O., Ph.D., diagnosed Claimant to have lumbar strain and lumbar range of motion decreased by 40% with moderate pain. He recommended a continuation of conservative therapy modalities and treatment, with medication for severe pain and muscle spasm. He also recommended an MRI[5] of the lumbar spine. (Petitioner’s Exhibit 1 at 117-118 and 190).3
  3. d.An MRI of Claimant’s sacrum and coccyx performed on May 24, 2001, by Eric Bennos, M.D., at Bexar County MRI revealed diffuse abnormal bone marrow signal within the S-5 segment at its articulation with the cornua of the proximal coccyx indicating an area of bone marrow stress edema and reparative change; no evidence of acute subluxation or dislocation of the sacrococcygeal junction; and normal lumbosacral alignment. (Petitioner’s Exhibit 1 at 122-123 and 190).
  4. e.On June 4, 2001, Tamara Uptigrove, D.C., read Claimant’s x-rays and found “no gross pathology”. (Petitioner’s Exhibit 1 at 39 and 190).
  5. d.On June 5, 2001, an examination by Dr. Larison indicated Claimant was experiencing low back/sacral pain at a level of 7 on a scale of 1-10, that the pain was strictly local to the sacral/coccyx area, with joint restriction and capsular swelling in the coccyx. He recommended electrical muscle stimulation to decrease muscle spasm, promote tissue healing, and for its analgesic effect; cryotherapy in acute phase of treatment to reduce tissue edema and promote analgesia; an MRI; X-rays; and that Claimant remain off work for a month. (Petitioner’s Exhibit 1 at 169-171).
  6. d.On June 13, 2001, Provider performed an initial functional capacity evaluation (FCE) on Claimant. (Petitioner’s Ex. 1 at 51-62 and 190). The FCE showed Claimant to be at a sedentary Physical Demand Capacity (PDC) level while her job requires a medium PDC level. She showed deficits in the critical physical demands of her job, including bending, stooping, and crouching. Her job requires her to stand six-to-eight hours, and she could only stand one-to-two hours. Her job requires her to walk six-to-eight hours, and she could only walk one-to-two hours. (Petitioner’s Exhibit 1 at 51-62).
  7. d.On June 13, 2001, Dr. Larison referred Claimant to Provider for work hardening five times per week for six-to-eight weeks. (Petitioner’s Exhibit 1 at 125).
  8. d.Claimant participated in work hardening from June 14, 2001, through July 18, 2001.
  9. d.On July 26, 2001, Eradio Arredondo, M.D., an orthopedic surgeon, evaluated Claimant. She told him she was practically over her tailbone injury. He assigned her a 0% impairment rating.He stated she should have recovered from her compensable injury within two weeks of its occurrence.(Petititoner’s Exhibit 1 at 49, 142, 182-186 and190).

m. On September 13, 2001, Chad Blackwell, D.C., determined Claimant had reached Maximum Medical Improvement with a whole body impairment rating of 2%, based on her lumbosacral ranges of motion. (Petitioner’s Exhibit 1 at 189-193).

  1. Claimant entered Provider’s work hardening program less than six weeks after her compensable injury occurred, during the initial phase of care as described in the Spine Treatment Guideline (STG) of the Texas Workers’ Compensation Commission (Commission).
  2. _____ denied payment for the FCE conducted by Provider on June 13, 2001, and for Claimant’s work hardening administered by Provider from June 14, 2001, through July 18, 2001.
  3. On November 14, 2001, Provider filed a Request for Medical Dispute Resolution with the Commission, seeking $9,068.00 in reimbursement.
  4. On June 18, 2002, the Commission’s Medical Review Division (MRD) ordered ____to pay Provider $300.00 for the FCE conducted on Claimant on June 13, 2001, but denied reimbursement of $8,768.00 for work hardening provided to Claimant from June 14, 2001, through July 18, 2001.
  5. On June 26, 2002, Provider filed a timely request for hearing before the State Office of Administrative Hearings (SOAH), appealing the denial of reimbursement of $8,768.00 for work hardening provided to Claimant from June 14, 2001, through July 18, 2001.
  6. Notice of the hearing was sent July 23, 2002.
  7. 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.
  8. The hearing was held November 14, 2002, with Administrative Law Judge Sharon Cloninger presiding. H. Douglas Pruett, attorney, represented Provider. _____was represented by Mark Sickles, attorney. The Commission did not participate in the hearing. The record closed the same day.

III. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (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 (SOAH) 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. Petitioner, in this case Provider, has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) § 148.21(h).
  5. Pursuant to Finding of Fact No. 2, Provider did not prove the medical necessity for work hardening for Claimant in her initial phase of care, and did not provide adequate documentation supporting deviation from the Commission’s Spine Treatment Guideline (STG). 28 TAC § 134.1001(e)(3)(B)(vi).
  6. Pursuant to Finding of Fact No. 2, Provider did not prove that Claimant required work hardening, an interdisciplinary program capable of addressing her functional, physical, behavioral, and vocational needs, during her initial phase of care. 28 TAC § 134.1001(e)(3)(B)(vi) and (g)(7)(A).
  7. Pursuant to Conclusions of Law Nos. 5 and 6, Provider did not meet its burden of proving it is entitled to reimbursement from _____ for work hardening.
  8. Provider’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED thatRehab 2112 is not entitled to reimbursement of $8,768.00 plus interest from ________________ for work hardening provided to Claimant from June 14, 2001, through July 18, 2001.

Signed January 8 , 2003.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Sacrococcygeal is of, relating to, or affecting, or performed by way of the sacrum and coccyx. Merriam Webster's Medical Dictionary, Merriam-Webster Incorporated, Springfield Massachusetts, 1995, at 610.
  2. The coccyx is a small bone that articulates with the sacrum and that usually consists of four fused vertebrae which form the terminus of the spinal column. Id. at 126.
  3. Sacroiliac is of, relating to, affecting, or being the region of the joint between the sacrum and the ilium. Id. at 611.
  4. Sacroiliitis is inflammation of the sacroiliac joint or region. Id. at 611.
  5. Magnetic resonance imaging is a non-invasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves. Id. at 389.
End of Document
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