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At a Glance:
Title:
453-02-3637-m5
Date:
March 25, 2003
Status:
Retrospective Medical Necessity

453-02-3637-m5

March 25, 2003

DECISION AND ORDER

I. INTRODUCTION

Continental Casualty Company (Carrier) has appealed a decision of the Texas Workers' Compensation Commission's (TWCC) Medical Review Division (MRD). The MRD order the Carrier to reimburse First Rio Valley Medical (Provider) $71.00 for an office visit, under billing code CPT 99214. The only contested issue is whether that service was medically necessary.

As set out below, the Administrative Law Judge (ALJ) does not find the disputed services were medically necessary. Therefore, Provider is not entitled to reimbursement.

On October 2, 2002, Bill Zukauckas, an Administrative Law Judge (ALJ) with SOAH held a hearing on the Carrier’s appeal at the William B. Clements Bld., 300 W. 15th Street, 4th Floor, Austin, Texas. The Carrier appeared at the hearing. The Provider did not appear at the hearing. The hearing concluded that same day, but the record remained open until March 10, 2003, because of Provider’s health issues and bankruptcy issues.

II. FINDINGS OF FACT

  1. Claimant sustained a compensable work-related neck and right shoulder injury in ____of ____ and another work-related injury to his low back and knee in a slip-and-fall accident on_______. His employer at the time was______, and Carrier was that company’s workers’ compensation insurance carrier.
  2. Provider saw Claimant at an office visit on September 7, 2001, for evaluation and management of patient pain under CPT Code 99214 and billed Carrier $71.00.
  3. Carrier denied the Provider’s request for reimbursement for the disputed services, asserting that they were not medically necessary.
  4. On November 15, 2001, the Provider filed a request for medical dispute resolution with the MRD regarding the disputed services.
  5. On December 7, 2001, the Carrier timely responded to the Provider’s request for medical dispute resolution.
  6. On June 13, 2002, MRD granted the Provider’s request for reimbursement of $71.00 for the disputed services.
  7. On June 25, 2002, Carrier appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
  8. On July 19, 2002, notice of an October 2, 2002, SOAH hearing on the appeal was mailed to the Carrier, the Provider, and the TWCC Staff.
  9. On October 2, 2002, Bill Zukauckas, an Administrative Law Judge (ALJ) with SOAH held a hearing on the Carrier’s appeal at the William B. Clements Bld., 300 W. 15th Street, 4th Floor, Austin, Texas. The Carrier appeared at the hearing. The Provider did not appear at the hearing.
  10. The record closed on March 10, 2003.
  11. Based on a review of the record, the ALJ finds insufficient evidence showing that the disputed service was medically necessary to treat the earlier compensable injuries.

III. CONCLUSIONS of Law

  1. TWCC has jurisdiction to decide the issues presented in this case, pursuant to TEX. LABOR CODE ANN. §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to TEX. LABOR 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. §§2001.051 and 2001.052.
  4. As the party appealing the MRD decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §148.21(h).
  5. Under Tex. Labor Code § 408.021 (a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed.
  6. Based on the Findings of Fact, medical services were not shown to be medically necessary.
  7. Based on the above Findings of Fact and Conclusions of Law, the Carrier’s appeal should be granted and it should not be required to reimburse the Provider $71.00 for the disputed September 7, 2001, office visit billed under CPT Code 99214.

ORDER

IT IS ORDERED THAT the Provider is not entitled to reimbursement for the September 7, 2001, office visit.

Signed March 25, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

BILL ZUKAUCKAS
Administrative Law Judge

End of Document
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