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At a Glance:
Title:
453-02-4032-m5
Date:
October 31, 2002
Status:
Retrospective Medical Necessity

453-02-4032-m5

October 31, 2002

DECISION AND ORDER

American Casualty Company of Reading, PA (Carrier) appealed the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) ordering reimbursement for work hardening and other services provided to___., an injured worker (Claimant). After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that Carrier has failed to meet its burden of proof. More specifically, Carrier has failed to show by a preponderance of the evidence that the services in issue were not medically necessary. Therefore, Rehab 2112 (Provider) is entitled to the reimbursement ordered in the MRD decision.

I. Background Facts

Claimant worked as a packer for_________., and was injured on___________, when he tripped over a jack and fell. He was diagnosed with lumbar strain. He went to Concentra for physical therapy and concluded his therapy by May 4, 2001. An MRI was performed on Claimant on May 18, 2001, and an x-ray was taken on May 22, 2001. Claimant’s treating physician, Dr. Chad Blackmon, referred Claimant to Provider for additional physical therapy and/or work hardening. Provider performed a functional capacity evaluation (FCE) on June 15, 2001 on Claimant to determine the effects of his injury, and Provider began providing work hardening treatment to Claimant on June 18, 2001. Claimant completed the work hardening program on August 2, 2001. Thereafter, Claimant was determined to be at maximum medical improvement with a 7% whole person impairment rating as of August 21, 2001.

Provider billed Carrier for the work hardening program and the related treatment. Carrier denied reimbursement, contending that the treatment was not medically necessary. When Carrier maintained its denial of reimbursement, Provider sought medical dispute resolution through the Commission’s MRD. MRD issued its findings and decision on July 18, 2002, ordering Carrier to reimburse Provider the sum of $10,371. Carrier then requested a hearing before the State Office of Administrative Hearings (SOAH). The hearing was conducted on October 24, 2002, before ALJ Craig R. Bennett at the SOAH Hearings Facility, 300 West 15th Street, Austin, Texas. Carrier appeared and was represented by its attorney, Jessica M. Warren. Provider appeared and was represented by its attorney, H. Douglas Pruett. After the introduction of evidence and arguments, the hearing concluded and the record closed the same day.

II. Discussion

Carrier contends that by May 4, 2001, Claimant’s condition had improved so significantly that he did not need any further treatment. Therefore, Carrier asserts that all treatment provided by Provider between June 11, 2001, and August 2, 2001, is not medically necessary.[1] Carrier relies on the report of Kellie Timberlake-Lancaster, D.C., dated July 19, 2001.[2] Dr. Timberlake-Lancaster’s report contains the medical opinion that the documents reviewed do not support any additional treatment for Claimant. More specifically, Dr. Timberlake-Lancaster notes that Claimant had merely suffered a soft tissue injury with no abnormalities and appeared to be pain-free on May 4, 2001.[3] According to Dr. Timberlake-Lancaster, approximately 85% of patients with similar injuries have their problems resolved within six weeks of the injury-often without any treatment. Dr. Timberlake-Lancaster points out that Claimant’s MRI of May 18, 2001, appeared normal, thus providing no objective documentation of a condition worse than a simple sprain/strain soft tissue injury.[4] Therefore, Dr. Timberlake-Lancaster opines that there is no need for ongoing care of Claimant after May 4, 2001. Carrier also argues that Claimant did not complete the full four weeks of physical therapy prior to beginning work hardening, and that work hardening should not have been deemed necessary absent Claimant’s completion of physical therapy.

Provider responds by arguing that Carrier failed to comply with the applicable Commission rules and therefore is barred from asserting that the treatment was not medically necessary. In particular, Commission Rule § 133.304(c) requires an insurance carrier, in the explanation of benefits (EOB), to “provide sufficient explanation to allow the sender to understand the reasons(s) for the insurance carrier’s actions.”[5] Provider argues that Carrier’s EOB merely cites the payment exception codes without additional explanation, and also does not cite all of the dates of service. Rather, as evidenced from the record, Carrier’s EOB that denied payment for lack of medical necessity merely cites the following dates: 6/11/01; 6/18/01; 6/25/01; 7/02/01; 7/09/01; and 7/17/01. On the EOB, the monetary amount listed for each of those dates is actually the sum of all amounts for that particular week, but only the first day of the week is listed as the date of service in dispute.

Provider also argues that Dr. Timberlake-Lancaster’s report does not establish a lack of medical necessity for work hardening. Provider points out that Dr. Timberlake-Lancaster’s report is merely a conclusory finding that Claimant needs no additional medical treatment, but contains no mention of work hardening and does not attempt to specifically address the medical necessity of work hardening.

After considering the record in its entirety, the ALJ concludes that Carrier’s evidence fails to establish that work hardening and the other services provided to Claimant by Provider were not medically necessary.[6] Dr. Timberlake-Lancaster’s report is based solely on a review of documents and not upon an examination of Claimant. Moreover, Dr. Timberlake-Lancaster summarily concluded that Claimant was completely healed and needed no further treatment based primarily on Claimant’s report of being pain free on May 4, 2001. Dr. Timberlake-Lancaster apparently gives no credence to Claimant’s later statements of experiencing some pain and limitations, as evidenced by the FCE report of June 15, 2001, and later documents. From reviewing Dr. Timberlake-Lancaster’s report, the ALJ is uncertain that all relevant, necessary medical documents were reviewed. More importantly, however, the ALJ notes that Dr. Timberlake-Lancaster’s report does not specifically address work hardening, a program that serves a specialized purpose beyond just healing the immediate effects of an injury. The Medicine Ground Rules, at II. E., define and describe Work Hardening as follows:

Work Hardening: A highly structured, goal-oriented, individualized program designed to maximize the ability of the persons served to return to work. Work hardening programs are interdisciplinary in nature with a capability of addressing the functional, physical, behavioral, and vocational needs of the injured worker. Work Hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. Work Hardening programs use real or simulated work activities in a relevant work environment in conjunction with physical conditioning tasks. These activities are used to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of the persons served.

The goal of work hardening is to return the employee to work. Dr. Timberlake-Lancaster’s report does not mention Claimant’s ability to work or lack of need for specific training to allow Claimant to return to work. Similarly, Dr. Timberlake-Lancaster’s report does not specifically address the other services provided immediately prior to work hardening. Those include some limited physical therapy and the FCE.

Because Carrier has the burden of proof in this case, it is Carrier’s responsibility to show by a preponderance of the evidence that the treatment in issue was not medically necessary. Ultimately, the ALJ simply finds Dr. Timberlake-Lancaster’s report to be conclusory and unpersuasive, and not directed toward the crucial issues in this hearing. For these reasons, the ALJ concludes that Carrier has not met its burden of proof.

III. Findings of Fact

  1. In__________. (Claimant) worked as a packer for ________At that time, American Casualty Company of Reading, PA (Carrier) provided workers’ compensation insurance coverage to Claimant.
  2. On_________, Claimant was injured when he tripped over a jack and fell.
  3. Claimant was diagnosed with lumbar strain. He was sent to Concentra for physical therapy and concluded his therapy by May 4, 2001.
  4. Claimant’s treating physician, Dr. Chad Blackmon, referred Claimant to Provider for additional physical therapy and/or work hardening.
  5. Provider performed a functional capacity evaluation (FCE) on Claimant on June 15, 2001.
  6. As a result of his injury, Claimant had pain and limited functioning as of June 15, 2001.
  7. Provider began providing work hardening to Claimant on June 18, 2001. Claimant completed work hardening on August 2, 2001. Thereafter, Claimant reached maximum medical improvement and had a 7% whole person impairment rating as of August 21, 2001.
  8. Provider billed Carrier for the work hardening program and the related treatments. Carrier denied reimbursement, contending that the treatment was not medically necessary.
  9. Provider sought medical dispute resolution through the Commission’s MRD, which issued its decision on July 18, 2002, ordering Carrier to reimburse Provider the sum of $10,371.
  10. On July 31, 2002, Carrier appealed the MRD decision and requested a hearing before the State Office of Administrative Hearings (SOAH).
  11. Notice of the hearing was sent by the Commission to all parties on August 22, 2002.
  12. A hearing before SOAH was conducted on October 24, 2002, before ALJ Craig R. Bennett at the SOAH Hearings Facility, 300 West 15th Street, Austin, Texas. Carrier appeared and was represented by its attorney, Jessica M. Warren. Provider appeared and was represented by its attorney, H. Douglas Pruett. After the introduction of evidence and arguments, the hearing concluded and the record closed the same day.

IV. Conclusions of Law

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. § 413.031.
  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 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 and 28 Tex. Admin. Code ch. 148.
  4. Carrier timely requested a hearing pursuant to 28 Tex. Admin. Code §148.3.
  5. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§2001.051 and 2001.052, and 28 Tex. Admin. Code § 148.4.
  6. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
  7. Carrier has failed to show by a preponderance of the evidence that work hardening, and the other medical services provided by Provider, were not reasonable and necessary medical care for Claimant under Tex. Lab. Code Ann. § 408.021(a)(1-3) and §401.011(19).
  8. Carrier is liable to reimburse Provider for work hardening and other medical services provided to Claimant, consistent with the order of the Medical Review Division of the Commission dated July 18, 2002.

ORDER

IT IS ORDERED that American Casualty Company of Reading, PA., reimburse Rehab 2112 for work hardening and other medical services provided to ___between June 11 and August 2, 2001, consistent with the order of the Commission’s Medical Review Division of July 18, 2002.

Signed this 31st day of October, 2002.

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

  1. Carrier challenged all of the services provided, but admitted at the hearing that it was focusing its evidence and arguments toward the work hardening program, and that the other services were not “in hot contention.”
  2. In addition to relying on Dr. Timberlake-Lancaster report, Carrier notes that MRD determined that work hardening was not medically necessary for dates of service between July 23, 2001 and August 2, 2001.
  3. Ex. 1, at 118.
  4. Id.
  5. 28 Tex. Admin. Code § 133.304(c).
  6. Given the ALJ’s conclusion that Carrier did not show that the treatment in issue was not medically necessary, the ALJ declines to specifically decide whether Carrier’s EOB was consistent with the Commission’s rules and sufficient to allow Carrier to raise the issue of medical necessity. Rather, giving Carrier the benefit of the doubt, the ALJ assumes that Carrier could raise the issue. But, ultimately, the ALJ finds that Carrier has failed to carry its burden of proof on such.
End of Document
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