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At a Glance:
Title:
453-03-0086-m5
Date:
April 4, 2003
Status:
Retrospective Medical Necessity

453-03-0086-m5

April 4, 2003

DECISION AND ORDER

This case involves a dispute over $9,472 in work hardening services provided by Buena Vista Workskills (Provider) to injured worker ____ (Claimant). The Administrative Law Judge (ALJ) concludes that Provider has shown that the work hardening program was medically necessary treatment for the Claimant, but finds that not all services were properly documented. Therefore, the ALJ orders reimbursement in part.

I. Background Facts

Claimant injured his feet and ankles on__________, during the course of his job as a drywall installer for_________. Specifically, Claimant suffered contusions to both feet and a possible fracture in his right foot when a large piece of sheet rock fell off a dolly and struck his feet and ankles. Claimant initially received treatment for his injury at the Texas Medical Center in San Antonio. Three days after his injury, Claimant was able to return to work. However, approximately a month after his injury, Claimant continued to have pain and saw Thimios Partales, D.C., on October 26, 2000. At that time, Dr. Partales had x-rays and an MRI taken of Claimant’s right foot and concluded that the MRI showed evidence of either a fracture or aseptic necrosis in Claimant’s right foot. Between November 10, 2000, and December 18, 2000, Claimant underwent a conservative physical therapy program. At the conclusion of the program, Dr. Partales referred Claimant to Provider for a functional capacity evaluation (FCE). As a result of the FCE and psychological screening, Claimant was recommended for work hardening because it was determined that Claimant was not able to return to work at that time.

Because Provider is a CARF-accredited facility, preauthorization was not required for the work hardening program. Claimant began the work hardening program on January 9, 2001, and continued in it through February 15, 2001. Provider then billed Carrier for the work hardening program. Carrier denied reimbursement for the entirety of the program, asserting that work hardening was not medically necessary treatment for Claimant. Moreover, Carrier also denied reimbursement for dates of service of January 9-12 and February 6, 7, and 9, 2001 for lack of documentation. After conducting medical dispute resolution, MRD declined to order reimbursement for work hardening. Provider then appealed, requesting a hearing before the State Office of Administrative Hearings.

II. Discussion

There are two questions to be resolved in this case: (1) was work hardening reasonably necessary treatment for Claimant? If so, (2) was work hardening properly documented as being provided to Claimant? After considering the evidence, the ALJ concludes that work hardening was reasonably necessary treatment for Claimant. But, the ALJ also concludes that Provider has not properly documented an interdisciplinary work hardening program as being provided. Both of these conclusions are discussed in more detail below.

The Commission’s Medicine Ground Rules, in effect at all times relevant to this dispute, set out the purpose of and criteria for work hardening. “Work hardening” is:

a highly structured, goal-oriented, individualized treatment 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.

  1. Entrance/admission criteria shall enable the program to admit:
    1. persons who are likely to benefit from the program;
    2. persons whose current levels of functioning due to illness or injury interfere with their ability to carry out specific tasks required in the workplace;
    3. persons whose medical, psychological, or other conditions do not prohibit participation in the program; and
    4. persons who are capable of attaining specific employment upon completion of the program.[1]

In this case, the Claimant underwent an FCE and psychological screening, both of which indicated he was a candidate for work hardening. Provider also presented Dr. Michael Smith as an expert witness. Dr. Smith testified at length at the hearing regarding the various reasons why Claimant was an appropriate candidate for work hardening. Of particular note, the evidence shows that, at the time, Claimant was limited in his physical functioning to duties consistent with a light/medium physical demand level (PDL), but his job as a drywall installer involved duties consistent with a heavy PDL. Further, Claimant suffered psychologically in that he perceived his injury as being more limiting than it was, and he attributed various social and marital problems to his injury and inability to work. Claimant’s answers to questioning show that because of his pain levels, physical limitations, and his psychosocial concerns, he was limited in his ability to return to work. Based on these and other factors, Dr. Smith concluded that Claimant was an appropriate candidate for work hardening. The ALJ found Dr. Smith to be a credible and reliable witness and is persuaded by his interpretation of the medical documentation.[2]

Carrier cites several reasons why Claimant was not an appropriate candidate for work hardening and why work hardening was not properly reflected by the documentation. Carrier argues that the evidence is inconclusive as to whether Claimant really suffered anything more than mild bruising in his feet and ankles, and asserts that such a mild injury would not have required work hardening. Carrier points out that Claimant worked for approximately one month after his injury before seeking additional treatment and was taken off work. Carrier also notes that Claimant’s condition improved only slightly through the conservative physical therapy that he underwent for approximately two months prior to work hardening. Carrier argues that the limited benefit from the prior treatment shows that additional treatment would be of limited benefit. Carrier also argues that Provider failed to show why other, more conservative care (such as an exercise program, additional physical therapy, or work conditioning) should not have been attempted first before attempting more intensive treatment like work hardening. Finally, Carrier argues that the documentation in the record shows that nothing more than work conditioning was really provided, pointing out that many of the treatment notes reflect only single-disciplinary, conditioning services.

The ALJ disagrees with most of Carrier’s arguments, finding that Dr. Smith’s testimony adequately addressed and refuted those arguments. In fact, some of Carrier’s arguments are inherently inconsistent. For example, Carrier argues that the limited benefit obtained from the initial conservative treatment supported a conclusion that additional, more intensive treatment would not be beneficial; but, Carrier goes on to argue that Provider should have shown why more conservative care was not provided for longer periods of time or other conservative treatments were not attempted first. Provider responds by pointing out that the limited benefit from the conservative care was one of the very reasons why more intensive care was needed and why additional conservative care would have been wasteful. Provider also points out that the work hardening program was effective in that Claimant, at the conclusion of the program, met most of his goals and was able to return to work.

The ALJ does agree with Carrier on one point, though. The documentation in the record is inadequate to show that interdisciplinary work hardening services were provided on all of the dates in question. While there are extensive daily and weekly treatment notes reflecting the many physical tasks performed by Claimant, the treatment notes usually have only one small paragraph devoted to behavioral or psychosocial treatments; and, those paragraphs are mostly illegible so it is difficult for the ALJ to determine what was actually provided in regard to behavioral services. Moreover, while the record does contain a couple of behavioral/psychological assessments, those documents do not adequately document the services provided to Claimant to address his behavioral/psychological issues.[3] So, the ALJ is unable to conclude from the bulk of the documentation that Provider properly provided an interdisciplinary program as required in work hardening.

Ultimately, as discussed above, the ALJ concludes that the evidence sufficiently establishes that the work hardening program was medically necessary treatment for Claimant; however, the evidence does not show that the work hardening treatment was properly documented or properly provided in regard to the behavioral/psychosocial component of the program. Therefore, Carrier’s denial of reimbursement for lack of documentation is upheld. Carrier denied only certain dates of service for lack of documentation. In particular, the dates of service denied for lack of documentation are January 9-12, and February 6, 7, and 9. The total reimbursement sought for these dates of service is $3,072, and this amount is disallowed in accordance with this decision. All other dates of service were denied only for lack of medical necessity. Having concluded that the Provider has shown that the treatment in issue was medically necessary, the ALJ finds that Provider is entitled to reimbursement in the amount of $6,400 for the remaining dates of service. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

III. Findings of Fact

  1. _____ (Claimant) suffered contusions to both feet and a possible fracture in his right foot on_____________, during the course of his job as a drywall installer for_______, when a large piece of sheet rock fell off a dolly and struck him.
  2. At the time of Claimant’s injury, Transportation Insurance Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
  3. Claimant initially received treatment for his injury at Texas Medical Center in San Antonio.
  4. Beginning three days after his injury, Claimant returned to work for one month.
  5. On October 26, 2000, Claimant saw Thimios Partales, D.C., for treatment for continued pain in his feet and ankles; on that date, Dr. Partales had x-rays and an MRI taken of Claimant’s right foot and concluded that the MRI showed evidence of either a fracture or aseptic necrosis in Claimant’s right foot.
  6. Between November 10, 2000 and December 18, 2000, Claimant underwent a conservative physical therapy program. At the conclusion of the program, Dr. Partales referred Claimant to Buena Vista Workskills (Provider) for a functional capacity evaluation (FCE).
  7. The FCE and psychological screening showed that Claimant was an appropriate candidate for work hardening, in that:

a.At the time, Claimant was limited in his physical functioning to duties consistent with a light/medium physical demand level (PDL), but his job as a drywall installer involved duties consistent with a heavy PDL;

b. Claimant was unable to return to work because of pain, limited functioning and behavioral/psychosocial limitations;

c.Claimant’s medical, psychological, or other conditions did not prohibit participation in the program;

d.Claimant was capable of attaining specific employment upon completion of the program; and

e. Claimant was likely to benefit from the program.

  1. Claimant underwent work hardening with Provider from January 9, 2001, until February 15, 2001.
  2. Provider failed to document the details of the behavioral component of the work hardening program with enough specificity to show that the program was interdisciplinary in nature and provided in a manner consistent with the Commission’s guidelines.
  3. Provider billed Carrier for the work hardening program.
  4. Carrier denied Provider’s request for reimbursement for the work hardening program.
  5. Provider filed a request for medical dispute resolution.
  6. On July 10, 2002, after conducting medical dispute resolution, MRD declined to order Carrier to reimburse Provider for the work hardening treatment.
  7. MRD mailed a copy of the decision on July 11, 2002.
  8. On July 22, 2002, Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  9. Notice of the hearing was sent on September 13, 2002.
  10. A hearing was conducted by SOAH, before Administrative Law Judge Craig R. Bennett, on March 13, 2003. Kevin Stouwie appeared on behalf of the Provider. Christine Karcher appeared on behalf of the Carrier. The Commission did not appear. The hearing adjourned and the record closed the same day.

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 work hardening program provided by it to Claimant between January 9, 2001 and February 15, 2001, was reasonably medically necessary treatment for Claimant.
  8. Provider failed to establish, by a preponderance of the evidence, that it properly documented the work hardening treatment provided to Claimant on dates of service of January 9-12, 2001, and February 6, 7, and 9, 2001.
  9. Provider’s request for reimbursement should be denied for dates of service of January 9-12, 2001, and February 6, 7, and 9, 2001. Provider’s request for reimbursement should be granted as to all other dates of service in issue.

ORDER

IT IS ORDERED that Transportation Insurance Company shall reimburse Buena Vista Workskills the amount of $6,400 for the work hardening treatments provided to Claimant between January 16 and February 5, 2001, and February 12-15, 2001.

Signed this 4th day of April 2003.

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

  1. TWCC 1996 Medical Fee Guideline, pp. 37-38.
  2. Dr. Smith not only appeared to be sincere and knowledgeable in his demeanor, but also has extensive practice experience and has served as a designated doctor under the Texas workers’ compensation system.
  3. See Ex. 1, at 160 and 196.
End of Document
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