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At a Glance:
Title:
453-03-0112-m5
Date:
June 9, 2003
Status:
Retrospective Medical Necessity

453-03-0112-m5

June 9, 2003

DECISION AND ORDER

This is a dispute over whether Mobile Diagnostics, Inc., the health care provider, should be reimbursed for a synaptic nerve block performed on a workers’ compensation claimant. The Administrative Law Judge (ALJ) concludes Mobile Diagnostics should not be reimbursed for that treatment.

I. Procedural History and Discussion

The Claimant, a baggage handler at_____________, was injured________. He sought treatment from Mobile Diagnostics, who diagnosed his injury as lumbosacral, cervical, and thoracic sprain/strain. Ex. 1 at 34. Because the Claimant continued to complain of headaches, right shoulder and neck pain, lumbar pain, and thoracic pain, Mobile Diagnostics performed the synaptic nerve block on April 20, 2001. The procedure reduced the Claimant’s perceived pain level from 2 out of 10 to zero.

Mobile Diagnostics sought reimbursement of $400.00 for the procedure from American Home Assurance Company (AHAC), the workers’ compensation carrier. AHAC denied reimbursement, and a request for reconsideration, on the grounds that the treatment was medically unnecessary. Mobile Diagnostics filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission. The Commission’s Medical Review Division (MRD) found in favor of Mobile Diagnostics. AHAC then requested a hearing before the State Office of Administrative Hearings (SOAH). The hearing was held May 9, 2003, at SOAH’s offices, with the undersigned ALJ presiding.

Because AHAC is the Petitioner, it has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).

The evidence in the case consisted of the 47-page record that was before the MRD, the testimony of Dr. Laning for Mobile Diagnostics, and the testimony of Dr. Hershkowitz for AHAC.

Dr. Hershkowitz questioned the benefits of the nerve block treatment in general. He stated that even if it were useful in some circumstances, it was not appropriate for a soft tissue injury. He argued the Claimant’s pain level was so low that it could have been treated with Aleve rather than with the synaptic nerve block.

Dr. Laning defended the synaptic nerve block procedure and pointed out that it had, in fact, relieved the Claimant’s pain. He observed Dr. Hershkowitz had never treated the Claimant and testified Dr. Hershkowitz invariably issued opinions that favored insurance carriers. The written documentation also contains a letter from Dr. Charles Marable explaining the synaptic nerve block procedure and affirming its efficacy in relieving pain.

Under Tex. Lab. Code Ann. §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. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

While Dr. Laning and Dr. Marable offered credible evidence in support of synaptic nerve blocks in general, neither persuasively rebutted Dr. Hershkowitz’s testimony that the Claimant’s injury did not require that procedure. The ALJ finds the Claimant’s pain, which was at the low level of 2 out of 10, could have been treated with Aleve rather than with the synaptic nerve block. Therefore, although the synaptic nerve block did provide pain relief, it was not reasonably required by the nature of the Claimant’s injury and should not be reimbursed.

II. Findings of Fact

  1. The Claimant, a baggage handler at___________, was injured_________.
  2. The Claimant sought treatment from Mobile Diagnostics, who diagnosed his injury as lumbosacral, cervical, and thoracic sprain/strain.
  3. Because the Claimant continued to complain of headaches, right shoulder and neck pain, lumbar pain, and thoracic pain, Mobile Diagnostics performed the synaptic nerve block on April 20, 2001.
  4. The procedure reduced the Claimant’s perceived pain level from 2 out of 10 to zero.
  5. Mobile Diagnostics sought reimbursement of $400.00 for the procedure from AHAC, the workers’ compensation carrier.
  6. AHAC denied reimbursement, and a request for reconsideration, on the grounds that the treatment was medically unnecessary.
  7. Mobile Diagnostics filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission.
  8. The MRD found in favor of Mobile Diagnostics on July 22, 2002.
  9. On August 9, 2002, AHAC requested a hearing before SOAH.
  10. Notice of the hearing was sent to the parties September 17, 2002.
  11. 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.
  12. The hearing was held May 9, 2003, at SOAH’s offices, with ALJ Henry D. Card presiding.
  13. The Claimant’s pain, which was at the low level of 2 out of 10, could have been treated with Aleve rather than with the synaptic nerve block.

III. Conclusions of Law

  1. 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.
  2. AHAC timely filed its request for a hearing, as specified in 28 Tex. Admin. Code §148.3.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. Because AHAC is the Petitioner, it has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. The synaptic nerve block was not reasonably required by the nature of the Claimant’s injury pursuant to Tex. Lab. Code Ann. §408.021(a).
  6. Mobile Diagnostics should not be reimbursed for the synaptic nerve block.

ORDER

IT IS, THEREFORE, ORDERED that American Home Assurance Company is not required to reimburse Mobile Diagnostics, Inc. for the synaptic nerve block performed on the Claimant April 20, 2001.

Signed this 9th day of June, 2003.

Henry D. Card
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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