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At a Glance:
Title:
453-03-0843-m5
Date:
March 27, 2003
Status:
Retrospective Medical Necessity

453-03-0843-m5

March 27, 2003

DECISION AND ORDER

This case involves a dispute over the decision by Continental Casualty Company (Carrier) not to reimburse A. Kent Rice, D.C. (Provider or Dr. Rice) for chiropractic treatments provided to workers’ compensation claimant ____ (the Claimant). The amount in dispute is $1,901, and the Carrier has appealed the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) ordering reimbursement of this amount. In this decision, the Administrative Law Judge (ALJ) concludes the disputed treatment was not medically necessary for Claimant’s compensable injury and, therefore, Carrier is not liable to reimburse Provider for it.

I. Background Facts

Claimant injured his back on________, during the course of his job with _________. In particular, Claimant suffered a lumbar strain while lifting a truck door. Between the date of his injury and January 3, 2001, Claimant saw Provider on approximately 64 occasions for chiropractic manipulations and related treatments for Claimant’s back injury. Claimant was determined to be at maximum medical improvement in May 2001. Sometime between July 2, 2001, and July 17, 2001, Claimant suffered one or more exacerbations of his injury.[1] Claimant saw Provider again for 21 visits between July 2, 2001, and September 17, 2001. Claimant continued to receive treatment from Provider and saw him on 13 more occasions between September 17, 2001 and October 22, 2001. Provider treated Claimant with chiropractic manipulations and related physical therapy treatments during these visits.

Provider billed Carrier for all treatments. Carrier denied reimbursement for the last 13 treatments provided between September 17, 2001 and October 22, 2001, asserting the treatments were not medically necessary in light of Claimant’s extensive prior treatment and the lack of medical benefit to Claimant from such treatment. After conducting medical dispute resolution, MRD ordered Carrier to reimburse Provider the sum of $1,901 for the treatments in issue. Carrier then appealed, requesting a hearing before the State Office of Administrative Hearings.

II. Analysis

The sole issue in this case is whether the chiropractic manipulations and related physical therapy treatments provided between September 17, 2001 and October 22, 2001, were medically necessary to treat Claimant’s work-related injury of_______. After considering the evidence, the ALJ concludes that they were not.

Provider agreed that the initial phase of care for the exacerbation of Claimant’s back injury would last eight weeks from the exacerbation. Given that Claimant’s exacerbation occurred, at the latest, on July 17, 2001, the initial phase of care ended on or about September 11, 2001. Dr. Rice testified that additional treatment was needed beyond this time because Claimant continued to have pain and was unable to return to work. Carrier argued that additional treatments were not necessary because Claimant had been able to return to work after his initial treatment through January 2001, and was off work at the time of his exacerbation not because of any injury but because his employer did not need him due to a work slowdown. The record supports Carrier’s position on this.[2] Moreover, the Carrier presented evidence from numerous peer review doctors who concluded that the extent of treatment provided by Dr. Rice exceeded that which was medically necessary given the nature of Claimant’s initial injury and exacerbation. At the hearing, Dr. Michael Bhatt testified that the injury was not considered acute more than eight weeks after the exacerbation and there was no need for ongoing one-on-one treatment like that provided by Dr. Rice. Moreover, Dr. Bhatt pointed out that such treatment was not providing medical benefits to Claimant and should not have been continued after the initial eight weeks of treatment.

After considering the entirety of the evidentiary record, and giving appropriate persuasive weight to the testimony of the medical experts, the ALJ finds that the preponderance of the evidence establishes that the treatments in issue were not medically necessary. In particular, the ALJ is persuaded by the peer review reports and the testimony of Dr. Bhatt that such intensive, ongoing treatment was not necessary for Claimant’s exacerbation of his injury, particularly given the fact that at least twenty such similar treatments had been provided to Claimant after his exacerbation, with little benefit to Claimant. Therefore, because the ALJ concludes that such treatments were not medically necessary, Carrier is not required to reimburse Dr. Rice for them. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

III. Findings of Fact

  1. ____ (Claimant) suffered a compensable injury to his back in ________ while performing work-related duties for his employer, _________.
  2. At the time of Claimant’s injury, Continental Casualty Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
  3. Between the date of his injury and January 3, 2001, Claimant saw A. Kent Rice, D.C. (Provider or Dr. Rice) on approximately 64 occasions for chiropractic manipulations and related treatments for Claimant’s back injury.
  4. Claimant was designated as reaching maximum medical improvement in May 2001.
  5. Between July 2, 2001 and July 17, 2001, Claimant suffered an exacerbation of his injury.
  6. At the time of his exacerbation, Claimant was not working due to a slowdown in his employer’s workload.
  7. Claimant saw Provider again for 21 visits between July 2, 2001, and September 17, 2001, receiving chiropractic manipulations and related physical therapy.
  8. The treatments in dispute that were provided by Dr. Rice were passive modalities.
  9. The acute phase of Claimant’s injury and resulting care lasted for eight weeks and ended by September 11, 2001.
  10. The record does not contain any documented cognitive deficits in Claimant that would justify continued, one-on-one, supervised passive modality treatments after September 11, 2001.
  11. Passive modalities were no longer appropriate or medically necessary for Claimant after September 11, 2001.
  12. Claimant continued to receive treatment from Provider and saw him on 13 occasions between September 17, 2001 and October 22, 2001, again receiving chiropractic manipulations and related physical therapy treatments on these occasions.
  13. Carrier denied reimbursement for the treatments provided on the 13 dates of service between September 17, 2001 and October 22, 2001, asserting the treatments were not medically necessary treatment for Claimant’s compensable injury.
  14. On December 12, 2001, Provider filed a request for medical dispute resolution with the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission.
  15. On August 30, 2002, after conducting medical dispute resolution, MRD ordered Carrier to reimburse Provider the sum of $1,901.00 plus accrued interest.
  16. MRD mailed a copy of the decision on September 3, 2002.
  17. On September 23, 2002, Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  18. Notice of the hearing was sent on October 28, 2002.
  19. A hearing was conducted by SOAH, before Administrative Law Judge Craig R. Bennett, on February 19, 2003. James Loughlin appeared on behalf of the Carrier. Provider appeared by telephone and represented himself. The Commission did not appear nor participate. The hearing adjourned the same day and the record closed on March 5, 2003, with the filing of additional documents.
  20. The treatments provided by Dr. Rice between September 17, 2001 and October 22, 2001, did not provide medical benefit to Claimant and were not medically necessary treatment of Claimant’s compensable injury of July 2000 or his exacerbation of that injury in July 2001.

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. Carrier 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. Carrier 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. Carrier established, by a preponderance of the evidence, that the treatments provided by Dr. Rice between September 17, 2001 and October 22, 2001, were not medically necessary for the treatment of Claimant.
  8. Provider’s request for reimbursement should be denied.

ORDER

IT IS ORDERED that A. Kent Rice, D.C. is not entitled to reimbursement from Continental Casualty Company for the treatments provided to claimant ____ between September 17, 2001 and October 22, 2001.

Signed this 27th day of March 2003.

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

  1. Dr. Rice’s reports reference an exacerbation of Claimant’s injury occurring on_____, and on_____. At the hearing, Dr. Rice was uncertain, and at times appeared confused, regarding the date(s) on which Claimant suffered an exacerbation of his injury. Because of the different testimony given on this issue, the ALJ can conclude only that Claimant suffered at least one exacerbation between July 2, 2001, and July 17, 2001.
  2. See Ex. 3, at 188.
End of Document
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