DECISION AND ORDER
This case is an appeal by Industrial Athletics, LLC (Provider or Petitioner) from a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) in a medical necessity dispute. The MRD denied reimbursement because Petitioner did not provide adequate documentation to Texas Mutual Insurance Company (Carrier or Respondent) of a work hardening program provided to Claimant. The Administrative Law Judge (ALJ) denies Petitioner’s request for reimbursement.
I. JURISDICTION AND VENUE
The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (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(d) of the Act and Tex. Gov’t Code Ann. ch. 2003.
II. STATEMENT OF THE CASE
The hearing in this docket convened on December 11, 2002, at SOAH facilities in the William P. Clements Building, 300 W. 15th St., Austin, Texas. The Texas Workers’ Compensation Commission (TWCC) did not participate in the hearing. The hearing concluded and the record closed the same day.
The evidence presented revealed that Claimant suffered a work-related injury to his ankle. From April 2 to April 17, 2001, Claimant participated in a work hardening program administered by Petitioner. Respondent denied payment because Petitioner did not present adequate documentation to support the work hardening program. MRD denied reimbursement because insufficient documentation was provided to MRD at the time of its review.
During the SOAH proceeding, Petitioner presented additional documentary evidence related to the treatment program provided to Claimant. The ALJ finds that the documentation presented to the MRD and the documentation submitted at the hearing do not sufficiently support the work hardening billed to the Respondent.
The ALJ finds Petitioner failed to provide proper documentation of a work hardening program. Instead, the record indicates Claimant primarily received a one‑discipline regime of physical therapy. Work hardening is an interdisciplinary program with a behavioral and psychological component that were not documented, and may not have been provided to Claimant.
Four elements are required in a work hardening program: vocational, behavioral, functional and physical. There is no documentation that Claimant received vocational or behavioral assistance. Claimant participated in strength and flexibility exercises, but there is no indication in the record of his occupation, or the requirements thereof. Therefore, it is not clear whether the exercises in which Claimant participated addressed his vocational needs. For these reasons, the ALJ finds that Petitioner did not meet its burden of proof to show documentation that Claimant received vocational training.
Petitioner presented behavioral notes as evidence of the behavioral component of the work hardening treatment provided to Claimant. These notes state only that Claimant complied with the treatment program, and the notes do not indicate that Claimant received any counseling or therapy. Furthermore, a physical therapy assistant signed the behavioral notes. Under the MFG, therapy must be performed by a Qualified Mental Health Provider (QMHP). A physical therapy assistant is not a QMHP. Nothing in the record specifically documents that Claimant received any behavioral treatment, as contemplated in the Medicine Ground Rules for work hardening.
Documentation of treatment is required both by the MFG and by the Lower Extremities Guideline, which is applicable because Claimant injured his ankle. The MFG provides that daily treatment and the patient’s response to treatment shall be documented. The Lower Extremities Guideline also requires documentation of clinical progress of the injured worker. There is no documentation in the record of vocational or behavioral treatment. Therefore, the ALJ finds that Petitioner did not demonstrate by a preponderance of the evidence that Claimant was provided work hardening, which must contain vocational and behavioral elements.
The ALJ concludes that Petitioner failed to document whether work hardening was provided to Claimant. The documentation provided shows that Claimant was provided strength and flexibility exercises, but there is no documentation of vocational or behavioral treatment. The physical training alone does not constitute work hardening, and Respondent properly denied payment.
VI. FINDINGS OF FACT
- Claimant suffered a work-related injury to his ankle.
- In the course of rehabilitation from his injury, Claimant was referred to a work hardening program administered by Industrial Athletics, LLC (Petitioner). Claimant participated in that program from April 2 through April 17, 2001.
- Petitioner sought reimbursement for the work hardening program from Texas Mutual Insurance Company (Respondent), the carrier for Claimant’s employer at the time of his injury.
- Respondent denied the reimbursement requested by Petitioner.
- By filing dated March 28, 2002, Petitioner made a timely request to the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) for medical dispute resolution with respect to the requested reimbursement.
- The MRD denied Petitioner’s request for reimbursement in a decision dated September 11, 2002.
- Petitioner requested in timely manner a hearing with the State Office of Administrative Hearings, seeking review and reversal of the MRD decision.
- The Commission mailed notice of the hearing’s setting to the parties at their addresses on November 1, 2002.
- A hearing in this matter was convened on December 11, 2002, at the William P. Clements Building, 300 W. 15th St., Austin, Texas. Petitioner and Respondent participated in the case.
- The dates of the work hardening program at issue in this case were April 2 through April 17, 2001.
- Vocational and behavioral treatments are required aspects of a work hardening program.
- The documentation in the record does not indicate that Claimant received vocational or behavioral treatment.
VII. CONCLUSIONS OF LAW
- The Texas Workers’ Compensation Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. § 413.031.
- The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, Tex. Gov’t Code Ann. ch. 2003.
- The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and the Commission’s rules, 28 Tex. Admin. Code § 133.305(g) and §§148.001-148.028.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
- Petitioner, the party seeking relief, bore the burden of proof in this case, pursuant to 28 Tex. Admin. Code § 148.21(h).
- Based upon the Findings of Fact, the work hardening program was not properly documented as required under the Medical Fee Guidelines, Medicine Ground Rule II. E., 28 Tex. Admin. Code §134.201, and the Lower Extremities Guideline, 28 Tex. Admin. Code §134.1003.
- Based upon the foregoing Findings of Fact and Conclusions of Law, Petitioner’s request for reimbursement for services provided from April 2 through April 17, 2001, should be denied.
IT IS THEREFORE, ORDERED that Petitioner, Industrial Athletics, is denied reimbursement from Respondent, Texas Mutual Insurance Company, for work hardening services provided to Claimant from April 2 through April 17, 2001.
Signed this 13th day of December, 2002.
WENDY K. L. HARVEL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS