DECISION AND ORDER

I. Introduction

Jesus E. Garcia, D.C. (Provider) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD), based on an independent review organization (IRO) review, regarding reimbursement for chiropractic services the Provider furnished to____. (Claimant). Agreeing with North River Insurance Company of New Jersey (Carrier), which had denied reimbursement, the IRO found the services were not medically necessary to treat the Claimant’s compensable injury. The only disputed issue is whether the chiropractic services were medically necessary.

As set out below, the Administrative Law Judge (ALJ) cannot find that the chiropractic services were reasonably medically necessary to relieve the Claimant’s pain, hence he denies the Provider’s request for reimbursement.

II. Medical Necessity

On ___________the Claimant sustained a work-related injury to his back. As a result of the compensable injury, the Claimant suffered pain in his back. On January 18, 2000, the Claimant began to receive chiropractic manipulations from the Provider for his back pain. The Claimant reached maximum medical improvement (MMI) with a whole-person impairment rating of five to seven percent by the end of July 2000.

One year after the Claimant reached MMI, he returned to the Provider and again complained of back pain. From July 18, 2001, through February 28, 2002, the Provider furnished 12 sessions of chiropractic services the 12 sessions, allegedly to treat the Claimant’s back pain (the 12 sessions). It is those 12 sessions that are in dispute.

The evidence does not reasonably suggest that the Claimant’s pain, which the Provider claims the 12 sessions treated, was due to the compensable injury. The 12 sessions began one and one-half years after the compensable injury and one year after the Claimant reached MMI. While possible, it is not obvious that back pain that much later was still caused by the compensable injury. The IRO could not so conclude after reviewing the Provider’s documentation. Neither can the ALJ. Nor did the Provider’s testimony explain the connection. Instead, the Provider testified that the Claimant’s back hurts every time the Claimant works and suggested the Claimant is constantly being re-injured. However, no other evidence objectively supports the notion of additional injuries, nor has there been a compensability determination concerning those alleged additional injuries.

The IRO’s decision is entitled to presumptive weight and the Provider, who seeks relief from the MRD decision, has the burden of proof. From the evidence, the ALJ cannot conclude that the 12 sessions of chiropractic services were medically necessary to treat the Claimant’s compensable injury or pain stemming from it. Hence the Provider’s request for reimbursement should be denied.

III. Findings of Fact

1. On___________, the Claimant sustained a work-related injury to his back.
2. On the date of injury, the Claimant’s employer was_______, and the Carrier was its workers’ compensation insurance carrier.
3. As a result of the compensable injury, the Claimant suffered pain in his back.
4. The Claimant began to receive chiropractic manipulations from the Provider for his back pain on January 18, 2000.
5. The Claimant reached maximum medical improvement (MMI) with a whole-person impairment rating of five to seven percent by the end of July 2000.
6. One year after the Claimant reached MMI, the Provider furnished 12 sessions of chiropractic services (the 12 sessions) to the Claimant from July 18, 2001, through February 28, 2002, to treat pain in the Claimant’s back.
7. The Claimant’s pain symptoms did not improve much, if at all, during the eight-month period when the 12 sessions occurred.
8. The Provider sought reimbursement from the Carrier of $50 per session for each of the 12 sessions under Current Procedural Terminology (CPT) code 99213.
9. The Carrier denied the Provider’s request for reimbursement for the 12 sessions, claiming the Provider’s documentation did not show that they were medically necessary to treat the compensable injury.
10. On June 5, 2002, the Provider filed a request for medical dispute resolution with the TWCC, seeking reimbursement for the 12 sessions.
11. TWCC referred the dispute to an independent review organization (IRO), which reviewed the medical dispute and found the 12 sessions were not medically necessary or effective to treat the Claimant’s compensable injury.
12. Based on the IRO’s review, the MRD, on August 23, 2002, denied the Provider’s request for reimbursement for the 12 sessions.
13. After the IRO review and the MRD denial, the Provider, on September 20, 2002, asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ) concerning the dispute.
14. On November 1, 2002, TWCC mailed notice of a December 11, 2002 contested-case hearing concerning the dispute to Carrier and the Provider.
15. On December 11, 2002, SOAH ALJ William G. Newchurch held a contested-case hearing on the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
16. The Provider appeared at the hearing, by telephone.
17. The Carrier appeared at the hearing through its attorney, Dan C. Kelly.

IV. Conclusions of Law

1. 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 Tex. Labor Code Ann. (Labor Code) §§402.073(b) and 413.031(k) (West 2002) and Tex. Gov’t Code Ann. (Gov’t Code) ch. 2003 (West 2001).
2. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §§ 2001.051 and 2001.052.
3. As the party seeking relief, the Provider has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h) (2002).
4. In all appeals from reviews of retrospective medical necessity disputes, the IRO’s decision has presumptive weight. 28 TAC § 133.308(v).
5. 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. Labor Code § 408.021 (a).
6. The above Findings of Fact do not overcome the presumptive weight of the IRO’s decision that the 12 sessions were neither medically necessary nor effective.
7. The above Findings of Facts do not reasonably show that the Claimant’s pain during the period of the 12 sessions, which began one and one-half years after the compensable injury and one year after the Claimant reached maximum medical improvement (MMI), was related to the compensable injury.
8. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for reimbursement for the 12 sessions should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request for reimbursement for the 12 sessions is denied.

Signed December 17, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge