DECISION AND ORDER

I. SUMMARY

MultiCare Medical Group (Provider), the provider of services in this case, seeks reimbursement for work hardening services provided an injured worker, ____ (Claimant). Twin City Fire Insurance Company (Carrier) denied payment indicating the services were not medically necessary and not properly documented. Subsequently, the Independent Review Organization (IRO) considered Provider’s claim for reimbursement and recommended no reimbursement. Provider appealed the IRO’s decision.

The Administrative Law Judge (ALJ) finds the work hardening program was not medically necessary and not properly documented; therefore, Provider is not entitled to reimbursement of $4,352.00.^[1]

II. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

On February 6, 2003, ALJ Michael J. O’Malley convened the hearing on the merits at the William P. Clements Building, 300 West 15^th Street, Austin, Texas. Carrier appeared through its attorney, James M. Loughlin. Provider appeared through its representative, Peter N. Rogers. After the evidence was presented, the record of the hearing closed on March 14, 2003, the last day to file closing arguments.

SOAH has jurisdiction to consider the medical necessity of the work hardening program, which would include compliance with the work hardening requirements, such as appropriate documentation. Provider raised the issue of whether SOAH had jurisdiction to determine whether the program was a qualified work hardening program because Carrier initially denied payment based on medical necessity only. The ALJ disputes that this is a jurisdictional question. The ALJ finds, however, that medical necessity would include compliance with the work hardening requirements, including proper documentation. Provider had sufficient notice, through the per review report and the IRO decision, that Carrier claimed the work hardening program failed to comply with the Texas Workers’ Compensation Commission (Commission) requirements for documentation.

III. BACKGROUND, EVIDENCE, AND DISCUSSION

Background

Claimant suffered a compensable lower back injury on________. Joint Ex. 1, Medical Documents at 1. Claimant was employed as a ______ at ________in Richardson, Texas. Claimant injured his lower back while lifting a series of boxes weighing approximately 30-40 pounds. Id at 59. Michael Margolies, D.C., a doctor for Provider, began treating Claimant on October 19, 2000. On October 23, 200, Dr. Margolies began treating Claimant with various physical therapy modalities. Between October 23, 2000, and December 15, 2000, Claimant had approximately 31 physical therapy sessions. Id. at 21-57. On December 22, 2000, Claimant had a Functional Capacity Evaluation (FCE). Id. at 83-111. The FCE showed that the job demand was heavy, but Claimant was only functioning in the medium category. Id. at 83. Based on the results of the FCE, Provider began the work hardening program on January 3, 2001.

1. Parties’ Positions and Evidence
2. Provider’s Position and Evidence

Provider claims that this case presents “an obvious compromise.” That compromise would require Carrier to reimburse for work conditioning instead of work hardening. Provider argues that the ALJ can order reimbursement of a lesser amount if he finds that another billing code more accurately reflects the service provided. Provider’s Closing Argument at 5.

As for the work hardening program, Provider contends that Claimant met the established criteria for work hardening as follows: Claimant was likely to benefit from the program; his functioning level as of January 3, 2001, interfered with his ability to do lifting as required by his job; his medical and psychological condition did not prohibit participation in the program; and the program was designed to assist Claimant in completing specific job duties, such as lifting. From the evidence, Provider recommended the work hardening program to increase Claimant’s lifting ability and to learn coping skills to deal with the injury. Joint Ex. 1, Medical Documents at 83 and 124.

Carrier’s Position and Evidence

Carrier disputes the medical necessity of the work hardening program. Carrier disputes that Claimant’s psychological assessment because the psycho-social evaluation did not occur until two days after the work hardening program began.^[2] In addition, Carrier argues that Provider was not specific as to Claimant’s psychological problems.^[3] In general, Carrier questions the need for the multi-disciplined work hardening program, given the late psychological evaluation and the vague and nonspecific psychological problems.

Also, Carrier contends that individual therapy was provided instead of group therapy as required by the Medicine Ground Rules. Most of the documentation refers to “Individual Therapy Progress Notes.” According to Carrier, Dr. Margolies, witness for Provider, could not provide an explanation as to why individual therapy might have been provided instead of group therapy. Carrier further points out that therapy notes were vague and provided very little information as to Claimant. Id. at 136, 163, and 170. Carrier states that Dr. Margolies admitted that the psychological notes provided very little information about Claimant’s condition.

Carrier also argues and its witness, Michael Bhatt, D. C., testified that the work hardening program did not have an individualized treatment plan, did not set program goals, and did not adequately document Claimant’s daily progress and response to treatment. Dr. Bhatt also testified that Claimant’s progress was not reviewed on a systematic basis and that there is no evidence that an interdisciplinary team met on a weekly basis to discuss Claimant’s progress. For these reasons, Dr. Bhatt opined that the work hardening program for Claimant was not medically necessary and did not comply with the documentation requirements for a work hardening program.

ALJ’s Analysis

The issues in this case are whether the work hardening program was medically necessary for Claimant, and whether the work hardening treatment was properly documented.^[4] The ALJ finds the work hardening was neither medically necessary nor properly documented, and Provider should not be reimbursed by Carrier.^[5]

Work hardening is an individualized, highly structured, goal-oriented treatment program designed to maximize the ability of the person receiving the treatment to return to work. Work hardening programs are interdisciplinary, intended to address the functional, physical, behavioral, and vocational needs of the Claimant. The Commission has adopted rules governing work hardening programs. The rules, found in the Medical Fee Guideline, relate to, among other things, when work hardening is appropriate, how such programs are to be administered and billed, and what documentation is required of work hardening programs.^[6] In this case, Provider has not shown the medical necessity of the work hardening program, nor has it shown that the program was properly documented.

As for medical necessity, the Provider failed to show that Claimant was an appropriate candidate for a work hardening program because there was no clear indication of psychological or behavioral problems. Dr. Margolies stated that Claimant had attitude problems but that testimony was not specific or convincing. Further, Dr. Margolies recommended the work hardening program before he had the benefit of a psychological evaluation. The psychological evaluation occurred two days after the work hardening had begun, and the ALJ found the psychological evaluation to be vague and nonspecific. The evaluation simply stated that Claimant needed psychotherapy to learn coping skills. Id. at 124. According to Medicine Ground Rule II. E. 2., an initial mental evaluation may be performed prior to entrance into the work hardening program. In this case, because Claimant did not have specific psychological problems other than attitude problems, it would have been appropriate to have a thorough evaluation before beginning the program.

As for the documentation, Provider did not follow the requirements of the Medicine Ground Rules. Provider did not have an individualized treatment plan for Claimant as required by Medicine Ground Rule II. E. 6. Dr. Margolies testified that he had not developed an individualized plan for Claimant. Additionally, there are no program goals for the work hardening program as required by Medicine Ground Rule II. E. For example, it would have been appropriate to chart goals for Claimant and to document his progress in meeting those goals. The daily progress notes and the work hardening daily activity sheets do not properly document Claimant’s progress. The documentation does not specify which weight machines Claimant used, the amount of weight lifted in the exercises, his ability to complete the exercises, or the progress Claimant was making in the work simulation activities.

As for the psychological component of the work hardening program, there needs to be evidence of progress in treating Claimant’s psychological issues, and there is none in this case. The therapy session notes refer to individual therapy notes and, for work hardening, group therapy is required. It is unclear from the notes whether Claimant participated in group therapy or individual therapy. In addition, the notes are not specific as to the Claimant.

For the reasons indicated above, Provider did not prove that the work hardening program for Claimant was medically necessary, and it did not show that it was properly documented. Accordingly, reimbursement is denied.

IV. FINDINGS OF FACT

1. Claimant____ (Claimant), employed as a ______ for ________in Richardson, Texas, sustained a compensable lower back injury on__________.
2. At the time of the injury, Claimant’s employer had workers’ compensation insurance through Twin City Fire Insurance Company (Carrier).
3. Michael Margolies, D. C., a doctor for MultiCare Medical Group (Provider), began treating Claimant on October 19, 2000. He treated Claimant with various physical therapy modalities.
4. Between October 23, 2000, and December 15, 2000, Claimant had approximately 31 physical therapy sessions.
5. On December 22, 2000, Claimant had a Functional Capacity Evaluation (FCE).
6. The FCE showed that the job demand was heavy, but Claimant was functioning at the medium level, which prompted Provider to recommend a work hardening program.
7. The work hardening program began on January 3, 2001, and lasted until February 9, 2001.
8. Claimant’s psychological evaluation was performed on January 5, 2001.
9. Claimant did not have documented psychological problems that warranted the multi-disciplined work hardening program.
10. Provider did not have a treatment plan for Claimant.
11. The documentation did not adequately detail Claimant’s performance, his weight lifting exercises, the goals of the work hardening program, or the progress made by Claimant.
12. The post-program FCE showed that Claimant was still functioning at the medium level and not capable of returning to his previous job.
13. Claimant did not return to work after completion of the work hardening program.
14. Provider seeks reimbursement for Claimant’s work hardening in the amount of $4,352.00.
15. Carrier denied reimbursement of the claim, indicating the services were not medically necessary and the work hardening documentation did not comply with the Medicine Ground Rules.
16. On August 23, 2002, an Independent Review Organization (IRO) denied Provider reimbursement.
17. On September 17, 2002, Provider appealed the IRO’s decision.
18. The Texas Workers’ Compensation Commission (Commission) sent notice of the hearing to the parties on November 1, 2002. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented, the time and place of the hearing, and the statutes and rules involved.
19. The hearing was held on February 6, 2003. Carrier appeared through its attorney, James M. Loughlin. Provider appeared through its representative, Peter N. Rogers. After the evidence was presented, the record of the hearing closed on March 14, 2003, the last day to file closing arguments.

V. CONCLUSIONS OF LAW

1. The Commission has jurisdiction to decide the issue presented, pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 413.031.
2. 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. Lab. Code Ann. §§402.073 and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
3. Proper and timely notice of the hearing was provided to the parties in accordance with Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code § 148.4(b).
4. Pursuant to 28 Tex. Admin. Code § 148.21(h) and (i), Provider had the burden of proving by a preponderance of the evidence that the work hardening program was medically necessary and that it properly documented the program as required by the Medicine Ground Rules.
5. Because there was no documented proof of psychological or behavioral problems, Claimant should not have been assigned to a work hardening program.
6. Provider failed to prove that the services rendered to Claimant from January 3, 2001, through February 9, 2001, met the requirements set out in the Medical Fee Guideline Medicine Ground Rule II. E. 6, 7 and 8.
7. Provider failed to meet the documentation requirements of Medical Fee Guideline Medicine Ground Rule II. E. 8.
8. Provider’s work hardening program did not enhance the ability of Claimant to return to work as required under Tex. Lab. Code Ann. ‘ 408.021(a).
9. Based on the Findings of Fact and Conclusions of Law, Provider’s work hardening program was not medically necessary.
10. Based on the foregoing Findings of Fact and Conclusions of Law, Provider should not be reimbursed $4,352.00.

ORDER

IT IS HEREBY ORDERED that the request for reimbursement of MultiCare Medical Group is denied as it did not prove that the services provided Claimant ____ from January 3, 2001, through February 9, 2001, were medically necessary and properly documented.

Signed this 27^th day of March 2003.

MICHAEL J. O’MALLEY
Administrative Law Judge
State Office of Administrative Hearing

1. Provider is seeking reimbursement for the January 3, 2001, through January 25, 2001. Provider’s Closing Argument at 6.↑
2. Jack Scherschell, Ph. D. conducted the psychological profile on January 5, 2001. Id. at 123.↑
3. Claimant’s attitude problems in dealing with his injury comprised the psychological component of the work hardening program.↑
4. The ALJ will not recommend reimbursement for the lesser work conditioning as suggested by Provider. Carrier could have agreed to pay for work conditioning to settle this case, but the hearing did not address the requirements of a work conditioning program.↑
5. In this case, Provider did not meet its burden of proof that the work hardening program was medically necessary, nor did it meets its burden to show that it properly documented the treatment and progress of Claimant.↑
6. See Medical Fee Guideline Medicine Ground Rule II. E. and 28 Tex. Admin. Code § 134.201.↑