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At a Glance:
Title:
453-03-0932-m5
Date:
February 14, 2003
Status:
Retrospective Medical Necessity

453-03-0932-m5

February 14, 2003

DECISION AND ORDER

Travelers Insurance Company (Carrier) appeals the conditional Findings and Decision[1] of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) ordering reimbursement to Sadi-Northeast Imaging (Provider) forX-rays and magnetic resonance imaging (MRI) provided to _____ (Claimant). The Administrative Law Judge (ALJ) concludes Carrier met its burden by proving the X-rays and MRI were not related to Claimant’s compensable injury, and denies reimbursement.

I. Jurisdiction, Notice, and Procedural History

The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (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 ch. 2003.

The MRD issued its conditional Findings and Decision on September 19, 2002, requiring Carrier to reimburse Provider for the disputed X-rays and MRI within 20 days of a final determination that the underlying claim was compensable and/or that the injury extends to or includes the disputed body part, region, area or medical condition in dispute. On October 2, 2002, Carrier filed a timely request for hearing before SOAH. Proper and timely notice of the hearing was issued on November 4, 2002. The hearing convened December 19, 2002, before ALJ Sharon Cloninger. Carrier was represented by Dan Flanagan, its Austin-area Texas Workers Compensation Representative. Todd Richey, President of U.S. Imaging, appeared bytelephone for Provider. The hearing adjourned and the record closed that same day.

II. Issue

The issue in this proceeding is whether Carrier should reimburse Provider $1,064.60 plus interest for an X-ray of Claimant’s right elbow, and an X-ray and MRI of Claimant’s cervical spine, all performed on October 19, 2000.

III. Applicable Law

Medical necessity is described at Tex. Lab. Code Ann. §§ 408.021 as follows:

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

Carrier, as the petitioner, has the burden of proof in this matter. 28 Tex.Admin. Code (TAC) §148.21(h).

IV. Evidence and Argument

The evidence in this case consisted of the 52-page certified record of the MRD proceeding (Provider’s Exhibit 1) and a document submitted by Carrier (Carrier’s Exhibit 1). Neither party called witnesses.

A. Evidence

Carrier denied payment of Provider’s claim on the basis that the X-rays and MRI were not related to Claimant’s compensable injury to her left arm and shoulder. Claimant and Carrier-but not Provider-signed a Benefit DisputeAgreement on January 24, 2002, agreeing that Claimant’s compensable injury of_____, includes only Claimant’s left CTS[2], left shoulder, and left elbow sprain, but not her cervical spine. (Carrier’s Exhibit 1 at 9).[3]

B. Carrier’s Argument

Carrier argued that any service or treatment related to Claimant’s cervical spine is not subject to reimbursement, because Claimant’s compensable injury was not to her cervical spine.

C. Provider’s Argument

Provider argued that Claimant’s treating physician prescribed the X-rays and MRI to further determine the proper course of treatment. Because Provider performed the X-rays and MRI at the treating doctor’s request, Provider should be reimbursed.

IV. Analysis

Provider performed X-rays and an MRI for Claimant on October 19, 2000, as prescribed by her treating doctor. Provider, as an imaging service, does not determine medical necessity for a prescription; the determination of medical necessity is made by the treating doctor. If an insurance carrier questions the medical necessity of a treatment, it is the treating doctor who must provide documentation establishing medical necessity. If the documentation demonstrates that the treatment is related to the claimant’s compensable injury, and is necessary to cure or relieve the effects of the injury, it is sufficient under Tex. Lab. Code Ann. § 408.021(a) to establish medical necessity.

The record contains no evidence to support the conclusion that X-rays of Claimant’s right elbow and cervical spine, and an MRI of Claimant’s cervical spine, were medically necessary to treat her compensable injury. The evidence establishes that Claimant’s compensable injury is related to her left CTS, left shoulder, and left elbow, and not to her right elbow or to her cervical spine. The X-rays and MRI were performed on Claimant’s right elbow and her cervical spine. The ALJ concludes that Carrier has met its burden of proving that the X-rays and MRI in dispute were not related to Claimant’s compensable injury, and that reimbursement should be denied.

IV. Findings of Fact

  1. ______,____(Claimant)suffered a compensable injury to her left elbow and left shoulder, including left cubital tunnel syndrome, while on the job for _____.
  2. Claimant’s injury is covered by workers’ compensation insurance written for Claimant’s employer by Travelers Insurance Company (Carrier).
  3. Claimant’s compensable injury does not extend to her cervical spine or right elbow.
  4. On October 19, 2000, Sadi-Northeast Imaging (Provider) performed X-rays of Claimant’s right elbow and cervical spine, and an MRI of her cervical spine, as prescribed by her treating doctor.
  5. Provider requested reimbursement for the X-rays and MRI listed in Finding of Fact No. 4, which Carrier denied on the basis that the treatment was not related to Claimant’s compensable injury.
  6. Provider filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  7. On September 19, 2002, the Commission’s Medical Review Division (MRD) issued its decision ordering Carrier to reimburse Provider within 20 days of a final determination that the underlying claim is compensable and/or that the injury extends to and includes the disputed body part, region, area, or medical condition at issue.
  8. On October 2, 2002, Petitioner filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  9. Notice of the hearing was issued November 4, 2002.
  10. 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.
  11. The hearing convened December 19, 2002, before Administrative Law Judge (ALJ) Sharon Cloninger. Carrier was represented by Dan Flanagan, its Austin-area Texas Workers Compensation Representative. Todd Richey, President of U.S. Imaging, appeared bytelephone for Provider.The hearing adjourned and the record closed that same day.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
  2. 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 ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov't Code § 2001.052.
  4. Carrier, as the petitioner, has the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 Tex. Admin. Code §148.21(h).
  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. Tex. Lab. Code Ann. § 408.021(a).
  6. Based on Findings of Fact Nos. 3-4, Carrier has met its burden of proving the X-rays and MRI were not medically necessary for the treatment of Claimant’s compensable injury within the meaning of Tex. Lab. Code Ann. § 408.021.
  7. Carrier should not reimburse Petitioner $1,064.60 plus interest for the disputed X-rays and MRI.

ORDER

IT IS, THEREFORE, ORDERED that Travelers Insurance Company is not to reimburse Sadi-Northeast Imaging for X-rays of Claimant’s left elbow and cervical spine, and an MRI of Claimant’s cervical spine, performed October 19, 2000.

Signed February 14th, 2003.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Carrier denied reimbursement to Sadi-Northeast Imaging on the basis that the treatment was not related to Claimant’s compensable injury. At the time the MRD issued its conditional Findings and Decision, it stated the extent of injury issue had not been resolved. However, Carrier and Claimant reached a Benefit Dispute Agreement regarding extent of injury on January 24, 2002. (Carrier’s Exhibit 1 at 9), and neither party asserted at the hearing that the extent of injury issue was still pending. Therefore, the ALJ concludes the issue has been resolved, and will use the January 24, 2002 agreement as the basis for this decision.
  2. “CTS” is not defined in the Benefit Dispute Agreement. Elsewhere in the record it is stated that Claimant suffers from left cubital tunnel syndrome. The ALJ presumes “CTS” stands for “cubital tunnel syndrome.”
  3. The agreement does not specifically mention Claimant’s right elbow, but because it states her compensable injury “only” includes her left CTS, elbow sprain, and shoulder, the ALJ concludes the right elbow is excluded from her compensable injury.
End of Document
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