Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
February 17, 2003
Retrospective Medical Necessity


February 17, 2003


Roland R. Hicks, D.C. (Provider) seeks reimbursement of $400.50 from United States Fire Insurance Company (Carrier) for chiropractic manipulations administered to an injured worker (Claimant) over a nine-month period. This decision finds that Provider failed to present objective evidence demonstrating the medical necessity of the manipulations. Consequently, reimbursement is not warranted.

I. Statement of the Case

Administrative Law Judge (ALJ) Gary Elkins convened a hearing on December 19, 2002. The hearing was closed on December 20, 2002, after Provider was given the opportunity to file an additional exhibit and Carrier was given an opportunity to object to its admissibility. The exhibit, marked as Exhibit 3, is admitted into the record and was considered in the ALJ's deliberations.

Provider appeared and represented himself at the hearing. Carrier appeared and was represented by Attorney Shane Thompson. Notice and jurisdiction, which were not disputed, are addressed in the Findings of Fact and Conclusions of Law without discussion here.

II. Discussion

In ________ Claimant was injured at work. In May 1999, Claimant began seeing Provider for chiropractic treatment. Provider seeks reimbursement for nine chiropractic evaluations and treatments performed from March 26, 2001, to November 15, 2001.

The majority of Provider's case presentation focused on what he concluded were procedural failures by Carrier, its agents, and peer reviewers in evaluating Claimant's medical needs and reviewing and responding to the reimbursement claim. The decision in this case does reach those issues, however. As the petitioner in this proceeding, Provider had the burden of proving the medical necessity of his services as contemplated by the Texas Workers= Compensation Act and the rules of the Texas Worker's Compensation Commission. Provider argued that because Claimant was already at maximum medical improvement when the treatments were administered, a showing of additional improvement was not possible, could not be demonstrated, and should not be a requirement of the Commission's Spine TreatmentGuideline (Guideline). Instead, Provider maintained, the goal of his treatment was to provide relief of pain from the injury and allow Claimant to maintain his employment. The treatment accomplished these goals, he argued, thus meeting the requirements of Section 408.021(a) of the Texas Workers= Compensation Act (Act):

(a) 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:

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

Provider filed to meet even this burden, however. Even though the evidentiary record in this case contains a number of documents demonstrating substantial interaction between Provider and Claimant, none reflect objectively quantified improvement in Claimant's condition or relief of his pain following his chiropractic treatments, requirements of the Commission's Spine Treatment Guideline (Guideline) for work related injuries.[1] Provider's SOAP notes for July 31, 2002, do refer to a statement by Claimant that Ahe has minimal to no pain in his neck, arm, low back or legs following his adjustments. The ALJ was unpersuaded, however, that a subjective comment of this nature, made on a single occasion, rises to the level of proof required to meet the requirements of either the Act or the Commission's rules relating to services deemed medically necessary. In fact, on most office visits to Provider Claimant reported his pain levels as unchanged.

Because the evidence fails to demonstrate that Provider's services were medically necessary as contemplated by the Act and the Commission's rules, he is not entitled to reimbursement for them.

III. Findings of Fact

  1. An injured worker (Claimant) suffered a compensable injury in ________.
  2. At the time of Claimant's injury, his employer held workers= compensation insurance coverage through United States Fire Insurance Company (Carrier).
  3. On nine occasions from March 26, 2001 to November 15, 2001, Roland R. Hicks, D.C. (Provider), performed chiropractic evaluations and manipulations on Claimant, for which he requested $400.50 in reimbursement from Carrier under CPT Code 99213.
  4. Carrier refused reimbursement.
  5. In response to Carrier's denial of reimbursement, Provider requested medical dispute resolution.
  6. Upon receiving the Medical Dispute Resolution Findings and Decision denying any reimbursement, Provider timely requested a hearing before the State Office of Administrative Hearings.
  7. The SOAH hearing was held on December 19, 2002.
  8. Notice of the hearing was sent to the parties on November 13, 2002. The notice informed the parties of the date, time, and location of the hearing, a statement of the matters to be considered, the legal authority under which the hearing would be held, and the statutory provisions applicable to the matters to be considered.
  9. Provider's medical documentation relating to Claimant did not show objectively quantified improvement in Claimant's condition following his chiropractic treatments.

IV. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the 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 Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ''2001.051 and 2001.052.
  4. As Petitioner, Provider has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) '148.21(h).
  5. Based on Finding 9 and pursuant to ' 408.021(a) of the Act and 28 TAC ' 134.1001, Provider failed to demonstrate that the manipulations rendered to Claimant were medically necessary to treat Claimant's compensable injuries.
  6. Provider's request for reimbursement should be denied.


IT IS ORDERED thatthe claim of Roland R. Hicks, D.C., for reimbursement from United States Fire Insurance Company is denied.

Signed this 17th day of February, 2003.

Gary W. Elkins
Administrative Law Judge

  1. See 28 TAC ' 134.1001(e)(2)(A)(vi)-(vii).
End of Document