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At a Glance:
Title:
453-03-1571-m5
Date:
September 15, 2003
Status:
Retrospective Medical Necessity

453-03-1571-m5

September 15, 2003

DECISION AND ORDER

The issue in this case is whether Mesquite ISD (Carrier) should reimburse Central Dallas Rehabilitation and Diagnostic (Provider) for services rendered to the Claimant from December 4, 2000 through June 26, 2001. The Administrative Law Judge (ALJ) finds that the Provider is entitled to reimbursement in part: physical therapy (CPT codes 99213, 97265, 97250, 97122) rendered between December 14, 2000 and January 31, 2001; work hardening rendered between June 13 and June 26, 2001; range of motion testing provided on December 28, 2000; the FCE performed on February 5, 2001; and reports dated March 29, June 6, and August 8, 2001.

Factual Background

The Claimant sustained an injury to her knee and back on when she slipped on a wet cafeteria floor while carrying a tray of coffee. She began receiving chiropractic services from the Provider on November 4, 2000 in the form of active and passive modalities four times a week. The Claimant continued to receive physical therapy through the end of January. On February 5, 2001, the Claimant began a six-week work hardening program which she completed on March 16, 2001. In June, the Carrier preauthorized an additional two weeks of work hardening, which the Claimant underwent from June 13, 2001 through June 26, 2001.

After the initial six weeks of physical therapy, the Carrier denied further physical therapy rendered to the Claimant after December 14, 2000 primarily on the grounds that it was not supported by sufficient documentation. The Carrier later denied payment for all work hardening. The Medical Review Division issued an order on September 27, 2002 which ordered payment for all of the work hardening, the functional capacity evaluations, range of motion testing, charges for reports, and all physical therapy except for the individual therapy sessions, which it found were not adequately documented. The Carrier filed an appeal to the decision on October 23, 2001.

Discussion

Physical Therapy Claims

The Carrier argues that the treatment notes are not sufficient to support the services rendered. The Carrier’s witness, Margaret Cunningham, D.C., testified that the Claimant did not improve sufficiently after six weeks of physical therapy to warrant additional treatment. Based on her review of the documentation, she stated that the Claimant should have been referred to an orthopaedist because she was not responding to physical therapy. Additionally, she maintained that the Provider should not be reimbursed for joint mobilizations and joint manipulations performed on the same date because these services were redundant. She further testified that the physical therapy services rendered lacked the appropriate level of documentation necessary to evaluate the efficacy of the treatment provided.

The Provider did not present any testimony, but relied upon the record and the MRD’s determination to establish the medical necessity of the services and the fact that they were appropriately documented.

The ALJ finds that the Carrier failed to meet its burden to demonstrate that the documentation was insufficient to establish medical necessity. It was incumbent upon the Carrier to show that the services were not appropriately documented, as this was the basis of its denial. The ALJ agrees that the documentation is sparse and barely supports the necessity for the seven dates of service; however, the ALJ finds that it was sufficient and the services were not so extensive as to require significantly more documentation to demonstrate necessity.

Work Hardening

Dr. Cunningham testified that the November 2000 MRI or the Claimant’s knee revealed a torn meniscus. She believed that the Claimant should have been referred out for an orthopaedic consult to determine if work hardening was appropriate in light of her condition. She believed that work hardening would aggravate this type of condition. The Carrier’s witness also testified that the documentation was insufficient to discern if the Claimant was making any progress during the course of the program. The daily notes are generalized, without specifying the types of tasks performed the number of repetitions or time limits. Dr. Cunningham further testified that the functional capacity evaluation (FCE) performed prior to work hardening showed the Claimant was only able to perform sedentary work. After six weeks of work hardening, she had only marginal improvements in her range of motion, insignificant pain relief, and could still not perform at a medium level of work.

The Provider relied upon the record to show that work hardening was appropriate, arguing that the Claimant made significant improvements.

The MFG[1] defines work-hardening as a highly structured, goal-oriented, individualized treatment program designed to maximize the ability of the persons served to return to work. The MFG further states that work hardening provides a transition between management of the initial injury and return to work while addressing the issues of productivity, safety, physical tolerances, and work behaviors. The MFG identifies the following criteria for admission into a work-hardening program:

  1. persons who are likely to benefit from the program;
  2. persons whose current levels of functioning due to illness or injury interfere with their ability to carry out specific tasks required in the workplace;
  3. persons whose medical, psychological, or other conditions do not prohibit participation in the program;
  4. persons who are capable of attaining specific employment upon completion of the program.

The ALJ finds that there is inadequate documentation in the record to support reimbursement for work hardening services rendered between February 5, 2001 and March 16, 2001. There is no documentation that the Provider adequately considered the Claimant’s knee condition prior to determining that she should undergo work hardening. Next, there is no evidence that the Claimant intended or could return to her previous employment as a cafeteria worker. Mechanically relying on the results of an FCE is not an adequate basis for determining that work hardening is an appropriate form of treatment for a claimant. Work hardening is an intensive and expensive endeavor, and in this instance, it was inappropriate due to her knee condition. Short of an FCE administered the same day she began the work hardening program, indicating that her admittance was perhaps a forgone conclusion, there is no evidence of consideration of any of these issues. Therefore, the ALJ finds that the Carrier met its burden of proof to show that the costs of the work hardening program, which the Claimant underwent from February 5, 2001 through March 16, 2001, should not be reimbursed. While the Claimant made modest gains in certain areas, notably range of motion, her limited progress is insufficient to overcome the lack of documented necessity.

The Carrier preauthorized two additional weeks of work hardening in June. There is no explanation in the record as to why the Carrier believed additional work hardening was medically necessary after it continually denied services. The ALJ, however, does not find the Carrier’s preauthorization of additional services in June relevant in determining the necessity for work hardening in February and March of 2001. The Carrier agreed at the hearing to reimburse the Provider for the preauthorized services, and it was not clear why it had not already reimbursed the Provider for these services having clearly preauthorized them over two years ago.

Testing and Reports

The Carrier appealed claims for range of motion testing (December 28, 2000), functional capacity evaluations (February 5, March 1 and 15, 2001) and the filing of reports (March 29, June 6 and August 8, 2001). The Carrier’s witness did not specifically address the appropriateness of reimbursement for these services. The ALJ finds that the FCE performed on February 5, 2001, to determine her need for work hardening, is reimbursable. However, the other two FCEs performed were administered in conjunction with work hardening program which the ALJ has found was not medically necessary. But for the work hardening program, the FCEs would not have been performed; therefore, these tests were not medically necessary.

The ALJ finds that the Carrier did not meet its burden of proof to demonstrate that the range of motion testing and filing of reports should not be reimbursed.

III. Findings of Fact

  1. The Claimant, a ___, sustained an injury to her knee and back when she slipped on a wet cafeteria floor while carrying a tray of coffee.
  2. The Mesquite ISD (Carrier) denied payment for certain treatment and services rendered from December 14, 2000 through August 8, 2001.
  3. Central Dallas Rehabilitation and Diagnostic (Provider) requested medical dispute resolution from the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission. The MRD agreed with the Provider that most of the treatment rendered was medically necessary.
  4. The Carrier appealed the decisions of the MRD.
  5. Notice of the hearing was sent January 10, 2003. 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.
  6. The hearing was convened on July 14, 2003 with Administrative Law Judge (ALJ) Janet Dewey presiding and representatives for the Carrier and Provider participating and the record closed the same day.
  7. An MRI performed in November, 2000, shortly after the Claimant’s injury, revealed a torn meniscus in her knee.
  8. The Claimant received seven physical therapy sessions between December 14, 2000 and January 31, 2001.
  9. The documentation was sufficient for the physical therapy rendered.
  10. Physical therapy (CPT codes 99213, 97265, 97250, 97122) rendered between December 14, 2000 and January 31, 2001 promoted the Claimant’s recovery and was medically necessary.
  11. The Claimant underwent work hardening between February 5 and March 16, 2001 based upon the results of a functional capacity evaluation (FCE) performed on February 5, 2001.
  12. The Provider failed to consider the Claimant’s knee condition and failed to have her evaluated by an orthopaedic specialist prior to enrolling her in their work hardening program.
  13. Undergoing work hardening with a torn meniscus in the knee is inappropriate without first consulting an orthopaedist.
  14. The Provider failed to consider whether the Claimant was capable of attaining specific employment upon completion of the program.
  15. The work hardening program the Claimant underwent between February 5 and March 15, 2001 was not appropriately documented by the Provider and was not medically necessary.
  16. The Carrier preauthorized two weeks of work hardening rendered to the Claimant by the Provider from June 13 through June 26, 2001.
  17. The FCE performed on February 5, 2001 was medically necessary.
  18. The FCEs performed on March 1 and 15, 2001 were not medically necessary as they were administered to evaluation the Claimant’s progress in the work hardening program, found above to be not medically necessary.
  19. The range of motion testing on December 28, 2000 and the reports dated March 29, June 6, and August 8, 2001 were medically necessary.

IV. Conclusions of Law

  1. 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(k) and Tex. Gov’t Code Ann. Ch. 2003 (Vernon 2000).
  2. The Provider timely filed its request for a hearing as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§ 2001.052.
  4. Physical therapy (CPT codes 99213, 97265, 97250, 97122) rendered between December 14, 2000 and January 31, 2001 was reasonably required health care under Tex. Lab. Code Ann.§408.021.
  5. The work hardening program the Claimant attended from February 5, 2001 through March 16, 2001 did not meet the criteria established in the 1996 Medical Fee Guideline, Medicine Ground Rules (MFG), II. E. at 37 adopted pursuant to 28 TAC §134.201 and was not medically necessary or reasonably required health care under Tex. Lab. Code Ann.§ 408.021.
  6. The FCEs performed on March 1 and 15, 2001 were not reasonably required health care under Tex. Lab. Code Ann.§ 408.021.
  7. Range of motion testing provided on December 28, 2000, the FCE performed on February 5, 2001 and reports dated March 29, June 6, and August 8, 2001 were reasonably required health care under Tex. Lab. Code Ann. § 408.021.
  8. The Carrier should reimburse the Provider for the two weeks of preauthorized work hardening the Claimant underwent from June 13 through June 26, 2003.

ORDER

IT IS, THEREFORE, ORDERED that the Mesquite Independent School District shall reimburse Central Dallas Rehabilitation and Diagnostic for: physical therapy (CPT codes 99213, 97265, 97250, 97122) rendered between December 14, 2000 and January 31, 2001; work hardening rendered between June 13 and June 26, 2001; range of motion testing provided on December 28, 2000; the FCE performed on February 5, 2001; and reports dated March 29, June 6, and August 8, 2001. Reimbursement for all other services is denied.

Signed September 15th, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JANET R. DEWEY
Administrative Law Judge

  1. 1996 Medical Fee Guideline, Medicine Ground Rules, II. E. at 37.
End of Document
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