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At a Glance:
Title:
453-03-1715-m5
Date:
June 4, 2003
Status:
Retrospective Medical Necessity

453-03-1715-m5

June 4, 2003

DECISION AND ORDER

David Dolezal, D.C., seeks reimbursement from Texas Mutual Insurance Company (TMIC) for office visits with manipulations, therapeutic exercises, gait training therapy, and neuromuscular re-education provided to claimant____ from March 18, 2002, to May 13, 2002. The amount in dispute is $8,812.00. The independent review organization (IRO) designated by the Texas Workers’ Compensation Commission (TWCC or Commission) determined that the treatments were not medically necessary. The Administrative Law Judge (ALJ) finds that the evidence supports the IRO’s decision, and determines that TMIC should not have to reimburse Dr. Dolezal for the services at issue.

I. Jurisdiction, Notice, and Procedural History

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. 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 and Tex. Gov’t Code Ann. ch. 2003.

The IRO issued its decision on November 21, 2002. Dr. Dolezal timely requested a hearing. Proper notice of the hearing was issued January 14, 2003. The hearing was convened April 11, 2003, with ALJ Shannon Kilgore presiding. Dr. Dolezal appeared by telephone. Jeff Boggess appeared for TMIC. The hearing was adjourned the same day. The record was held open for the post-hearing submission of written closing arguments. The record closed April 29, 2003.

II. Legal Standards

Section 408.021 of the Texas Labor Code states:

(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.

Section 401.11(19) defines “health care” to include “all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services.”

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

III. Discussion

Background. The workers’ compensation claimant in this case suffered a work-related injury on__________, when she was lifting a 50-pound sack of onions and felt a pain in her lower back. She began seeing Dr. Dolezal on September 21, 2001. Dr. Dolezal treated the claimant with passive modalities and physical medicine through late November 2001. After November 2001, she did not see Dr. Dolezal again until March 2002.[1] The claimant underwent an MRI on March 18, 2002, that revealed a “posterior central radial annular tear with posterior focal central disc protrusion without extrusion and with impression upon the thecal sac.” Petitioner Exhibit 1, p. 15. On the same day, she began a program administered by Dr. Dolezal consisting of manipulations, therapeutic exercises, gait training therapy, and neuromuscular re-education. The claimant received such therapy on 20 different days over an eight-week period from March 18 through May 13, 2002. Dr. Dolezal billed for these treatments under CPT Codes: 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97116 (gait training therapy), and 99213-MP (office visit with manipulation). TMIC declined to pay for these services, asserting that they were medically unnecessary. See Petitioner Exhibit 1, pp. 59 - 108. Dr. Dolezal requested medical dispute resolution.

On November 21, 2002, an independent review organization (IRO) issued a decision finding that the disputed services were unnecessary. The IRO stated that Dr. Dolezal’s documentation was inadequate and it appeared from the documentation available that the claimant’s condition was unchanged by the therapy.

Dr. Dolezal’s evidence. Dr. Dolezal provided his direct testimony in the form of a written statement. See Petitioner Exhibit 1, pp. 4 - 6 (“Addendum for Inclusion in SOAH Dispute”). Dr. Dolezal noted that on February 27, 2002, Richard Channing, D.C., a designated doctor, examined the claimant and issued a report. Petitioner Exhibit 1, pp. 8 - 13. The report stated that the claimant suffered from low back pain radiating into her left leg, as well as limited range of motion in her lumbar spine. The intensity of her pain was four on a scale of zero to ten. The pain was causing mild to moderate diminution in her ability to carry out activities of daily living. Dr. Channing stated that the claimant was not at maximum medical improvement, and would likely have continued future problems. He recommended an MRI to rule out a herniated disc and, depending on the results of the MRI, a work hardening program.

Dr. Dolezal stated that the claimant’s range of motion improved over the course of the therapy. He also asserted that his examination of the patient in November 2001, Dr. Channing’s examination in February 2002, and the MRI done in March all provided a sufficient baseline for the commencement of the treatment program in March.

There are exam notes for four dates in the record. The first is for November 12, 2001, when Dr. Dolezal reported that the claimant’s pain was at a level of four on a scale of zero to ten. On November 28, 2001, the claimant reported that her pain was up to a level of five. These first two dates were during the period when the claimant was receiving passive therapy and physical medicine treatment, over three months prior to the beginning of the disputed exercise and training program. The next exam note in the record is from April 17, 2002 B about four weeks into the exercise and training program. This note says that the claimant’s pain was at a level of 3/4 and that her range of motion was improved (although the note does not say against what prior range of motion assessment her current condition was being compared). The last exam note is from May 22, 2002. This date was after the dates of service at issue here. In this exam note, Dr. Dolezal stated that the claimant was doing better but still had lower back pain. The note does not specify the level of pain. Dr. Dolezal reported modest improvements in range of motion compared to the April 17 assessment. He also mentioned the possibility that the claimant would receive epidural steroid injections if the therapeutic exercise did not fully resolve her pain. Other than these April 17 and May 22 exam notes, the HCFA-1500 billing forms are the only documents in evidence that record what happened on the disputed dates of service.[2]

TMIC’s evidence. The carrier offered the testimony of William D. Defoyd, D.C., as well as a set of guidelines for chiropractic practice[3] and the Spine Treatment Guideline.[4] Dr. Defoyd asserted that Dr. Dolezal’s documentation does not establish medical necessity for the disputed course of therapy.[5] He testified that Dr. Dolezal should have done a baseline assessment of the claimant’s condition shortly before commencing the therapeutic exercise program, especially since Dr. Dolezal had not seen the claimant for about four months when he began administering the exercise program. He further stated that Dr. Dolezal should have checked to see if the patient’s symptoms were consistent with the results of the MRI.

Dr. Defoyd testified that Dr. Dolezal’s documentation was so inadequate it is impossible to know exactly what was done at each visit and whether the treatments were effective. In particular, he stated that the documentation fails to reflect the exact body part involved in each treatment, the reason for the treatment, the frequency and intensity of each particular exercise, and the patient’s response. According to Dr. Defoyd, full documentation is necessary for good patient care and to determine whether the treatments were helpful. He asserted that the patient’s progress should have been re-evaluated at about two-week intervals to determine if the treatment was working. Dr. Defoyd stated he is unable to tell from the documentation why the claimant underwent gait training and neuromuscular re-education, treatments usually provided for patients who have suffered a stroke or spinal cord injury. He also noted that for every visit Dr. Dolezal billed for two hours therapeutic exercise as well as both neuromuscular re-education and gait training. Dr. Defoyd stated that the sparse documentation makes it impossible to ensure that Dr. Dolezal was not double-billing.

As to the manipulations, Dr. Defoyd testified that according to professional guidelines on which he relies, lumbar manipulation is not recommended for treatment of a herniated disc.

ALJ’s analysis. The ALJ agrees that Dr. Dolezal’s documentation fails to establish that the treatments provided were medically necessary. There is insufficient information in the record to justify an eight-week course of intensive, unvarying treatment. There is no indication that the patient’s progress was closely followed and the course of therapy reassessed (and adjusted, if necessary) at periodic intervals depending on the patient’s response to treatment. It is not possible to tell from the record whether the program was effective and, if so, how effective it was. Pain was one of the patient’s chief complaints; however, there is no report of the patient’s level of pain from March, when the program began, nor from May, when it ended. With respect to range of motion, there is no documentation of her status in March, when the disputed treatment began. The ALJ is not persuaded that the range of motion assessment done in November is adequate for use in assessing the effectiveness of the treatment begun in mid-March.[6] There is therefore no sufficient baseline in the record against which to compare the range of motion assessments performed by Dr. Dolezal in April and May.

In addition, the ALJ is troubled by Dr. Defoyd’s testimony that gait training and neuromuscular re-education are treatments usually employed in cases of stroke or spinal cord injury. The ALJ could find nothing in the record that would explain why these treatments were administered to this patient.

Accordingly, the ALJ finds no reason to disturb the conclusion of the IRO.

IV. Findings of Fact

  1. The claimant____ suffered a compensable back injury.
  2. Texas Mutual Insurance Company (TMIC) is the workers’ compensation insurer with respect to the claims at issue in this case.
  3. David Dolezal, D.C., provided treatment to the claimant on 20 different days over an eight-week period from March 18 through May 13, 2002. Dr. Dolezal administered manipulations, therapeutic exercises, gait training therapy, and neuromuscular re-education.
  4. Dr. Dolezal billed for these treatments under CPT Codes: 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97116 (gait training therapy), and 99213-MP (office visit with manipulation).
  5. TMIC declined to pay for these services, asserting that they were medically unnecessary.
  6. The amount in dispute is $8,812.00.
  7. Dr. Dolezal requested medical dispute resolution.
  8. On November 21, 2002, an independent review organization (IRO) issued a decision finding that the disputed services were unnecessary. The IRO stated that Dr. Dolezal’s documentation was inadequate and it appeared from the documentation available that the claimant’s condition was unchanged by the therapy.
  9. Dr. Dolezal timely requested a hearing.
  10. Notice of the hearing was issued January 14, 2003.
  11. 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.
  12. The hearing was convened April 11, 2003, with ALJ Shannon Kilgore presiding. Dr. Dolezal, representing himself, appeared by telephone. Jeff Boggess appeared for TMIC. The hearing was adjourned the same day. The record was held open for the post-hearing submission of written closing arguments. The record closed April 29, 2003.
  13. There is insufficient information in the record to justify an eight-week course of intensive, unvarying treatment.
  14. There is no indication that the patient’s progress was closely followed and the course of therapy reassessed (and adjusted, if necessary) at periodic intervals depending on the patient’s response to treatment.
  15. Pain was one of the patient’s chief complaints; however, there is no report of the patient’s level of pain from March, when the program began, nor from May, when it ended.
  16. There is no documentation of the patient’s range of motion in March, when the disputed treatment began, and there is therefore no sufficient baseline in the record against which to compare the range of motion assessments performed by Dr. Dolezal in April and May.
  17. It is not possible to tell from the documentation whether the program was effective and, if so, how effective it was.
  18. There is no justification in the record for administration of gait training and neuromuscular re-education to this patient.
  19. The disputed treatments were medically unnecessary.

V. 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 ch. 401 et seq.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code § 413.031; Tex. Gov’t Code ch. 2003.
  3. 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 § 408.021.
  4. Adequate and timely notice of the hearing was provided in accordance with the Administrative Procedure Act. Tex. Gov’t Code § 2001.052.
  5. Dr. Dolezal has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
  6. Based on Findings of Fact 13 through 19, TMIC does not have to reimburse Dr. Dolezal for the disputed treatments.

ORDER

IT IS THEREFORE ORDERED that Texas Mutual Insurance Company need not pay for manipulations, therapeutic exercises, gait training therapy, and neuromuscular re-education administered to the claimant_____ on 20 days over an eight-week period from March 18 through May 13, 2002.

Signed this 4th of June, 2003.

Shannon Kilgore
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Apparently, the gap in treatment was related to the pendency of a compensability dispute.
  2. See Petitioner Exhibit 1, pp. 59 - 109. On cross-examination, Dr. Dolezal testified that his “SOAP” (subjective, objective, assessment, plan) notes from the contested period of treatment, which are not in evidence and were apparently not provided to the IRO, did not include any detailed information about the therapies provided, but only listed date, area of complaint, treatment delivered, and date to return. For identification of the treatment, Dr. Dolezal would check a box by each relevant item (e.g., “gait training” or “neuromuscular re-education”). While the form had a place for the doctor to make comments, no comments were written on any of the forms relating to the disputed dates of service.
  3. Respondent Exhibit 2 (Guidelines for Chiropractic Quality Assurance and Practice Parameters, Proceedings of the Mercy Center Consensus Conference, 1993).
  4. See 28 Tex. Admin. Code § 134.1001 (West 2002) (abolished by statute effective January 1, 2002). Though not presently in effect, the Spine Treatment Guideline can provide some guidance about the reasonableness of treatments for spinal conditions. The Spine Treatment Guideline addresses the need for adequate documentation by health care providers. See Respondent Exhibit 3, pp. 8 - 11, 15.
  5. TMIC also argues that because Dr. Dolezal’s documentation is so poor, it is not clear that Dr. Dolezal even provided the services in question. The ALJ is not persuaded by this argument.
  6. Dr. Channing performed range of motion testing in February. Petitioner Exhibit 1. p. 10. However, Dr. Channing’s assessment results are not very helpful. First, the ALJ lacks the expertise to compare the results of his assessment, which are recorded as numerous values on a worksheet, to the numbers reported by Dr. Dolezal in November 2001 and April 2002. Petitioner Exhibit 1, pp. 17 - 20. Second, Dr. Channing’s assessment was done three weeks prior to the initiation of Dr. Dolezal’s treatment program.
End of Document
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