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At a Glance:
Title:
453-03-2173-m2
Date:
July 18, 2003
Status:
Pre-Authorization

453-03-2173-m2

July 18, 2003

DECISION AND ORDER

This case concerns a request for preauthorization for a workers’ compensation claimant (Claimant) to participate in a chronic pain management program. The Administrative Law Judge (ALJ) concludes preauthorization should be granted.

I. Discussion

The Claimant incurred a compensable back injury_________. He underwent a lumbar fusion in December of 1999, and has received several types of conservative treatment, including rest, medication, physical therapy, chiropractic treatment, counseling, steroid injections, and biofeedback. North Texas Pain Management[1](NTPM) requested preauthorization to provide the Claimant thirty sessions of a chronic pain management program. The carrier, Sentry Insurance (Sentry), denied preauthorization. NTPM then filed a Request for Medical Dispute Resolution. The Independent Review Organization (IRO) denied the request on January 8, 2003. NTPM filed a timely request for a hearing, on January 22, 2003.

The hearing was held May 28, 2003, with ALJ Henry D. Card presiding. Representatives of NTPM and Sentry participated in the hearing, which was adjourned the same day.

The evidence shows the Claimant has received some relief from his previous therapy, but remains in considerable pain. Although his pain level cannot be objectively demonstrated, he is not malingering or otherwise exaggerating his symptoms. The Claimant’s pain is chronic, affects his activities of daily living, and has not responded to the individual treatment methods that have been employed.

On behalf of NTPM, Kenneth N. Walker, Ph.D., testified that the interdisciplinary approach of a chronic pain management program may achieve results that separate treatment modalities cannot. Dr. Walker provided a summary of rehabilitative guidelines and criteria that supported that assertion, and testified that the Claimant meets the guidelines for admission into the program. Those guidelines were unchallenged. The Claimant’s medical records showed he exhibits the physical symptoms, emotional and psychological difficulties, and treatment history that would warrant an interdisciplinary program.

The IRO decision suggested there was little likelihood of success without a clear statement of the patient’s status, treatment goals, and likely results. NTPM provided that information in the September 25, 2002, treatment plan that was included in evidence as part of the Claimant’s records. Ex. 1, page 17-20.

NTPM has the burden of proof in this proceeding. 28 Tex. Admin. Code '148.21(h). The ALJ concludes it met that burden and showed that the chronic pain management program is reasonably required by the nature of the Claimant’s injury, pursuant to Tex. Lab. Code Ann. §408.021, and should be preauthorized pursuant to 28 TAC §134.600.

II. Findings of Fact

  1. The Claimant incurred a compensable back injury_________.
  2. The Claimant underwent a lumbar fusion in December of 1999, and has received several types of conservative treatment, including rest, medication, physical therapy, chiropractic treatment, counseling, steroid injections, and biofeedback.
  3. NTPM requested preauthorization to provide the Claimant thirty sessions of a chronic pain management program.
  4. After Sentry denied preauthorization, NTPM filed a Request for Medical Dispute Resolution.
  5. The IRO denied the request on January 8, 2003.
  6. NTPM filed a timely request for a hearing, on January 22, 2003.
  7. Notice of the hearing was sent to the parties February 18, 2003.
  8. 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.
  9. The hearing was held May 28, 2003, with ALJ Henry D. Card presiding. Representatives of NTPM and Sentry participated in the hearing, which was adjourned the same day.
  10. The Claimant has received some relief from his previous therapy, but remains in considerable pain.
  11. Although the Claimant’s pain level cannot be objectively demonstrated, he is not malingering or otherwise exaggerating his symptoms.
  12. The Claimant’s pain is chronic, affects his activities of daily living, and has not responded to the individual treatment methods that have been employed.
  13. The interdisciplinary approach of a chronic pain management program may achieve results that separate treatment modalities cannot.
  14. The Claimant exhibits the physical symptoms, emotional and psychological difficulties, and treatment history that would warrant an interdisciplinary pain management program.
  15. NTPM provided a clear statement of the Claimant’s status, treatment goals, and likely results.

III. Conclusions of Law

  1. 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.
  2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  3. NTPM has the burden of proof in this proceeding. 28 Tex. Admin. Code §148.21(h).
  4. The chronic pain management program is reasonably required by the nature of the Claimant’s injury, pursuant to Tex. Lab. Code Ann. §408.021.
  5. The chronic pain management program should be preauthorized pursuant to 28 TAC §134.600.

ORDER

IT IS, THEREFORE, ORDERED that North Texas Pain Management is authorized to provide the Claimant thirty sessions of a chronic pain management program.

Signed this 18th day of July, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. North Texas Pain Management formerly was known as Lake Arlington Center for Pain Management.
End of Document
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