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At a Glance:
Title:
453-03-2349-m4
Date:
May 22, 2003
Status:
Medical Fees

453-03-2349-m4

May 22, 2003

DECISION AND ORDER

The issue in this case is whether the University of Texas System (Carrier) should reimburse $5,218.00 for discography rendered to the Claimant on May 30, 2001, and June 6, 2001. The Administrative Law Judge finds the Provider is not entitled to any additional reimbursement.

The hearing convened before Janet R. Dewey, Administrative Law Judge (ALJ), at the State Office of Administrative Hearings (SOAH) on April 24, 2003, 300 West 15th Street, Fourth Floor, Austin, Texas. Ashley Russell appeared on behalf of the Carrier. The Provider failed to appear in person or through counsel and failed to file a motion for continuance. After the conclusion of the hearing, the Provider requested that the hearing be reset and the ALJ denied the request.

Based upon the evidence presented the ALJ finds that the Carrier is not required to pay additional reimbursement to the Provider because the Carrier has already reimbursed the Provider for the preauthorized discogram.

I. Findings of Fact

  1. The Claimant sustained a compensable injury on___________.
  2. The Carrier denied payment for discograms performed on May 30, 2001, and June 6, 2001.
  3. The Provider requested dispute resolution from the Medical Review Division of the Texas Workers' Compensation Division.
  4. On April 2, 2002, the Carrier reimbursed the Provider $2,742.50, which represented payment for five levels of discography.
  5. On December 31, 2002, the MRD found that all of the services were preauthorized and the Provider was owed $4,606.50 in additional reimbursement. The MRD did not have a record of the Carrier's previous payment to the Provider.
  6. On January 6, 2003, the Carrier appealed the MRD decision.
  7. Notice of hearing was sent March 6, 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.
  8. The hearing was convened on April 24, 2003 with Administrative Law Judge (ALJ) Janet Dewey presiding and representatives for the Carrier participating. The Respondent failed to appear and did not file a motion for continuance. The hearing was recessed and the record closed the same day.
  9. On March 1, 2001, Dr. Stephen Esses, M.D., an orthopaedic surgeon, requested that the Claimant’s treating physician, Dr. Mark Plummer, D.C., arrange for CT discograms at the T 7-8, T 8-9, T 8-9 levels of the Claimant’s spine. He also wrote out a prescription that identified the specific levels of the spine for which he ordered discography.
  10. On April 12, 2001, Mark Plummer, D.C. filed a request with the Carrier to preauthorize a referral to the Provider for AImaging-CT Discogram T7/8, T8/9 and T9/10.
  11. On pril 17, 2001, the Carrier preauthorized a one-time ACT Discogram Thoracic, but did not specify particular levels of the spine.
  12. On May 30, 2001, the Provider performed discography on the T 8-9, T 9/-10, T 10-11, T 11-12, and T 12-L1 level of the spine. On June 6, 2001, the Claimant returned and the Provider performed discography on the T5-6, T6-7 and T7-8 levels of her spine.
  13. Discography on the T5-6, T6-7, T10-11, T11-12, and T12-L1 levels of the spine were not approved or recommended by Dr. Plummer.

II. 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(k) (Vernon Supp. 2003) and Tex. Gov’t Code Ann. Ch. 2003 (Vernon 2000 and Vernon Supp. 2003).
  2. The Carrier 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 (Vernon 2002).
  4. The Provider has the burden of proof in this matter. 28 TAC '148.21(h).
  5. Pursuant to Tex. Lab. Code Ann.§ 408.021 (Vernon 1996) employees who sustain compensable injuries are entitled to all health care reasonably required by the nature of the injury as and when needed. Except in an emergency, all health care must be approved or recommended by the employee’s treating doctor.
  6. Because discography on the T5-6, T6-7, T10-11, T11-12, and T12-L1 levels of the spine were not approved or recommended by Dr. Plummer, the Carrier is not required to provide additional reimbursement, despite that fact that the preauthorization did not specify particular levels of the spine.

ORDER

IT IS, THEREFORE, ORDERED that Downtown Plaza Imaging’s claim for additional reimbursement from the University of Texas System is DENIED.

Signed May 22nd, 2003

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JANET R. DEWEY
Administrative Law Judge

End of Document
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