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At a Glance:
Title:
453-03-2355-m5
Date:
July 31, 2003
Status:
Retrospective Medical Necessity

453-03-2355-m5

July 31, 2003

DECISION AND ORDER

Central Dallas Rehab (the Petitioner) seeks reimbursement from Continental Casualty Company (the Carrier) for $1,450.00 for several services involving nerve testing provided to workers’ compensation claimant ____ on ___. The Petitioner challenges the decision of an Independent Review Organization, which awarded reimbursement for only $48.00 because it found that all but one of the disputed services were not medically necessary and were inadequately documented. This decision orders reimbursement in the amount of $1,450.00.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues regarding notice of the hearing. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

The hearing convened June 16, 2003, at the Hearings Facility of the State Office of Administrative Hearings (SOAH) before SOAH Administrative Law Judge (ALJ) John H. Beeler. The Petitioner appeared by telephone represented by Attorney Scott Hilliard. The Carrier was represented by Attorney Phong Phan. The Commission did not appear. After receipt of evidence, the record was closed the same day.

II. EVIDENCE AND BASIS FOR DECISION

Although the parties offered conflicting evidence concerning the issue of medical necessity, that issue does not need to be addressed. Carrier denied reimbursement based on Code V, unnecessary treatment based on a peer review. The undisputed evidence received in the hearing established that there has been no peer review concerning the disputed services. Commission Rule set out at 28 TAC §133.304 (c) requires the Carrier to specifically state the reasons for denial of payment. Because the Carrier’s basis for denial is nonexistent, reimbursement is ordered.

III. FINDINGS OF FACT

  1. On_________, Claimant_____ sustained a compensable injury to her back.
  2. At the time of the Claimant’s compensable injury, Continental Casualty Company (the Carrier) was the workers’ compensation insurer for Claimant’s employer.
  3. On November 11, 2001, Central Dallas Rehab, (Petitioner) provided services to the Claimant.
  4. The Carrier denied reimbursement for expenses in the amount of $1,450.00 associated with the services identified in Finding of Fact No. 3.
  5. The stated basis for denial was Code V, which means unnecessary based on a peer review.
  6. No peer review was done concerning the services provided to Claimant by Petitioner.
  7. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission, which referred the matter to an Independent Review Organization.
  8. The Independent Review Organization (IRO) ordered reimbursement in the amount of $48.00.
  9. The Petitioner timely appealed the IRO decision.
  10. Notice of the hearing was sent February 3, 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 held June 16, 2003.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (the Act), Tex. Lab. Code Ann. § 413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and Tex. Gov't Code Ann. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov't Code Ann. ch. 2001.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov't Code Ann. §§ 2001.051 and 2001.052.
  5. The Carrier’s denial of the disputed services was not in compliance with 28 TAC §133.304 (c).
  6. Based on the foregoing, the Petitioner’s claim for reimbursement from the Carrier for the disputed chiropractic treatment should be sustained.

ORDER

Continental Casualty Company shall reimburse Central Dallas Rehab $1,450.00, plus applicable interest, for the services in dispute.

Signed this 31st day of July, 2003.

JOHN H. BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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