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At a Glance:
Title:
453-03-3035-m5
Date:
September 23, 2003
Status:
Retrospective Medical Necessity

453-03-3035-m5

September 23, 2003

DECISION AND ORDER

Main Rehab & Diagnostic (Provider) appealed an Independent Review Organization (IRO) determination upholding a Liberty Mutual Fire Insurance Company (Carrier) decision denying it reimbursement, on the basis of medical necessity, for certain chiropractic services it provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that the claim should be denied because the services at issue were not medically necessary to treat Claimants compensable injury.

I. Procedural History and Jurisdiction

A hearing convened on July 21, 2003, before the undersigned ALJ at the State Office of Administrative Hearings (SOAH), 300 West 15th Street, Austin, Texas. Provider by appeared by telephone and was represented by Attorney Scott C. Hilliard. Carrier appeared and was represented by Attorney Charlotte Salter. The hearing concluded on July 21, 2003, and the record closed on August 4, 2003.

As there were no issues concerning notice or jurisdiction, those matters are stated in the fact findings and legal conclusions without further discussion here.

II. Discussion

A.Background

This case involves a 46-year-old female who sustained a work related injury on_________, as a result of dropping a box on her left wrist and forearm. A thorough orthopedic and neurological evaluation showed carpal tunnel syndrome accompanied with cervical segmental dysfunction complicated by a component of reflex sympathetic dystrophy. Provider treated Claimant with passive therapies and range of motion exercises. Claimant did not show improvement under Provider's care and later underwent carpal tunnel surgery.

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 injury; (2) promotes recovery; or (3) enhances the ability to return to or retain employment. Tex. Labor Code Ann. § 408.021. "Health care" includes "all reasonable and necessary medical . . . services.§§Tex. Labor Code §401.011(19).

B.Analysis

Both parties offered testimony relating to the medical necessity of the treatments. Provider offered the testimony of the treating chiropractor, Osler Karnath, who stated that the treatments were necessary because the diagnosis of carpal tunnel syndrome was not clear for a period of time and that the treatments were of benefit to Claimant. Carrier's witness Thomas Sato, also a chiropractor, referred to documentary evidence that indicated the diagnosis of carpal tunnel syndrome was made before the treatments in issue and that Claimant should have been referred to a hand surgeon immediately. Dr. Sato added that Claimant received no benefit from the treatments and none could have been reasonably predicted.

The ALJ concludes that the disputed services were not medically necessary. The documentary evidence indicates that the diagnosis of carpal tunnel syndromewas made prior to the treatments. Consequently, Claimant should have been referred to a hand surgeon at the time the diagnosis was made. The documentary evidence further indicates that the treatments did not benefit Claimant and that the treatment should not have been expected to benefit Claimant. The ALJ concludes, therefore, that the treatments were not medically necessary and Provider should not be reimbursed.

III. Findings of Fact

  1. Main Rehab & Diagnostic (Petitioner or Provider), appealed an Independent Review Organization determination upholding a Liberty Mutual Fire Insurance Company (Carrier) decision denying it reimbursement, on the basis of medical necessity, for certain chiropractic services it provided to an injured worker (Claimant) from April 25, 2002, through September 24, 2002.
  2. All parties received not less than 10 days notice of the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing was to be held; the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
  3. The disputed care consists of passive therapies and range of motion exercises provided by Main Rehab & Diagnostic.
  4. The Claimant was a 46-year-old female who suffered a work-related injury on________, when she dropped a box on her left wrist and forearm.
  5. Claimant was diagnosed with carpal tunnel syndrome accompanied with cervical segmental dysfunction complicated by a component of reflex sympathetic dystrophy.
  6. Claimant did not improve under Providers care.
  7. Providers treatment of Claimant could not have been reasonably calculated to result in any benefit for Claimant.

IV. Conclusions of Law

  1. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code Ann. '413.031(d) and Tex. Govt Code Ann. ch. 2003.
  2. All parties received adequate and timely notice of the hearing. Tex. Govt Code Ann. '' 2001.051 and 2001.052.
  3. Providers treatment of the Claimant was not medically necessary. Tex. Lab. Code Ann. '413.021.
  4. Providerss claim for treatment to the Claimant should be denied.

ORDER

IT IS, THEREFORE, ORDERED that the claim of Main Rehab & Diagnostic against Liberty Mutual Fire Insurance Company for treatments and services to Claimant from April 25, 2002, through September 24, 2002. is denied.

Signed September 23rd, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JOHN H. BEELER
Administrative Law Judge

End of Document
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