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At a Glance:
Title:
453-03-3611-m5
Date:
December 18, 2003
Status:
Retrospective Medical Necessity

453-03-3611-m5

December 18, 2003

DECISION AND ORDER

Mega Rehab, (Provider) appealed the Findings and Decision of the Texas Workers' Compensation Commission (Commission) acting through Maximus, an Independent Review Organization (IRO), denying Provider reimbursement for certain physical therapy sessions for the period June 14, 2002, through September 5, 2002, (Disputed Services). The amount in controversy is $1,260.00 plus interest. The Administrative Law Judge (ALJ) finds Petitioner is entitled to $1,260.00 plus applicable interest.

I. DISCUSSION

A hearing convened on October 22, 2003, before Administrative Law Judge (ALJ) Stephen J. Pacey. Stephen A. Dudas, D.C., represented Provider, Tommy Lueders represented Grapevine Colleyville ISD (Carrier). Christopher R. Mann, D.O., who provided the treatment to Claimant, testified on Petitioner’s behalf. There were no contested issues of notice or jurisdiction. The record closed following adjournment of the hearing the same day.

The Claimant suffered a work-related injury on ___. Claimant injured his back while lifting a commode into a box. On April 24, 2002, Dr. Guyer performed lumber fusion surgery on Claimant’s back at levels L4-L5 and L5-S1. The disputed services involve physical therapy sessions performed post-operative to Claimant.

Carrier refused to reimburse provider for the disputed services on the basis that the medical records of Dr. Mann did not indicate improvement in Claimant’s condition. In addition Carrier asserted that Claimant had a gap of service between June 14, 2002, and July 22, 2002, which indicated that further therapy was unnecessary.

Provider argued that although there was a gap in the chart outlining disputed services, there was not a gap in the patient’s therapy treatments. Dr. Mann testified that there were five therapy sessions during the purported gap period. Dr. Mann indicated that Claimant bounced back dramatically for a person who experienced very traumatic surgery a few months earlier. In Dr. Mann’s opinion, the documents reflected that Claimant was weaned off his back brace; had increased strength and range of motion; had increased physical activity; and most important, following a L4/L5 and L5/S1 fusion, and after twenty physical therapy sessions, Claimant was released to work full time.

The evidence preponderates in favor of the Provider. The Carrier has denied physical therapy services rendered approximately six weeks after a four vertebra back fusion.[1] The ALJ concurs with Provider that Claimant’s return to work in approximately three months and twenty therapy sessions indicated that Claimant was progressing and improving from the sessions. Provider is also correct in its assertion that most back surgeries require work hardening, which would have cost much more than physical therapy. The ALJ finds that the treatment provided was medically necessary.

II. FINDINGS OF FACT

  1. The Claimant suffered a work-related injury on ___, while lifting a commode into a box.
  2. On April 24, 2002, Dr. Guyer performed lumber fusion surgery on Claimant’s back at levels L4-5 and L5-S1.
  3. Provider performed physical therapy on Claimant from May 28, 2002, through September 5, 2002.
  4. By letter dated April 24, 2003, MAXIMUS, an independent review organization (IRO), concluded the services provided from June 14, 2002, through September 5, 2002, were not medically necessary for treatment of Claimant’s condition.
  5. By Order dated April 20, 2003, the Medical Review Division of the Texas Workers’ Compensation Commission, based upon the IRO decision, denied Provider’s claims for reimbursement from June 14, 2002, through September 5, 2002.
  6. Provider filed its request for a hearing on June 20, 2003.
  7. Notice of hearing was sent on July 1, 2003.
  8. The hearing convened on October 2215, 2003 with Administrative Law Judge (ALJ) Stephen J. Pacey presiding. Stephen A. Dudas, D.C., represented Provider and Tommy Lueders represented Carrier. The record closed the same day.
  9. There was no gap in Provider’s treatment of Claimant.
  10. The physical therapy sessions performed on Claimant improved Claimant’s condition. The therapy resulted in the following improvement:

a. Claimant no longer had to wear a brace.

b. Claimant had increased strength and range of motion.

c. Claimant had increased physical activity.

d. Claimant returned to work approximately three months from the beginning of physical therapy.

III. CONCLUSIONS OF LAW

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act, Tex. Lab. Code Ann. § 413.031.
  2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. § 413.031(k) and Tex. Gov’t Code Ann. Ch. 2003.
  3. Petitioner timely filed its request for a hearing as specified in 28 Tex. Admin. Code (TAC) § 148.3.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  5. Provider has the burden of proof in this matter. 28 TAC §148.21(h).
  6. Provider met its burden of proving that all of the services were medically necessary or reasonably required health care under Tex. Lab. Code Ann.§ 408.021.

ORDER

THEREFORE IT IS ORDERED that ____(employer) shall reimburse Mega Rehab $1,260.00 plus applicable interest.

Signed this 18th day of December 2003.

STEPHEN J. PACEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Carrier originally denied reimbursement for all physical therapy after the surgery. Carrier’s documentation opined that the back injury requiring surgery was not caused by the accident. Carrier did not raise this issue at the hearing. As this forum is inappropriate to make a compensability decision, this decision is based solely on the medical necessity of the physical therapy.
End of Document
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