DECISION AND ORDER

Texas Mutual Insurance Company (Petitioner) requested a hearing to contest the July 22, 2003, Findings and Decision of the Texas Workers’ Compensation Commission (Commission) authorizing reimbursement for office visits,^[1] therapeutic exercises,^[2] aquatic therapy,^[3] phonophoresis and phonophoresis cream,^[4] massage therapy,^[5] diagnostic interview,^[6] and preparation of report^[7] from January 28, 2002, through May 7, 2002 (Disputed Services).^[8] Carrier has the burden of showing by a preponderance of the evidence that the Disputed Services were not medically necessary. This decision denies the relief sought by Carrier and grants reimbursement to Provider for the Disputed Services.

The hearing convened on February 2, 2005, before Administrative Law Judge (ALJ) Catherine C. Egan at the State Office of Administrative Hearings, Austin, Texas. Attorneys Chris Trickey and Tom Hudson represented Carrier. Attorney Keith Gilbert represented Provider. William DeFoyd, D.C., Nicholas Tsourmas, M.D., and Alfred Ball testified for Carrier. Robert S. Howell, D.C., Provider’s owner, testified for Provider. There were no contested issues of notice or jurisdiction.

The hearing adjourned and, at the request of the parties, the record remained open for the filing of briefs regarding the admission of a deposition and other items. On February 16, 2005, Carrier filed a brief in support of the admission of the deposition of Sam Allen, D.C. Provider filed no response, and, on February 21, 2005, the deposition was admitted and the record closed.

I. BACKGROUND

___ (Claimant), a 54-year old male, sustained a work-related injury on ___, when he slipped and fell into a ditch while carrying plywood. Claimant experienced lower back pain that radiated into his left leg. He was treated with passive physical therapy through May 11, 2000, that was unsuccessful in relieving his pain. On May 9, 2000, Claimant underwent a lumbar MRI that showed “a small left subligamentous L4-5 disc herniation and also borderline spinal stenosis . . . chronic degenerative disc changes at the L2 level, but without a disc herniation or stenosis at L2.”^[9] On May 26, 2000, Claimant went to Provider for treatment. Provider treated Claimant in May, June, July and August 2000, but Claimant’s condition continued to deteriorate.

On September 11, 2000, Claimant underwent lumbar spinal fusion surgery. Claimant returned to Provider for rehabilitative therapy following this surgery. On August 23, 2001, Claimant underwent spinal surgery to insert a trial spinal cord stimulator on his spine. On October 4, 2001, a permanent spinal cord stimulator was inserted. After the dates of the Disputed Services, the battery

of the stimulator had to be replaced surgically on June 18, 2002. Ultimately, on April 1, 2003, Claimant underwent spinal surgery to remove the hardware from prior surgeries.

II. LEGAL ISSUE

Pursuant to 28 Tex. Admin. Code (TAC)§ 133.304(c), when a carrier denies payment, the carrier must send an explanation of benefit (EOB) to the appropriate party with the proper exception code and “sufficient explanation to allow the sender to understand the reason(s) for the insurance carrier’s action(s). A generic statement that simply states a conclusion such as not sufficiently documented’ or other similar phrases with no further description of the reason for the reduction or denial of payment does not satisfy the requirements of this section.”

Carrier denied most of the claims for the Disputed Services under payment exception code “U” for “unnecessary treatment (without peer review).”^[10] Carrier’s explanation for denying these services was set out in Carrier’s rationale code “RG,” described on the EOB as “the treatment/service provided exceeds medically accepted utilization review criteria and/or reimbursement guidelines established for severity of injury, intensity of service and appropriateness of care.”^[11] Occasionally, Carrier would change the rationale code. Another rationale code used by Carrier was “YU” which is described in the EOB as “[t]his service has been deemed unnecessary medical treatment based on a review of the claim file, billing records, and written review protocols established for appropriate health care treatment.”^[12]

Provider filed a request for reconsideration with Carrier on the denied claims and asked that Carrier explain the protocols, criteria, and guidelines it relied on to deny the claims. According to Dr. Howell, Carrier’s rationale codes did not explain the reason Carrier found the services were

medically unnecessary. Carrier did not disclose to Provider the relevant protocols, criteria, and guidelines. Carrier did not retain Dr. Tsourmas or Dr. DeFoyd until late in 2004, well after this contested case proceeding began. Obviously, neither of them was involved in Carrier’s decision to deny this claim nor could they testify as to the meaning of the criteria and guidelines Carrier relied upon in the EOBs.^[13]

Mr. Ball currently serves as Carrier’s dispute analyst, but began as a nurse on an audit team reviewing spinal surgery and hospital bills. Mr. Ball explained that Carrier’s medically accepted utilization review criteria and its reimbursement guidelines established for severity, intensity, and appropriateness of care are “proprietary and confidential.” Therefore, this information was not given to Provider.^[14]

Crrier may not substitute at a much later date a reason or an explanation other than that provided by Carrier when it denied the claims. The physicians who testified at the hearing on behalf of Carrier were unable to testify regarding Carrier’s criteria and guidelines referenced in the EOBs using rationale codes ARG and AYU. Under the Commission’s rules, Carrier’s explanation was insufficient. The Commission’s rules will not permit Carrier now to substitute an explanation that was not furnished in compliance with 28 TAC ‘ 133.304(c).^[15] Therefore, where Carrier failed to timely submit a sufficient explanation of its denial, it may not now create one to deny the claim based on lack of medical necessity.

Crrier did, however, deny some of the Disputed Service claims with sufficient information on the EOB to allow Provider to understand the reason the Carrier denied the claims. Specifically, Carrier denied the office visits billed under CPT Code 99211 with rationale code AJY for the office visits provided on February 1, 4, 6, 8, 11, 13, 15, 18, 20, and 22, 2002. Rationale code AJY is

defined on Crrier’s EOBs as the level, type, extent, or frequency of service and/or deviation from TWCC medical/acute care fee guidelines was not support by documentation submitted. This service is denied as medically unnecessary.^[16] Carrier’s rationale code AJY provides a sufficient explanation for Provider to understand why Carrier denied these claims.

Likewise, the same is true for the Disputed Service claims provided on March 28, 2002, for a special report (unbundling); the office visit provided on April 9, 2002, denied due to illegible supporting documentation; and for the psychiatric examination and report provided on May 7, 2002, denied for lack of preauthorization. For these Disputed Claims, Carrier’s explanation for denying the claims was sufficient for Provider to have understood the reason Carrier denied the claims.

III. WERE THE DISPUTED MEDICAL SERVICES

MEDICALLY UNNECESSARY?

A. IRO’s Decision and the Medical Record

On January 31, 2003, after chronicling Claimant’s lengthy medical history, the independent review organization (IRO) determined that the services in dispute were medically necessary.^[17] The IRO reported that Carrier did not present any documentation to substantiate its reason for denying payment as required by Commission rule 133.304(c) Aother than to say that the care exceeded medically accepted UR criteria and TWCC treatment guidelines.^[18] The IRO disagreed and affirmed that the Spinal Treatment Guidelines^[19] allow for the care provided to Claimant by Provider in the tertiary phase of care. According to the IRO, Claimant’s condition Aat the time of treatment is consistent with the clinical indicators for tertiary phase of care . . ..^[20]

The IRO concluded that the aquatic therapy, massage therapy, therapeutic exercise, physical medicine procedures, phonophoresis and the supplies, were medically necessary treatment. The IRO wrote A[t]he documentation presented indicates that Claimant needed the treatment, the treatment was performed, and Claimant benefitted from the treatment. Claimant’s injury required very individualized care that was interdisciplinary in nature. Claimant improved as a result of the care provided.^[21]

The MRD determined that medical necessity was not the only issue in dispute and reviewed a number of the Disputed Services. The MRD determined that the remaining services were supported by Provider’s documentation.^[22]

Provider documented in its February 19, 2002, interim assessment report that Claimant continued to have complaints of lower back pain and left lower extremity pain with numbness and tingling. Claimant did show some signs of improvement as Claimant’s visual analog pain scale had decreased, his Oswestry pain scale had improved, and his strength had improved. Provider’s explanation for aquatic therapy included the following:

The medical necessity of aquatic therapy is simple. It is a commonly accepted fact in the medical community that healing tissues should never be overstressed. If Claimant were subjected to active therapy (resistive/progressive) exercise too quickly, the consequences may be detrimental. Re-injury, increased pain, and decreased range of motion are the most common side effects. This will of course increase the amount of time it takes to heal the soft tissues. The longer the time it takes to heal the more costly it is. This is not the goal of the TWCC or the guidelines

it uses. By placing Claimant in water, his body weight or the affected area weight is reduced and stress is minimized significantly. By minimizing the stress on the injured area, range of motion will usually increase because the gravity factor is lowered therefore allowing for the naturally occurring sticking points of conventional progressive weights to be overcome with much more ease.^[23]

The following month, Provider documented in the March 19, 2002, interim assessment report that Claimant complained of moderate to severe lower back and left hip pain that radiated down both his legs. The muscle grading evaluation revealed abnormalities in Claimant’s hip flexion, extension and abduction; knee flexion and extension, and in his ankle and foot. Provider recommended that Claimant undergo a chronic pain management program.^[24] Throughout the dates of the Disputed Services, Claimant continued to experience improvements in his condition which periodically deteriorated due to the complications with his compensable injury.

B. Carrier’s Position and Evidence

Dr. Tsourmas, an orthopedic surgeon who works for Carrier as a medical director, reviewed Provider’s medical records to assess the medical necessity of the services in dispute. According to Dr. Tsourmas, he has referred patients to aquatic therapy when they suffered with lower extremity issues, such as a broken bone. He opined that during the time that a patient has to be careful with weight bearing exercises, short-term aquatic therapy is useful. However, the patient should progress to a land-based program as soon as it can be tolerated because it is “more efficacious regarding producing results with range of motion and strength.”^[25] Transitioning a patient from aquatic to land-based therapy may overlap, but not more than a few weeks-“Certainly not months or – or longer.”^[26]

As for this Claimant, Dr. Tsourmas testified that by January 2002, Claimant did not need one-on-one therapy at all.^[27] While Claimant may have needed “some reeducation, or augmenting a home program, or augmenting a self-directed program,” Carrier adequately reimbursed Providers by paying “one unit out of what actually was billed.”^[28] Therefore, Dr. Tsourmas opined, Claimant did not need any therapy in February, March, April, or May, 2002.^[29]

Dr. Tsourmas explained that one-on-one land-based physical therapy was unnecessary because Claimant already had a year and a half of experience in these programs. All Provider needed, in his opinion, was to check on Claimant and monitor his progress. As for the office visits to monitor Claimant to see if he would have an adverse reaction to the phonophoresis cream, Dr. Tsourmas testified, that once it was clear he did not react to the cream, it was not medically necessary to monitor him for an adverse reaction each time he had the treatment.^[30]

Dr. DeFoyd practices at the Spine and Rehab Center and treats spinal injuries.^[31] Dr. DeFoyd acknowledged that Claimant was documented as a non-swimmer, but he contends it did not justify one-on-one aquatic therapy. Claimant had sufficient instruction prior to this time in aquatic therapy

to know how to do the exercises without one-on-one supervision.^[32] Dr. DeFoyd noted that Claimant had no special needs that required one-on-one instruction. In conclusion, Dr. DeFoyd found that neither the aquatic therapy nor one-on-one therapy was medically necessary at this time.

Between January 2002 and May 2002, Dr. DeFoyd observed that Provider was treating Claimant with a mixture of both one-on-one aquatic therapy and one-on-one land-based therapy. Dr. DeFoyd disagreed that Claimant needed “to be in the water because weight is reduced and stress is minimized significantly.”^[33] Dr. DeFoyd maintains that land-based therapy is preferable to aquatic therapy for several reasons. First, humans function on land, not in water. Second, it is easier to encourage a patient to do a home program if the exercises do not require a pool. Finally, land-based exercise programs are generally less costly than aquatic programs. Aquatic therapy is used in cases where the patient cannot tolerate a land-based program because of weight bearing intolerance.^[34]

Dr. DeFoyd agreed with Dr. Tsourmas that the office visits to watch Claimant after a phonophoresis treatment to see if Claimant had an adverse reaction were not medically necessary. Moreover, Dr. DeFoyd opined that phonophoresis was not medically necessary at this stage of Claimant’s treatment.^[35] Similarly, he contends that all passive forms of therapy were not medically necessary two years after the compensable injury.^[36] According to Dr. DeFoyd, “[t]pically the longer someone goes with this kind of failed back surgery, difficult situation for this man – the less likely these passive things are going to be of significant benefit.”^[37]

C. Provider’s Position and Evidence

Dr. Howell has been a licensed chiropractor in Texas since October 1990. Provider’s clinic is a 12,300-square-foot facility with a junior Olympic indoor pool (77,000 gals), a 1,000-square-foot gym with modern weight lifting equipment, massage therapy rooms, examination rooms, physical

therapy rooms, an adjusting room, a reception area, administrative offices, bathrooms with six showers, a return-to-work area, and a chronic pain management area.^[38]

Dr. Howell testified that Claimant could only speak Spanish, was a diabetic, and could not swim. Claimant had degenerative spur formation at L2/L3 and L3/4, a laminectomy at L4/5, and degeneration at L5.^[39] As a result of Provider’s treatment, Claimant’s range of motion improved, his pain decreased, he improved in his ability to engage in activities of daily living, and his strength improved.^[40]

According to Dr. Howell, Claimant was suffering with displacement of lumbar intervertebral disc without myelopathy, lumbosacral joint or ligament sprain, sprain and strain of his left hip, radiculitis and myalgia and myositis, unspecified.^[41] Claimant was in the second and tertiary phases of care during this time period and Claimant’s orthopedic surgeon, Jorge Tijmes, M.D., directed Claimant to continue his physical therapy with Dr. Howell.^[42] Claimant was on several medications to treat his compensable injury, including Darvocet, a painkiller.^[43]

Dr. Howell testified that Carrier did not send Provider the required EOBs on most of these claims; hence, Provider did not know why Carrier had not paid them. Provider did file requests for reconsideration, asking for additional information as to the reason and protocols Carrier relied upon to deny the claims. Carrier did not provide this information.

D. ALJ’s Analysis

Crrier was required to show by a preponderance of the evidence that it properly denied Provider’s claims for services provided to Claimant due to a lack of medical necessity. Under the Commission’s rules, Carrier is required to provide an explanation for why it determined Provider’s medical services were not medically necessary at the time it issued the EOB. Carrier’s explanation codes ARG and AYU with their corresponding definitions provided no explanation, as the definitions relied upon Carrier’s confidential protocols, criteria and guidelines which Carrier chose not to disclose. Carrier’s own expert, Dr. Tsourmas, was unable to explain what Carrier meant in its definition of ARG, and neither expert knew what Carrier’s criteria and guidelines were. Despite Provider’s request for clarification about what protocols, criteria, and guidelines Carrier was referring to, Carrier failed to provide this information.

The ALJ notes that neither of Carrier’s experts could testify about why Carrier denied Provider’s claims at the time Carrier denied the claims, particularly since neither knew what Carrier’s criteria and guidelines provided. Carrier chose not to offer any evidence explaining what its proprietary criteria and guidelines stated or to clarify the rationale for denying the claims other than the global statement that they were not medically necessary. Consequently, the ALJ finds Carrier failed to show by a preponderance of the evidence why it denied Provider’s claims.

Carrier did comply with the Commission’s rules in providing a sufficient explanation to Provider for why it denied the office visits provided on February 1, 4, 6, 8, 11, 13, 15, 18, 20, and 22, 2002, under CPT 99211. Likewise, for Disputed Service claims provided on March 28, 2002, for a special report; the office visit provided on April 9, 2002; and for the psychiatric examination and report provided on May 7, 2002, Carrier’s explanation for denying the claims was sufficient for Provider to have understood the reason Carrier denied the claims.

The ALJ further finds Carrier failed to show by a preponderance of the evidence that the Disputed Services provided by Provider from January 28, 2002, through May 7, 2002, were not medically necessary. According to Carrier’s experts, passive therapy is not medically necessary two years after the compensable injury. However, Carrier appears to disregard the number of spinal surgeries Claimant has endured as a result of the compensable injury. Provider and the IRO maintain the passive therapies are medically necessary given Claimant’s condition as a result of the compensable injury. The ALJ agrees. Carrier’s experts further argued that Claimant did not need one-on-one aquatic and therapeutic therapy, office visits, massage therapy, and phonophoresis, at this stage of his treatment. This contradicts the opinion of Dr. Howell, the IRO, and Dr. Tijmes who maintain that because of Claimant’s disabling condition, he needed individualized and continued physical therapy treatment.

Claimant had undergone several spinal surgeries, both major and minor. Provider’s treatment helped Claimant’s physical condition given that he continued to experience debilitating pain and trauma to his spine. With Provider’s treatment, Claimant’s pain levels improved and his range of motion improved. As for the lack of preauthorization for Claimant’s mental health evaluation and report, the ALJ finds insufficient evidence to show that Provider had not requested preauthorization. Provider contends it did receive preauthorization; Carrier contends it did not. Carrier had the burden of proof. Therefore, the ALJ finds that Carrier failed to carry its burden of proof and Provider is entitled to recover the amount due for the Disputed Services.

IV. FINDINGS OF FACT

1. Claimant, a 54-year-old male, sustained a work-related injury on ___, when he slipped and fell into a ditch while carrying plywood (compensable injury).
2. On May 26, 2000, Claimant sought treatment from Robert S. Howell, First Rio Valley Medical, P.A. (Provider).
3. On September 11, 2000, Claimant underwent lumbar spinal fusion surgery.
4. Claimant continued to experience a great deal of lower back pain that radiated into his leg.
5. On August 23, 2001, Claimant underwent spinal surgery to insert a trial spinal cord stimulator.
6. On October 4, 2001, Claimant underwent spinal surgery to insert a permanent spinal cord stimulator.
7. On June 18, 2002, Claimant underwent spinal surgery to replace the battery on the spinal cord stimulator.
8. Provider diagnosed Claimant with failed back syndrome, thoracic or lumbosacral neuritis or radiculitis, displacement of lumbar intervertebral disc without myelopathy, and neuropathy.
9. Provider treated Claimant’s compensable injury from January 28, 2002, through May 7, 2002, and requested reimbursement from Carrier for the office visits, one-on-one aquatic therapy and therapeutic exercises, electrical stimulation, massage therapy, phonophoresis and phonophoresis cream, and mental health diagnostic interview and report (Disputed Services).
10. Texas Mutual Insurance Company (Carrier) issued an explanation of benefits (EOB) paying for one unit of the four units billed on January 28 and 30, 2002, for aquatic therapy and one unit of the two units billed for therapeutic exercises, but denying all other reimbursement.
11. Crrier denied reimbursement for the Disputed Services under the payment exception code AU, for Aunnecessary treatment (without peer review).
12. On most of the EOBs denying these Disputed Services, Carrier used the rationale code ARG,and its definition for this code, as its explanation to Provider for denying the claims.
13. Crrier defined ARG on the EOB as the treatment/service provided exceeds accepted utilization review criteria and/or reimbursement guidelines for severity of injury, intensity of service and appropriateness care.
14. Crrier also used AYU and its definition as another rationale code on the EOB to explain why it was denying Provider’s claims.
15. Crrier defined AYU on the EOB as A[t]his service has been deemed unnecessary medical treatment based on a review of the claim file, billing records, and written review protocols established for appropriate health care treatment.
16. Crrier refused to disclose to Provider the relevant protocols, utilization review criteria and/or reimbursement guidelines referenced in rationale codes ARG and AYU, asserting they were proprietary and confidential.
17. Carrier’s failure to disclose to Provider the relevant protocols, utilization review criteria and reimbursement guidelines rendered Carrier’s explanation insufficient for Provider to understand Carrier reason(s) for denying Provider’s claims.
18. Provider filed requests for reconsideration of the Disputed Services with Carrier and asked Carrier to identify what guidelines it was using as a basis to deny the claims and to explain the rationale behind its denial of the Disputed Services.
19. Carrier denied the requests for reconsideration, and failed to provide any additional information regarding the rationale behind its denial of the disputed claims, including the contents of the criteria and guidelines it relied upon.
20. Carrier denied the Disputed Service claims with a sufficient explanation on the EOB to allow Provider to understand the reason the Carrier denied the claims for the office visits provided on February 1, 4, 6, 8, 11, 13, 15, 18, 20, and 22, 2002, and billed under CPT Code 99211, because Carrier explained that the level, type, extent, or frequency of the service and/or deviation from TWCC medical/acute care fee guidelines was not supported by the documentation submitted.
21. Carrier denied the special report billed on March 28, 2002,with a sufficient explanation on the EOB to allow Provider to understand the reason the Carrier denied the claim was for unbundling.
22. Carrier denied the claim for the office visit provided on April 9, 2002, with sufficient explanation on the EOB to allow Provider to understand that the reason the Carrier denied the claims was because the supporting documentation was illegible.
23. Carrier denied the claims for the psychiatric examination and report provided on May 7, 2002, with sufficient explanation on the EOB to allow Provider to understand the reason the Carrier denied the claims was because Provider had not received preauthorization.
24. Carrier presented insufficient evidence to establish that Provider had not obtained preauthorization for Claimant’s mental health examination and report.
25. Claimant had undergone several spinal surgeries, both major and minor, and continued to experience debilitating pain and trauma to his spine.
26. The condition of Claimant’s lumbar spine after multiple spine surgeries rendered him disabled and in need of individualized treatment.
27. Provider’s treatment helped Claimant’s physical condition following his spinal surgeries.
28. As a result of Provider’s treatment from January 28, 2002, through May 7, 2002, Claimant’s range of motion improved, his pain decreased, his ability to engage in regular activities of daily living improved, and his strength improved.
29. The Disputed Services provided by Provider to Claimant were medically necessary to treat claimant’s compensable injury.
30. On January 31, 2003, an independent review organization (IRO) concluded that the Disputed Services were medically necessary to treat the compensable injury.
31. By Decision dated July 22, 2003, based on the IRO decision, the Texas Workers’ Compensation Commission (Commission) Medical Review Division determined the Disputed Services were medically necessary and granted Provider reimbursement.
32. Carrier timely requested a hearing to contest the Commission’s decision.
33. 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 matters asserted.
34. A hearing was convened by Administrative Law Judge Catherine C. Egan on February 2, 2005, in the hearing rooms of the State Office of Administrative Hearings. The hearing adjourned and the record closed February 21, 2005.
35. For the dates of service in question, Carrier failed to show that the Disputed Services were not medically necessary to treat Claimant’s compensable injury.

V. CONCLUSIONS OF LAW

1. 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 Tex. Lab. Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Carrier timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) § 102.7 and 148.3.
3. Notice of the hearing was proper and complied with the requirements of Tex. Gov’t. Code Ann. ch. 2001.
4. Carrier had the burden of proof in this matter, which was the preponderance of evidence standard. 28 TAC §§ 148.21(h) and (i); 1 TAC §155.41(b).
5. When an insurance carrier makes or denies payment on a medical bill, the carrier must include on the EOB the correct payment exception code and a sufficient explanation to allow the sender (Provider) to understand the reason for the carrier’s action. A general statement that simply states a conclusion is not sufficient. 28 TAC ‘ 133.304(c).
6. Crrier’s explanation for denying the claims using rationale codes ARG and AYU from January 28, 2002, through May 7, 2002, was legally inadequate as it failed to deny reimbursement in compliance with the Commission’s rules.
7. Carrier may not assert grounds not stated in the Explanation of Benefits. 28 TAC ‘ 133.304(c).
8. Based on the Findings of Fact, Carrier failed to demonstrate that the Disputed Services were not reasonable and medically necessary for the treatment of Claimant’s compensable injury.
9. Based upon the Findings of Fact and Conclusions of Law, Provider is entitled to reimbursement for the Disputed Services as they were reasonable and medically necessary.

ORDER

THEREFOREIT IS ORDERED that Texas Mutual Insurance Company reimburse First Rio Valley Medical, P.A., for the Disputed Services provided to Claimant from January 28, 2002, through May 7, 2002, in the amount of $11,714.00, plus any and all applicable interest.

Signed April 22, 2005.

CATHERINE C. EGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. CPT Codes 99211, 99212 and 99214.↑
2. CPT Code 97110.↑
3. CPT Code 97113.↑
4. CPT Codes 97139-PH and 99070-PH.↑
5. CPT Code 97124.↑
6. CPT Code 90801.↑
7. CPT Code 90899.↑
8. By Decision dated January 31, 2003, an independent review organization determined the Disputed Services were medically necessary. A copy of the claims log showing the dates and services in dispute is attached as

Appendix A.↑

9. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 201.↑
10. Carrier’s Ex. 3A, Tab 3 at 1-108.↑
11. Id.↑
12. Carrier’s Ex. 3A at 43.↑
13. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 52; Tab 3, Prefiled Testimony of Dr. Tsourmas at 57-58.↑
14. Ex. 16, Tab 2, Prefiled Testimony of Mr. Ball at 25-26.↑
15. See also 28 TAC ‘ 133.307(j)(2).↑
16. Carrier’s Ex. 3A, Tab 3 at 29.↑
17. Joint Ex. 3, Tab 1 at 268-270.↑
18. Id. at 269.↑
19. The Spine Treatment Guidelines have been repealed.↑
20. Id.↑
21. Id. t 270. The name of the Claimant was deleted and the word AClaimant inserted to ensure the confidentiality of Claimant’s identity.↑
22. Joint Ex. 3, Tab 1 at 262-266.↑
23. Joint Ex. 3, Tab 1 at 299.↑
24. Joint Ex. 3, Tab 1 at 345-346.↑
25. Ex.16, Tab 3, Prefiled Testimony of Dr. Tsourmas at 19-20.↑
26. Ex. 16, Tab 3, Prefiled Testimony of Dr. Tsourmas at 28.↑
27. Ex. 16, Tab 3, Prefiled Testimony of Dr. Tsourmas at 237.↑
28. Id.↑
29. Ex. 16, Tab 3, Prefiled Testimony of Dr. Tsourmas at 237-239.↑
30. Ex. 16, Tab 3, Prefiled Testimony of Dr. Tsourmas at 241.↑
31. Dr. DeFoyd has been a chiropractor for 18 years. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 9.↑
32. . Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 211.↑
33. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 223.↑
34. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 21-24.↑
35. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 245-246.↑
36. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 247-248.↑
37. Ex. 16, Tab 1, Prefiled Testimony of Dr. DeFoyd at 248.↑
38. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. I at 5-6.↑
39. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. III at 78.↑
40. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. III at 79-81.↑
41. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. III at 55.↑
42. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. III at 66. See also Joint Ex. 3, Tab 2 at 1233.↑
43. Ex. 16, Tab 4, Prefiled Testimony of Dr. Howell Vol. III at 56.↑