DECISION AND ORDER

First Rio Valley Medical, P.A., (Provider) challenged the decision of an Independent Review Organization (IRO) denying reimbursement for services provided to an injured worker (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Provider failed to show by a preponderance of the evidence that the services in issue were medically necessary. Therefore, Provider is not entitled to reimbursement for the amounts in controversy.

I. BACKGROUND

Claimant suffered compensable injuries to her head and neck on ___, when she was involved in an automobile accident. Thereafter, Claimant underwent numerous treatments and services, including those presently in dispute: an MRI, work hardening, and special report (disputed services). All of the disputed services were provided between January 21, 2002, and June 11, 2002.

Commerce & Industry Insurance Company (Carrier), as the workers’ compensation insurance carrier for Claimant’s employer, declined to reimburse these treatments and services, contending they were not medically necessary. Based on Carrier’s denial of reimbursement, Provider sought medical dispute resolution through the Texas Workers’ Compensation Commission (Commission). The matter was referred to an IRO designated by the Commission for the review process. The IRO determined that the disputed services were not medically necessary treatment for Claimant’s compensable injury. Provider then requested a hearing before the State Office of Administrative Hearings (SOAH). The hearing convened on February 7, 2005, with ALJ Tommy Broyles presiding. Provider and Carrier appeared either represented by an attorney or on their own behalf. The hearing concluded on the same day but the record did not close until February 15, 2005, with the filing of supplementation to the record. No party objected to notice or jurisdiction.

II. DISCUSSION AND ANALYSIS

Provider maintains that the disputed treatments were medically necessary. Robert S. Howell, D.C., testified that the MRI was medically necessary to determine whether Claimant needed to be referred out for surgical evaluation. He contended that two orthopaedic tests were not normal so he needed an MRI to make the appropriate diagnosis. Dr. Howell argued that the 5% impairment rating

assigned Claimant supported his contention that an MRI was needed to see if further intervention was necessary. Dr. Howell suggested that the medical necessity of the work hardening program was not properly at issue because it was preauthorized. To support his contention, he offered an April 8, 2002 preauthorization letter from Respondent.

fter reviewing the records, Brian Glenn, D.C., testified on behalf of Carrier. Dr. Glenn noted that Claimant was much improved as demonstrated by comparing her functional capacity evaluations (FCE) of December 28, 2001 (sedentary to light work) and January 10, 2002 (moderate to heavy work). He opined that for an MRI to be medically necessary, he would expect some of the following: guarded and decreased range of motion; radicular pain and numbness from her neck down her right arm; loss of reflex, sensation or strength; and/or a failure to obtain improvement with chiropractic care. For Claimant, he found none of these. Instead, by January 2002, her ROM was Aclassically normal, she had minimal pain, and minimal self-perceived disability. Dr. Glenn testified that there was no clinical reason to order an MRI.

As to the work hardening program, Carrier offered an April 9, 2002 letter denying the request for preauthorization and stating that clinical findings did not support the medical necessity of the requested treatment. Dr. Glenn testified that the work hardening program was not medically necessary.

After considering the arguments and evidence presented, the ALJ concludes that the disputed services provided to Claimant were not medically necessary for treatment of Claimant’s compensable injury. Therefore, the ALJ finds that Provider is not entitled to reimbursement. In reaching this decision , the ALJ finds Dr. Glenn’s testimony to be credible and persuasive. Claimant was recovering well and the clinical findings do not support the treatments requested. As to the work hardening, the ALJ concludes that Carrier mistakenly approved the treatment on April 8, 2005, but quickly corrected the mistake by letter of April 9, 2005. Finally, Provider failed to offer evidence suggesting the report was medically necessary.

In considering the totality of the record, the ALJ concludes that the preponderance of the evidence shows that the treatments in issue were not medically necessary. Therefore, Provider has not met its burden of showing that the treatments were medically necessary. As such, Provider is not entitled to reimbursement for the treatments. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. Claimant suffered a compensable, work-related injury on ___.
2. Commerce & Industry Insurance Company (Carrier) is the provider of workers’ compensation insurance covering Claimant for her compensable injury.
3. Claimant underwent numerous treatments and services, including those presently in dispute: an MRI, work hardening, and special report (disputed services).
4. The disputed services occurred between January 21, 2002 and June 11, 2002.
5. Carrier denied reimbursement for the services, contending they were not medically necessary.
6. Provider requested medical dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which referred the matter to an Independent Review Organization (IRO).
7. MRD declined to order reimbursement on August 6, 2003, based on the IRO physician reviewer’s determination that the services in issue were not medically necessary.
8. On September 16, 2003, Provider requested a hearing and the case was referred to the State Office of Administrative Hearings (SOAH).
9. Notice of the hearing was sent by the Commission to all parties on September 17, 2003.
10. All parties received not less than ten 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 statues and rules involved; and a short, plain statement of the matters asserted.
11. On February 7, 2005, Administrative Law Judge Tommy Broyles convened a hearing in this case. Provider appeared through Robert S. Howell, D.C. Carrier appeared through its attorney, Steven Tipton. The hearing concluded on that same day.
12. The record closed on February 15, 2005.
13. On January 10, 2002, Claimant performed a functional capacity evaluation (FCE) which indicated she was functioning at the moderate to heavy load levels and had very minimal complaints of pain.
14. At the time the MRI was ordered, Claimant did not demonstrate guarded and decreased range of motion; radicular pain and/or numbness down her right arm; nor losses in reflex, sensation or strength.
15. Claimant was improving rapidly as demonstrated by the FCE’s performed in December 2001 and January 2002.
16. In January 2002, Claimant had minimal self-perceived disability.
17. There were no clinical reasons to order an MRI in January 2002.
18. Carrier denied pre-authorization for the work hardening in 2002.
19. Provider failed to prove that the work hardening in 2002 was medically necessary.
20. Provider did not prove the medical report was medically necessary.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act, specifically Tex. Labor Code
2. Ann. §413.031(k) 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 and 28 Tex. Admin. Code ch. 148.
4. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code § 148.3.
5. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
6. Provider has the burden of proof. 28 Tex. Admin. Code §§ 148.21(h) and 133.308(w).
7. Provider has not shown, by a preponderance of the evidence, that the services in issue provided to Claimant between January 21, 2002, and June 11, 2002, were medically necessary for treatment of Claimant’s compensable injury.
8. Carrier is not liable to reimburse Provider for the treatments and services provided to Claimant between January 21, 2002, and June 11, 2002.

ORDER

IT IS, THEREFORE, ORDERED that First Rio Valley Medical, P.A. take nothing from Commerce & Industry Insurance Company for the treatments provided to Claimant between January 21, 2002, and June 11, 2002.

Signed April 1, 2005.

TOMMY L. BROYLES
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS