DECISION AND ORDER

Pacific Employers Insurance Company (Pacific) denied payment for office visits, sacroiliac joint injections, ADRX 9000″ therapy, and hot/cold therapy for a worker with neck and low back injuries. The doctor, Richard Taylor, D.O., a board-certified family practitioner, requested medical dispute resolution. An independent review organization (IRO) concluded that the disputed procedures were appropriate, reasonable and necessary medical care. Pacific requested a hearing. The amount in dispute is $714.00.^[1]

I.

DISCUSSION

A. Background Facts

The claimant, _______, was injured on _______. He experienced a twisting injury to his back. He was in his early twenties at the time of the injury. He has had persistent cervical and lower back pain, with pain extending into his right hip. MRI tests of the cervical and lumbar spine were normal. The claimant underwent physical therapy and chiropractic treatment. Electrodiagnostic tests performed March 14, 2003, suggested possible lumbar radiculopathy. The office visits and treatments at issue occurred at Dr. Taylor’s clinic between June 27, 2002, and March 25, 2003.

Procedural History

The IRO issued its decision August 6, 2003. Pacific requested a hearing August 21, 2003. The hearing was convened on November 3, 2003, before State Office of Administrative Hearings (SOAH) Judge Shannon Kilgore. Pacific was represented by Charles C. Finch. Dick Swift appeared by telephone for Dr. Taylor. The hearing adjourned, and the record closed, the same day.

C. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (Act) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims.^[2] In particular, the Act provides in pertinent part that:

(a) 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 compensable injury;
2. promotes recovery; or
3. enhances the ability of the employee to return to or retain employment.

Health care includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.^[3]

D. Burden of Proof

Under the Commission’s rules, an IRO decision is deemed a Commission decision and order.^[4] The burden of proof in this case is on Pacific to prove by a preponderance of the evidence that the disputed services were not reasonable and necessary medical treatments.^[5]

E. The Disputed Services

The disputed services are as follows:

Date of service CPT Code Description Amount

6-27-02	99213	office visit	$48.00
8-22-02	99213	office visit	$48.00
1-13-03	99213	office visit	$48.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-22-03	20610	sacroiliac joint injection	$40.00
1-29-03	99213	office visit	$48.00
3-5-03[6]	99213	office visit	$48.00
3-19-03	99213	office visit	$48.00
3-25-03	64999	DRX	$175.00
3-25-03	97010	hot/cold pack	$11.00

Total: $714.00

Pacific denied reimbursement for these services as Aunnecessary treatmentBwith peer review.^[7]

F. IRO Decision

In its report, the IRO stated:

The reviewer finds that the procedures in dispute were appropriate and reasonable medical care, and were medically necessary. The fact that the patient did not improve does not mean that the procedures were not indicated, and did not mean that the patient’s injuries were not in need of treatment. From electrodiagnostic studies, this patient had neuropathic pain which persists much longer than simple sprains and strains. The reason for denial by the carrier was not clearly delineated in the records provided. The reviewer finds in favor of the medical necessity of the disputed procedures listed above.^[8]

G. General Description of the Evidence

The evidence in this case consists of medical records, including reports of evaluations of the claimant’s condition by G. Peter Foox, M.D., Sofia M. Weigel, M.D., and Wright W. Singleton, M.D.^[9] In addition, the following witnesses testified:

Dr. Taylor; and

Wright W. Singleton, M.D.

H. Analysis and Recommendation

General nature of injury. Much of this dispute relates to the nature of the injury and the treatment provided. Dr. Weigel (who performed a record review and issued a report on June 25, 2002), Dr. Foox (who examined the patient and issued a report on March 21, 2003), and Dr. Singleton (who performed a record review and issued a report on August 27, 2003, as well as testified at hearing) all essentially regarded the claimant’s injury as a soft tissue injury that should have resolved in 3-6 weeks. They therefore saw little utility in much further treatment. Dr. Singleton noted that the claimant was deemed to have reached maximum medical improvement in July 2002.

Dr. Taylor testified that initially he had diagnosed the claimant with a simple strain/sprain, but the claimant developed sciatica and facet syndrome as well. He stated that the treatments at issue were designed to address the claimant’s continuing pain, and that the electrodiagnostic studies from March 2003 support the diagnoses of sciatica and facet syndrome.

Dr. Weigel did not have the benefit of the results of the electrodiagnostic studies, since they were performed well after her review and report. Dr. Foox may not have seen them, either, since they were performed just before he issued his report; in any event, he did not mention them. Dr. Singleton’s report did not discuss the results of the studies. At hearing, he testified that these kinds of tests can have false positives and to be meaningful would have to correlate with the patient’s condition. When asked if the claimant in this case presented with symptoms consistent with radiculopathy, Dr. Singleton replied that he did not recall.

As a general matter, the ALJ sees insufficient reason to disturb the IRO’s determination that this patient had a condition that necessitated treatment beyond the ordinary duration for simple strains and sprains. Even after a worker has reached MMI, measures to alleviate pain are reimbursable.

Office visits. According to Dr. Singleton, in a case of back injury where the MRI is normal, scheduled office visits for monitoring purposes should occur only about every six months. Pacific argued that at most only one or two office visits for medications should have been necessary for the period in question (even though Pacific denied payment for all six office visits at issue).

The ALJ finds that the record supports the need for the visits. On June 27, 2002, the claimant went to the clinic for medications.^[10] On August 22, 2002, the claimant went in because of his pain, and he was given medications; at the same visit, the decision was made to go ahead with facet injections. The January 13, 2003, visit was a follow-up after injections administered on January 2, 2003.^[11] The January 29, 2003, visit was a follow-up visit after injections on January 22, 2003.^[12] The March 6, 2003,^[13] visit addressed the patient’s ongoing severe pain and the diminishing effectiveness of injections; it was at this visit that the clinic decided to use the DRX-9000. The visit on March 19, 2003, was related to the claimant’s having just begun the DRX-9000 therapy.^[14]

Injections. The injections at issue were administered on January 22, 2003.^[15] Dr. Taylor decided to give the claimant these injections in another attempt to relieve somewhat the claimant’s considerable reported pain.^[16]

There is insufficient evidence in the record to wrrant overturning the IRO’s decision with respect to the injections on January 22. Indeed, the report of the carrier’s own witness, Dr. Singleton, stated, A[I]njection procedures would have been medically necessary until 2/19/03; after that full cessation of care for the 10/16/01 injury should have occurred. In other words, Pacific’s expert witness believes that the injections were medically necessary.

DRX-9000 and associated hot/cold pack therapy. Pacific argues, based on Dr. Singleton’s testimony, that the DRX-9000 therapy should not be reimbursed because it was not helpful and it was traction B passive therapy inappropriate so long after the initial soft tissue injury. Materials offered by the provider state that the DRX-9000 is not a traction device, but rather provides both decompression and joint mobilization.^[17] The materials also say that the device can be used to treat facet syndrome. Dr. Singleton says the DRX-9000 is a traction machine; Dr. Taylor says it is not. Dr. Taylor testified that the DRX-9000 was used to treat a flare-up of the claimant’s back pain from his facet syndrome. He also stated that a hot/cold pack is used after DRX-9000 therapy to prevent muscle spasms.

The carrier has not offered anything clear or persuasive enough to overcome the IRO’s determination that this was a reasonable treatment for the claimant’s continuing pain. The March 25, 2003, treatment date at issue was approximately the fourth of ten treatments in the claimant’s course of therapy with the DRX-9000. On that date, the claimant had a pain level of three out of ten.^[18] Arguments by Pacific that this therapy should have been discontinued because it was not producing results may have merit with respect to later dates of service not at issue here, but are not persuasive for the episode of treatment involved in this case. The hot/cold pack was related to the DRX treatment, and should be reimbursed.

Summary. The ALJ concludes that all the disputed services were reasonable and necessary and should be reimbursed.

II.

FINDINGS OF FACTS

1. The claimant _______ suffered a compensable back injury.
2. Pacific Employers Insurance Company (Pacific) is the workers’ compensation insurer with respect to the claims at issue in this case.
3. Dr. Richard Taylor, D.O., or his clinic provided the claimant with the following services from June 27, 2002, to March 25, 2003: office visits, sacroiliac joint injections, DRX-9000 spinal decompression and joint mobilization therapy, and hot/cold pack therapy.
4. Dr. Taylor or his clinic billed for these services with the following CPT Codes: 99213 (office visits), 20610 (sacroiliac joint injections), 64999 (DRX-9000), and 97010 (hot/cold pack).
5. Pacific declined to pay for these services. Pacific asserts that they were medically unnecessary.
6. The amount in dispute is $714.00.
7. Dr. Taylor or his clinic requested medical dispute resolution.
8. On August 6, 2003, an independent review organization (IRO) issued a decision finding that the disputed services were reasonable and necessary.
9. Pacific requested a hearing.
10. Notice of the hearing was issued September 19, 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 convened on November 3, 2003, before State Office of Administrative Hearings (SOAH) Judge Shannon Kilgore. Pacific was represented by Charles C. Finch. Dick Swift appeared by telephone for Dr. Taylor. The hearing adjourned, and the record closed, the same day.
13. Dr. Richard Taylor, D.O., initially diagnosed the claimant with lumbar sprain/strain, and then with facet syndrome and sciatica.
14. MRI tests of the cervical and lumbar spine were normal.
15. The claimant underwent physical therapy and chiropractic treatment.
16. Electrodiagnostic tests performed March 14, 2003, suggested possible lumbar radiculopathy.
17. The office visits at issue were medically necessary. The June 27, 2002, visit was for medications. The August 22, 2002, visit was to address the claimant’s pain; he was given medications, and the decision was made to go ahead with facet injections. The January 13, 2003, visit was a follow-up after injections administered on January 2, 2003. The January 29, 2003, visit was a follow-up visit after injections on January 22, 2003. The March 6, 2003, visit addressed the patient’s ongoing severe pain and the diminishing effectiveness of injections; it was at this visit that the clinic decided to use the DRX-9000. The visit on March 19, 2003, was related to the claimant’s having recently begun the DRX-9000 therapy.
18. The injections at issue were administered on January 22, 2003, in an attempt to alleviate the claimant’s severe pain.
19. The injections administered on January 22, 2003, were reasonable and necessary.
20. The DRX-9000 is a device that provides decompression and joint mobilization.
21. The use of the DRX-9000 device on March 25, 2003 (along with the hot/cold pack afterwards) was reasonable and necessary.

III.

CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code ‘ 413.031; Tex. Gov’t Code ch. 2003.
3. 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. Tex. Lab. Code ‘ 408.021.
4. Pacific timely filed a notice of appeal as specified in 28 Texas Administrative Code ‘ 148.3.
5. Adequate and timely notice of the hearing was provided in accordance with the Administrative Procedure Act. Tex. Gov’t Code ‘ 2001.052.
6. Pacific has the burden of proof in this matter. 28 Tex. Admin. Code ” 133.308(p)(5) and (w), 148.21(h)-(i).
7. Based on the Findings of Fact, and pursuant to ‘ 408.021 of the Texas Labor Code, Pacific must reimburse Dr. Taylor for the disputed treatments.

ORDER

IT IS THEREFORE ORDERED that Pacific Employers Insurance Company pay for office visits (June 27 and August 22, 2002, and January 13 and 29, March 5 and March 19, 2003), sacroiliac joint injections (January 22, 2003), ADRX 9000″ therapy (March 25, 2003), and hot/cold therapy (March 25, 2003) administered to the claimant _______ by Richard Taylor, D.O., or his clinic.

Issued this December 5, 2003.

SHANNON KILGORE

State office of administrative hearings
Administrative Law Judge

1. In his opening statement, counsel for Respondent stated the evidence would show that the amount in controversy is $2,900. However, he never offered or directed the Administrative Law Judge’s attention to such evidence. The table of disputed services shows the amount to be $714.00. Carrier’s Exhibit 1.↑
2. Tex. Lab. Code ‘ 408.021.↑
3. Tex. Lab. Code ‘ 401.011(19).↑
4. 28 Tex. Admin. Code ‘ 133.308(p)(5).↑
5. 28 Tex. Admin. Code ” 133.308(p)(5) and (w), 148.21(h)-(i).↑
6. The date may have been March 6, 2003. See discussion below.↑
7. See Carrier Ex. 3.↑
8. Provider Ex. 1.↑
9. See Carrier Ex. 6 (Foox), Carrier Ex. 7 (Weigel), and Carrier Ex. 8 (Singleton).↑
10. Provider Ex. 1.↑
11. Carrier Ex. 5 at 1.↑
12. Carrier Ex. 5 at 6-7.↑
13. The clinic note for this visit was dated March 6, 2003, although the clinic billed for a March 5 visit. Nothing in the record suggests that there were visits both days. See Carrier Ex. 5 at 9.↑
14. Carrier Ex. 5 at 11.↑
15. Carrier Ex. 5 at 4. These injections are not the only injections Dr. Taylor’s clinic administered to the claimant during his course of treatment, but they are the only injections at issue in this case.↑
16. It is not cler from the record whether the injections were pre-authorized. On page 1 of Carrier Ex. 4, the APrecertification Check List refers to a procedure to be done on January 2, 2003. Injections were, in fact, administered to the claimant on that date, but they did not provide enough relief and the further injections at issue were administered on January 22. The ACertification Notice on page 2 states that the certification period was 12-31-02 to 1-30-03. It does not reference a limit on the number of injections. The Carrier did not argue at hearing that reimbursement for the injections should be denied because they were not pre-authorized.↑
17. Provider Ex. 1.↑
18. Provider Ex. 1.↑