DECISION AND ORDER

Medway Health Centers (Provider) challenges an Independent Review Organization (IRO) decision denying it reimbursement for a work hardening program provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes the services provided were not medically necessary to treat the Claimant’s injury. Consequently, reimbursement is denied.

I. Statement of the Case

Administrative Law Judge (ALJ) Gary Elkins convened and closed a hearing on April 29, 2004. Provider appeared at the hearing and was represented by Attorney William Maxwell. The insurance carrier, Continental Casualty Company (Carrier), appeared and was represented by Attorney Karen Booher.

Notice and jurisdiction, which were not disputed, are addressed in the Findings of Fact and Conclusions of Law.

II. Discussion

A. Background

Claimant suffered a compensable injury in ___ when he reported headaches, right upper extremity paresthesias, and spasms on the right side of his neck and upper back while working at his clerical job. The injury was determined to be the result of repetitive movements required by Claimant’s job responsibilities. As a result of the injury, Claimant received chiropractic treatment from January 29, 2002, until April 11, 2002. Later, Claimant received work hardening services from Provider. It is the work hardening services provided from April 25, 2002 to May 14, 2002, in the amount of $5632.00 for which Provider seeks reimbursement.

B. Evidence and Argument

In support of its position that the services provided to Claimant were necessary for the treatment of his injuries, Provider argues the following:

• Claimant was placed in the work hardening program because he was not able to perform his job duties, which included repetitive keying, reaching, and sitting eight hours per day. The program, through strength conditioning, allowed him to build strength in his upper trunk, cervical spine, and arms, thereby enhancing his ability to reach forward without placing undue strain on his body and re-injuring himself.
• After completing the work hardening program, Claimant was able to return to work and perform all job functions.
• Claimant was intentionally placed in better physical condition than he was prior to the injury to ensure he would not re-injure himself. Such an approach serves the workers= compensation system well by ensuring the injured worker does not become a chronic case that over time could result in far greater medical expenses.

Carrier responded by pointing out the following:

• Work hrdening was not medically necessary in light of Claimant’s physical abilities reflected in a functional capacity evaluation conducted prior to the work hardening program, which listed his ACurrent Functional Capacity as meeting light work requirements. Consequently, he was already physically able to meet the sedentary demands of his job.
• Based on the nature of Claimant’s jobBclerical duties with sedentary physical demands and the nature of his injuryBa sprain-strainBthe work hardening program constituted excessive treatment.
• Intentionally placing Claimant in better physical condition than he was prior to his injury is not supported in the Workers= Compensation Act, which requires only that an injured worker be placed in his pre-injury condition.
• Claimant had already received two months of intensive chiropractic care immediately prior to the work hardening program.

C. Analysis and Conclusion

Provider filed to prove it is entitled to reimbursement for the work hardening program. The ALJ agrees with Carrier that prior to entering the work hardening program Claimant met light physical demand levels, a physical status that appeared to meet or exceed the requirements of his sedentary-level job demands. The fact that his post-treatment physical status was measured at a Amedium job level was not shown to add anything to his ability to meet his job requirements. Instead, the program appeared to exceed the level of post-injury care contemplated by ‘ 408.021(a) of the Workers= Compensation Act (Act):

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.

The ALJ understands Provider’s argument that placing a worker in a physical condition surpassing his pre-injury status will serve the workers= compensation system well by reducing the incidence of future or chronic injuries. Moreover, the Act does not appear to prohibit reimbursement for medical treatment that, although reasonably calculated to achieve results limited to those contemplated in ‘408.021, produces the unintentional result of placing a worker in better physical condition than intended. Here, though, Provider exceeded the mandate of ‘ 408.021(a) either by intentionally seeking to enhance Claimant’s physical abilities beyond his pre-injury status or by failing to formulate a treatment plan more reasonably limited to curing or relieving his compensable injury. Consequently, while the medical care appears to have enhanced Claimant’s ability to return to work, which ‘ 408.021(a)(3) addresses, the care clearly exceeded the mandate of that provision. Concomitant with this conclusion, Carrier is absolved from responsibility to reimburse for such services, and Provider’s claim is denied.

III. Findings of Fact

1. Claimant, suffered a compensable injury in ___ when he reported headaches, right upper extremity paresthesias, and spasms of the right side of his neck and upper back. The injury was determined to be the result of repetitive movements required by Claimant’s job responsibilities.
2. At the time of Claimant’s injury, his employer had workers= compensation insurance coverage with Continental Casualty Company (Carrier).
3. As a result of the injury, Claimant received chiropractic treatment from January 29, 2002, until April 11, 2002.
4. Claimant received work hardening services from Provider from April 25, 2002, to May 14, 2002, in the amount of $5632.00, for which Provider seeks reimbursement.
5. Carrier denied reimbursement for the services as not medically necessary.
6. In response to Carrier’s denial of reimbursement, Provider requested medical dispute resolution.
7. An Independent Review Organization (IRO) concluded Provider was not entitled to reimbursement for the disputed services.
8. Upon receiving the IRO decision, Provider timely requested a hearing before the State Office of Administrative Hearings (SOAH).
9. Notice of the hearing was sent to the parties on January 14, 2004. The notice informed the parties of the date, time, and location of the hearing, a statement of the matters to be considered, the legal authority under which the hearing would be held, and the statutory provisions applicable to the matters to be considered.
10. The hearing convened and closed April 29, 2004.
11. Claimant’s job responsibilities were sedentary in nature, consisting of light clerical work that included repetitive keying, reaching, answering the phone, working at a computer, and sitting eight hours per day.
12. Prior to entering the work hardening program with Provider, Claimant met light work requirements on a current functional capacity evaluation. He could lift 40 pounds to bench height; he could lift 25 pounds to shelf height; and he could carry 50 pounds.
13. Climant’s reported pain level the week of April 5, 2002, to April 12, 2002, was Afive on a scale of zero to ten.
14. Claimant received chiropractic care for eight weeks prior to entering the work hardening program.
15. Use of a work hardening program to prevent future injury is not reasonably necessary workers= compensation care.

IV. Conclusions of Law

1. SOAH has jurisdiction over this proceeding pursuant to ‘413.031(k) of the Act and Tex. Gov=t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ”2001.051 and 2001.052.
3. As Petitioner, Central Dallas Rehab bears the burden of proof in this matter. 28 Tex. Admin. Code (TAC) ‘148.21(h).
4. Petitioner failed to prove the disputed work hardening services were reasonably required by the nature of the claimant’s injury, cured or relieved the effects naturally resulting from the compensable injury, promoted Claimant’s recovery, or enhanced Claimant’s ability return to or retain employment as contemplated by Tex. Lab. Code Ann. ‘408.021(a).
5. The work hardening program was excessive based on the nature of the Claimant’s compensable injury and his functional capacity prior to the program.
6. Petitioner is not entitled to reimbursement for the disputed services.

ORDER

IT IS ORDERED thatthe reimbursement claim of Medway Health Centers for chiropractic services provided to Claimant from April 25, 2002 to May 14, 2002, is denied.

Signed June 28, 2004.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS