DECISION AND ORDER

Humpal Physical Therapy (Petitioner) appealed the findings and decision of the Texas Workers= Compensation Commission’s designee, an independent review organization (IRO), which found that physical therapy Petitioner provided a workers= compensation claimant (Claimant) was not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by Facility Insurance Company (Respondent). This decision and order finds the physical therapy sessions in dispute were reasonable and medically necessary for Claimant.

I. NOTICE, JURISDICTION, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction or notice. Those issues are set out only in the Findings of Fact and Conclusions of Law below.

The hearing in this matter convened and the record closed December 8, 2003, before State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ) John H. Beeler. Owner Scott Humpal represented Petitioner and attorney Steve Tipton represented Respondent. The Commission Staff did not participate in the hearing.

II. DISCUSSION

A. Factual Background

Claimant sustained a compensable injury to her lower back on December 19, 1991. At the time of the injury, Respondent was the workers= compensation insurance carrier for her employer.

Claimant’s injury resulted in a chronic sacroiliac problem, a leg length discrepancy, and range of motion limitations around the pelvic girdle area. Claimant’s treating physician treated her for several years for chronic pain resulting from the injury. During these years of treatment, which included facet blocking injections, Claimant experienced only temporarily relief.

Because Claimant was still experiencing severe pain after about ten years, her treating physician referred her to Petitioner for physical therapy. Petitioner billed Respondent for the physical therapy sessions and Respondent denied reimbursement on the basis of medical necessity.

B. Legal Standards

Petitioner has the burden of proof in this proceeding. 28 Tex. Admim. Code (TAC) ” 148.21(h) and (i); 1 TAC ‘ 155.41. Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. CodeAnn. ‘ 408.021(a). Health care includes all reasonable and necessary medical services. Tex. Lab. CodeAnn. ‘ 401.011(19)(A). The IRO was authorized to hear the medical dispute pursuant to 28 TAC ‘ 133.308.

C. Petitioner’s Evidence

Scott Humpal, a licensed physical therapist and Petitioner’s owner, testified that all the physical therapy in dispute was medically necessary. Before coming to Petitioner, Clamant was in constant pain except for short periods of time following her injections. She was able to sit for no more than 20 minutes at a time and had a leg length discrepancy as well as limited range of motion. Petitioner provided Claimant with myofascial release, joint mobilization, electric stimulation, and aquatic therapy from September 30, 2002, through December 12, 2002.

After the above described therapy, Claimant’s leg length discrepancy was gone and she had reduced pain and greater range of motion. She was also able to sit for up to two hours without experiencing extreme pain. Mr. Humpal believes that Respondent denied reimbursement solely because the date of injury was so remote.

D. Respondent’s Evidence

Respondent presented the testimony of Dr. Casey Cochran, MD., who is board certified in family practice and occupational medicine. Dr. Cochran testified that he spent about 45 minutes reviewing documents concerning Claimant’s condition and treatment and concluded that the physical therapy was not medically necessary. He opined that Texas leads the country in the use of physical therapy, which, in many cases, is of no better use than a placebo. Claimant would have done just as well on a home stretching and exercise program. He added that none of the treatment provided by Petitioner would have helped Claimant at all. In addition, aquatic therapy was unnecessary and is usually prescribed only to recoup the cost of building and maintaining the pool.

E. Analysis

Petitioner proved tht the physical therapy sessions were reasonable and medically necessary healthcare for Claimant. While Dr. Cochran testified that the type of care provided to Claimant by Petitioner was not medically necessary, he did not dispute that Claimant showed dramatic improvement while undergoing the therapy. In fact, it is undisputed that Claimant’s level of pain was substantially reduced, her range of motion increased, and her leg length discrepancy was eliminated. Respondent argues that the same result could have been achieved with a home based stretching and exercise program, and while that possibility cannot be completely ruled out, the fact remains that Claimant improved significantly under Petitioner’s care. The physical therapy, therefore, certainly Apromoted recovery, as contemplated by Tex. Lab. CodeAnn. ‘ 408.021(a).

Petitioner is entitled to reimbursement for physical therapy sessions provided Claimant from September 30, 2002, through December 12, 2002. The parties agreed that, if the therapy was found to be medically necessary, the reimbursement amount would be $8,500.00

III. FINDINGS OF FACT

1. On December 19, 1991, Claimant sustained an injury to her lower back that was compensable under the Texas Workers’ Compensation Act (Act).
2. At the time of the compensable injury, Facility Insurance Company (Respondent), was the workers’ compensation insurance carrier for Claimant’s employer.
3. After his injury, Claimant suffered from ongoing pain in her lower back, limited range of motion, and a leg length discrepancy.
4. Claimant’s treating physician treated Claimant for several years with facet blocking injections but her pain relief was only temporary.
5. Claimant’s treating physician referred her to petitioner for physical therapy
6. Petitioner provided physical therapy for Claimant from September 30, 2002, through December 12, 2002.
7. The physical therapy provided by Petitioner for Claimant resulted in reduced pain, increased range of motion, and the elimination of a leg length discrepancy.
8. Respondent denied Petitioner’s request for reimbursement for the physical therapy sessions from September 30, 2002, through December 12, 2002, and Petitioner’s appeal of the denial was considered by the Commission’s Independent Review Organization (IRO).
9. The IRO’s decision upheld Respondent’s denial of reimbursement on the basis that the physical therapy sessions were not medically necessary. Petitioner timely appealed the IRO decision.
10. The Commission’s notice of hearing stated the date, time, and location of the hearing and cited to the legal statutes and rules involved along with a short, plain statement of the factual matters involved.
11. Petitioner and Respondent were present at the hearing.

IV. CONCLUSIONS OF LAW

1. Texas Workers= Compensation Commission (Commission) has jurisdiction over this matter pursuant to the Texas Workers’ Compensation Act (Act),Tex. Lab. CodeAnn. ‘ 413.031.
2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to ‘ 413.031(d) of the Act and Tex. Gov=tCodeAnn. ch. 2003.
3. The IRO was authorized to hear the medical dispute pursuant to 28 TAC ‘ 133.308.
4. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=tCodeAnn. ch. 2001 and the Commission’s rules, 28 Tex. Admin. Code (TAC) ‘ 133.308(u).
5. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov=tCodeAnn. ” 2001.051 and 2001.052.
6. Petitioner had the burden of proof in this proceeding. 28 TAC ” 148.21(h) and (i); 1 TAC ‘ 155.41.
7. Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Tex. Lab. CodeAnn. ‘ 408.021(a).
8. Health care includes all reasonable and necessary medical services. Tex. Lab. CodeAnn. ‘ 401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. Tex. Lab. CodeAnn. ‘ 401.011(31).
9. Claimant’s physical therapy from September 30, 2002, through December 12, 2002, was reasonable and medically necessary healthcare.
10. Petitioner is entitled to reimbursement from Respondent for the physical therapy sessions provided Claimant from September 30, 2002, through December 12, 2002.

ORDER

It is ORDERED that Humpal Physical Therapy be reimbursed by Facility Insurance Company for the physical therapy provided Claimant from September 30, 2002, through December 12, 2002.

Signed February 4, 2004.

JOHN H. BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS