DECISION AND ORDER

I. INTRODUCTION

Sheriff Ilo, D.C. (Provider) disagrees with a Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) decision, based on an independent review organization (IRO) review, concerning medical services for R.O. (Claimant). The IRO and MRD agreed with American Protection Insurance, Co. (Carrier) that certain services that the Provider furnished the Claimant were not reasonably medically necessitated by the Claimant’s compensable injury.

The total amount in dispute is $9,950. The parties agree that the Claimant suffered a compensable injury, the only disputed issue is whether the disputed services were medically necessitated by the Claimant’s compensable injury, and the Provider has the burden of proof. However, the Provider argues that the services that it provided the Claimant are automatically necessary once it is determined that the injury is compensable. That is legally incorrect.

Each medical service must be reasonably required by the nature of the injury as and when needed 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. Labor Code ‘ 408.021 (a). Accordingly, the Administrative Law Judge (ALJ) considers the necessity of each service by that standard.

As set out below, the Administrative Law Judge (ALJ) finds that the services provided to the Claimant through March 25, 2003, were reasonably medically necessary to treat pain resulting from her compensable injury. He cannot, however, find that the services provided after that date were reasonably medically necessitated by her compensable injury. Accordingly, the ALJ orders the Carrier to reimburse the Provider $2,842 for the services provided through March 25, 2003, and denies the Provider’s request for further reimbursement.

II. FINDINGS OF FACT

1. On February 28, 2003, R.O. (Claimant) sustained a work-related injury to her lumbar region and right knee as a result of her work activities (Compensable Injury).
2. On the date of injury, the Claimant’s employer was Walgreens and its workers’ compensation insurance carrier was American Protection Insurance, Co. (Carrier).
3. From March 6, 2003, through May 9, 2003, Sheriff Ilo (Provider) furnished the medical services (Disputed Services) with the Current Procedural Terminology (CPT) codes and maximum allowable reimbursements (MARs) to the Claimant as shown below:

CPT	SERVICE DESCRIPTION	MAR	NUMBER OF SERVICES	TOTAL
97110	Therapeutic procedure provided in a one‑to‑one setting	$35.00	238	$8,330.00
97035	Ultrasound	$22.00	42	$924.00
97032	Electrical muscle stimulation	$22.00	12	$264.00
97010	Hot or cold pack	$11.00	8	$88.00
97265	Joint mobilization	$43.00	2	$86.00
97250	Myofascial release	$43.00	6	$258.00
	GRAND TOTAL			$9,950.00

1. The Provider later agreed that it should have billed for only 4 hot or cold packs, CPT code 97010, one per treatment session, rather than the 8 for which is billed the Carrier.
2. With the exception of the hot or cold pack, 97010 service, the Provider, on March 6, 2003, prescribed the Disputed Services to the Claimant to decrease her knee and lumbar pain, increase her range of motion, and strengthen her injured joints.
3. Some or all of the Disputed Services were also provided to treat the Claimant’s neck, which was not compensably injured.
4. On each date of service from March 6, 2003, through May 9, 2003, the Provider prescribed the Disputed Services that were furnished to the Claimant on that date.
5. The Provider’s documentation did not indicate the services that were provided to the Claimant’s neck which was not compensably injured.
6. On March 10, 2003, a magnetic resonance image (MRI) showed that the Claimant’s right knee was within normal limits.
7. On March 6, 2003, the Claimant had moderate to severe restrictions in her lumbar spine.
8. On May 1, 2003, the Claimant continued to have lumbar radiculopathy, a pathological condition of her lumbar-spine serve roots, however, she had no acute fracture, dislocation, or osseous destructive lesion involving her lumbar spine.
9. There is no evidence that the Claimant’s range of motion in her lumbar spine increased or that her injured joints were strengthened by the Disputed Services.
10. On March 6, 2003, the Claimant’s self-reported pain level was eight out of ten.
11. By March 25, 2003, the Claimant’s self-reported pain level had fallen to three out of ten and until May 9, 2003, remained at approximately that level whenever she thereafter reported it.
12. The Provider did not interrupt treatment for any significant period of time after March 25, 2003, to determine if the Disputed Services were still necessary to treat the Claimant’s pain stemming from her Compensable Injury.
13. From March 6, 2003, through March 25, 2003, the Provider furnished the following Disputed Service to the Claimant as shown below:

CPT	SERVICE DESCRIPTION	MAR	NUMBER OF SERVICES	TOTAL
97110	Therapeutic procedure provided in a one‑to‑one setting	$35.00	50	$1,750.00
97035	Ultrasound	$22.00	20	$440.00
97032	Electrical muscle stimulation	$22.00	12	$264.00
97010	Hot or cold pack	$11.00	4	$44.00
97265	Joint mobilization	$43.00	2	$86.00
97250	Myofascial release	$43.00	6	$258.00
	GRAND TOTAL			$2,842.00

1. The Provider timely sought reimbursement from the Carrier for the Disputed Services.
2. The Carrier sent an explanation of benefit (EOB) to the Provider denying the requested reimbursement and claiming the medical services were not reasonably medically necessitated by the Compensable Injury.
3. The Provider timely filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission’s (TWCC’s) Medical Review Division (MRD).
4. TWCC referred the dispute to an independent review organization (IRO) for review.
5. The IRO could not find that the Disputed Services were reasonably medically necessitated by the Compensable Injury.
6. Based on the IRO’s findings, MRD denied the Provider’s request to reimbursed for the Disputed Services.
7. After the IRO decision and MRD order were issued, the Provider asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
8. On October 22, 2003, notice of a December 9, 2003, contested-case hearing concerning the dispute was mailed to the Carrier and the Provider.
9. On December 9, 2003, SOAH ALJ William G. Newchurch held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
10. The Carrier appeared at the hearing through its attorney, Tommy W. Lueders.
11. The Provider appeared at the hearing through his designated representative, Innocent Abakwue.

III. 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. Labor Code Ann. (Labor Code) ” 402.073(b) and 413.031(k) (West 2003) and Tex. Gov’t Code Ann. (Gov’t Code) ch. 2003 (West 2003).
2. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code ” 2001.051 and 2001.052.
3. Based on the above Findings of Fact and Gov’t Code ‘ 2003.050 (a) and (b), 1 Tex. Admin. Code (TAC) ‘ 155.41(b) (2004), and 28 TAC ” 133.308(v) and 148.21(h) (2003), the Provider has the burden of proof in this case.
4. 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 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. Labor Code ‘ 408.021(a).
5. Based on the above Findings of Fact and Conclusions of Law, the Disputed Services provided to the Claimant from March 6, 2003, through March 25, 2003, were reasonably medically necessary to treat the Claimant’s pain from her compensable injury.
6. Based on the above Findings of Fact and Conclusions of Law, the Disputed Services provided to the Claimant after March 25, 2003, were not reasonably medically necessitated by the Claimant’s compensable injury.
7. Based on the above Findings of Fact and Conclusions of Law, the Carrier should reimburse the Provider $2,842 for the Disputed Services and the Provider’s request for further reimbursement for the Disputed Services should be denied.

ORDER

IT IS ORDERED THAT the Carrier shall reimburse the Provider $2,842 for the Disputed Services and the Provider’s request for further reimbursement for the Disputed Services is denied.

Signed February 2, 2004.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS