DECISION AND ORDER

Danny Doyle, D. C. (Provider) challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission upholding Liberty Mutual Insurance Company’s (Carrier) denial of reimbursement for seven sessions of physical medicine administered between June 26, 2002, and October 28, 2002. Both Carrier and the MRD concluded that physical medicine modalities were not medically necessary to treat ___ (Claimant) on those dates.

Based on the evidence, Provider met its burden of proof to show that treatments provided on the dates of services of June 26, and July 3 and 10, 2002, for pain relief and to maintain arm and hand functioning were medically necessary. However, Provider failed to show that treatments on dates of service of October 18, 21, 25, and 28, 2002, were medically necessary to treat Claimant’s compensable injury.

The hearing in this matter convened on December 17, 2003, in Austin, Texas, with Administrative Law Judge (ALJ) Cassandra Church presiding. The record closed that day. Dr. Doyle represented himself. Carrier was represented by Kevin Franta, attorney. The Commission did not participate in the hearing.

I. DISCUSSION

On ___, Claimant injured her right wrist while using a computer keyboard and mouse, with radiating pain to her upper arm, shoulder, and neck. She was diagnosed with repetitive motion injury, primarily carpal tunnel syndrome. Conservative treatment from her date of injury through May 2002 achieved some reduction in her pain, but did not eliminate it. For example, her pain prevented her from participating in an active rehabilitation course of treatment scheduled for May 2002. She reached a plateau in May 2002 and did not make further gains.

In May 2002, the TWCC-designated doctor, Dennis A. Harris, D.C., recommended that Claimant be evaluated by a hand specialist and that conservative care be continued in the interim. Provider also recognized that Claimant needed medical evaluation due to her failure to progress further.

In June 2002, Provider referred Claimant to a medical doctor, Alan Hurshman, M.D., who confirmed there was tissue and ligament damage. He examined her at the end of July. In August and

September, Dr. Hurshman treated Claimant with a series of three nerve injections which reduced her pain by some 80 per cent. Dr. Hurshman had also recommended that conservative care continue until the nerve injection treatments occurred.

Claimant was employed during the entire period of treatment, between ___, and October 28, 2002, although a portion of that was part time employment at light duty.

On all of the disputed dates of service, Provider administered passive modalities, including in various combinations, myofascial release, joint mobilization, ultrasound treatment, and joint manipulations. On July 10, 2002, Provider administered treatment with a vasopneumatic device to improve blood flow in the affected area and reducing swelling (edema). The treatments provided in June and July were essentially continuation of the treatment that Provider had been administering since Claimant’s injury. Provider explained that the series of treatments in October was provided to treat a flare-up in Claimant’s pain which occurred after the series of joint injections. Provider argued that all treatments had been successful in reducing Claimant’s pain, although admittedly not eliminating it, and were medically necessary to reduce scar tissue, reduce edema, and to maintain or improve Claimant’s hand and arm functioning.

Carrier argued that the continued passive treatments after April or May 2002 were not medically necessary because they were not required to return Claimant to work, and were not successful in either relieving the effects of Claimant’s injury or promoting recovery. Carrier argued that the failure of Claimant to improve by late Spring 2002 demonstrated that she had an undiagnosed injury that was not susceptible to treatment or to effective pain control by physical medicine. Thus, Claimant is not entitled to reimbursement for physical medicine sessions in June, July, or October of 2002.

Based on the evidence in this case, as discussed above and as set forth in the Findings of Fact, the ALJ concludes that Provider met its burden of proof to show that continued chiropractic care was needed in June and July of 2002 to alleviate Claimant’s pain and to maintain Claimant’s arm and hand function pending evaluation by a hand specialist. Both Provider and Dr. Harris recommended that course of action. Further, Dr. Hurshman himself recommended that conservative care continue until the nerve injections could be performed. Conservative care prior to the nerve injection treatments was medically necessary.

However, Provider failed to meet his burden of proof to show that the series of treatments in the latter part of October 2002 was needed to treat Claimant’s compensable injury. Although Provider discussed a general flaring of symptoms, the most particular description of Claimant’s condition in October 2002 is her own report that she had “overused” her hand playing Foosball, but had been doing well before that. Pet. Exh. 1, p. 55. Even aside from the issue of whether reimbursement would be warranted for treatment of a re-injury or a flare-up of a compensable injury caused by a worker’s participation in a voluntary recreational activity, Provider failed to articulate any medical reasons why the minor overuse condition Claimant presented required four sessions of multiple-modality physical medicine to treat.

II. FINDINGS OF FACT

1. On ___, ___ (Claimant) injured her right upper arm and shoulder and neck while using a computer keyboard and mouse. Liberty Mutual Insurance Company (Carrier)
2. was the responsible insurer.
3. Immediately after her injury, Danny Doyle, D. C. (Provider), diagnosed Claimant as suffering from carpal tunnel syndrome, cervical brachial radiculitis, myositis myalgia, and unspecified dysfunction of the cervical and thoracic areas of her spine.
4. Provider administered passive modalities for pain relief for of approximately three to four weeks, then modified her therapy to include a home exercise program, ultrasound, myofascial releases, and joint mobilization.
5. Claimant remained employed from her date of injury through October 2002, although was on part-time, light duty in Summer and early Fall of 2002.
6. In May 2002, Claimant was scheduled for a hand and arm rehabilitation program but was unable to participate in that program because the rehabilitation activities caused a recurrence of her pain.
7. Physical medicine treatments reduced Claimant’s pain temporarily, but her pain levels remained the range of 4-5, on a 10-point scale, throughout the Spring and early Summer of 2002. Her pain increased when she performed her daily living activities.
8. On May 22, 2002, the examination by the TWCC-designated doctor, Dennis A. Harris, D.C., showed that Claimant still had sharp pain in the right wrist, radiating to the right shoulder, as well as limitations on her range of motion and strength.
9. On May 22, 2002, Dr. Harris recommended that Claimant be evaluated by a hand specialist and that conservative care continue in the interim.
10. In June 2002, Provider referred Claimant to a hand specialist, Alan B. Hurschman, M.D., for evaluation. It is Provider’s standard practice to refer a patient to a specialist when that patient reaches a plateau and fails to make additional gains in function or achieve relief from pain notwithstanding continuing physical medicine treatments.
11. Due to scheduling difficulties, Dr. Hurshman did not examine Claimant until July 31, 2002.
12. On July 31, 2002, Dr. Hurshman diagnosed Claimant as having right wrist carpal degeneration and possible triangular fibrocartilage degeneration, and mild, right cubital tunnel syndrome, all secondary to the repetitive motion injury that had occurred on ___.
13. On July 31, 2002, Dr. Hurshman proposed administration of peripheral nerve injections in the upper arm to reduce inflammation, with possible joint injections in her right wrist. He also prescribed the use of ibuprofen and an electric cold pack at home to treat the pain and inflammation
14. On July 31, 2002, Dr. Hurshman also recommended that Claimant continue with chiropractic adjustments and physical therapy twice a week for four weeks, a period would have ended by approximately September 30, 2002.
15. An MRI conducted on August 1, 2002, at Dr. Hurshman’s request, found Claimant was suffering from a tear of the triangular fibrocartilage of the wrist, and small radiocarpal and distal radial ulnar joint effusions, and revealed small bone cysts between her fingers.
16. Dr. Hurshman administered nerve injections on August 7, 14, and 21, 2002. By September 4, 2002, the nerve injections had reduced Claimant’s pain by 80 per cent.
17. On June 26, 2002, Provider administered a session of neuromuscular retraining (CPT Code 97112), one-on-one physical therapy (CPT Code 97530), and conducted an office visit which included manipulation (CPT Code 99213-MP).
18. On July 3, 2002, Provider administered myofascial release (CPT Code 97250), ultrasound treatment (CPT Code 97035), joint mobilization (CPT Code 97265), and conducted an office visit which included manipulation.
19. On July 10, 2002, Provider administered swelling (edema) reduction therapy by use of a vasopneumatic device (CPT Code 97015), and conducted an office visit which included manipulation.
20. On October 18, 2002, Claimant stated she had overused her right hand playing Foosball and reported her average pain intensity at that time was a three, on a 10-point scale.
21. On October 18, 2002, Provider conducted an office visit which included manipulation.
22. On each of the three additional dates of service, October 21, 25 and 28, 2002, Provider administered myofascial release, ultrasound treatment, and conducted an office visit which included manipulation.
23. After the October 28, 2002, session, Provider released Claimant from further treatment.
24. Carrier denied payments for all treatments administered on June 26, and July 3 and 10, and on October 18, 21, 25, and 28, 2002.
25. Provider appealed the Carrier’s denial of reimbursement to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission).
26. On September 23, 2003, based on the review by an Independent Review Organization (IRO), Envoy Medical Systems, the MRD denied reimbursement to Provider for all treatments provided on June 26, and July 3 and 10, and on October 18, 21, 25, and 28, 2002.
27. On September 29, 2003, Provider requested a hearing on the MRD decision on the denial of reimbursement.
28. On October 27, 2003, the Commission issued a notice of hearing that included the date, time, and location of the hearing, the applicable statutes under which the hearing would be conducted, and a short, plain statement of matters asserted.
29. Administrative Law Judge Cassandra Church conducted a hearing on the merits of this case on December 17, 2003, and the record closed that day.

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. Lab. Code Ann. §413.031 and Tex. Gov’t Code Ann. ch. 2003.
2. Provider timely requested a hearing, as specified in 28 Tex. Admin Code § 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§§ 2001.051 and 2001.052.
4. Provider, as the petitioning party, has the burden of proof in this proceeding pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin Code § 148.21(h).
5. Provider met its burden of proof to show that treatments provided on June 26, and July 3 and 10, 2002, for pain relief and to maintain arm and hand functioning were medically necessary to treat or reasonably required to relieve the effects of or promote recovery from a compensable injury suffered by Claimant, within the meaning of Tex. Lab. Code Ann. §§ 408.021 and 401.011(19).
6. Provider failed to meet its burden of proof to show that treatments on October 18, 21, 25, and 28, 2002, were medically necessary to treat or reasonably required to relieve the effects of or promote recovery from a compensable injury suffered by Claimant, within the meaning of Tex. Lab. Code Ann. §§ 408.021 and 401.011(19).

ORDER

IT IS ORDERED that Liberty Mutual Insurance Company is required to reimburse Danny Doyle, D. C., for all physical medicine treatments (CPT Codes 97112, 97530, 97250, 97265, and 97035 and 970916) and office visits with manipulations (CPT Code 99213-MP) provided to ___ (Claimant) on the dates of service of June 26, and July 3 and 10, 2002.

Signed January 13, 2004.

CASSANDRA J. CHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS