DECISION AND ORDER

After an Independent Review Organization (IRO) granted preauthorization for ten biofeedback and counseling sessions, the City of San Antonio (Carrier) appealed. The Administrative Law Judge (ALJ) concludes Carrier failed to meet its burden of proving the treatment program was not medically necessary and preauthorizes the treatment.

I. DISCUSSION

Background

On March 13, 2001, the Claimant sustained a work-related neck injury resulting in pain, tingling, and numbness in her left arm and limited strength in her left hand. She underwent a cervical spine fusion and, following the surgery, has had problems swallowing, limited range of motion, neck pain, and anxiety. Claimant’s treating physician prescribed ten biofeedback and counseling to treat Claimant’s condition and Carrier timely denied preauthorization.

The Provider appealed, and by decision issued October 9, 2003, the IRO determined that the prescribed treatment was medically necessary. Carrier timely appealed the IRO decision.

Carrier’s Witness

At the Carrier’s request, neurologist Dr. Wayne Gordon reviewed Claimant’s medical record. He testified that biofeedback and counseling are not the standard of care for Claimant’s condition. Normal treatment would be physical therapy, medications, and possibly injections. In the past he has referred patients for biofeedback only to treat tension headaches. Claimant simply has an anxiety problem and he would recommend treating her with medications. He knows of no supporting material for his opinion that biofeedback and counseling are not the standard of care in situations such as Claimant=s.

Provider’s Witness

Daniel Burdin, D.C., testified that he is a licensed chiropractor in the State of Texas and works in a clinic with a neurologist, a psychologist, a surgeon, a counselor, a psychiatrist, and a pain management specialist. He is one of the treating doctors for Claimant and is familiar with her condition. She has progressed as far as she can with medication and various treatments and is at the point where she must learn to live with and deal with her condition and pain. Biofeedback, in conjunction with counseling, would provide her with tools to cope. Other patients with her condition have improved with such treatment.

Claimant’s Medical Records

The medical records describe Claimant’s medical history and present condition. Also included are the results of two biofeedback sessions documenting Claimant’s improvement during those sessions.

II. APPLICABLE LAW

n 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 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.^[1] AHealth care includes all reasonable and necessary medical services.^[2]

Certain categories of health care, require preauthorization before they can be provided within the strictures of the Workers= Compensation Act; preauthorization is granted if there is a prospective showing of medical necessity.^[3]

III. FINDINGS OF FACT

1. On March 13, 2001, Claimant suffered a compensable work-related injury to her neck resulting in pain, tingling, and numbness in her left arm and limited strength in her left hand.
2. At the time of Clamant’s injury, she was employed by the City of San Antonio, a self-insured employer (the Carrier).
3. Claimant underwent a cervical spine fusion and, following the surgery, has had problems swallowing, limited range of motion, neck pain, and anxiety.
4. Claimant’s treating physician prescribed ten biofeedback and counseling sessions to treat Claimant’s condition and Carrier timely denied preauthorization.
5. The Provider appealed the denial of preauthorization, and by decision issued October 9, 2003, the IRO determined that the prescribed treatment was medically necessary. Carrier timely appealed the IRO decision.
6. The Commission sent notice of the hearing on the appeal in this matter to all parties on November 20, 2003.
7. The notice of hearing 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.
8. The hearing was held on January 29, 2004, and both parties were represented. The record closed that same day.
9. Ten biofeedback and counseling sessions are reasonably calculated to relieve the effects naturally resulting from Claimant’s compensable injury, promote recovery, or enhance the ability of Claimant to return to or retain employment.

IV. CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘ 413.031(k) and Tex. Gov=t Code Ann. ch. 2003.
2. The Carrier timely requested a hearing, as specified in 28 Tex. Admin. Code (TAC) ‘ 148.3.
3. Proper and timely notice of the hearing was provided in accordance with Tex. Gov=t Code Ann. ‘ 2001.052 and 28 TAC ‘ 148.4.
4. The Carrier had the burden of proof in this matter pursuant to 28 TAC ‘ 148.21(h).
5. Tex. Lab. Code Ann. ‘413.014 and 28 TAC ‘134.600 require that biofeedback and counseling programs be preauthorized, dependent on a showing of medical necessity.
6. The Carrier failed to establish that the ten biofeedback and counseling sessions would not cure or relieve the effects naturally resulting from the claimant’s injury, promote her recovery, or enhance her ability to return to or retain employment.
7. The Carrier did not establish that the ten biofeedback and counseling sessions are not medically necessary to treat the claimant’s injury.
8. Based on the foregoing Findings of Fact and Conclusions of Law, preauthorization for the requested ten biofeedback and counseling sessions should be approved, pursuant to Tex. Lab. Code Ann. ‘ 413.014 and 28 TAC ‘ 134.600.

ORDER

It is ORDERED that ten biofeedback and counseling sessions are preauthorized for the claimant whose self-insured employer is the City of San Antonio.

Signed February 26, 2004.

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

1. Tex. Lab. Code Ann. ‘ 408.021.↑
2. Tex. Lab. Code Ann. ‘ 401.011(19).↑
3. Tex. Lab. Code Ann. ‘ 413.014; 28 TAC ‘ 134.600.↑