DECISION AND ORDER

I.DISCUSSION

In this case, Carlos Gonzalez, D.C., the Petitioner, seeks reimbursement for chiropractic treatments and office visits provided a workers’ compensation claimant (Claimant) from August 21, 2002 through January 30, 2003. The Administrative Law Judge (ALJ) finds the Petitioner should be reimbursed for the first six weeks of the services and office visits, but not for the remainder.

The Claimant was injured _______. She received considerable treatment, including six weeks of work hardening beginning December 10, 2001. She was able to return to work, and was found to be at maximum medical improvement as of May 1, 2002. Her pain returned, however, which led to the chiropractic treatments and office visits at issue here. Ultimately, the Claimant underwent spinal fusion surgery.

Liberty Mutual Insurance Company, the Respondent, refused to pay for the treatments and office visits from August 21, 2002, through January 30, 2003. The Petitioner filed a request for medical dispute resolution, in which the Independent Review Organization (IRO) found in favor of

the Respondent. The Petitioner filed a timely request for a hearing. After proper and timely notice, the hearing was held March 11, 2004.

Under 28 Tex. Admin. Code (TAC) §148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann. §413.031.

The Petitioner testified at the hearing on his own behalf. Thomas B. Sato, D.C., testified for the Respondent. Their testimony and the documentary evidence established that it was reasonable for the Petitioner to treat the recurrence of the Claimant’s pain as a flare-up of her previous condition. In that circumstance, six weeks of conservative treatment is reasonable and necessary under recognized treatment guidelines. However, her condition did not improve during those six weeks of conservative treatment. Under the guidelines, she should have been referred then for possible surgery or another course of treatment, even though surgery was not a course she wanted to take at that time.

The ALJ finds that the Respondent should be required to pay for six weeks of chiropractic treatment and office visits beginning August 21, 2002, but should not be required to pay for treatments or visits after that six-week period. The record does not contain a schedule of disputed services and amounts; therefore, the ALJ does not set those out in this decision.

II. FINDINGS OF FACT

1. The Claimant was injured _______.
2. The Claimant received considerable treatment, including six weeks of work hardening beginning December 10, 2001.
3. The Claimant was able to return to work, and was found to be at maximum medical improvement as of May 1, 2002.
4. The Claimant’s pain returned, which led to her receiving additional chiropractic treatments and office visits.
5. Ultimately, the Claimant underwent spinal fusion surgery.
6. Liberty Mutual Insurance Company, the Respondent, refused to reimburse the Petitioner, Carlos Gonzalez, D.C., for treatments and office visits from August 21, 2002, through January 30, 2003.
7. The Petitioner filed a request for medical dispute resolution, in which the Independent Review Organization (IRO) found in favor of the Respondent.
8. The Petitioner filed a timely request for a hearing.
9. Notice of the hearing was sent to the parties November 10, 2003.
10. The notice 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.
11. The hearing was held March 11, 2004, and adjourned the same day.
12. It was reasonable for the Petitioner to treat the recurrence of the Claimant’s pain as a flare-up of her previous condition.
13. Six weeks of additional conservative treatment for the Petitioner was reasonable and necessary under recognized treatment guidelines.
14. The Claimant’s condition did not improve during those six weeks of conservative treatment.
15. Under the treatment guidelines, the Claimant should have been referred for possible surgery or another course of treatment after six weeks, even though surgery was not a course she wanted to take at that time.

III. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(d) 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. §2001.052.
3. Under 28 Tex. Admin. Code (TAC) §148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann. §413.031.
4. The Respondent should be required to pay for six weeks of chiropractic treatment and office visits beginning August 21, 2002.
5. The Respondent should not be required to pay for treatments or visits after the six-week period that began August 21, 2002.

ORDER

The Respondent, Liberty Mutual Insurance Company, shall reimburse the Petitioner, Carlos Gonzalez, D.C., for six weeks of chiropractic treatments and office visits provided the Claimant beginning August 21, 2002. The Respondent shall not be required to reimburse the Petitioner for the remainder of the treatments and visits at issue in this proceeding.

Signed April 28, 2004.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS