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Title: 

453-04-1979-m5

Date: 

June 28, 2004

Type: 

Retrospective Medical Necessity

453-04-1979-m5

DECISION AND ORDER

I. DISCUSSION

Texas Mutual Insurance Company, (Petitioner) requested a hearing following a November 14, 2003 Decision of the Texas Workers’ Compensation Commission (Commission). The Commission, relying upon a May 20, 2003 decision of Maximus, an Independent Review Organization (IRO), authorized reimbursement for chiropractic services provided by Central Dallas Rehab (Respondent) to injured worker ___ (Claimant) from April 2, 2002, through July 31, 2002, and denied reimbursement for chiropractic services provided by Respondent to Claimant from August 1, 2002, through October 4, 2002. Respondent did not request a hearing on the denial of reimbursement for the August to October period. This Decision and Order will only address the April through July chiropractic services.

The amount in dispute is $7,424.00.[1] After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that the chiropractic services provided by Respondent from April 2, 2002, through May 22, 2002, were reasonable and medically necessary and that the following office visits were reasonable and medically necessary: (1) May 29; (2) June 5, 12, 19 and 26; and (3) July 3, 8, 16, 23 and 30. The other chiropractic services provided by Respondent from May 23, 2002, through July 31, 2002, were not medically necessary.

The parties prefiled all exhibits and testimony. The hearing convened on May 6, 2004, with State Office of Administrative Hearings (SOAH) ALJ Howard S. Seitzman presiding. Katie Kidd represented Petitioner and Scott Hilliard represented Respondent. Following conclusion of closing arguments, the parties agreed to file a stipulation of the amount in dispute. The parties filed the stipulation on May 11, 2004, and the record closed that day. Neither party objected to notice or jurisdiction.

Claimant suffered a work-related injury to his left wrist on ___. Claimant began treating with Respondent on March 22, 2002, with Ted Krejci, D.C., as the treating professional. Several

physicins also examined Claimant on referral during the April through July 2002 period. James E. Laughlin, D.O., examined Claimant on April 15, 2002. At that time, Dr. Laughlin noted progress was less than expected with Aconservative care alone and recommended an injection to the wrist. On April 22, 2002, Dr. Laughlin performed the injection and returned Claimant to Respondent for Atotal care. Specifically recommended by Dr. Laughlin were active and passive range of motion exercises and whirlpool.

David J. Zehr, M.D., examined Claimant on May 22, 2004. Dr. Zehr is a well-respected hand surgeon. Dr. Zehr recommended casting the wrist for six weeks to let it rest and then follow with mobilization. Instead, Respondent continued treating Claimant with active and passive modalities.

Petitioner had the burden of proof. With the exception of one office visit per week, Petitioner demonstrated by a preponderance of the evidence that the chiropractic services provided to Claimant from May 23, 2002, through July 31, 2002, were not medically necessary. Petitioner failed to prove that the chiropractic services provided to Claimant from April 2, 2002, through May 22, 2002, were not reasonable and medically necessary. Respondent is entitled to reimbursement for chiropractic services provided Claimant between April 2, 2002, and May 22, 2002, and for ten additional office visits between May 29, 2002 and July 30, 2002. Respondent is not entitled to reimbursement for other chiropractic services from May 23, 2002, through July 31, 2002.

II. FINDINGS OF FACT

  1. ___ (Claimant) suffered a work-related injury on ___.
  2. Claimant began treating with Central Dallas Rehab (Respondent) on March 22, 2002, with Ted Krejci, D.C ., as the treating professional.
  3. Several physicians also examined Claimant on referral between April 2002 and July 2002.
  4. James E. Laughlin, D.O., examined Claimant on April 15, 2002, and recommended an injection to the wrist.
  5. On April 22, 2002, Dr. Laughlin performed the injection and returned Claimant to Respondent for total care. Specifically recommended by Dr. Laughlin were active and passive range of motion exercises and whirlpool.
  6. David J. Zehr, M.D., examined Claimant on May 22, 2004.
  7. Dr. Zehr is a well-respected hand surgeon.
  8. Dr. Zehr recommended casting the wrist for six weeks to let it rest.
  9. Respondent continued treating Claimant with active and passive modalities.
  10. Claimant’s wrist was not immobilized and was not rested.
  11. The treatment dates in issue are April 2, 2002, through July 31, 2002.
  12. Texas Mutual Insurance Company (Petitioner) denied Respondent reimbursement for the chiropractic services provided Claimant between April 2, 2002, and October 4, 2002, as not medically necessary.
  13. The Texas Workers’ Compensation Commission (Commission), acting through an Independent Review Organization (IRO), Maximus, found that the chiropractic services provided by Respondent between April 2, 2002, and July 31, 2002, were medically necessary and that the chiropractic services provided by Respondent between August 1, 2002, and October 4, 2002, were not medically necessary for the treatment of Claimant.
  14. Petitioner timely requested a hearing before the State Office of Administrative Hearings (SOAH) regarding the medical necessity of the chiropractic services provided to Claimant between April 2, 2002, and July 31, 2002.
  15. Respondent did not request a hearing before SOAH regarding the medical necessity of the chiropractic services provided to Claimant between August 1, 2002, and October 4, 2002.
  16. The parties prefiled all exhibits and testimony.
  17. The hearing convened on May 6, 2004, with SOAH Administrative Law Judge Howard S. Seitzman presiding. Katie Kidd represented Petitioner and Scott Hilliard represented Respondent. Following conclusion of closing arguments, the parties agreed to file a stipulation of the amount in dispute. The parties filed the stipulation on May 11, 2004, and the record closed that day.
  18. The amount in dispute is $7,424.00.

III. CONCLUSIONS OF LAW

  1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers= Compensation Act, specifically Tex. Labor Code Ann. ‘ 413.031(k), and Tex. Gov=t Code Ann. ch. 2003.
  2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov=t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
  3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code ‘ 148.3.
  4. Adequate and timely notice of the hearing was provided according to Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
  5. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code ” 148.21(h) and 133.308(w).
  6. The chiropractic services provided by Respondent from April 2, 2002, through May 22, 2002, and the office visits of (1) May 29; (2) June 5, 12, 19 and 26; and (3) July 3, 8, 16, 23 and 30; were reasonable and medically necessary. The other chiropractic services provided by Respondent from May 23, 2002, through July 31, 2002, were not medically necessary.

ORDER

THEREFORE IT IS ORDERED that Central Dallas Rehab is entitled to reimbursement from Texas Mutual Insurance Company for charges, plus any applicable interest, associated with chiropractic services provided to injured worker ___ from April 2, 2002, through May 22, 2002, and for the office visits of (1) May 29; (2) June 5, 12, 19 and 26; and (3) July 3, 8, 16, 23 and 30.

IT IS FURTHER ORDERED that Central Dallas Rehab is not entitled to reimbursement from Texas Mutual Insurance Company for charges associated with other chiropractic services provided to injured worker ___ from May 23, 2002, through July 31, 2002.

Signed June 28, 2004.

HOWARD S. SEITZMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. 1 The parties filed a stipulation on May 11, 2004.↑