DECISION AND ORDER

Zurich American Insurance Company (Carrier) appealed a decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission) that authorized reimbursement of $549.00 to Andrew Block, Ph.D. (Provider) for psychological therapy, evaluation, and testing. Carrier contended that the services and office visits were not medically reasonable or necessary. Based on the evidence, the ALJ agrees with the decision of the MRD.^[1]

The particular facts and reasoning in support of this decision are set forth below in the Findings of Fact, and the legal conclusions derived from those facts appear in the Conclusions of Law. The Administrative Law Judge convened a hearing on these issues on March 15, 2004, and the record closed the same day.

II. EVIDENCE

The record in this case consisted of the documents submitted by the parties during the MRD proceeding, admitted into evidence as Carrier’s Exhibit 1 and Provider’s Exhibit 1, and the testimony of Dr. Block. Dr. Block testified that the services he provided to Claimant in October and November of 2002, were pre-authorized by Carrier.

III. FINDINGS OF FACT

1. Claimant suffered a compensable worker’s compensation injury on ___.
2. Claimant’s injury is covered by worker’s compensation insurance provided by her employer, and carried through Zurich American Insurance Company (Carrier).
3. On October 17, 2002, Andrew Block, Ph.D. (Provider) received preauthorization from Carrier to provide two hours of individual therapy, evaluation and testing to Claimant. The preauthorization included one hour of testing.
4. On October 21, 2002, Provider saw Claimant on an initial visit and performed testing. Provider billed Carrier $375.00 for three hours of testing as CPT Code 90830 (testing), and $180.00 for CPT Code 90801 (initial visit).
5. The Maximum Amount Recoverable (MAR) for CPT Code 90830 under the Medical Fee Guidelines is $125.00 per hour.
6. On October 23, 2002, Provider received preauthorization from Carrier to provide individual therapy to Claimant for eight visits over twelve weeks as an outpatient.
7. On November 22, 2002, Provider provided psychological therapy services to Claimant and billed Carrier $125.00 for CPT Code 90844 (therapy). The Maximum Allowable Recovery (MAR) amount for CPT Code 90844 under the Medical Fee Guidelines is $122.00.
8. The services provided to Claimant on October 21 and November 22, 2002, were within the scope of Carrier’s preauthorization.
9. Carrier denied payment of the charges for the therapy, testing, and office visits on October 21 and November 22, 2002, claiming that they were not medically necessary.
10. On January 13, 2003, Provider requested reconsideration of Carrier’s decisions.
11. Provider requested dispute resolution by the Texas Worker’s Compensation Commission Medical Review Division (MRD).
12. On December 5, 2003, the MRD issued a decision approving reimbursement of $549.00 for the psychological evaluation, testing, and therapy Claimant received from Provider on October 21 and November 22, 2002.
13. On December 12, 2003, Carrier appealed the MRD’s decision.
14. On January 23, 2004, the Commission sent a notice of hearing to the parties. The notice contained a statement of the time and place of the hearing; a statement of the legal authority
15. and jurisdiction under which the hearing was to be held; a reference to the particular section of the statutes and rules involved; and a short plain statement of the matters asserted.
16. The hearing was convened on March 15, 2004, and all parties appeared and participated in the hearing.

VI. CONCLUSIONS OF LAW

1. The Texas Worker’s Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant the Texas Worker’s Compensation Act (Act), Tex. Labor Code Ann. § 413.031.
2. The State Office of Administrative Hearings has jurisdiction over matters related to this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and Tex. Govt. Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.052 and 2001.057.
4. As the party appealing the MRD decision, the Carrier has the burden of proof in this matter, pursuant to 28 Tex. Admin. Code (TAC) § 148.21(h).
5. Preauthorization must be received from Carrier for all psychological, testing and psychotherapy, prior to providing those services, pursuant to 28 TAC § 134.600(h).
6. Carrier is liable for all reasonable and necessary medical costs if preauthorization for the health care was approved prior to providing the health care. 28 TAC § 134.600(b)(1)(B).
7. Once a Carrier has preauthorized medical services, it is precluded from challenging the services on the grounds of medical necessity. 28 TAC § 133.301(a).
8. Based on the above Findings of Fact and Conclusions of Law, Petitioner is entitled to reimbursement of $549.00 under Tex. Labor Code §§ 413.015 and 408.021(a) for the services provided to Claimant on October 21 and November 22, 2002.

ORDER

IT IS ORDERED that Carrier reimburse Andrew Block, Ph.D. in the amount of $549.00 for the psychological testing, evaluation and therapy provided to Claimant on October 21, and November 22, 2003.

Signed March 25, 2004.

SUZANNE FORMBY MARSHALL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The Commission withdrew this case from review by an Independent Review Organization (IRO) on the basis that the disputed issue was really a fee dispute, instead of a dispute over medical necessity, because the Carrier had preauthorized the services provided in this matter. Consequently, the Commission’s MRD issued a decision treating the matter solely as one of a fee dispute. The ALJ agrees that once Carrier has preauthorized services, it is precluded from asserting that there is no medical necessity for them. 28 Tex. Admin. Code (TAC) §§ 133.301(a); 134.600(b)(1)(B). The ALJ does not conclude that the case is really a fee dispute, but instead, is a medical necessity dispute in which Carrier, by its preauthorization, cannot prevail.↑