DECISION AND ORDER

Liberty Mutual Insurance Company (Carrier) challenges an Independent Review Organization decision concluding that College Hospital Costa Mesa (Provider) is entitled to reimbursement for outpatient surgery performed on an injured worker. Petitioner had refused reimbursement based on Respondent’s failure to obtain preauthorization prior to performing the surgery. Administrative Law Judge (ALJ) Gary Elkins convened and closed a hearing on March 24, 2004. Petitioner appeared at the hearing and was represented by Attorney Kevin Franta. Respondent did not appear at the hearing. The ALJ agrees with Petitioner’s position, and concludes that reimbursement should be denied. The findings and conclusions supporting this decision are set forth below.

I. FINDINGS OF FACT

1. College Hospital Costa Mesa (Provider) performed a percutaneous disk decompression/diskectomy (surgical procedure) on an injured worker on April 30, 2002.
2. Liberty Mutual Insurance Company (Carrier) denied reimbursement based on its conclusion preauthorization was not obtained prior to the surgical procedure.
3. An Independent Review Organization (IRO) concluded Provider was entitled to reimbursement for the disputed services.
4. Upon receiving the IRO decision, Carrier timely requested a hearing before the State Office of Administrative Hearings (SOAH).
5. Notice of the hearing was sent to the parties on February 6, 2004. The notice informed the parties of the date, time, and location of the hearing, a statement of the matters to be considered, the legal authority under which the hearing would be held, and the statutory provisions applicable to the matters to be considered.
6. The hearing convened and closed March 24, 2004. Carrier appeared at the hearing. Provider did not appear.
7. Preauthorization is required for the surgical procedure.
8. Provider sought preauthorization for the surgical procedure on April 11, 2003.
9. Carrier denied the April 11, 2003, preauthorization request on April 16, 2003.
10. Provider submitted a second preauthorization request on April 29, 2003.
11. Carrier denied the second request for preauthorization.
12. Provider filed a request for medical dispute with the Texas Workers’ Compensation Commission on August 20, 2003.

II. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding pursuant to §413.031(k) of the Act 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. §§2001.051 and 2001.052.
3. The surgical procedure required preauthorization, pursuant to 28 Tex. Admin. Code §134.600(b)(1).
4. Provider is not entitled to reimbursement for the disputed services.

ORDER

IT IS ORDERED thatthe reimbursement claim of College Hospital Costa Mesa for the percutaneous disk decompression/diskectomy performed on April 30, 2003, is denied.

Signed May 21, 2004.

Gary W. Elkins
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS