DECISION AND ORDER

I. INTRODUCTION

PRIDE (Provider) disputes a decision of the Texas Workers= Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services for ___ (Claimant). Those services were participation in a chronic-pain-management program, current procedural terminology (CPT) code 97799-CP-AP, provided from August 30, 2001 through October 23, 2001; and supplies and material, CPT 99070, provided on October 9, 2001. The total maximum allowable reimbursement (MAR) amount in dispute is $19,374.

The MRD found that the Connecticut Indemnity Company (Carrier) was not required to reimburse the Provider because the billing documents did not show that the chronic-pain-management services were provided to due to the compensable injury rather than the Claimant’s non-compensable degenerative-disc disease. The MRD did not address the supplies-and-material reimbursement request. The only disputed issue is whether the disputed services were beyond the extent of the Claimant’s compensable injury. The Provider has the burden of proof.

As set out below, the Administrative Law Judge (ALJ) cannot find that the disputed services were provided to treat the Claimant’s compensable injury rather than his non-compensable degenerative-disc disease. Hence, the Provider’s request for reimbursement should be denied.

II. FINDINGS OF FACT

1. On ___, the Claimant sustained a compensable work-related injury to his back.
2. On the date of injury, the Claimant’s employer was ___, and the Carrier was its workers= compensation insurance carrier.
3. The Provider furnishes a chronic-pain-management program to injured claimants to allow train them to cope with that type of pain. The program is multi-disciplinary and includes physical therapy, various types of counseling, and other services designed to return claimants to work.
4. In the fall of 2001, the Claimant was complaining of back pain and his Treating Doctor prescribed a chronic-pain-management program for the Claimant.
5. On October 1, 2001, the Provider sought pre-authorization from the Carrier for the Claimant to participate in 10 sessions of the Provider’s chronic-pain-management program.
6. An independent third-party utilization reviewer, on behalf of the Carrier, found that the Claimant’s participation in ten sessions of the Provider’s chronic-pain-management program to be completed by November 1, 2004, was reasonably medically necessary and pre-authorized those services.
7. The utilization reviewer specifically indicated that it was not determining legal liability for payment.
8. The Provider furnished medical services to the Claimant on the dates, for the number of service hours, and with the CPT codes and MARs shown below:

DATES	CPT	SERVICE HOURS	MAR	SERVICE DESCRIPTIONS
8/27/01 through 10/23/01	97799-CP-AP	151	$128 per hour	chronic-pain-management program
10/09/01	99070		$46	supplies and materials

1. After the Claimant completed the chronic-pain-management program, the Provider sought reimbursement of $19,374 from the Carrier for the above services.
2. The diagnosis codes in the Provider’s requests for reimbursement indicated that the disputed services were furnished to the Claimant to address the following diagnoses:

a.lumbago, which is lower back pain;

b.stiffness of joint;

c.muscle atrophy; and

3. d.psychiatric factor.
4. The Claimant has degenerative spinal disc disease (including a bulge and degenerative changes at lumbar vertebra 5), spinal stenosis (narrowing of the spinal canal which may cause pinching of the spinal cord and nerves), and lumbar vertebra 4 through sacral vertebra 1 rigidity.
5. On February 12, 2003, a TWCC Hearing Officer found that the Claimant’s compensable injury did not include, cause, or aggravate the Claimant’s degenerative-disc disease.
6. On that same date, the same TWCC Hearing Officer also found that the Claimant had continuing pain with segmental rigidity from his compensable injury when he began the Provider’s chronic-pain-management program.
7. The diagnosis codes that the Provider furnished to the Carrier are general and could describe either the Claimant’s compensable injury, his non-compensable degenerative-disc disease, or both.
8. The Provider did not furnish other documentation to the Carrier to reasonably indicate that the disputed services were provided to treat the Claimant’s compensable-injury pain rather than his non-compensable degenerative-disc-disease pain.
9. The Carrier timely sent explanations of benefit (EOBs) to the Provider denying the requested reimbursement for the following reasons:

CPT CODES	DENIAL REASONS
97799-CP-AP	beyond the extent of the compensable injury
99070	beyond the extent of the compensable injury

1. The Provider timely filed a request for medical dispute resolution with TWCC.
2. The TWCC MRD could not find from the diagnostic codes and other billing documents whether the Provider furnished the chronic-pain-management services to treat the Claimant’s compensable-injury pain or his non-compensable degenerative-disc-disease pain.
3. After the MRD order was issued, the Provider asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) ALJ.
4. Required notice of a contested-case hearing concerning the dispute was mailed to the Carrier and the Provider.
5. On April 21, 2004, SOAH ALJ William G. Newchurch held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
6. The Carrier appeared at the hearing through its attorney, Tommy W. Lueders, II.
7. The Provider appeared by telephone at the hearing through its attorney, Peter N. Rogers.

III. CONCLUSIONS OF LAW

1. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. (Labor Code) ” 402.073(b) and 413.031(k) (West 2004) and Tex. Gov=t Code Ann. (Gov=t Code) ch. 2003 (West 2004).
2. Adequate and timely notice of the hearing was provided in accordance with Gov=t Code ” 2001.051 and 2001.052.
3. Based on the above Findings of Fact and Gov’t Code ‘ 2003.050 (a) and (b), 1 Tex. Admin. Code (TAC) ‘ 155.41(b) (2004), and 28 TAC ” 133.308(v) and 148.21(h) (2004), the Provider has the burden of proof in this case.
4. An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed 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. Labor Code ‘ 408.021 (a).
5. TWCC must specify by rule which health care treatments and services require express pre-authorization by a carrier. A carrier is not liable for those specified treatments and services unless pre-authorization is sought by the claimant or a health care provider and either obtained from the carrier or ordered by TWCC. Labor Code ‘413.014
6. Pre-authorization is required for a claimant’s participation in a chronic-pain-management program. 28 TAC ‘ 134.600(h)(10)(B).
7. A carrier must approve or deny requests for preauthorization based solely upon the reasonable and necessary medical health care required to treat the injury, regardless of unresolved issues of compensability, extent of or relatedness to the compensable injury or the carrier’s liability for the injury. 28 TAC ‘ 134.600(f)(1)(A) and (B).
8. An insurance carrier may not retrospectively review the medical necessity of a medical bill for treatments or services for which the health care provider has obtained pre-authorization. However, a carrier may retrospectively review the billing for treatments or services unrelated to the compensable injury. 28 TAC ‘ 133.301(a)(5).
9. Based on the above Findings of Fact and Conclusions of Law, the Carrier’s pre-authorization of the chronic-pain-management program conceded that the Claimant reasonably medically needed that service, but not that he needed it as a result of his compensable injury.
10. The evidence does not show that the Claimant more likely than not needed the disputed services due to his compensable injury.
11. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for reimbursement should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request for reimbursement is denied.

Signed June 4, 2004.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

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