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Title: 

453-04-3715-m5

Date: 

January 7, 2005

Type: 

Retrospective Medical Necessity

453-04-3715-m5

DECISION AND ORDER

Texas Mutual Insurance Company (TMIC) seeks review of a decision by the Texas Workers’ Compensation Commission (Commission), acting through an independent review organization (IRO), in a dispute regarding the medical necessity of physical medicine treatments that Southeast Health Services (Southeast) provided to Claimant ___, who suffered from a lower back injury. This decision finds that Southeast should be reimbursed $604.00 for certain services provided.

I. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION

The hearing convened on November 16, 2004, at the facilities of the State Office of Administrative Hearings, 300 W. 15th St., Austin, Texas. Administrative Law Judge (ALJ) Katherine L. Smith presided. TMIC was represented by Ryan Willett, an attorney. Southeast was represented by Bryan Weddle, D. C. The record closed the same day. Neither party challenged the adequacy of notice or jurisdiction.

II. BACKGROUND

Claimant suffered a compensable injury to his lower back on ___, when he was lifting a heavy chunk of concrete. Dr. Weddle began treating Claimant at Southeast on June 11, 2002. Dr. Weddle diagnosed Claimant with severe low back pain with spasms and bilateral lower extremity radiculitis. TMIC found certain of the treatments provided not to be medically necessary and denied reimbursement. The IRO found that the majority of treatments were medically necessary, because Claimant experienced exacerbations warranting follow-up care, but that the electrical stimulation and therapeutic activities provided from July 11 through July 22, 2002, were not.

The Commission’s Medical Review Division (MRD) reviewed the IRO’s decision and found, in addition, that the office visits of June 27, June 28, July 3, July 10, July 17, September 11, and October 9, 2002, were not sufficiently documented to justify reimbursement. MRD issued its decision on January 27, 2004. TMIC appealed the decision. The following services are still in dispute:

CPT CODES

DESCRIPTION

DATES OF CARE

99212

Office visit

7/11/02, 7/12/02, 7/16/02, 7/18/02, 7/19/02, 7/22/02

99213

Office visit

9/5/02, 10/16/02, 11/6/02, 12/6/02

97265

Joint mobilization

7/11/02, 7/12/02, 7/16/02, 7/17/02, 7/18/02, 7/19/02, 7/22/02, 9/5/02, 10/16/02, 11/6/02, 12/6/02

97016

vasopneumatic device

7/11/02, 7/12/02, 7/16/02, 7/17/02, 7/18/02, 7/19/02, 7/22/02

97250

Myofascial Release

7/22/02

III. ANALYSIS

July 11 to 22

TMIC presented David Alvarado, D.C., as its expert witness. Dr. Alvarado testified that the medical record does not justify the continued use of passive treatments, including joint mobilization, myofascial release, and vasopneumatic treatment, beyond the acute phase of care, that is, four to six weeks after the injury, particularly since Dr. Weddle’s evaluation of July 26, 2002, indicates that Claimant was pain-free for two weeks previous.[1] According to Dr. Alvarado, passive therapy is not needed when the pain is gone. Dr. Alvarado testified, however, that it was appropriate to evaluate Claimant’s progress at weekly office visits in July. But he also noted that it was inappropriate to bill for joint mobilization when billing for an office visit during which manipulations were performed, because joint mobilization is a precursor to manipulation therapy, and manipulation therapy duplicates joint mobilization.

Based on Dr. Alvarado’s testimony, the ALJ finds that Southeast should be reimbursed for three office visits on July 11, 16, and 22, 2002. But the ALJ is not as persuaded by Dr. Alvarado’s testimony that no passive modalities were warranted during the time in question. Although Dr. Weddle noted on July 26, 2002, that Claimant had been pain-free for two weeks, to assume that the period was a precise two weeks is being overly particular. The reference to two weeks could have meant anywhere between one to three weeks. Furthermore, the rehab notes indicate that Claimant was experiencing pain through July 19, 2002.[2] The ALJ, therefore, finds that the vasopneumatic treatments provided on July 11, 12, 16, 17, 18, and 19, 2002, and joint mobilizations provided on July 12, 17, 18, and 19, 2002, were medically necessary to treat Claimant’s pain. The ALJ finds, however, based on Dr. Alvarado’s testimony, that reimbursement for joint mobilizations provided on July 11, 16, and 22, 2002, is inappropriate.

Dr. Alvarado also noted that the necessity for passive treatments more than six weeks after the injury needed to be documented, which did not occur in this case. Finding this testimony to be persuasive and also noting that the rehab notes do not document any pain on that date, the ALJ finds

that the myofascial release and vasopneumatic treatment provided on July 22, 2002, were not medically necessary.[3]

September 5 through December 16

Dr. Alvarado testified that no documentation justified the office visits and joint mobilizations of September 5, 2002, October 16, 2002, November 6, 2002, and December 6, 2002. Dr. Alvarado noted that the record indicates Claimant was able to tolerate the physical demand level of his work with little or no pain on July 29, 2002.[4]In response, Dr. Weddle argued that the record shows that Claimant exacerbated his injury, calling for additional treatment on October 16, November 6, and December 6, 2002. The ALJ concludes that the record does document increased levels of pain on those dates.[5] Therefore, the ALJ finds that the office visits of those dates should be reimbursed. As for the office visit of September 5, 2002, the ALJ finds sufficient documentation justifying the follow-up visit.[6] But as noted above, the billing for joint mobilizations on those dates duplicates the billing for the office visits.

Conclusion

Accordingly, TMIC is required to reimburse Southeast for the office visits of July 11, 16, and 22, 2002, billed under CPT code 99212, and the office visits of September 5, October 16, November 6, and December 6, 2002, billed under CPT code 99213. TMIC is also required to reimburse Southeast for the vasopneumatic treatments provided on July 11, 12, 16, 17, 18, and 19, 2002, billed under CPT code 97016, and the joint mobilizations performed on July 12, 17, 18, and 19, 2002, billed under CPT code 97265, for a total of $604.00.

IV. FINDINGS OF FACT

  1. Claimant ___ suffered a compensable injury on ___, resulting in pain at his lower back.
  2. At the time of the injury, Claimant’s employer had workers’ compensation insurance coverage with Texas Mutual Insurance Co. (TMIC).
  3. Bryan Weddle, D.C., who practiced through Southeast Health Services (Southeast), began treating Claimant on June 11, 2002, and diagnosed Claimant with severe low back pain with spasms and bilateral lower extremity radiculitis.
  4. Southeast sought reimbursement for services provided to Claimant from TMIC.
  5. TMIC found certain of the treatments provided to be not medically necessary and denied reimbursement.
  6. Southeast made a timely request to the Texas Workers’ Compensation Commission (Commission) for medical dispute resolution.
  7. The independent review organization (IRO) to which the Commission referred the disputefound that the majority of treatments were medically necessary, because Claimant experienced exacerbations that warranted follow up care, but that electrical stimulation and therapeutic activities provided from July 11 through September 5, 2002, were not.
  8. The Commission’s Medical Review Division (MRD) reviewed the IRO’s decision and found that the office visits of June 27, June 28, July 3, July 10, July 17, September 11, October 9, 2002, were not sufficiently documented to justify reimbursement. MRD issued its decision on January 27, 2004.
  9. TMIC requested a hearing in a timely manner with the State Office of Administrative Hearings (SOAH), seeking review of the MRD decision.
  10. On March 16, 2004, the Commission issued the notice of the hearing, which stated the date, time, and location of the hearing and cited to the statutes and rules involved, along with a short, plain statement of the factual matters involved.
  11. The hearing convened on November 16, 2004, at 300 W. 15th St., Austin, Texas.
  12. Claimant received physical medicine treatments at Southeast consisting of joint mobilization (CPT code 97265), myofascial release (CPT code 97250), and vasopneumatic treatments (CPT code 97016).
  13. Southeast also billed for office visits using CPT codes 99212 and 99213.
  14. Weekly office visits, occurring on July 11, 16, and 22, 2002, were appropriate to evaluate Claimant’s progress.
  15. Joint mobilization is a precursor for manipulation therapy, and manipulation therapy duplicates joint mobilization.
  16. Billing for joint mobilizations, when also billing for an office visit during which manipulation therapy was provided, is not appropriate.
  17. The rehab notes indicate that Claimant was experiencing pain through July 19, 2002.
  18. The vasopneumatic treatments provided on July 11, 12, 16, 17, 18, and 19, and joint mobilizations provided on July 12, 17, 18, and 19, 2002, were provided during the acute phase of care, that is, up to six weeks after the injury, and were used to treat Claimant’s pain.
  19. The medical record does not justify why myofascial release and vasopneumatic treatment were being provided on July 22, 2002, beyond the acute phase of care, when Claimant was not complaining of pain at that time.
  20. The medical records document that Claimant was suffering from increased levels of pain on October 16, November 6, and December 6, 2002, justifying the need for an office visit.
  21. The medical record of September 5, 2002, justifies the need for a follow-up visit.
  22. Billing for joint mobilizations on September 5, October 16, November 6, and December 6, 2002, duplicates the billing for the office visits on those dates.
  23. The total maximum allowable reimbursement from the Commission’s Medical Fee Guideline for the services outlined in Findings of Fact Nos 14, 18, 20 and 21 is $604.00.

V. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. § 413.031.
  2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(k) of the Act and Tex. Gov’t Code Ann. ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’tCode Ann. §§ 2001.051 and 2001.052.
  4. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and the Commission’s rules, 28 Tex. Admin Code (TAC) §§ 148.1-148.28.
  5. Under Tex. Labor Code § 408.021(a)(1), 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.
  6. TMIC had the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41.
  7. The weekly office visits of July 11, 16, and 22, September 5, October 16, November 6, and December 6, 2002, were medically necessary health care.
  8. The vasopneumatic treatments provided on July 11, 12, 16, 17, 18, and 19, and joint mobilizations provided on July 12, 17, 18, and 19, 2002, were medically necessary health care.
  9. The joint mobilizations provided to Claimant on July 11, 16, and 22, September 5, October 16, November 6, and December 6, 2002, were not medically necessary health care.
  10. The myofascial release and vasopneumatic treatment provided on July 22, 2002, were not medically necessary health care.
  11. Based upon the foregoing Findings of Fact and Conclusions of Law, Southeast’s request for reimbursement is Granted, except for the treatments outlined in Conclusions of Law Nos. 9 and 10.

ORDER

IT IS THEREFORE, ORDERED that TMIC shall reimburse Southeast $604.00, plus interest. As for the other disputed claims at issue in this case, TMIC owes nothing.

Signed January 7, 2005.

KATHERINE L. SMITH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. TMIC Ex. 1 at 70.↑
  2. Southeast Ex. 1 at 86-101.↑
  3. Id. at 84.↑
  4. TMIC Ex. 1 at 76-77.↑
  5. Southeast Ex. 1 at 1-2, 4.↑
  6. Id. at 5.↑