DECISION AND ORDER

I. DISCUSSION

Integrative Medical Clinics (Petitioner) requested a hearing following a February 3, 2004, Decision of the Texas Workers’ Compensation Commission (Commission). The Commission, relying upon a January 30, 2004, decision of Maximus, an Independent Review Organization (IRO), denied reimbursement for chiropractic services Petitioner provided to injured worker ___ (Claimant) from September 3, 2002, through June 25, 2003.

The amount in dispute is approximately $8,000.00.^[1] After considering the evidence presented and the parties= arguments, the Administrative Law Judge (ALJ) concludes that Petitioner failed to establish that the chiropractic services at issue were medically necessary.

The hearing convened on August 31, 2004, with State Office of Administrative Hearings (SOAH) ALJ Renee M. Rusch presiding. Petitioner appeared pro se though its employee, Cassandra Ramos, D.C. Attorney Tommy Lueders, II, represented Respondent, Royal and Sun Alliance. The record closed the same day. Neither party objected to notice or jurisdiction.

Claimant ___ suffered a work-related back injury on ___. Claimant began treating with Dr. Ramos on April 5, 2002, i.e., approximately two months after her injury. Claimant reported low back pain with pain traveling down her left leg; she told Dr. Ramos that another doctor, either Claimant’s family doctor or a surgeon, had recommended surgery. A lumbar ultrasound on April 12, 2002, indicated that Claimant had mild bilateral facet area inflammation at L1-L3.

Dr. Ramos= course of treatment for Claimant included physical therapy, electrical muscle stimulation, and therapeutic procedures. According to Dr. Ramos, this course of treatment ultimately rendered Claimant virtually pain-free, although Claimant did experience occasional flare-ups. Based upon a review of Claimant’s medical records, a chiropractic peer reviewer determined that Claimant should have received active therapy for no more than six to eight weeks following the initiation of treatment, and thus, Claimant’s treatment should have ended approximately May 31, 2002. An IRO chiropractor noted that Claimant was treated from September 6, 2002, through October 30, 2002, without any documented complaints of pain; the documentation did not contain objective findings supporting the length of care; and the documentation did not demonstrate that the treatment provided was promoting a cure.

Petitioner had the burden of proof by a preponderance of the evidence. Based on the evidentiary record described above, the ALJ finds that Petitioner failed to establish that the chiropractic services Dr. Ramos provided to Claimant after May 31, 2002, were medical necessary. Thus, Petitioner is not entitled to reimbursement for the services it provided to Claimant between September 3, 2002, and June 25, 2003.

II. FINDINGS OF FACT

1. ___ (Claimant) suffered a work-related injury on ___.
2. At the time Claimant sustained the compensable injury, Royal and Sun Alliance (Respondent) was the workers= compensation insurance carrier for Claimant’s employer.
3. Claimant began treating with Cassandra Ramos, D.C. on April 5, 2002, i.e., approximately two months after her injury.
4. Dr. Ramos is employed by Petitioner, Integrative Medical Clinics (Petitioner).
5. On April 5, 2002, Claimant told Dr. Ramos she was experiencing low back pain with pain traveling down her left leg; she also told Dr. Ramos that another doctor, either Claimant’s family doctor or a surgeon, had recommended surgery.
6. A lumbar ultrasound on April 12, 2002, indicated Claimant had mild bilateral facet area inflammation at L1-L3.
7. Dr. Ramos= course of treatment for Claimant included physical therapy, electrical muscle stimulation, and therapeutic procedures.
8. Petitioner provided the chiropractic services at issue in this case between September 3, 2002, through June 25, 2003.
9. Respondent denied reimbursement for the services provided between September 3, 2002, through June 25, 2003, on the basis that they were not medically necessary.
10. The chiropractic services Petitioner provided to Claimant from September 3, 2002, through June 25, 2003, were not medically necessary.
11. The Texas Workers’ Compensation Commission (Commission), acting through an Independent Review Organization (IRO), Maximus, found that the chiropractic services provided by Petitioner from September 3, 2002, through June 25, 2003, were not medically necessary for Claimant’s treatment.
12. Petitioner timely requested a hearing before the State Office of Administrative Hearings (SOAH) regarding the medical necessity of the chiropractic services at issue.
13. The hearing convened on August 31, 2004, with SOAH Administrative Law Judge Renee M. Rusch presiding. Petitioner appeared pro se though its employee, Cassandra Ramos, D.C. The record closed the same day.
14. The amount in dispute is approximately $8,000.00.

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. Petitioner failed to carry its burden of proving that the services provided from September 3, 2002, through June 25, 2003, were medically necessary. Tex. Lab. Code Ann. ” 408.021(a); 401.011(19) and (31).
7. Petitioner is not entitled to reimbursement for the services at issue.

ORDER

IT IS ORDERED that Petitioner’s request for payment for services it provided to Claimant ___ from September 3, 2002, through June 25, 2003, is hereby denied.

Signed October 21, 2004.

RENEE M. RUSCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. ¹ Petitioner failed to prefile the documents it intended to offer into evidence. Thus, the exact amount in dispute is not in evidence, nor is documentation regarding individual dates of service in evidence.↑