DECISION AND ORDER

Dr. Suhail Al-Sahli (Provider) challenges an Independent Review Organization (IRO) decision confirming the denial of reimbursement for services provided to Claimant from September 13, 2001, through May 31, 2002. The Administrative Law Judge (ALJ) concludes the disputed services were not shown to be medically necessary to treat Claimant’s injury. Consequently, reimbursement should be denied.

I. STATEMENT OF THE CASE

Administrative Law Judge (ALJ) Suzanne Formby Marshall convened and closed the hearing on October 18, 2004. Dr. Al-Sahli (Provider) represented himself and appeared by telephone. Texas Mutual Insurance Company (Carrier) appeared and was represented by attorney Timothy Riley. Notice and jurisdiction were not disputed and are addressed in the Findings of Fact and Conclusions of Law.

II. DISCUSSION

A. Background.

Claimant suffered a compensable injury on___, when a high pressure water hose sprayed Claimant’s hand, resulting in hydroblast injuries. Shortly after the injury, Claimant was treated by Jan Garcia, Jr., M.D., who performed two reconstructive operations on Claimant’s hand. After the surgeries, Claimant received physical therapy from Advantage Physical Therapy from December 1997 through February 1998. Dr. Suhail Al-Sahli (Provider) began treating Claimant on February 10, 2000.^[1]

The disputed services, provided from September 13, 2001, through May 31, 2002, include office visits with manipulation, therapeutic exercises, miscellaneous DME, ultrasound, myofascial release, and unusual physician travel.^[2] The unusual physician travel consisted of transportation by someone from Dr. Al-Sahli’s office to pick up and return Claimant to his home in order to receive treatment.

According to Dr. Al-Sahli, the treatment provided to Claimant improved his physical condition and allowed him to continue to work. Carrier contends that the services were not medically necessary because they did not help Claimant’s condition, nor did they provide hope of continued improvement.

After Carrier denied reimbursement for the services rendered, Provider responded by filing a request for medical dispute resolution. An Independent Review Organization (IRO) reviewing physician concluded the services were not medically necessary because Claimant’s condition should have resolved by the time the services were provided and he should have reached maximum medical improvement. Provider requested a hearing before the State Office of Administrative Hearings to appeal the decision of the IRO, which was adopted by the Commission’s Medical Review Division.

B.Summary of Evidence and Argument

Provider testified and introduced medical records to support his contention that the disputed services were medically necessary. According to Provider:

• Claimant needed care to relieve the effects of his injury due to continued nerve pain in his hand.^[3]
• Carrier continued to deny requests for carpal tunnel surgery, even though it had been recommended by several doctors.
• The care provided to Claimant allowed him to continue to work.
• The treatment relieved the effects of Claimant’s injury.
• Claimant’s entire span of treatment should be reviewed to ascertain medical necessity due to fluctuations that may occur from day to day.

Carrier also introduced medical records to support its contention that the treatment was not medically necessary. Further, it relied upon the testimony of Dr. David Alvarado^[4] who testified that

Claimant’s medical records did not document the need for continued medical treatment and that it was inappropriate to continue using passive care modalities three and one-half to four years post-injury. According to Dr. Alvarado:

• The type of passive modalities administered by Provider may have been appropriate during the acute phase of injury, but Provider administered it for one to two years, well beyond the acute phase. At the time the services were provided, more than three years had passed since Claimant’s injury.
• Claimant had received services from Advantage Physical Therapy after his surgeries consisting of 31 units of active exercise post-surgery, 17 units of myofascial release, 18 units of hot and cold treatment.
• Claimant was released to regular work duty on February 25, 1998, after completing his course of physical therapy with Advantage Physical Therapy.
• Two years later, in 2000, Provider treated Claimant with 51 units of ultrasound, 25 units of myofascial release, 27 units of joint mobilization, 6 units of hot and cold treatment, 1 unit of massage, and 187 units of one-on-one therapy. This treatment occurred prior to the disputed dates of service.
• The records do not reflect a progression in the care of Claimant but, instead, the treatment was repetitive as indicated by the chart notes which are essentially identical.
• It is inappropriate to continue to provide the same type of treatment if the Claimant is not making progress.
• The records do not reflect documentation of an appropriate treatment plan containing specific goals and objectives, nor does it contain notations of Claimant’s response to the treatment plan.
• Records that indicate Claimant increased his strength and range of motion are inconclusive because of Claimant’s failure to give maximum effort in testing. Further, the test results do not support the care that was rendered.
• One-on-one therapy is not medically necessary when the patient can be educated on how to perform exercises. There is no justification for a staff member to watch Claimant perform exercises for approximately two hours per day.
• The quality of documentation in the medical notes was lacking due to the lack of specificity describing the need for the treatment, the desired goals, and Claimant’s response to the treatment.
• The medical records reflect that Claimant was doing well in 1998, had completed treatment goals and was released to return to work.

C. Analysis and Conclusion

Provider did not prove the disputed services were medically necessary. A review of the medical records indicates that Claimant was treated by Dr. Jan Garcia after the injury.^[5] Dr. Garcia performed two surgeries on Claimant’s left hand. Dr. Garcia’s post-surgical SOAP notes indicate that Claimant was progressing satisfactorily, but complained of shoulder pain, chest pain, and pain in both hands. Carrier’s Ex. 1, pp. 1-4. Dr. Garcia referred Claimant for further evaluation of these complaints, noting that the shoulder and chest pain were unrelated to the injury. Carrier’s Ex. 1, pp. 3-4. Claimant continued to complain of pain and Dr. Garcia encouraged him to continue with exercises to increase his strength.

From December 31, 1997, through February 25, 1998, Claimant received physical therapy services from Advantage Physical Therapy. A progress report of Claimant’s physical therapy was issued on February 23, 1998, indicating that Claimant had increased his total active motion, increased his coordination/dexterity to good, was instructed in the use of home exercises, and otherwise met all treatment goals. Carrier’s Ex. 1, pp. 8-9.

However, Claimant continued to complain of pain in his hands and Dr. Garcia suspected that Claimant might have carpal tunnel syndrome. Further diagnostic testing consisting of a nerve conduction study was negative, however.^[6] On August 2, 1999, Dr. Garcia advised Claimant that, despite his continued pain, there was nothing surgically that would address it and encouraged Claimant to continue to work on pain management at John Sealy hospital. Claimant’s pain was consistently self-reported as moderate to severe throughout his treatment by Provider. If he received any relief from pain as a result of the treatment, it was short-lived. Claimant was well beyond the acute phase of injury, the evidence demonstrated that the use of passive modalities beyond the acute phase was inappropriate, and Provider failed to demonstrate that Claimant presented special circumstances warranting its continued use.

Provider claims that Claimant needed carpal tunnel surgery and Carrier’s refusal to authorize the surgery necessitated treating Claimant’s continued pain. While there may be some truth to this argument, Provider did not sufficiently document the need for continued treatment, including its objectives and goals, nor why the treatment plan did not vary even when Claimant’s pain level remained virtually the same throughout. Further, some of the treatment provided required pre-authorization and Provider failed to prove that pre-authorization had been obtained. Lastly, Provider failed to demonstrate entitlement to reimbursement for providing transportation to Claimant in order that he could receive treatment. Because Provider failed to prove that the treatment provided to Claimant three to four years post-injury was medically necessary, reimbursement of those services is not warranted.

III. FINDINGS OF FACT

1. An injured worker (Claimant) suffered a compensable hydroblast injury to his left hand in ___.
2. At the time of Claimant’s injury, his employer held workers’ compensation insurance coverage with Texas Mutual Insurance Company (Carrier).
3. Claimant’s injury was diagnosed as a hydroblast injury to the left hand.
4. On February 10, 2000, Dr. Suhail Al-Sahli of the NBC Healthcare Center (Provider) began treating Claimant with manipulation, therapeutic exercises (including one-on-one care), miscellaneous durable medical equipment (DME), and passive physical therapy modalities that included ultrasound and myofascial release. Provider also provided transportation for Claimant to and from the Center.
5. Carrier denied reimbursement for the treatments provided from September 13, 2001, to May 31, 2002, as not medically necessary.
6. In response to Carrier’s denial of reimbursement, Provider filed a request for medical dispute resolution. An Independent Review Organization (IRO) assigned to review Provider’s claim concluded the services were not medically necessary.
7. In response to the IRO decision, Provider timely requested a hearing before the State Office of Administrative Hearings.
8. Notice of the hearing was sent to the parties on August 20, 2003. 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.
9. The hearing convened and closed on October 18, 2004.
10. At the time the disputed services were provided, Claimant was well beyond the acute phase of his December 1997 injury and had already undergone two surgeries to the hand as well as physical therapy from another provider.
11. Claimant met all treatment goals of the physical therapy provided in 1997 and 1998 and was able to return to work.
12. Treating Claimant with passive physical therapy modalities three to four years post-injury and after sufficient physical therapy was not shown to be medically necessary.
13. The medical records reflect that there was not a treatment plan, containing specific goals and objectives, for Claimant’s care.
14. Claimant’s treatment remained virtually unchanged throughout the time period covered by the disputed dates of service.
15. Provider failed to support the need for continued one-on-one physical therapy.
16. Provider failed to demonstrate that it was entitled to reimbursement for its provision of transportation services for Claimant to and from the treatment center during the disputed dates of service.
17. Provider failed to prove that it had obtained pre-authorization for those services that required it.
18. Claimant’s pain level remained at a moderate to severe level throughout the course of treatment.
19. Claimant had returned to work sometime after the surgeries performed by Dr. Garcia and after receiving physical therapy from Advantage Physical Therapy.
20. The treatment from Provider did not assist Claimant in returning to work or relieve his pain levels resulting from the effects of his injury.

IV. 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. As Petitioner, Dr. Suhail Al-Sahli (Provider) bears the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
4. Provider failed to prove the disputed physical therapy services were reasonably required by the nature of the claimant’s injury, cured or relieved the effects naturally resulting from the compensable injury, promoted Claimant’s recovery, or enhanced Claimant’s ability return to or retain employment. Tex. Lab. Code Ann. §408.021.
5. The disputed services were not medically necessary to treat Claimant’s compensable injury.
6. Provider is not entitled to reimbursement for the disputed services.

ORDER

IT IS ORDERED thatthe reimbursement claim of Dr. Suhail Al-Sahli for services provided to Claimant from September 13, 2001, through May 31, 2002, is denied.

Signed December 14, 2004

SUZANNE FORMBY MARSHALL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Carrier’s records reflect that Claimant continued treatment with Dr. Garcia through 1999.↑
2. Dr. Al-Sahli agreed during hearing that the cost for psychological testing on October 16, 2001, had already been paid by Carrier. He further agreed that the table of disputed services contained duplicate entries for December 7, 2001, and that one set should be excluded. Lastly, he agreed that the appropriate maximum amount recoverable for ultrasound was $ 22.00 instead of $ 25.00 that was billed for CPT Code 97035 on December 7, 2001.↑
3. According to Dr. Al-Sahli, Claimant’s worker’s compensation claim was either not filed by the employer or denied by Carrier until April 30, 2001, when the parties reached agreement about the extent of injury. Dr. Al-Sahli testified that Claimant received minimal medical care during that time and his condition went from bad to worse.↑
4. Dr. Alvarado practices with Southwest Chiropractic in Austin, Texas. Like Provider, he is a Doctor of Chiropractic medicine.↑
5. Dr. Garcia treated Claimant from December 29, 1997, through August 2, 1999.↑
6. The records indicate that Claimant ultimately underwent carpal tunnel surgery in May 2002.↑