DECISION AND ORDER

I. INTRODUCTION

After an Independent Review Organization (IRO) reviewer and the Commission’s Medical Review Division (MRD) determined physical-medicine treatment was medically necessary for a workers’ compensation claimant, Texas Mutual Insurance Company (Carrier) appealed. In this Decision and Order, the Administrative Law Judge (ALJ) sustains the Carrier’s appeal as to $2,415 in charges for active therapy but denies the appeal as to other charges and orders the Carrier to reimburse the provider for $3,908 in charges.

Notice and jurisdiction were not contested and are discussed only in the Findings of Fact and Conclusions of Law. The hearing convened on November 9, 2004, at the State Office of Administrative Hearings, 300 West Fifteenth Street, Austin, Texas, before the undersigned Administrative Law Judge (ALJ). Attorney R. Scott Placek represented the Carrier, and attorney Scott C. Hilliard represented the Provider, Main Rehab & Diagnostic. The hearing concluded and the record closed the same day.

II. DISCUSSION

A. Provider’s Witness

By deposition, Osler Kamath, D.C., who is associated with the Provider, testified about his treatment of the claimant. The claimant was injured on ___, when a freezer door slammed into the claimant’s right upper extremity. The claimant saw Dr. Kamath, the treating doctor, three days later, on ___.

According to Dr. Kamath’s testimony and records, the claimant suffered a contusion and complained of intense right forearm and wrist pain and superficial numbness. He had moderate forearm edema and hand and wrist stiffness that was aggravated by motion. Dr. Kamath diagnosed him with bursitis in the right wrist, parethesia, and muscle spasm of the right arm.

From the beginning of the claimant’s treatment, Dr. Kamath used both active and passive modalities for treatment, and the same modalities were used on almost every service date. Active, one-on-one exercises included wrist, forearm, and elbow range of motion, stretching, and flexion. In

Dr. Kamath’s opinion, one-on-one therapy was needed because the claimant’s injury was fairly serious, and such therapy is more effective than group therapy. For passive treatments, he used manual traction, myofascial release, and joint mobilization.^[1]

The dates of service in dispute are April 25, May 15, 22, 23, 27, 28, 29; June 3, 4, 9, 10, 11, 17, 19, 24, 25, 30; July 1, 2, 7, 9, 10, and 15. After deducting the amount for which appeal was waived ($1,573),^[2] the amount in dispute is $6,323.

After a May 1, 2003, EMG indicated that the claimant had mild-to-moderate bilateral carpal tunnel syndrome (CTS), on the right more than the left, Dr. Kamath referred the claimant to an orthopaedic surgeon, Charles Whittenburg, D.O. On May 19, 2003, Dr. Whittenburg diagnosed the claimant with bilateral CTS. Dr. Whittenburg recommended conservative care with splinting, anti-inflammatories, and conservative physical therapy. The claimant returned to Dr. Whittenburg a month later and had not responded well to treatment. The claimant underwent carpal tunnel release surgery on July 17, 2003.

The claimant’s subjective complaints did not change significantly during the course of his treatment with Dr. Kamath. However, objective test results showed the claimant made progress. Most range-of-motion measurements improved and muscle strength and extension also increased. Because the claimant improved during the course of therapy, Dr. Kamath thought it was appropriate to continue the therapy until the scheduled surgery. A patient who is in good physical condition will recover more easily, Dr. Kamath testified.

B. IRO

According to the IRO, passive therapy for two to four weeks with a progression into active therapy is the standard of care. But, the IRO continued, “there is . . . sufficient documentation to warrant additional passive care for up to two months in conjunction with active therapy. In addition, guidelines allow for a month of active therapy along with office visits.” The IRO determined that Dr. Kamath’s treatment with therapeutic exercises and office visits from April 25, 2003, through

July 15, 2003, and joint mobilization, myofascial release, manual traction, and a physical performance test, from April 25, 2003, through June 4, 2003, were medically necessary.

C. Carrier’s Witness

For the Carrier, Gary Pamplin, M.D., testified; he is a board-certified orthopaedic surgeon with additional qualifications in hand surgery. Dr. Pamplin faulted Dr. Kamath for not documenting

details about the claimant’s symptoms, such as range-of-motion measurements, and for failing to specify the site of the diagnosed bursitis. A person has two bursa in the area of the claimant’s injury, Dr. Pamplin stated. One is located on the wrist, and the other is in the area of the proximal palm.

Bilateral CTS is an irritation on the medial nerve, and in Dr. Pamplin’s opinion, splinting is one appropriate treatment for the syndrome. But, at the claimant’s June 16, 2003, visit Dr. Whittenburg also recommended continued physical therapy. At that time, the claimant had already had physical therapy for ten weeks without improving. Keeping a patient conditioned prior to surgery is not a reason to continue physical therapy prior to carpal tunnel release. The carpal tunnel involves no muscles, so conditioning is immaterial, according to Dr. Pamplin.

In addition, Dr. Pamplin said he did not understand Dr. Kamath’s rationale for using both active and passive therapy. The passive modality of myofascial release is related to muscles, and only tendons, not muscles, cross the wrist. Joint mobilization is normally used when active range of motion is not possible. However, the claimant could do active exercises because his range-of-motion measurements were all at least 50% of normal. Dr. Pamplin also testified that manual traction generally is not used to treat CTS symptoms, and there was no evidence of radiculopathy (abnormal nerve function). The best treatment for the edema would have been ice, Dr. Pamplin said.

As for the active exercises, Dr. Pamplin said the claimant was a good candidate for a home-exercise program. The exercises were simple, and home exercises are preferable because a patient can complete them more often.

Finally, there is no medical literature based on appropriate testing that shows physical therapy changes the underlying pathology of CTS symptoms, Dr. Pamplin said. Based on these observations, Dr. Pamplin concluded that the IRO did not rely on credible scientific data.

D. Legal Standard

Pursuant to Tex. Labor Code Ann. § 408.021(a), 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. The employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the compensable injury; (2) promotes recovery; or (3) enhances the ability of the employee to return to or retain employment.

E. Analysis

Although the claimant’s primary diagnosis was CTS, his injury also involved a contusion and edema. In the ALJ’s opinion, it was reasonable to use physical therapy to treat the resulting symptoms, which included stiffness. Finding two to four weeks of passive therapy with a

progression into active therapy to be the usual standard of care, the IRO also determined that in this case, additional passive care in conjunction with active therapy was warranted for up to two more months. And, the IRO said, guidelines allowed for a month of active therapy along with office visits.

The therapy Dr. Kamath used did not relieve the claimant’s pain or numbness. But the claimant’s strength and range of motion increased. Thus, they relieved the effects naturally resulting

from the compensable injury. Dr. Pamplin, who is certainly well-qualified, testified in some detail about the reasons passive and one-on-one active therapy should not have been used. The treating provider, surgeon, and IRO, all found the therapy was reasonable and necessary. From the record, it appears that, although the claimant continued to suffer from the same pain and numbness, he did gain muscle strength and flexibility.

On the other hand, the ALJ was convinced by Dr. Pamplin’s testimony that, at least by June 4, 2003, the claimant could have been performing active exercises on his own. By that time, the claimant should have been well-aware of how to do the exercises, which were described as quite simple. Therefore, the ALJ sustains the Carrier’s appeal in part and denies any treatment for active exercises after June 4, 2003. The ALJ deducts the maximum allowable reimbursement for CPT code 97110 charges between June 9, and July 15, 2003. Those charges total $2,415, leaving $3,908 as the remaining amount due to Dr. Kamath.

III. FINDINGS OF FACT

1. The claimant was injured on ___, when a freezer door slammed into the claimant’s right upper extremity.
2. On the date of injury, the claimant’s employer had workers’ compensation insurance with Texas Mutual Insurance Company, the Carrier.
3. The claimant began treatment with Osler Kamath, D.C., the treating doctor, three days later, on ___.
4. The claimant suffered a contusion and complained of intense right forearm and wrist pain and superficial numbness. He had moderate forearm edema and hand and wrist stiffness that was aggravated by motion.
5. The claimant’s initial diagnosis was bursitis in the right wrist, parethesia, and muscle spasm of the right arm.
6. From the beginning of the claimant’s treatment, Dr. Kamath used both active and passive modalities for treatment, and the same modalities were used on almost every service date.
7. Disputed service dates were April 25; May 15, 22, 23, 27, 28, 29; June 3, 4, 9, 10, 11, 17, 19, 24, 25, 30; July 1, 2, 7, 9, 10, and 15.
8. After a May 1, 2003, EMG indicated that the claimant had mild-to-moderate bilateral carpal tunnel syndrome (CTS), on the right more than the left, Dr. Kamath referred the claimant to an orthopaedic surgeon, Charles Whittenburg, D.O.
9. On May 19, 2003, Dr. Whittenburg diagnosed the claimant with bilateral CTS.
10. The claimant underwent carpal tunnel release surgery on July 17, 2003.
11. The claimant’s subjective complaints did not change significantly during the course of his treatment with Dr. Kamath.
12. The claimant made progress as measured by objective test results. Most range-of-motion measurements improved and muscle strength and extension also increased.
13. It was reasonable to use physical therapy to treat the claimant’s symptoms, which included stiffness.
14. Through June 4, 2003, active and passive physical therapy relieved the effects naturally resulting from the claimant’s compensable injury.
15. The claimant could do active exercises because his range-of-motion measurements were all at least 50% of normal.
16. The claimant was a good candidate for a home-exercise program because the exercises were simple, and home exercises are preferable because a patient can complete them more often.
17. At least by June 4, 2003, the claimant could have completed active exercises on his own.
18. By decision dated February 19, 2004, an Independent Review Organization reviewer determined that Dr. Kamath’s treatment with therapeutic exercises and office visits from April 25, 2003, through July 15, 2003, and joint mobilization, myofascial release, manual traction, and a physical performance test, from April 25, 2003, through June 4, 2003, were medically necessary.
19. On March 9, 2004, the Commission’s Medical Review Division adopted the IRO’s decision, and the Carrier timely requested a hearing before the State Office of Administrative Hearings (SOAH).
20. Notice of the hearing was sent to both parties on April 28, 2004.
21. The notice of hearing contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
22. The hearing convened on November 9, 2004, and both parties were represented.

IV. 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. §§ 402.073(b) and 413.031(k), and Tex. Gov’t Code Ann. ch. 2003.
2. The hearing request was timely made pursuant to 28 Tex. Admin. Code § 148.3.
3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
4. The Carrier had the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h).
5. The Carrier failed to sustain its burden of proof regarding active and passive physical therapy through June 4, 2003.
6. The Carrier failed to sustain its burden of proof regarding office visits through July 15, 2003.
7. The Carrier sustained its burden of proving that active physical therapy after June 4, 2003, was not medically necessary.
8. The amount in dispute was $6,323, and the maximum allowable reimbursement for active therapy charges after June 4, 2003, is $2,415.
9. When $2,415 is subtracted from $6,323, the amount remaining and due to Dr. Kamath is $3,908.

ORDER

THEREFORE, IT IS ORDERED that the Carrier’s appeal is denied in part, and the Carrier shall reimburse the Provider the amount of $3,908, plus applicable interest.

Signed January 7, 2005.

SARAH G. RAMOS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. According to Dr. Kamath, myofascial release is a massage-type technique used to mobilize soft tissues by increasing blood flow and diminishing adhesion. Manual traction is a sudden force used to separate joints and is intended to break up fixations in the hand or wrist, so that range of motion can improve. Joint mobilization involves moving a joint in more than one plane of motion and is used to counteract stiffness, tightness, and rigidity.↑
2. Dr. Kamath initially cross-appealed, but at the hearing, he waived his cross appeal as to the services provided on June 9, 2003, through July 15, 2003, which the IRO found were not medically necessary — joint mobilization, CPT code 97265; myofascial release, CPT code 97250; and manual traction, CPT code 97122.↑