DECISION AND ORDER

I. INTRODUCTION

Mary C. Hodgkinson, P.T. (M.C.H.P. or Provider) has appealed a decision issued by the Texas Workers’ Compensation Commission’s (TWCC) Medical Review Division (MRD), which adopted an Independent Review Organization’s (IRO) determination that The Provider should be denied reimbursement for medical services she provided to ___ (Claimant).

The only disputed issue is the medical necessity of physical therapy modalities provided to the Claimant from December 31, 2002, through February 17, 2003.

As set forth in the findings of fact and conclusions of law below, the Administrative Law Judge (ALJ) finds that the disputed services (myofascial release, electric stimulation, hot and cold ice packs, and therapeutic exercises) provided three years after the compensable injury were too far removed from the date of the injury to be medically necessary treatment for the Claimant’s compensable sprain/strain to her cervical spine. The Provider is not entitled to reimbursement.

II. FINDINGS OF FACT

1. On ___, ___ (Claimant) sustained a sprain/strain to the cervical spine while performing duties for her employer.
2. On the date of injury, the Claimant’s employer, ___, carried workers’ compensation insurance with Texas Mutual Insurance Company (Carrier).
3. On the dates shown in the table, Mary C. Hodgkinson, P.T. (M.C.H.P. or Provider) treated the Claimant at each visit with three passive physical therapy modalities, which are designated below by their Current Procedural Terminology (CPT) codes and maximum allowable reimbursements (MARs):

Dates	Treatments Provided on Each Date, Current Procedural Terminology (CPT) Code, and Maximum Allowable Reimbursement (MAR)
12-31-02 1-3-03 1-6-03 1-10-03 1-13-03 1-16-03 1-17-03 1-22-03 1-28-03 1-30-03 2-4-03 2-10-03 2-13-03 2-17-03	Myofascial Release CPT Code 97250 MAR: $43.00 Electrical Stimulation CPT Code 97032 MAR: $22.00 Hot or Cold Ice Packs CPT Code 97010 MAR: $11.00

1. On January 13, 2003, the Provider also treated the Claimant with therapeutic exercises, designated below by its CPT and MAR:

Dates	Treatment Provided, Current Procedural Terminology (CPT) Code, and Maximum Allowable Reimbursement (MAR)
1-13-03	Therapeutic Exercises CPT Code 97110 MAR: $35.00

1. The Provider sought reimbursement in the amount of $1,650.00 from the Carrier, which represented the MAR for all of the medical treatments in dispute.
2. The Carrier denied reimbursement and the Provider filed a request for medical dispute resolution with the TWCC on January 7, 2004.
3. An independent review organization (IRO) reviewed the medical dispute and found the medical treatments were not reasonable or medically necessary.
4. On March 18, 2004, the TWCC’s Medical Review Division (MRD) ordered that payment for the disputed dates of service be denied based on the IRO determination.
5. After the MRD order was issued, the Provider asked for a contested hearing before a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
6. Required notice of a contested hearing was mailed to the Carrier, the Provider, the Treating Physician, and the Claimant on May 6, 2004.
7. On October 21, 2004, SOAH ALJ Deborah L. Ingraham held a contested hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded that day and the record closed on November 10, 2004.
8. The Provider appeared at the hearing and represented herself.
9. The Carrier appeared at the hearing through its attorney, Katie Kidd.
10. The Claimant’s injury required a maximum of twelve weeks of physical therapy treatments.
11. After sustaining her injury, the Claimant received physical therapy treatments for twelve weeks in 2000 and 2001.

IV. 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. Based on the ALJ’s findings of fact, the disputed medical treatments provided after 2001 were not medically reasonable or necessary.

ORDER

IT IS HEREBY ORDERED that the Provider’s appeal for reimbursement in the amount of $1,650.00 is DENIED.

Signed January 10, 2005.

DEBORAH L. INGRAHAM
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS