DECISION AND ORDER

I. INTRODUCTION

Texas Mutual Insurance Company (Carrier) disputes several decisions of an independent review organization (IRO) and the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services for ___ (Claimant). The disputes concern services that SCD Back & Joint (Provider) furnished to the Claimant. The Provider also disputes a few of MRD’s decisions concerning services that it claims to have provided to the Claimant. The maximum allowable reimbursement (MAR) amounts in dispute total $18,832.

As set out below, the Administrative Law Judge (ALJ) finds that the Carrier should reimburse the Provider $3,598 for some of the disputed services and that the Provider’s remaining requests for reimbursement should be denied.

II. FINDINGS OF FACT

1. On ___, Claimant sustained a work-related injury to his lower back as a result of his work activities (Compensable Injury).
2. On the date of injury, the Claimant’s employer was ___, and the Carrier was its workers’ compensation insurance carrier.
3. As a result of his injury, the Claimant had lower back pain and received various medical services to treat that pain in 2001 from health care professionals other than the Provider.
4. On December 19, 2001, the Claimant had an Intradiscal Electrothermal Annuloplasty (IDET) procedure to a disc in his spine in an attempt to relieve his pain.
5. After the IDET, the Claimant received 99 units, approximately 24.75 hours, of Current
6. Procedural Terminology (CPT) Code 97110, one-on-one supervised therapeutic exercise, services from January 28, 2002, through March 21, 2002, from Brazos Valley Rehabilitation Center (Brazos Valley).
7. The Carrier reimbursed Brazos Valley for all of those services.
8. The above 97110 exercises consisted of stretching and chest and shoulder muscle exercises.
9. By March 13, 2002, the Claimant had no significant radicular pain, only mild back pain, and a greater ability to sit without pain. He was ready to return to work, though at a job that required less sitting than his former job.
10. Beginning on May 17, 2002, the Claimant began to be treated by the Provider for back and radicular pain.
11. On July 3, 2002, the Claimant returned to work on light duty but stopped working on August 24, 2001.
12. From May 17 through October 22, 2002, the Provider furnished to the Claimant and sought reimbursement of $18,832 from the Carrier for the following services (Disputed Services):

CPT Code	Description	Units	Maximum Allowable Reimbursement (MAR) per unit
97110	One-on-one therapeutic Exercise	257	$35
97213	Subsequent office visit	45	$48
97250	Myofascial release	42	$43
97750MT	Muscle testing	48	$43
95851	Range of motion measurements	10	$36
97265	Joint mobilization	43	$43
97150	Group therapeutic exercises	37	$27
97014	Electrical stimulation	5	$17
99070	Supplies and materials	2	$25 and $8

99080-73	TWCC 73	3	$15
97024	Diathermy	7	$21
99214	Extended Office Visit	2	$71
99215	Comprehensive office visit	1	$103
72050-WP	Cervical 4 Views	1	$81

1. The Provider timely sought reimbursement from the Carrier for each of the above services, and the Carrier timely denied reimbursement for each, except as noted below, by claiming that it was not medically necessary:

CPT Code	Dates 2002	Units	Reason for Denial
97750-MT	May 17 June 28 July 3 October 18	4 3 6 6	Unbundling
95851	May 17 July 3 October 18	1 2 3	Unbundling
99080-73	August 22 and October 18	2	Fee guideline reduction

1. No medical fee guideline and no evidence shows that either 97750-MT or 95851 services are global and bundled in the cost of any other service that the Provider furnished the Claimant.
2. There is no evidence that the Provider prepared or submitted work status reports, CPT Code 99080-73, on August 22 or October 18, 2002.
3. The 97110 exercises that the Claimant performed under the Carrier’s care were very simple stretches, rotations, and weight lifts that a reasonably intelligent and cooperative patient who had previously received extensive and very similar 97110 services could have safely performed at home after six units, approximately 90 minutes, of reeducation in a one-on-one setting.
4. The Claimant was reasonably intelligent and cooperative.
5. The disputed 37 sessions of unspecified 97150 group therapeutic exercises services were provided to increase the Claimant’s endurance, coordination, flexibility, and stamina.
6. There is no evidence that those 97150 services were provided to ease the Claimant’s pain or did so.
7. Because the Claimant’s pain had returned, a four week trial of office visits, passive therapies and medications was reasonably medically necessary beginning on May 17, 2002.
8. Among the Disputed Services, from May 17, 2002, through June 16, 2002, the Provider provided such passive therapy services and medications to the Claimant in the following forms:

CPT CODES	SERVICE DESCRIPTIONS	Total Units	MAR per unit
97250	Myofascial release	8	$43
97265	Joint mobilization	8	$43
97014	Electrical stimulation	2	$17
99070	TENS consumable supplies	1	$25
99070	Analgesic balm	1	$8
95851	Range of motion measurements	1	$40
97024	Diathermy	2	$25

1. After receiving the above passive therapy services and medications from the Provider for approximately one month, the Claimant’s reported pain level, though it varied each day, averaged nearly the same: five out of ten.
2. Even after receiving similar passive therapy and medications through October 22, 2002, the Claimant’s pain level, though it varied each day, continued to average nearly the same: five out of ten.
3. Among the Disputed Services, from May 17 through August 19, 2002, the Carrier provided the following remaining services to the Claimant:

CPT Code	Description	Units
99213	Limited office visit	33
99215	Comprehensive office visit	1
72050-WP	Cervical 4 views	1
97750MT	Muscle testing	13

1. On August 20, 2002, as found by an uninvolved doctor designated by TWCC who examined the Claimant, the Claimant had reached maximum medical improvement (MMI), his condition was stable and unlikely to change, and no further medical treatment was necessary.
2. The Provider filed a request for medical dispute resolution with the TWCC concerning the above described disputed services.
3. Upon referral by TWCC, the IRO reviewed the services that were alleged not to be medically necessary and found that they were so necessary.
4. MRD reviewed the other disputed services and ordered the Carrier to reimburse the Provider for all of them except the claimed August 22 and October 18, 2002, 99080-73 services.
5. After the IRO decisions and the MRD order were issued, the Carrier asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
6. The required notice of a contested-case hearing concerning the dispute was mailed to the Carrier and the Provider.
7. On October 18, 2004, SOAH ALJ William G. Newchurch held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded on that same day.
8. The record closed on January 7, 2005, when the Carrier filed its written closing argument.
9. The Carrier appeared at the hearing through its attorney, R. Scott Placek.
10. The Provider appeared at the hearing through its attorney, William Maxwell.

III. 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 Carrier has the burden of proof as to every service in dispute in this case except for the CPT Code 99080-73 services claimed to have been provided on August 22 and October 18, 2002, as to which the Provider has the burden of proof.
4. Based on the above Findings of Fact and Conclusions of Law, the Carrier should reimburse the Provider for the following services, which are not bundled with any others :

CPT Code	Dates 2002	Units	MAR	Total
95851	May 17 July 3 October 18	1 2 3	$36 per unit	$216

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, promotes recovery, or enhances the ability of the employee to return to or retain employment. Labor Code § 408.021 (a).
2. Based on the above Findings of Fact and Conclusions of Law, only six units, approximately 90 minutes, of the 97110 services that the Provider furnished the Claimant from May 17, 2002, through October 16, 2002, were reasonably medically necessary due to the Claimant’s compensable injury.
3. Based on the above Findings of Fact and Conclusions of Law, the Provider should be reimbursed a total of $210 for 6 units of the 97110 services that it furnished to the Claimant from May 21, 2002, through October 16, 2002.
4. Based on the above Findings of Fact and Conclusions of Law, the remaining 97110 services that the Provider furnished to the Claimant during that timeframe were not reasonably medically necessary due to the Claimant’s compensable injury and the Provider should not be reimbursed for them.
5. Based on the above Findings of Fact and Conclusions of Law, none of the 37 sessions of unspecified 97150 group therapeutic exercises services that the Provider furnished to the
6. Claimant between May 17 through October 22, 2002, were reasonably medically necessary
7. due to the Claimant’s compensable injury and the Provider should not be reimbursed for them.
8. Based on the above Findings of Fact and Conclusions of Law, the following passive therapy services and medications provided to the Claimant from May 17 through June 16, 2002, were reasonably medically necessary due to the Claimant’s compensable injury and the Provider should be reimbursed for them:

CPT CODES	Total Units	MAR	Total
97250	8	$43	$344
97265	8	$43	$344
97014	2	$17	$34
99070	1	$25	$25
99070	1	$8	$8
95851	1	$40	$40
97024	2	$25	$50

1. Based on the above Findings of Fact and Conclusions of Law, none of the other passive therapy and medications with the same CPT Codes as the above that the Provider furnished to the Claimant after June 16, 2002, were reasonably medically necessary due to the Claimant’s compensable injury and the Provider should not be reimbursed for them.
2. Based on the above Findings of Fact and Conclusions of Law, the following services provided from May 17 through August 19, 2002, were reasonably medically necessary due to the Claimant’s compensable injury, the 97750MT services were not bundled with any other service, and the Carrier should reimburse the Provider for them:

CPT Code	Units	MAR	Total
99213	33	$48	$1584
99215	1	$103	$103
72050-WP	1	$81	$81
97750MT	13	$43	$559

1. Based on the above Findings of Fact and Conclusions of Law none of the services, medications, etc. which the Provider furnished to the Claimant on or after August 20, 2002, were reasonably medically necessary due to the Claimant’s compensable injury and the Provider should not be reimbursed for them.
2. Based on the above Findings of Fact and Conclusions of Law, the Carrier should reimburse the Provider $3,598 for the services, etc., in dispute in this case and Provider’s other requests for reimbursement should be denied.

ORDER

IT IS ORDERED THAT the Carrier shall reimburse the Provider $3,598 for the reasons set out above and the Provider’s remaining requests for reimbursement are denied.

Signed January 21, 2005.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS