DECISION AND ORDER

I. INTRODUCTION

Texas Mutual Insurance Co. (Carrier) disputes a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (TWCC) and a separate Medical Review Division (MRD) decision, both regarding medical services for ____ (Claimant). The Carrier had denied Southeast Health Services, Inc. (Provider) reimbursement for certain services provided to the Claimant between September 10, 2002, and November 14, 2002. The IRO and MRD found that the Carrier should reimburse the Provider for those services, thus the Carrier has the burden of proof.

The Carrier contends that the Provider failed to show that most of the disputed services were reasonably medically necessary. As set out below, the Administrative Law Judge (ALJ) finds that those services were reasonably medically necessary until November 10, 2002, but not thereafter.

At the hearing, the Carrier’s own expert witness testified that it was reasonable to try those services for one month to see if they would decrease the Claimant’s pain, improve his mobility, or allow him to return to work. After a month of receiving those services every few days, however, the Claimant made no progress. The same Carrier expert testified that continuing to provide them for a

second month when they had not been even minimally effective was unreasonable. The ALJ agrees. Moreover, the Provider failed to offer any significant evidence showing why continuing to provide ineffective services was either reasonable or necessary.

That leaves two services in dispute for which the Carrier questions the sufficiency of the documentation that the Provider furnished when seeking reimbursement. For one of them, TWCC has set no maximum allowable reimbursement (MAR), and the Carrier contends that the documentation was insufficient to support the reimbursement sought. For the other, the Carrier contends that the documentation was wholly inadequate.

As to the reimbursement-level-documentation dispute, the ALJ finds that the Provider adequately documented that it billed its usual and customary charge for that service. Accordingly, the ALJ finds that the Carrier should reimburse that full amount to the Provider. As to the other documentation dispute, the ALJ agrees that the documentation was inadequate, particularly since it failed to show why service, provided in the second month of service, was reasonably medically necessary.

Taking all of the above into account, the ALJ orders the Carrier to reimburse the Provider a total of $4,136, as set out below, and denies the Provider’s request for additional reimbursement beyond that amount.

II. FINDINGS OF FACT

1. On ____, the Claimant sustained a work-related injury to his lower back.
2. On the date of injury, the Claimant’s employer was ___ (Employer), and Texas Mutual Insurance Company (Carrier) was its workers’ compensation insurance carrier.
3. As a result of the compensable injury, the Claimant suffered lower back and right radicular leg pain.
4. On April 1, 2002, the Claimant underwent a laminectomy to lumbar vertebrae (L) 4 and L5 to attempt to relieve that pain.
5. Beginning on September 10, 2002, the Claimant began to receive post-surgical rehabilitation services from Southeast Health Services, Inc. (Provider).
6. The Provider furnished medical services to the Claimant on the dates, for the number of units, and with the Current Procedural Terminology (CPT) codes and maximum allowable reimbursements (MARs) shown below:

CPT	SERVICE DESCRIPTIONS	MAR	UNITS AND DATES
97113	aquatic therapy exercises	$65.00	Four units on 9/10/02, 9/12/02, 9/13/02, 9/17/02, 9/30/02, 10/4/02, 10/14/02, 10/22/02, 10/30/02, 10/31/02, 11/04/02, 11/08/02, 11/11/02, 11/12/02 Three units on 9/24/02, 9/26/02, 10/25/02 Two units on 10/02/02, 10/28/02, 11/14/02
97110	Therapeutic exercises	$35.00	Four units on 9/17/02, 9/30/02, 10/02/02, 10/04/02, 10/28/02 Three units on 9/10/02, 9/24/02, 9/26/02, 10/14/02, 10/30/02 Two units on 9/12/02, 9/13/02, 10/22/02
97016	Vasopneumatic device therapy	$25.00	Four units on 9/17/02 Three units on 9/10/02, 9/26/02, 10/14/02, 10/30/02 Two units on 9/12/02, 9/13/02, 10/02/02, 10/18/02, 10/22/02, 10/25/02, 10/28/02, 10/31/02, 11/04/02, 11/08/02, 11/11/02, 11/12/02, 11/14/02
97032	Electrical stimulation	$20.00	Three units on 9/26/02 Two units on 9/12/02, 9/13/02, 10/02/02, 10/18/02, 10/22/02, 10/25/02, 10/28/02, 10/31/02, 11/04/02, 11/08/02, 11/11/02, 11/12/02, 11/14/02
99243	Office consultation	$116.00	9/30/02, 11/14/02
E0745-P	Neuromuscular electronic shock unit	none	10/14/02
E0745-R	Neurotransmitter electronic shock unit	none	11/14/02
97250	myofascial release	$45.00	10/18/02, 10/25/02, 10/31/02

1. The Provider sought a total reimbursement of $7,121 from the Carrier for the above services.
2. The Carrier sent explanations of benefit (EOBs) to the Provider, paying $150 for the E0745‑P service on 10/14/02 and denying the remaining requests for reimbursement.
3. In the EOBs, the Carrier denied reimbursement of the following for the reasons stated below:

CPT	DATE	DENIAL REASONS
E0745-P	10/14/02	No MAR; partial payment and partial denial.
E0745-R	11/14/02	Pre-authorization required but not requested
97110	10/22/02	Fee guideline MAR reduction
99243	11/14/02	Fee guideline MAR reduction and not appropriately documented

1. Except for those four services, the Carrier denied reimbursement for the remaining disputed services (Remaining Services) by contending that they were not reasonably medically necessary.
2. The Provider filed a request for medical dispute resolution with the TWCC.
3. As to the 97110 service on October 22, 2002, and the E0745-R service on November, 14, 2002, MRD agreed with the Carrier and denied reimbursement and the Provider did not ask for a timely hearing before a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
4. The TWCC has set no MAR for E0745-P services, and the Provider and the Carrier have not agreed on an appropriate compensation amount for that service.
5. As to the E0745-P service on October 14, 2002, MRD found that the Provider had provided sufficient documentation to show that it should be reimbursed an additional $345, beyond the $150 that the Carrier had paid for the service, and ordered the Carrier to reimburse that additional amount.
6. The documentation that the Provider submitted to the Carrier showed that the Provider’s usual and customary charge for the above E0745-P service was $495.
7. As to the 99243 service on November 14, 2002, MRD found that the Provider had provided sufficient documentation to show that the service was reasonably medically necessary and ordered the Carrier to reimburse the Provider the $116 MAR for that service.
8. As to the Remaining Services, whose medical necessity the Carrier disputed, MRD referred the dispute to an IRO, which determined that those services were medically necessary.
9. After the IRO decision and MRD order were issued, the Carrier asked for a contested-case hearing by a SOAH ALJ.
10. Following his surgery, it was reasonable for the Claimant to receive the Remaining Services for approximately one month to determine if they would reduce his pain, improve his mobility, or allow him to return to work.
11. However, the Remaining Services never significantly reduced the Claimant’s pain, improved his mobility, or made it possible for him to return to work, either in the first month or thereafter.
12. The Remaining Services provided by the Provider to the Claimant after October 10, 2002, were not reasonably medically necessitated by the Claimant’s compensable injury.
13. The Provider submitted no documentation to the Carrier reasonably explaining why the Provider’s 99243 office consultation with the Claimant on November 14, 2002, was reasonably medically necessary when the underlying Remaining Services had not been reasonably medically necessary for over one month and the Claimant was only under the Provider’s care in order to obtain those Remaining Services.
14. Required notice of a contested-case hearing concerning the above dispute was mailed to the Carrier and the Provider.
15. On November 1, 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 and the record closed on that same day.
16. The Carrier appeared at the hearing through its attorney, Ryan T. Willett.
17. The Provider appeared at the hearing through its representative, Bryan Weddel, D.C.

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 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. In all workers compensation cases, reimbursement for medical services shall be the least of: the MAR amount established by the TWCC, the health care provider’s usual and customary charge, or the health care provider’s workers’ compensation negotiated and/or contracted amount that applies to the billed service. 28 TAC ‘ 134.202(d).
6. Based on the above Findings of Fact and Conclusions of Law, the Carrier should be ordered to reimburse the Provider a total of $4,136 as shown below for the following services:

CPT	SERVICE DESCRIPTIONS	REIMBURSEMENT PER UNIT	UNITS AND DATES
97113	aquatic therapy exercises	$65.00	Four units on 9/10/02, 9/12/02, 9/13/02, 9/17/02, 9/30/02, 10/4/02 Three units on 9/24/02, 9/26/02 Two units on 10/02/02
97110	Therapeutic exercises	$35.00	Four units on 9/17/02, 9/30/02, 10/02/02, 10/04/02 Three units on 9/10/02, 9/24/02, 9/26/02 Two units on 9/12/02, 9/13/02
97016	Vasopneumatic device therapy	$25.00	Four units on 9/17/02 Three units on 9/10/02, 9/26/02 Two units on 9/12/02, 9/13/02, 10/02/02
97032	Electrical stimulation	$20.00	Three units on 9/26/02 Two units on 9/12/02, 9/13/02, 10/02/02
99243	Office consultation	$116.00	9/30/02
E0745-P	Neuromuscular electronic shock unit	$345.00	10/14/02

1. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for additional reimbursement for the services in dispute in this case should be denied.

ORDER

IT IS ORDERED THAT the Carrier shall reimburse the Provider $4,136 as set out above and the Provider’s request for additional reimbursement for the services in dispute in this case is denied.

Signed November 15, 2004.

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