DECISION AND ORDER

The issue involved is whether American Home Assurance Company (Carrier) correctly denied payment of $9,381 billed by Troy M. Hurst, D.C. (Provider) for chiropractic services provided to an injured worker (Claimant) between July 1, 2002, and February 2, 2003. Carrier challenged the medical necessity of the treatment, but Provider contended Claimant’s pain decreased between the beginning and end of each treatment. The Administrative Law Judge (ALJ) finds Provider failed to establish the medical necessity for the disputed services and is therefore not entitled to reimbursement.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

On January 25, 2005, ALJ Georgie B. Cunningham conducted the hearing on the merits at the William P. Clements Building, 300 West 15^th Street, Austin, Texas. Attorney Steven M. Tipton represented Carrier, and Provider appeared pro se. The parties did not contest jurisdiction or notice. Therefore, those issues are addressed in the findings of fact and conclusions of law without discussion. The ALJ closed the hearing on January 31, 2005, after Carrier, with Provider’s agreement, filed the Table of Disputed Services.^[1]

II. DISCUSSION

At the hearing, Carrier presented the telephonic testimony of John Braswell, D.C., and Provider testified in his own behalf. Both parties presented documentary evidence. According to the documentary evidence, Claimant had a compensable injury on ___, which resulted in her seeking treatment from Provider in early April 2001. The claims at issue here occurred between July 1, 2002, and February 6, 2003. Claimant had pain in her left hand and wrist, which was diagnosed as carpal tunnel syndrome.

Carrier established that Provider had treated Claimant during 296 visits between April 2001 and February 6, 2003. According to Dr. Braswell, the standard of care for chiropractic treatment is that carpal tunnel syndrome should be resolved with three to eight weeks of treatment or the patient should be referred to a neurologist. Dr. Braswell pointed out that many of the treatment modalities Provider used, such as team conferences, ultrasound, and neuromuscular reeducation, are not appropriate treatment modalities for carpal tunnel syndrome.

Carrier’s documents included numerous medical opinions. William W. Timberlake, D.C., according to his written statement, reviewed records in this case from twenty-five sources. Based on his review, Dr. Timberlake issued the following written opinion:

[T]here appears to be a complete absence of meaningful documentation to support such intensive and lengthy treatment . . . . [T]here does not appear to be a reasonable basis for ongoing, unproductive, intensive chiropractic treatment or physical therapy treatment in an intensive setting for over two years.

Provider failed to furnish credible evidence to establish that the treatments and services were medically necessary. All of Provider’s treatment notes end with the comment:

The above care is medically necessary as it is focused on curing or relieving symptoms and is geared toward returning this patient back to work. . . . [T]his criteria makes the above care medically necessary.

Referencing a statutory provision alone will not make care medically necessary. The length of treatment exceeded the standard of care without establishing the need. Even though Provider testified Claimant reported a decrease in pain between the beginning and end of each treatment, her condition was not resolved with chiropractic care, and she eventually had to undergo surgery. Provider demonstrated no attempt to gradually reduce treatment levels. Furthermore, Provider failed to show why he had not instructed Claimant in performing home exercises or changed Claimant’s treatment modalities when her condition worsened rather than improved.

The ALJ agrees with the IRO reviewer and the Carrier’s peer reviewer and expert witness that Provider’s treatment went beyond the established standards of chiropractic care without the necessity of continued treatment being demonstrated. The reasoning is set forth in more detail in the findings of fact herein.

III. FINDINGS OF FACT

1. During April 2001, Troy M. Hurst, D.C. (Provider) started treating Claimant for carpal tunnel syndrome in her left hand and wrist.
2. American Home Assurance Company (Carrier) denied payment of $9,381 for the treatments and services Provider furnished Claimant from July 1, 2002, through February 6, 2003.
3. Provider requested medical dispute resolution based on Carrier’s denial.
4. On December 19, 2003, an Independent Review Organization determined that the treatments and services were not medically necessary.
5. On April 14, 2004, the Medical Review Division of the Texas Workers= Compensation Commission issued its decision that Provider had not prevailed on its claims.
6. On May 6, 2004, Provider requested a hearing on this matter before the State Office of Administrative Hearings.
7. On June 8, 2004, the Commission sent a hearing notice advising the parties of the matters to be determined; the right to appear and be represented by counsel; the date, time, and place of the hearing; and the statues and rules involved.
8. Provider treated Claimant for carpal tunnel syndrome during 296 visits between April 2001 and February 6, 2003.
9. If carpal tunnel syndrome has not resolved in three to eight weeks of chiropractic care, the patient should be referred to a neurologist.
10. By the end of April 2001, Provider was treating both of Claimant’s hands and elbows.
11. As of July 6, 2001, Claimant had no abnormalities in the upper limbs.
12. Additional tests on April 3 and May 8, 2002, confirmed that Claimant had left carpal tunnel syndrome only.
13. Provider’s claims for visits not reimbursed by the Carrier involved team conferences, myofascial release, therapeutic procedures, ultrasound, office visits, neuromuscular reeducation, physical medicine treatments, electrical stimulation, and hot and cold pack therapy.
14. Ultrasound, team conferences, and neuromuscular reeducation are not appropriate treatments for carpal tunnel syndrome.
15. Appropriate treatment for carpal tunnel syndrome includes using anti-inflammatory medication, splinting, passive modalities, modified activities, applying heat and ice packs, and performing stretching exercises.
16. A patient with carpal tunnel syndrome can administer much of the appropriate treatment at home.
17. Surgery may be necessary to resolve carpal tunnel syndrome.
18. Claimant’s carpal tunnel gradually worsened until she stopped working in March 2002.
19. On February 3, 2003, Claimant had surgery for carpal tunnel syndrome.
20. Provider did not document improvement in Claimant’s condition.
21. Provider had Claimant follow the same general regimen each session without documenting the need to continue the use of failed modalities.
22. Provider did not document Claimant’s need to have one-on-one physical therapy, frequent office visits, or team conferences.

IV. CONCLUSIONS OF LAW

1. The Texas Workers= Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers= Compensation Act, Tex. Lab. Code Ann. ‘ 413.031.
2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ” 402.073 and 413.031(k), and Tex. Gov=t Code Ann. ch. 2003.
3. Adequate and timely notice of the hearing was provided to the parties in accordance with Tex. Gov=t Code Ann. ” 2001.051 and 2001.052.
4. Provider had the burden of proving it was entitled to reimbursement for the claim, pursuant to 28 Tex. Admin. Code ‘ 148.21(h) and (i).
5. Based on the findings of fact and conclusions of law, Provider did not show the disputed services were medically necessary, as specified in Tex. Lab. Code Ann. ‘ 408.021.

ORDER

IT IS, THEREFORE, ORDERED that Troy M. Hurst, D.C., is not entitled to reimbursement from American Home Assurance Company for the disputed services from July 1, 2002, through February 6, 2003.

Signed April 1, 2005.

GEORGIE B. CUNNINGHAM
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. The Table of Disputed Services was admitted as Exhibit 3.↑