DECISION AND ORDER

The issue involved is whether Insurance Company of the State of Pennsylvania (Carrier) correctly denied payment of $893 billed by Trev Dixon, D.C. (Provider) for chiropractic services provided to an injured worker (Claimant) between May 14 and September 18, 2002. Carrier challenged the medical necessity of the treatment, but Provider contended that health care which enhances a claimant’s ability to retain employment is necessary. 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 April 14, 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 Peter McCauley 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 April 14, 2005.

II. DISCUSSION

At the hearing, Carrier presented the telephonic testimony of Robert M. Hamby, 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 on that date. Claimant, a jewelry sales person, injured herself when she bent over to tape a box. Provider’s diagnosis indicated she had lumbosacral plexus disorder, lumbar subluxation, sacroiliac sprain/strain, and muscle spasm. She was deemed to have reached MMI in May 1998. A July 1998 examination also found that she had reached MMI.

The ALJ finds that Provider failed to furnish credible evidence to establish that the chiropractic treatments were medically necessary. Although Provider contended that the care was medically necessary as it relieved the Claimant’s pain and helped her retain her employment, referencing a statutory provision alone will not make care medically necessary. Provider did not furnish objective evidence of why Claimant needed the chiropractic care four years post-injury when a medical doctor had determined that her sprain/strain had resolved seven months after the injury.

Provider seemed to rely on a medical opinion issued nine-months post-injury that Claimant would need follow-up care. The chiropractor issuing that opinion also wrote that additional tests might be necessary to evaluate Claimant’s condition. The opinion did not state whether Claimant’s need for additional care was immediate, on-going, or of a limited duration. The opinion, therefore, does not establish that Claimant needed care four years post-injury.

Provider relied on the four-year old diagnosis, assumed the need for additional care might be indefinite, and failed to update the diagnosis or order additional tests even though Claimant had some different symptoms from her initial injury. In one entry, Provider wrote that Claimant had a second injury, but at the hearing he testified that he meant to write second flare-up. The evidence was unclear whether Claimant was suffering from a flare-up or a subsequent injury.

The ALJ agrees with the IRO reviewer and the Carrier’s expert witness that Provider did not submit objective evidence of why chiropractic care was needed four years after Claimant’s injury. Provider failed to furnish a current diagnosis or careful documentation to demonstrate medical necessity. The reasoning for the conclusion is set forth in the findings of fact herein.

III. FINDINGS OF FACT

1. On ___, Trev Dixon, D.C. (Provider) began treating Claimant for a low back injury that occurred while she was taping a box at work.
2. Insurance Company of the State of Pennsylvania (Carrier) denied payment of $893 for chiropractic services Provider furnished Claimant from May 14 through September 18, 2002.
3. Provider requested medical dispute resolution based on Carrier’s denial.
4. On April 20, 2004, an Independent Review Organization determined that the chiropractic services were not medically necessary.
5. On April 27, 2004, the Medical Review Division of the Texas Workers’ Compensation Commission (Commission) issued its decision that Provider had not prevailed on its claims.
6. On May 7, 2004, Provider requested a hearing on this matter before the State Office of Administrative Hearings.
7. On June 9, 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 statutes and rules involved.
8. Claimant was diagnosed with lumbosacral plexus disorder, lumbar subluxation, sacroiliac sprain/strain, and muscle spasm.
9. On May 14, 1998, Claimant’s diagnosis was lumbar strain.
10. As of May 14, 1998, Claimant’s lumbar strain had been resolved.
11. As of May 14, 1998, Claimant was authorized to continue her full-duty employment.
12. As of May 14, 1998, Claimant’s condition did not indicate a need for continued chiropractic care.
13. Claimant was deemed to have reached MMI on May 14, 1998, with a three percent impairment rating.
14. During the seven visits between May 14 and September 18, 2002, Provider treated Claimant with manipulation, therapeutic exercises, neuromuscular reeducation, massage therapy, mechanical traction, and electric stimulation.
15. Provider did not perform a new diagnosis on Claimant documenting why she had presented again so many years after a 1997 injury.
16. Provider’s assessment and diagnosis of Claimant in 2002 remained the same as those in 1997.
17. Claimant’s condition may have changed since her previous diagnosis.
18. Chiropractic standards of care provide that a chiropractor must consult with and examine a patient after a break in coverage.
19. On Jnuary 7, 1998, magnetic resonance imaging (MRI) revealed that Claimant had a Aprobable small left paracentral disc protrusion.
20. On June 28, 2002, Provider concluded Claimant had a rather large disc fragment.
21. Provider did not order another MRI or other tests for Claimant in 2002.
22. Provider did not document the basis for his observation about Claimant’s disc condition after indicating it was probably from a second injury.
23. On September 12, 2002, Provider carried Claimant from her car into his office.
24. Provider accepted Claimant’s subjective report of pain and inability to walk without examining her.
25. According to chiropractic standards of care, Provider should have examined Claimant to ascertain her inability to walk rather than relying on her 1997 assessment.
26. Provider did not furnish objective evidence of why the chiropractic care was needed four years following Claimant’s injury.

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 Trev Dixon, D.C., is not entitled to reimbursement from Insurance Company of the State of Pennsylvania for the disputed services from May 14, 2002, through September 18, 2002.

Signed June 13, 2005.

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