DECISION AND ORDER

Main Rehab and Diagnostic (Provider) challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission denying reimbursement to it for sessions of physical therapy and work hardening that Provider administered to ___ (Claimant) from March 13, 2003, through June 9, 2003. Dallas Fire Insurance Company (Carrier) appealed that portion of the MRD Decision ordering reimbursement to Provider for sessions of physical medicine conducted between February 20, 2003, and March 12, 2003. The MRD ruled that treatment was necessary through March 12, 2003, but unnecessary after that date. The MRD also ruled that certain treatments were undocumented.

The Administrative Law Judge (ALJ) finds no reimbursement is due for any of the disputed dates of service.

The hearing in this matter convened on November 10, 2004, in Austin, Texas, with ALJ Cassandra Church presiding. The record closed that day. Provider was represented by Scott C. Hilliard, attorney. Carrier was represented by Christine B. Karcher, attorney. The Commission did not participate in the hearing.

Matters of jurisdiction and notice were not disputed, so are set forth in the Findings of Fact and Conclusions of Law without further discussion here.

I. DISCUSSION

A. Burden of Proof

As each party timely petitioned for hearing on that portion of the MRD decision adverse to it, each has the burden of proof in regard to those matters it disputes.^[1]

B. Medical History

On ___, Claimant was injured in a fall from a ladder or scaffolding. Claimant was diagnosed as suffering an acute sprain/contusion (bruising) of the right ankle and heel, sprain of the right wrist, acute lumbar strain, and contusion to the right hip. He neither fractured any bones nor suffered any

neurological impairment as a result of the fall. In short, all injury was to Claimant’s soft tissue.

Claimant was initially treated in a hospital emergency room. Claimant was provided a supportive boot, crutches, and a wrist brace. He was instructed to ice the injured areas. The leg support was later changed to an ankle stirrup, then to a wrap.^[2] He was prescribed pain medications.

The hospital doctor authorized Claimant to return to work. In addition, Michael Seeley, M.D., who treated Claimant after his emergency room care, returned Claimant to work on December 20, 2002, and on January 6, 2003, reauthorized his return to work. Claimant did return to work for a brief period.

On January 7, 2003, Crawford Sloan, M.D., referred Claimant to Provider for evaluation and treatment. On January 8, 2003, Osler Kamath, D.O., a chiropractor employed by Provider, took Claimant off work for rest and rehabilitation.^[3] Dr. Kamath then initiated a course of passive modalities and physical therapy which continued through March 12, 2003. Treatments during that period including one-on-one physical therapy, joint mobilization, manual traction, and myofascial release. Provider also conducted frequent office visits, administered a functional capacity evaluation (FCE), and conducted range of motion (ROM) measurement.

Between March 13, 2003, and June 9, 2003, Provider’s staff administered a work hardening program to Claimant. Claimant apparently returned to work at the end of that program.

C. Physical Therapy and Modalities

Carrier’s experts agreed that a course of conservative chiropractic care was appropriate to treat Claimant’s injuries.^[4] However, they disagreed that such care would generally be needed for more than 12 weeks. Robert B. Honigsfeld, D.C., who reviewed the records of this case in June 2003, supported administration of conservative chiropractic care for six weeks, or through approximately the end of January 2003.^[5]

On February 17, 2003, Gregory W. Baker, D. C., concluded that no chiropractic treatment was warranted after 12 weeks from the initial date of injury.^[6] Dr. Baker found no indicators in

Provider’s records that Claimant’s condition was remarkable in any way or that recovery would have taken any longer than the time period usual for the types of injuries he sustained, which he estimated at eight to twelve weeks. Dr. Baker was the peer reviewer in this case.

Provider’s records themselves failed to identify any factors which explained why physical therapy and passive modalities for an additional month were necessary to treat Claimant.^[7] Nothing in the records indicated that Claimant had re-injured himself or had exacerbated his injuries during his brief return to work in late December 2002.

Dr. Kamath’s initial evaluation stated that the treatment goals were to alleviate Claimant’s pain, increase his ROM and strength, and enhance his functionality.^[8] However, the daily treatment notes that follow are simply repetitions of the same canned notes. They fail to describe the specific exercises provided to enhance functionality and also fail to document changes in Claimant’s pain over time. According to those records, Claimant reported moderate and intermittent pain levels throughout his treatment. Although Dr. Kamath asserted the treatments were progressive over the period of therapy, his assertion was not supported by the records made at the time the treatment was administered. In sum, these notes were not credible sources of information on Claimant’s medical condition or his progress toward the treatment goals.^[9]

The credible medical evidence in this case supports a conclusion that no additional physical therapy or passive modalities were medically necessary between February 20, 2003, and March 12, 2003, to treat Claimant’s injury. These dates are all more than 12 weeks after the date of injury and there is no credible evidence demonstrating that Claimant exhibited symptoms that would justify an extended treatment period. Reimbursement for treatments and office visits during that period are denied.

Although testing to evaluate a patient’s reconditioning efforts is reimbursable, there is no reason to reimburse for testing in support of a course of medical treatment that itself is not medically necessary. Therefore, reimbursement is denied for the FCE administered on March 12, 2003, and the ROM measurement on March 10, 2003.

D. Work Hardening

The treatment guidelines for interdisciplinary programs applied by the parties dictate that a work hardening program must be an individualized program to progressively improve the biomechanical, neuromuscular, cardiovascular/metabolic, behavioral, attitudinal, and vocational functioning of an injured worker.^[10]

Dr. Kamath testified that, as a person with limited education, job skills, and Spanish-only fluency, Claimant would be vulnerable to workplace exploitation, i.e., being laid off if injured or being compelled to work while injured. Dr. Kamath said the presence of these elements would be sufficient to warrant a work hardening program. During the course of the work hardening program, Claimant expressed some general anxiety and concern about not being able to find and keep work. However, Provider presented no credible documentation that Claimant, as an individual, had psychological or behavioral symptoms that required treatment to enable Claimant to return to work. Indeed, Provider’s counselor noted several times that Claimant displayed no psychological issues and had good coping skills. The ALJ concluded that Claimant’s injury was only physical in nature.

Additionally, Claimant displayed no need for a vocational retraining. To the contrary, Dr. Kamath stated that, due to Claimant’s limited education and skill level, the best course of action would be reconditioning him to return to work as a laborer.

Dr. Baker stated that the absence of any fracture or neurological complications indicated that Claimant could have been reconditioned with a minimal treatment program. He said that any deconditioning Claimant had experienced due to inactivity during his recovery period could have been overcome with one to two weeks of supervised exercise followed by an exercise program performed by Claimant at home or in a gym.

Further, Provider’s records gve no indication that Provider tailored a program for Claimant. Rather, it showed that Claimant went through a course with standardized components such as Aanger management and Aneed for recreation, although there was no showing that Claimant had deficits in those areas that impeded his return to work.

In sum, Provider failed to meet its burden of proof to show that a work hardening program was medically necessary to treat Claimant. Reimbursement for any services during the work hardening period, March 13, 2003, through June 9, 2003, is hereby denied.

E. Documentation Issues

Most of the services for which the MRD denied reimbursement on the basis of lack of documentation fall after March 13, 2003, the commencement date of the work hardening program. Since no treatments during this period were found to be medically necessary, reimbursement is also denied for treatments labeled undocumented, including physical therapy sessions.

Provider did not document the nature of or need for the unidentified procedure (CPT 99080-73) provided on May 8, 2003, or the medical supply item (CPT EO745) used on April 17, 2003.

Provider requested reimbursement for four treatments on March 12, 2003, the last date of the modalities course of treatment. Provider requested reimbursement for joint mobilization, myofascial release, manual traction, and physical therapy on that date. The notes of the office visit fail to indicate that any of the listed modalities were provided.^[11] Reimbursement is denied for joint mobilization, myofascial release, manual traction, and physical therapy on March 12, 2003.

III. FINDINGS OF FACT

1. On ___, ___ (Claimant) injured his right wrist, right ankle, right hip, and low back in fall from a ladder or scaffolding to a concrete floor.
2. Dallas Fire Insurance Company (Carrier) was the responsible insurer.
3. Claimant’s diagnosis was acute sprain/contusion (bruising) of the right ankle and heel, sprain of the right wrist, acute lumbar strain, and contusion to the right hip.
4. Claimant did not fracture any bones or suffer any nerve injury or compromise as a result of the fall.
5. The emergency room physician treating Claimant on December 17, 2002, authorized Claimant to return to work.
6. Claimant was initially given crutches to aid his walking, supportive braces for his ankle and wrist, and was instructed to ice the injured areas. He was prescribed pain medications.
7. On December 20, 2002, and on January 6, 2003, Michael Seely, M.D., authorized Claimant to work with no restrictions.
8. Claimant returned to work on some days between December 20, 2002, and January 8, 2003.
9. Claimant did not re-injure himself or exacerbate his injury during his brief return to work.
10. Between February 8, 2003, and March 12, 2003, Claimant reported experiencing intermittent, moderate bouts of pain, numbness, and tingling in his right wrist, right ankle, and low back.
11. Claimant was treated at a hospital on December 17, 2002, and had some follow-up care between December 17, 2002, and January 6, 2003.
12. On January 7, 2003, Crawford Sloan, M.D., referred Claimant to Provider for evaluation.
13. Osler Kamath, D.C., a chiropractor employed by Main Rehab and Diagnostic (Provider), diagnosed Claimant as having lumbar disk disorder, parethesia, contusion of the right hand and wrist, and tenosynovitis/bursitis of the right foot and ankle.
14. Dr. Kamath took Claimant off work on January 8, 2003, for rest and rehabilitation.
15. Claimant’s job as a laborer at the time of his injury was a heavy physical demand job under the U.S. Department of Labor physical demand ratings.
16. Between February 20, 2003, and March 12, 2003, Provider billed Carrier under the following CPT codes:

99213 Office visit, established patient

97265 Joint mobilization

97250 Myofascial release

97122 Manual traction

97750-FCTesting, functional capacity evaluation (FCE)

97110 One-on-one physical therapy

95851 Range of motion (ROM) measurement

1. Six to twelve weeks is the usual or average recovery period for the types of soft-tissue injuries that Claimant suffered.
2. Claimant did not present any unusual or complicating physical factors that would have required a longer-than-normal recovery period.
3. Provider did not document that it provided joint mobilization, myofascial release, manual traction, or physical therapy on March 12, 2003.
4. Between March 13, 2003, and June 9, 2003, Provider administered a course of work hardening sessions, physical therapy, and conducted office visits with Claimant.
5. Provider administered FCEs to Claimant on March 12, 2003, and on April 21, 2003, and conducted ROM measurement on March 10, 2003.
6. Claimant had no attitudinal, behavioral, or psychological conditions requiring psychological treatment to enable Claimant to return to work. Claimant had good coping skills.
7. Claimant did not need vocational retraining or re-direction to enable him to return to work.
8. Claimant needed physical conditioning to enable him to return to work in a heavy physical demand job.
9. Physical reconditioning through a one- to two-week course of supervised exercise followed by a home or gym program undertaken by the worker on his own would recondition a worker after soft-tissue injuries of the type Claimant suffered.
10. Claimant was not an appropriate candidate for work hardening.
11. For treatments provided between March 13, 2003, and June 9, 2003, Provider did not provide a goal-oriented, individualized treatment program.
12. Provider did not document the nature of or need for the unidentified procedure provided on May 8, 2003, or the medical supply item used on April 17, 2003.
13. Carrier denied payment for treatments and work hardening sessions that Provider administered to Claimant from February 20, 2003, through June 9, 2003, on the grounds they were not medically necessary.
14. Provider appealed the Carrier’s determination to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission.
15. On May 4, 2004, based on the review by an Independent Review Organization (IRO), Independent Review Incorporated, the MRD ordered Carrier to reimburse Provider for all services and treatments rendered between February 20, 2003, and March 12, 2003, on the basis that they were medically necessary.
16. On May 4, 2004, the MRD denied reimbursement for treatments and services between March 13, 2003, and May 6, 2003, on the basis that they were not medically necessary.
17. On May 4, 2004, the MRD denied reimbursement to Provider for additional services provided between March 12, 2003, and June 9, 2003, on the basis that Provider failed to document that it provided the services for which it had sought reimbursement.
18. On May 12, 2004, Provider requested a hearing on the May 4, 2004, MRD decision.
19. On May 14, 2004, Carrier requested a hearing on the May 4, 2004, MRD decision.
20. On June 17, 2004, the Commission issued a notice of hearing on both requests for hearing that included the date, time, and location of the hearing, the applicable statutes under which the hearing would be conducted, and a short, plain statement of matters asserted.
21. On November 10, 2004, Administrative Law Judge Cassandra Church conducted a hearing on the merits of both appeals. The record closed that day.

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. Lab. Code Ann. § 413.031 and Tex. Gov’t Code Ann. ch. 2003.
2. Provider and Carrier each timely requested a hearing, as specified in 28 Tex. Admin Code § 148.3.
3. Proper and timely notice of the hearing on both requests was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
4. Provider has the burden of proof as to matters adverse to it and Carrier has the burden of proof as to matters adverse to it, pursuant to Tex. Lab. Code Ann. § 413.031, 1 Tex Admin. Code § 155.41 (b), and 28 Tex. Admin Code § 148.21(h).
5. Provider failed to meet its burden of proof to show work hardening, all related testing procedures, and services administered from March 13, 2003, through June 9, 2003, were medically necessary to treat or reasonably required to relieve the effects of or promote recovery from a compensable injury suffered by Claimant, within the meaning of Tex. Lab. Code Ann. §§ 408.021 and 401.011(19).
6. Provider failed to meet its burden of proof to document that it provided an unidentified procedure on May 8, 2003, a medical supply item on April 17, 2003, and joint mobilization, myofascial release, manual traction, and physical therapy on March 12, 2003, as required by 28 Tex. Admin. Code § 133.301 and 133.307(g)(3)(A-F).
7. Carrier met its burden of proof to show that physical therapy and passive modalities, office visits, and all related testing and procedures administered between February 20, 2003, and March 12, 2003, were not medically necessary to treat or reasonably required to relieve the effects of or promote recovery from a compensable injury suffered by Claimant, within the meaning of Tex. Lab. Code Ann. §§ 408.021 and 401.011(19).

ORDER

IT IS ORDERED that all claims by Main Rehab and Diagnostic for reimbursement for all treatments and procedures, related office visits, medical supplies, and testing administered to Claimant ___ from February 20, 2003, through June 9, 2003, are hereby denied.

Signed January 6, 2005.

CASSANDRA J. CHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Tex. Lab. Code Ann. § 413.031, 1 Tex Admin. Code § 155.41 (b), and 28 Tex. Admin Code § 148.21(h).↑
2. Carrier Exh. 2, p. 22.↑
3. Claims by Provider for services that it rendered to Claimant on dates earlier in February 2003 were resolved in a separate hearing. Docket No. 453-04-0673.M5 (March 11, 2004). Reimbursement was denied for all services performed on the dates of service of February 3, 2003, through February 19, 2003. The judge ruled that Provider failed to meet its burden of proof to show the services were medically necessary. Reimbursement was ordered for an MRI test administered to Claimant on February 3, 2003.↑
4. The IRO reviewer noted that six to eight weeks of care would be consistent with Texas chiropractic care guidelines. However, it appears that the IRO reviewer may have calculated the treatment period from the beginning of Provider’s care, a period that began nearly three weeks after the date of injury, rather than the date of injury itself. Carrier Exh. 1.↑
5. Carrier Exh. 2, pp. 21-25.↑
6. Carrier Exh. 2, pp. 18-20.↑
7. Provider Exh. 1, pp. 217-236.↑
8. Provider Exh. 1, pp. 206-208.↑
9. Some of the treatment notes stated that Claimant was working throughout the treatment period. Dr. Kamath stated that this note was a clerical error and that Claimant was not working. This repeatedly-uncorrected error concerning a factor of some importance in assessing the severity of Claimant’s injury further undermined the credibility of Provider’s records.↑
10. Medical Fee Guideline (MFG), 28 Tex. Admin. Code § 134.201 (repealed effective January 1, 2002), Single and Interdisciplinary Programs, pp. 36-41.↑
11. Provider Exh. 1, pp. 235-236.↑