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Title: 

453-04-6385-m5

Date: 

January 11, 2005

Type: 

Retrospective Medical Necessity

453-04-6385-m5

DECISION AND ORDER

I. SUMMARY

Main Rehab and Diagnostic (Provider) appealed the decision of Envoy Medical Systems, LP, an independent review organization (IRO) certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) tracking number M5-04-0470-01, denying reimbursement for medical services provided to the Claimant. Additionally, the Provider appealed the MRD’s decision denying reimbursement for services not considered by the IRO. This decision orders that Texas Mutual Insurance Company (Carrier) is not required to reimburse the Provider for the services in dispute.

The Administrative Law Judge (ALJ) convened a hearing on November 30, 2004. The hearing was concluded that day but the evidentiary record was closed on December 7, 2004, following the filing of a deposition by the Provider. The Provider appeared through its representative Scott C. Hilliard, attorney. The Carrier appeared through Ryan T. Willett, attorney.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this proceeding is whether the Carrier should reimburse the Provider $2,591.50[1] plus interest for medical services provided between April 30, 2003, and July 15, 2003, and billed under CPT Codes 99211 (office visit), 99213 (office visit), 97110 (therapeutic exercises), 97750-MT (physical performance test), and A4558 (conductive paste or gel). The Carrier argued that none of the medical services provided to the Claimant were medically necessary or reasonably required to treat the compensable injury. Further, the Provider appealed the MRD decision denying reimbursement in the amount of $12.50 for services billed under CPT Code 99080 (special reports).[2] The Carrier denied payment on the basis that the Provider failed to submit relevant information to meet documentation criteria.[3]

The documentary record in this case consisted of six exhibits (Provider’s Exh. 1 – 89 pages, Provider’s Exh. 2 – 115 pages, Provider’s Exh. 3 – 43 pages, Carrier’s Exh. 1 – 276 pages,[4] Carrier’s Exh. 2 – 20 pages, Carrier’s Exh. 3 – 350 pages[5]). Additionally, David Alvarado, D.C., testified as an expert witness on behalf of the Carrier.

The Claimant, a 49-year-old woman, suffered an injury to her thoracic spine on ___, while unloading a tall cart full of bags and boxes.[6] The Claimant was treated by Tamara K. Hanby, D.O., from June 5, 2002, through December 4, 2002.[7] On January 23, 2003, the Claimant began seeing the Provider, who diagnosed her with thoracic disc disorder and muscle spasms.[8] The Carrier paid for the services provided to the Claimant by the Provider through April 28, 2003.[9]

Osler Kamath, D.C., works for the Provider and was the Claimant’s treating doctor. He has been a practicing chiropractor in Dallas, Texas, since 1999, and his testimony was submitted through a deposition taken on November 5, 2004.[10] Dr. Kamath testified that he immediately began the Claimant on a course of active therapy following an initial examination on January 23, 2003. The Claimant’s active therapy consisted of five exercises:

  1. Prone on elbows spinal mobility. The Claimant performed this strength exercise by lying prone on the floor on her stomach and pushing up her upward body. This exercise is commonly referred to as a push up.
  2. Lumbar rotation in non-weight bearing. The Claimant performed this exercise by sitting on a bench and rotating her lower back from side to side.
  3. Angry cat stretch. The purpose of this exercise is to enhance low back flexibility. The Claimant performed this exercise by getting on the floor on her hands and knees and arching her back upwards and then returning to a neutral position.
  4. Double knee to chest stretch. To perform this exercise, the Claimant assumed a supine position on the floor and in a bicycle movement she first brought one knee to her chest and then the other knee.
  5. Lumbar rotation stretch. This exercise is performed in the standing position. The Claimant used her right hand to touch her left foot and her left hand to touch her right foot.[11]

Each of the exercises took approximately 15 minutes to perform. The Provider billed a total of five fifteen-minute units for completion of the exercise routine.[12]

Dr. Kamath described the Claimant as severely obese. He testified that it took her approximately three minutes to complete one set of ten repetitions of an exercise because she needed frequent breaks.[13] Dr. Kamath justified one-on-one billing of the exercises on the basis of the severity of the Claimant’s injury.[14] He admitted that the Claimant performed the same exercise throughout her course of treatment.[15]

Dr. Alvarado has been a practicing chiropractor since 1988. He reviewed the Claimant’s medical records in preparation for his testimony. Dr. Alvarado testified that the Claimant’s diagnosis was a sprain/strain of the thoracic spine. Regarding the five therapeutic exercises performed by the Claimant, he stated they were simple, without safety issues, and could have been performed in 30 minutes instead of 90 minutes. Further, he stated there was no indication that the Claimant was below average intelligence and one 15-minute unit of one-on-one treatment would have been sufficient for instructional purposes because the Claimant did the same exercises over the entire course of treatment.

Dr. Alvarado testified that the Claimant failed to show improvement in range of motion after February 19, 2003, and actually has some regression. Further, he stated that the Provider’s treatment did not provide relief for the Claimant’s pain, making continued treatment and testing following April 28, 2003, unnecessary. Additionally, Dr. Alvarado pointed out that the Claimant could have performed the exercises in either a group setting or at home.The ALJ concludes the provider failed to prove that the medical services delivered from April 30, 2003, through July 15, 2003, were medically necessary and reasonably required to treat the Claimant’s compensable injury. As testified to by Dr. Alvarado, the Claimant was very familiar with the exercise program and she could have participated in it through either group therapy sessions or performed the exercises at home. One-on-one direct supervision was not medically necessary. Additionally, the record did not support the necessity for office visits, testing, and other treatment delivered by the Provider following April 28, 2003. Therefore, the Provider should not be reimbursed for the contested services delivered to the Claimant.

III. FINDINGS OF FACT

  1. On ___, the Claimant suffered a compensable injury to her thoracic spine.
  2. The Claimant’s injury is covered by workers’ compensation insurance written for the Claimant’s employer by Texas Mutual Insurance Company (Carrier).
  3. Main Rehab and Diagnostic (Provider) began treating the Claimant on January 23, 2003, for a diagnosis of thoracic sprain/strain.
  4. The Carrier reimbursed the Provider for services delivered to the Claimant until

April 30, 2003.

  1. The Carrier denied reimbursement to the Provider for medical services provided between April 30, 2003, and July 15, 2003, and billed under CPT Codes 99211 (office visit),
  2. 99213 (office visit), 97110 (therapeutic exercises), 97750-MT (physical performance test), and A4558 (conductive paste or gel) on the basis that the treatment was not medically necessary to treat the injury.
  3. The Carrier denied reimbursement to the Provider for medical services provides on
  4. June 6, 2003, billed under CPT Code 99080 (special reports), on the basis that the Provider failed to submit relevant information to meet documentation criteria.
  5. The Claimant failed to show significant improvement in range of motion after

February 19, 2003.

  1. The provider billed five 15-minute units for each day that the Claimant performed the exercises.
  2. The exercises were simple, without safety issues, and could have been performed in

30 minutes instead of 90 minutes.

  1. There was no indication that the Claimant was below average intelligence, and one
  2. 15-minute unit of one-on-one treatment would have been sufficient for instructional purposes because the Claimant did the same exercises over the entire course of treatment.
  3. Direct one-on-one contact with the treating physician at each session of therapy was not necessary to treat the Claimant’s injury.
  4. The Claimant could have done her exercises in either a group or home-based setting instead of a one-on-one setting.
  5. The Provider’s treatment did not provide relief for the Claimant’s pain.
  6. Continued treatment and physical performance testing following April 28, 2003, was unnecessary.
  7. The Provider failed to submit relevant information to meet documentation criteria for

CPT Code 99080 (special reports).

  1. The Provider timely requested dispute resolution by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC).
  2. On May 11, 2004, the MRD issued its decision concluding that the disputed expenses

should not be paid, and the Provider timely appealed the decision.

  1. TWCC sent notice of the hearing to the parties on June 21, 2004. The hearing notice informed the parties of the matter to be determined, the right to appear and be represented by counsel, the time and place of the hearing, and the statutes and rules involved.
  2. The hearing on the merits convened November 30, 2004, before Michael J. Borkland, Administrative Law Judge. The Provider appeared through Scott C. Hilliard, attorney. The Carrier appeared through Ryan T. Willett, attorney.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (TWCC) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  2. 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 §413.031 and Tex. Gov’t Code ch. 2003.
  3. Based on Finding of Fact No. 18, the Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov’t Code §2001.052.
  4. The Provider has the burden of proving by a preponderance of the evidence that he should prevail in this matter. Tex. Labor Code §413.031.
  5. The services referred to in Finding of Fact No. 5 were not medically necessary.
  6. Based on Findings of Fact Nos. 7 – 15, the Provider failed to prove that reimbursement for treatment provided from April 30, 2003, through July 15, 2003, should be ordered.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company is not required to reimburse Main Rehab and Diagnostic for the disputed services provided in treating the Claimant.

Signed January 11, 2005.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. This amount was determined from the Provider’s table of disputed services. (Carrier’s Exh. 2)↑
  2. There was no mention of this item at the hearing.↑
  3. In summary, this case had both a fee dispute and a medical necessity dispute.↑
  4. The pages of the exhibit are numbered 1 – 276.↑
  5. The pages of the exhibit are numbered 277 – 618.↑
  6. Carrier’s Exh. 1, page 189.↑
  7. Carrier’s Exh. 2, pages 1 – 5.↑
  8. Carrier’s Exh. 3, page 352.↑
  9. The Provider paid for computer data analysis services billed on April 30, 2004, but denied all other services beginning on that date as being unnecessary. Carrier’s Exh. 2, pages 5 – 13.↑
  10. Provider’s Exh. 3.↑
  11. Provider’s Exh. 3, pages 12 – 15.↑
  12. Provider’s Exh. 3, page 15.↑
  13. Provider’s Exh. 3, page 15.↑
  14. Provider’s Exh. 3, page 17.↑
  15. Provider’s Exh. 3, page 19.↑