DECISION AND ORDER

This case involves medical treatments and testing provided by Results Rehab to workers’ compensation claimant ____ (the Claimant) from December 11, 2002, through April 16, 2003. The Administrative Law Judge (ALJ) concludes the workers’ compensation carrier, Texas Mutual Insurance Company (TMIC), proved the disputed treatments were not medically necessary and that reimbursement should be denied.

I. HISTORY

The Claimant was injured ___, when his right middle finger was caught in a laundry folding machine. He underwent surgery on January 4, 2002, followed by physical therapy. His finger did not heal properly, however. He developed a deformity in the middle joint of that finger secondary to vascular necrosis of small fracture fragments. On September 4, 2002, the Claimant underwent a second surgery, in which a silastic joint was implanted into that finger. He underwent approximately two months of physical therapy, with a reevaluation of his condition performed on November 21, 2002. He began additional therapy with Results Rehab on December 11, 2002. The treatments rendered by Results Rehab, which lasted from December 11, 2002, through April 16, 2003, included paraffin baths (97018) therapeutic procedures (CPT Code 97110), one-on-one therapeutic procedures (97530), unlisted physical medicine procedures (97799), and an unlisted cardiovascular procedure

(93799). Tests included physical performance tests or measurements (97750), muscle testing of the hand (95832), muscle testing of the total body, including the hands (95834), range-of-motion measurement of the hand (95852), and other range-of-motion measurements (95851). The charges also included an initial office consultation (99243) and an office visit (99212).

TMIC paid for the physical therapy after the initial surgery and the first two months of therapy after his September 2002 surgery. It declined to reimburse Results Rehab for the treatments and testing that began December 11, 2002, on the ground that they were not medically necessary.

Results Rehab filed a timely request for dispute resolution with the Texas Workers’ Compensation Commission (the Commission), for a disputed amount of $6,437.00. The Medical Dispute Review Division (MRD) referred the matter to an Independent Review Organization (IRO), which found the disputed services to be medically necessary. TMIC filed a timely request for a hearing with the State Office of Administrative Hearings (SOAH).^[1]

Notice of the hearing was sent to both parties June 29, 2004. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.

The hearing was held December 14, 2004. TMIC appeared at the hearing. Although the notice had been sent to Results Rehab at its mailing address as shown on its health insurance claim forms, Results Rehab did not appear at the hearing. After testimony and argument from TMIC, the hearing was adjourned the same day.

II. DISCUSSION

Gary Pamplin, M.D., who is Board-certified in orthopaedic surgery and hand surgery, testified for TMIC. Dr. Pamplin observed that the Claimant’s physical therapist, on November 21, 2002, found the Claimant was progressing well and should be able to return to work. Dr. Pamplin stated the Claimant’s testing results at the time showed a good range of motion.^[2]

The Claimant’s surgeon, Tom C. Diliberti, M.D., P.A., nevertheless recommended additional therapy for the Claimant. In Dr. Pamplin’s view, that additional therapy was unnecessary and home exercises should have been sufficient for the Claimant’s recovery. He testified that the one-on-one therapy, in particular, was unnecessary because Claimant’s exercises were not complex and did not

require one-on-one supervision. He also considered the other therapeutic procedures to be inadequately explained. Dr. Pamplin further believed the two hours of therapy per day performed by the Claimant was excessive and detrimental to his recovery.

Dr. Pamplin also contended the testing performed by Results Rehab was unnecessary. In his opinion, because the injury was limited to the finger, range of motion could have been determined in 15 or 20 seconds without the need for the more elaborate procedures in which Results Rehab engaged.

The ALJ finds TMIC proved the disputed services were not medically necessary. Although Dr. Diliberti recommended further physical therapy, his rationale is not clear. The other documentary evidence, particularly the physical therapist’s report, does not support that recommendation. Moreover, Dr. Pamplin was convincing in his testimony that the therapeutic procedures provided by Results Rehab were not medically necessary and that a home exercise

program would have been adequate and preferable. Therefore, TMIC should not be required to reimburse Results Rehab for the medical treatments and testing Results Rehab provided the Claimant from December 11, 2002, through April 16, 2003.

III. FINDINGS OF FACT

1. Workers’ compensation claimant ____ (the Claimant) was injured ___, when his right middle finger was caught in a laundry folding machine.
2. The Claimant underwent surgery on January 4, 2002, followed by physical therapy.
3. The Claimant’s finger did not heal properly and developed a deformity in the middle joint secondary to vascular necrosis of small fracture fragments.
4. On September 4, 2002, the Claimant underwent a second surgery, in which a silastic joint was implanted into his injured finger.
5. The Claimant underwent approximately two months of physical therapy, with a reevaluation of his condition performed on November 21, 2002.
6. The Claimant began additional therapy with Results Rehab on December 11, 2002.
7. The treatments rendered by Results Rehab, which lasted from December 11, 2002, through April 16, 2003, included paraffin baths (97018) therapeutic procedures (CPT Code 97110), one-on-one therapeutic procedures (97530), unlisted physical medicine procedures (97799),
8. and an unlisted cardiovascular procedure (93799). Tests included physical performance tests or measurements (97750), muscle testing of the hand (95832), muscle testing of the total body, including the hands (95834), range-of-motion measurement of the hand (95852), and other range-of-motion measurements (95851). The charges also included an initial office consultation (99243) and an office visit (99212).
9. TMIC paid for the physical therapy after the initial surgery and the first two months of therapy after his September 2002 surgery. TMIC declined to reimburse Results Rehab for the treatments and testing that began December 11, 2002, on the ground that they were not medically necessary.
10. Results Rehab filed a timely request for dispute resolution with the Texas Workers’ Compensation Commission (the Commission), for a disputed amount of $6,437.00.
11. The Medical Dispute Review Division (MRD) referred the matter to an Independent Review Organization (IRO), which found the disputed services to be medically necessary.
12. TMIC filed a timely request for a hearing with the State Office of Administrative Hearings (SOAH).
13. TMIC hd also denied approximately $280.00 of services under Codes AF or AG, which refer to fee reductions per MAR guidelines and unbundling. The MRD denied reimbursement for those services. Results Rehab did not request a hearing on those denials.
14. Notice of the hearing was sent to both parties June 29, 2004.
15. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
16. The hearing was held December 14, 2004.
17. TMIC appeared at the hearing. Although the notice had been sent to Results Rehab at its mailing address as shown on its health insurance claim forms, Results Rehab did not appear at the hearing.
18. After testimony and argument from TMIC, the hearing was adjourned the same day.
19. On November 21, 2002, the Claimant’s physical therapist found the Claimant was progressing well and should be able to return to work.
20. The Claimant’s testing results on November 21, 2002, showed a good range of motion.
21. After November 21, 2002, additional supervised therapy was unnecessary and home exercises should have been sufficient for the Claimant’s recovery.
22. The medical treatments and testing Results Rehab provided the Claimant from December 11, 2002, through April 16, 2003, were not medically necessary.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. ‘413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. ‘2001.052.
3. Under 28 TAC ‘148.21(h), the Petitioner has the burden of proof in hearings, such as this one, conducted pursuant to Tex. Lab. Code Ann.’413.031.
4. TMIC should not be required to reimburse Results Rehab for the medical treatments and testing Results Rehab provided the Claimant from December 11, 2002, through April 16, 2003.

ORDER

IT IS, THEREFORE, ORDERED that Texas Mutual Insurance Company is not required to reimburse Results Rehab for the medical treatments and testing Results Rehab provided the Claimant from December 11, 2002, through April 16, 2003.

Signed February 10, 2005.

HENRY D. CARD
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. TMIC hd also denied approximately $280.00 of services under Codes AF or AG, which refer to fee reductions per MAR guidelines and unbundling. The MRD denied reimbursement for those services. Results Rehab did not request a hearing on those denials.↑
2. See TMIC Ex. 2, page 5.↑