DECISION AND ORDER

The provider in this case, Mega Rehab (Petitioner) billed $741.82 for a surgical tray – a set of supplies – used in administering a cervical epidural steroidal injection on June 13, 2003. The carrier, Liberty Mutual Insurance Corporation (Respondent), paid $100.00 for the tray. There is no applicable maximum allowable reimbursement (MAR), and Petitioner was required to provide documentation supporting the amount billed. Respondent argues that Petitioner had failed to offer sufficient information. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) agreed with Respondent, and ordered no additional reimbursement. Petitioner requested a hearing. The amount in dispute is $641.82.

The Administrative Law Judge (ALJ) concludes that Respondent need not pay Petitioner the amount in dispute.

I. DISCUSSION

A. Procedural History

The hearing was convened on January 10, 2005, before State Office of Administrative Hearings (SOAH) Judge Shannon Kilgore.^[1] Stephen Dudas, D.C., appearing by telephone, represented Petitioner. Kevin Franta represented Respondent. The hearing adjourned, and the record closed, the same day.

B. Applicable Law

Provider has the burden of proof in this proceeding.^[2] Where reimbursement for services is not identified in an established fee guideline they “shall be reimbursed at fair and reasonable rates as described in the Texas Workers’ Compensation Act, Section 413.011.”^[3] When a carrier is to pay a health care provider for treatments or services for which the Commission

has not established an MAR, the carrier must develop and consistently apply a methodology to determine fair and reasonable reimbursement amounts to ensure that similar procedures provided in similar circumstances receive similar treatment.^[4]

The 1996 Medical Fee Guideline (MFG), which applies to this dispute,^[5] provides:

Documentation of procedure (DOP) in the maximum allowable reimbursement column indicates that the value of this service shall be determined by written documentation attached to or included in the bill. DOP is used when the services provided are not specifically listed or are unusual or too variable to have an assigned MAR.^[6]

The MFG goes on to state that DOP is required for any single supply that is billed at $50.00 or greater.^[7] DOP includes: a description of the services provided; the nature, extent, and need for the service; the time required to perform the service; the skill level necessary to perform the service; the equipment used; and other information as necessary.^[8]

C. MRD Decision

In a decision dated May 27, 2004, the MRD concluded that no further reimbursement for the surgical tray was warranted because the provider, Petitioner, had failed to offer documentation demonstrating that the amount of reimbursement sought is fair and reasonable.^[9]

D. Discussion and Conclusion

The medical necessity of the cervical epidural steroidal injection administered on June 13, 2003, is not in dispute. Petitioner billed for the surgical tray under CPT Code 99070, a general supply code with no MAR; this choice of CPT code was proper.^[10] Petitioner’s documentation consists of the physician’s procedure note, some exam and procedure notes prior to the date of service, and an itemized list of the supplies on the tray, including a price for each item.^[11] Petitioner

asserted that this is its customary manner of billing and it has had few problems.^[12]

The applicable rules and guidelines establish that a provider must give the carrier documentation to support a claim for reimbursement for which there is no applicable MAR. The rules and guidelines fail to dictate precisely what that documentation must include when supplies are billed under CPT Code 99070. However, logic suggests that any meaningful showing that a bill for a set of supplies is fair and reasonable would include two elements: first, an itemization of the supplies and prices included and, second, some information supporting the reasonableness of the price of each item. In this case, Petitioner identified the items included in the surgical tray and showed how its request for $741.82 was broken down item-by-item. However, Petitioner offered nothing B with its bill or at the hearing B to show the basis for each component price. Providing such information would not be unduly burdensome; for example, a provider could offer an invoice showing what it paid for each item (or similar item). Given Petitioner’s failure to offer any evidence concerning the reasonableness of the prices charged for the various items included in the surgical tray, the ALJ concludes that the MRD decision should not be overturned. Respondent is not required to reimburse Petitioner further.

II. FINDINGS OF FACTS

1. Liberty Mutual Insurance Corporation (Respondent) is the workers’ compensation insurer with respect to the claims at issue in this case.
2. On June 13, 2003, Alan B. Hurschman, M.D., treated claimant ___’s compensable work-related injury by administering a cervical epidural steroid injection.
3. Mega Rehab (Petitioner) requested reimbursement in the amount of $741.82 for the surgical tray B i.e., the set of supplies – involved in the administration of the cervical epidural steroid injection.
4. Petitioner billed for the surgical tray under CPT Code 99070, a code for supplies for which there is no applicable maximum allowable reimbursement.
5. Respondent paid $100.00 for the surgical tray, but declined to pay more on the grounds that the requested amount was excessive.
6. The amount in dispute is $641.82.
7. Petitioner requested medical dispute resolution.
8. The Medical Review Division of the Texas Workers’ Compensation Commission issued an order on May 27, 2004, concluding that no further reimbursement for the surgical tray was warranted because the provider, Petitioner, had failed to offer documentation demonstrating that the amount of reimbursement sought is fair and reasonable.
9. Petitioner requested a hearing.
10. Notice of the hearing was issued July 5, 2004.
11. 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.
12. The hearing was convened on January 10, 2005, before State Office of Administrative Hearings (SOAH) Judge Shannon Kilgore. Stephen Dudas, D.C., appearing by telephone, represented Petitioner. Kevin Franta represented Respondent. The hearing adjourned, and the record closed, the same day.
13. There is no evidence concerning the fairness and reasonableness of the prices Petitioner charged for the various items included in the surgical tray.

III. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter. Tex. Lab. Code ch. 401 et seq.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order. Tex. Lab. Code § 413.031; Tex. Gov’t Code ch. 2003.
3. Adequate and timely notice of the hearing was provided in accordance with the Administrative Procedure Act. Tex. Gov’t Code § 2001.052.
4. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code § 148.21(h) and (i); Tex. Labor Code § 413.031.
5. Where reimbursement for services is not identified in an established fee guideline they “shall be reimbursed at fair and reasonable rates as described in the Texas Workers§ Compensation Act, Section 413.011.” 28 Tex. Admin. Code § 134.1(c).
6. Reimbursement for services and treatments provided prior to August 1, 2003, is governed by the Commission’s 1996 Medical Fee Guideline. 28 Tex. Admin. Code § 134.202; Texas AFL-CIO v. Texas Workers Compensation Commission, 137 S.W.3d 342 (Tex. AppBAustin 2004).
7. Documentation of procedure (DOP) is required for any single supply that is billed at $50.00 or greater. 1996 Medical Fee Guideline General Instructions IV.
8. The DOP requirement means that written documentation must be attached to or included in the bill. 1996 Medical Fee Guideline General Instructions III. A.
9. DOP includes: a description of the services provided; the nature, extent, and need for the service; the time required to perform the service; the skill level necessary to perform the service; the equipment used; and other information as necessary. 1996 Medical Fee Guideline General Instructions III. A.
10. Information provided by Petitioner failed to show that the amount billed for the surgical tray was fair and reasonable.

ORDER

IT IS THEREFORE ORDERED that Liberty Mutual Insurance Corporation need not pay any additional amount for the surgical tray used in administering a cervical epidural steroidal injection to claimant ___ on June 13, 2003.

Issued March 10, 2005.

SHANNON KILGORE

STATE OFFICE OF ADMINISTRATIVE HEARINGS
Administrative Law Judge

1. Although this case has a docket number with an AM5″ suffix suggesting that the case is a medical necessity dispute, this is in fact a fee dispute. It appears that perhaps a medical necessity issue was part of the case at one point, but had been dismissed or otherwise resolved before the case was heard at SOAH.↑
2. 28 Tex. Admin. Code § 148.21(h) and (i); Tex. Labor Code § 413.031.↑
3. 28 Tex. Admin. Code § 134.1(c).↑
4. 28 Tex. Admin. Code § 133.304(i)(1).↑
5. For services and treatments rendered following August 1, 2003, the Commission’s 2002 Medical Fee Guideline is applicable. 28 Tex. Admin. Code § 134.202; Texas AFL-CIO v. Texas Workers Compensation Commission, 137 S.W.3d 342 (Tex. AppBAustin 2004). Reimbursement for services and treatments provided prior to August 1, 2003, is governed by the Commission’s 1996 Medical Fee Guideline.↑
6. 1996 Medical Fee Guideline General Instructions III. A.↑
7. 1996 Medical Fee Guideline General Instructions IV.↑
8. 1996 Medical Fee Guideline General Instructions III. A.↑
9. Carrier Exhibit 1 at A24-A26.↑
10. See 1996 Medical Fee Guideline General Instructions IV.↑
11. Provider Exhibit 1 at 1-11. The itemized list of supplies billed as part of the surgical tray is at page 10.↑
12. Petitioner directed the ALJ’s attention to portions of several other MRD decisions that, according to Petitioner, support its case. See Petitioner Exhibit 1 at 12-15, 18-24. However, one of the cases was a medical necessity dispute. Id. at 12-15. Further, the excerpts from the other cited cases do not indicate what information was in the record when the MRD made its decisions.↑