DECISION AND ORDER

I. INTRODUCTION

Mega Rehab (Provider) disputes a decision of an independent review organization (IRO) on behalf of the Texas Workers= Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services that the Provider furnished to ___ (Claimant). Liberty Mutual Insurance Company (Carrier) contends, and the IRO agreed, that the services were not shown to be reasonably medically necessary due to the Claimant’s compensable injury. The maximum allowable reimbursement (MAR) amounts in dispute total $8,986.08.

As set out below, the Administrative Law Judge (ALJ) cannot find that the disputed services were reasonably medically necessary due to the Claimant’s compensable injury. Accordingly, the Provider’s request to be reimbursed for them is denied.

II. FINDINGS OF FACT

1. On ___, Claimant sustained a work-related injury (Compensable Injury) to her neck as a result of her work activities.
2. On the date of injury, the Claimant’s employer was___, and the Carrier was its workers= compensation insurance carrier.
3. As a result of the injury, the Claimant had neck pains, headaches, and spells of dizziness.
4. On December 3, 2002, the Claimant had ten-out-of-ten level (the highest level) pain.
5. On December 13, 2002, the Claimant had a microdiskectomy in an attempt to relieve the above symptoms that resulted from her Compensable Injury.
6. On September 19, 2003, the Claimant’s predominant complaints were pain and stiffness in her neck.
7. On September 25, 2003, the Claimant had residual neck pain and her incision was sore and her treating doctor referred her to the Provider for a work-conditioning program.
8. From October 3 through November 14, 2003, the Provider furnished to the Claimant, and sought reimbursement of $8,986.08 from the Carrier for, the following services:

CPT Code	Description	Units	Maximum Allowable Reimbursement (MAR) per unit
97750-FC	Functional capacity test	1	$282
97545-WH	Work hardening, initial two hours	25	$128
97546-FC	Work hardening, additional hours	25	$128

1. The above listed functional capacity test was to gather base-line data to measure the Claimant’s progress during the work hardening program.
2. When she began to receive the above-listed work hardening services, the Claimant’s predominant complaint stemming from her compensable injury was pain.
3. Work hardening services are provided to enhance a claimant’s ability to return to or retain employment and not primarily to reduce a claimant’s pain level.
4. When she began to receive the disputed services, the Claimant had three-out-of-ten level pain, and approximately six weeks later, on November 10, 2004, she had a two-out-of-ten level pain.
5. Shortly after receiving the disputed services, the Claimant, on January 22, 2004, had severe ten-out-of-ten level pain 95 percent of the time and was sad, frustrated, and irritable.
6. The Claimant has not returned to work.
7. The Provider timely sought reimbursement from the Carrier for each of the disputed services.
8. The Carrier timely denied reimbursement for each of the disputed services by claiming that they had not been shown to be reasonably medically necessary.
9. The Provider filed a request for medical dispute resolution with the TWCC concerning the disputed services.
10. Upon referral by TWCC, the IRO found that the disputed services were not medically necessary due to the Claimant’s compensable injury.
11. After the IRO decision was issued, the Carrier asked for a contested-case hearing by a State Office of Administrative Hearings (SOAH) Administrative Law Judge (ALJ).
12. The required notice of a contested-case hearing concerning the dispute was mailed to the Carrier and the Provider.
13. On January 11, 2005, SOAH ALJ William G. Newchurch held a contested-case hearing concerning the dispute at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. The hearing concluded and the record closed on that same day.
14. The Carrier appeared at the hearing through its attorney, Charlotte Salter.
15. The Provider appeared at the hearing through its owner, Stephen Dudas.

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. Labor Code Ann. (Labor Code) ” 402.073(b) and 413.031(k) (West 2004) and Tex. Gov=t Code Ann. (Gov=t Code) ch. 2003 (West 2004).
2. Adequate and timely notice of the hearing was provided in accordance with Gov=t Code ” 2001.051 and 2001.052.
3. An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. Labor Code ‘ 408.021(a).
4. Based on the above Findings of Fact and Gov’t Code ‘ 2003.050(a) and (b), 1 Tex. Admin. Code (TAC) ‘ 155.41(b) (2004), and 28 TAC ” 133.308(v) and 148.21(h) (2004), the Provider has the burden of proving that the disputed services were reasonably medically necessary due to the Claimant’s compensable injury.
5. The evidence does not show that the disputed services significantly cured or relieved the Claimant’s pain or any other effect naturally resulting from her compensable injury, promoted her recovery, or enhanced her ability to return to or retain employment.
6. The evidence does not show that the disputed services were reasonably likely to cure or relieve the Claimant’s pain or any other effect naturally resulting from her compensable injury, promote her recovery, or enhance her ability to return to or retain employment.
7. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request to be reimbursed for the disputed services should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request to be reimbursed for the disputed services is denied.

Signed January 31, 2005.

WILLIAM G. NEWCHURCH
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS