DECISION AND ORDER

James Wetz, D.C. (Provider), appealed the decision of an Independent Review Organization (IRO) upholding the denial of reimbursement for a physical therapy program rendered to ___ (Claimant) from February 19, 2003, through April 9, 2003. In this decision, the Administrative Law Judge (ALJ) finds that Provider failed to meet its burden of showing that the treatment was reasonable and medically necessary for Claimant’s compensable injury. Therefore, City of Houston (Carrier) is not ordered to reimburse Provider for the treatment rendered.

The hearing convened and closed on January 6, 2005, before Steven M. Rivas, ALJ. Provider appeared and represented himself. Carrier appeared and was represented by Tommy Leuders, attorney.

I. DISCUSSION

A. Background Facts

Claimant sustained a compensable back injury on ___. Claimant sought treatment from Provider immediately after his injury and was placed on a therapy program that included therapeutic exercises and activities, and office visits between February 19, 2003, and April 9, 2003.^[1] Provider billed Carrier for the treatment rendered, which Carrier denied as not medically necessary. Provider filed a request for Medical Dispute Resolution with the Medical Review Division of the Texas Workers’ Compensation Commission. The dispute was sent to an IRO, which upheld all but one of Carrier’s denials of reimbursement, and Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH).

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the Act) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. § 408.021(a) provides that 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. The statute further states an employee is specifically entitled to health care 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.”

Under Tex. Lab. Code Ann. §401.011(19), health care “includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.”

C. Evidence and Analysis

Provider’s primary position was that he should be reimbursed for the disputed dates of service because the treatment rendered to Claimant was effective enough to allow Claimant to continue working throughout his entire treatment period. According to Provider, Claimant lost no time from work (as a firefighter) as a result of his injury. Additionally, Provider asserted that Claimant’s return to work at full-duty with no restrictions was a clear indication that the treatment rendered was effective.

Conversely, Carrier argued that Claimant’s return to work was an indication that the disputed treatment was not medically necessary and that he should have been prescribed a home exercise program instead. In support of its position, Carrier offered a peer review by W. Brian Woods, D.C., dated February 27, 2003. Based on his review of the records, Dr. Woods stated additional chiropractic therapy did not appear to be reasonable or necessary based on Claimant’s return to work and relatively low pain complaints. On January 9, 2003, prior to the disputed dates of service, Claimant reported his pain as 2 on a scale of 1 to 10, with 10 being the worst pain. On the first date of service, February 19, 2003, Claimant again reported his pain as 2. Dr. Woods also stated that Claimant should be released from conservative care and placed on a home exercise program.

Provider testified Claimant was placed on a home exercise program in addition to his treatment. However, Provider mentioned Claimant’s home exercise program only once in his notes, and had no explanation why it was not noted anywhere else.

Under 408.021(a), health care is reasonable if it enhances the employee’s ability to return to or retain employment. In this case, there is no question that Claimant returned to full duty before the disputed dates of service. Taking this into consideration along with Claimant’s low pain complaints and Dr. Woods’ home exercise recommendation, the ALJ believes the services rendered over the disputed dates of service were not medically necessary.

II. FINDINGS OF FACT

1. Claimant sustained a compensable back injury on ___.
2. Between February 19, 2003, and April 9, 2003, Claimant participated in five sessions of physical therapy with Provider, James D. Wetz, D.C., which included therapeutic exercises and activities, and office visits.
3. Provider sought reimbursement for the physical therapy program from City of Houston (Carrier), which was denied as not medically necessary.
4. Provider requested medical dispute resolution through the Medical Review Division of the Texas Workers’ Compensation Commission (the Commission). The dispute was
5. referred to an Independent Review Organization (IRO), which upheld the denial of reimbursement.
6. Provider timely appealed the IRO decision to the State Office of Administrative Hearings (SOAH).
7. Notice of the hearing in this case was mailed to the parties on July 7, 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. In the notice, the Commission’s staff indicated that it would not participate in the hearing.
8. The hearing convened and closed on January 6, 2005, with Administrative Law Judge Steven M. Rivas presiding. Provider appeared and represented himself. Carrier appeared and was represented by Tommy Leuders, attorney.
9. Claimant reported low pain complaints prior to the disputed dates of service.
10. Claimant returned to full duty with no restrictions prior to the disputed dates of service.
11. Provider offered insufficient evidence that the physical therapy program was necessary to treat Claimant’s compensable injury.

III. CONCLUSIONS OF LAW

1. The Commission has jurisdiction over this matter pursuant to Tex. Lab. Code Ann. § 413.031.
2. 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.
3. Provider timely filed its notice of appeal, as specified in 28 Tex. Admin. Code § 148.3.
4. Proper and timely notice of the hearing was effected upon the parties according to Tex.
5. Gov’t Code Ann. §§ 2001.051, 2001.052 and 28 Tex. Admin. Code § 148.4.
6. Provider had the burden of proof on its appeal by a preponderance of the evidence, pursuant to 28 Tex. Admin. Code §148.21(h).
7. Under Tex. Lab. Code Ann. § 408.021(a)(3), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury.
8. The physical therapy program rendered to Claimant from dates of service February 19, 2003, through April 9, 2003, was not medically necessary for treatment of Claimant’s compensable injury.
9. Based on the Findings of Fact and Conclusions of Law, Provider’s appeal for reimbursement should be denied.

ORDER

IT IS ORDERED THAT the reimbursement requested by Provider for the physical therapy program for dates of service February 19, 2003, through April 9, 2003, be denied.

Signed on March 3, 2005.

STEVEN M. RIVAS

STATE OFFICE OF ADMINISTRATIVE HEARINGS
Administrative Law Judge

1. ¹ Provider treated Claimant for a period of time before February 19, 2003. Apparently every date of service billed before February 19, 2003, was reimbursed by Carrier. Additionally, some treatment dates between the disputed dates of service may have been reimbursed as well.↑