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Title: 

453-04-8086-m5

Date: 

January 5, 2005

Type: 

Retrospective Medical Necessity

453-04-8086-m5

DECISION AND ORDER

I. DISCUSSION

First Rio Valley Medical, P.A. (Petitioner), requested a hearing to contest the June 23, 2004 Findings and Decision of the Texas Workers’ Compensation Commission (Commission) denying reimbursement for (1) office visits with manipulations,[1] aquatic therapy,[2] special reports,[3] and massage therapy[4] from December 12, 2003, through January 7, 2004 (Disputed Services).[5]

This decision GRANTS the relief sought by Petitioner and orders payment for the Disputed Services.

The hearing convened on December 7, 2004, before Administrative Law Judge (ALJ) Howard S. Seitzman. Keith Gilbert represented Petitioner. Dan Flanigan represented Travelers Indemnity Company of Connecticut (Respondent). There were no contested issues of notice or jurisdiction. The hearing adjourned and the record closed the same day.

II. BACKGROUND

___ (Claimant) sustained a work-related injury on ___. In December 2003, Claimant return to Petitioner for treatment and was treated by Robert S. Howell, D.C. Respondent denied reimbursement for the Disputed Services on the basis of a peer review. The amount in dispute is $1811.20.

III. DISPOSITIVE LEGAL ISSUE

At the hearing, Petitioner raised the issue that although Respondent denied reimbursement on the basis of a peer review, it failed to supply the peer review to Petitioner until approximately 10 days prior to the hearing. The ALJ finds this issue is dispositive of this case. Respondent’s failure to provide a peer review report in compliance with the Commission’s rules results in Respondent’s being liable for reimbursement for the Disputed Services.

A carrier who reduces or denies payment for a treatment or service on the recommendation of a peer review is required to provide the peer review report to the sender of the bill with the Explanation of Benefits (EOBs).[6] In this case, the evidence established that Petitioner did not receive a peer review report with the EOBs denying reimbursement for the Disputed Services. After receiving the EOBs, Petitioner requested the peer review report. Despite the request, Respondent did not provide a copy of the peer review until approximately 10 days prior to the hearing on the merits.

Under the circumstances, the ALJ concludes that Respondent’s denial of reimbursement is legally inadequate, as it has failed to deny reimbursement in compliance with the Commission’s rules. This position is consistent with past SOAH decisions.[7] Because Respondent has never properly denied reimbursement in compliance with the Commission’s rules, it is required to provide reimbursement.[8] Based on this threshold legal ruling, the ALJ does not address any medical necessity issues. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

IV. FINDINGS OF FACT

  1. ___ (Claimant) sustained a work-related injury on or about ___.
  2. In December 2003, Claimant return to First Rio Valley Medical, P.A. (Petitioner), for treatment and was treated by Robert S. Howell, D.C.
  3. Petitioner requested reimbursement for (1) office visits with manipulations, aquatic therapy, special reports, and massage therapy from December 12, 2003, through January 7, 2004 (Disputed Services).
  4. Travelers Indemnity Company of Connecticut (Respondent) denied reimbursement for the Disputed Services on the basis of a peer review.
  5. The amount in dispute is $1811.20.
  6. Petitioner did not receive a peer review report with the Explanation of Benefits (EOBs) denying reimbursement for the Disputed Services.
  7. After receiving the EOBs, Petitioner requested the peer review report.
  8. Respondent failed to supply the peer review report to Petitioner until approximately 10 days prior to the hearing on the merits.
  9. By decision dated June 23, 2004, the Texas Workers’ Compensation Commission (Commission) denied Petitioner reimbursement for the Disputed Services.
  10. Medical Review of Texas, an Independent Review Organization (IRO), determined by decision dated May 11, 2004, and revised June 9, 2004, that the Disputed Services were not medically necessary.
  11. Petitioner timely requested a hearing to contest the Commission’s decision.
  12. The Commission issued a notice of hearing on July 29, 2004.
  13. A hearing was convened by Administrative Law Judge Howard S. Seitzman on December 7, 2004, in the hearing rooms of the State Office of Administrative Hearings. The hearing adjourned and the record closed the same day.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 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. Lab. Code Ann. § 413.031(k) and Tex. Gov’t. Code Ann. ch. 2003.
  3. Petitioner timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) §§ 102.7 and 148.3.
  4. Notice of the hearing was proper and complied with the requirements of Tex. Gov’t. Code Ann. ch. 2001.
  5. A carrier who reduces or denies payment for a treatment or service on the recommendation of a peer review is required to provide the peer review report to the sender of the bill with the explanation of benefits (EOBs). 28 TAC § 133.304(h).
  6. Respondent’s denial of reimbursement is legally inadequate, as it has failed to deny reimbursement in compliance with the Commission’s rules.
  7. Because Respondent never properly denied reimbursement in compliance with the Commission’s rules, it is required to provide reimbursement.
  8. Petitioner had the burden of proof in this matter, which was the preponderance of evidence standard. 28 TAC §§ 148.21(h) and (i); 1 TAC § 155.41(b).
  9. Based upon the Findings of Fact and conclusions of Law, Petitioner is entitled to reimbursement for the Disputed Services provided to Claimant.

ORDER

THEREFOREIT IS ORDERED that Respondent Travelers Indemnity Company of Connecticut pay Petitioner First Rio Valley Medical, P.A., $1811.20, plus any and all applicable interest, for the Disputed Services provided to Claimant.

Signed January 5, 2005.

HOWARD S. SEITZMAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. CPT Codes 99213 and 99214.↑
  2. CPT Code 97113.↑
  3. CPT Code 99080.↑
  4. CPT Code 97124.↑
  5. By Decision dated May 11, 2004, and revised June 9, 2004, Medical Review of Texas, an Independent Review Organization (IRO) determined the Disputed Services were not medically necessary.↑
  6. 6 28 Tex. Admin. Code ‘ 133.304(h).↑
  7. 7See SOAH Docket Nos. 453-02-0991.M5, Decision and Order (April 12, 2002) (ALJ Ingraham); 453-03-2310.M5, Decision and Order (September 3, 2002) (ALJ Wood); 453-03-2355.M5, Decision and Order (July 31, 2003) (ALJ Beeler); and 453-03-3682.m5, Decision and Order (October 17, 2003) (ALJ Bennett); 453-03-3613.M5, Decision and Order (December 2, 2003) (ALJ Seitzman).↑
  8. 8 The ALJ’s determination is limited to the facts before him. The ALJ does not decide whether or not an initially defective denial can be remedied by the carrier.↑