DECISION AND ORDER

I. INTRODUCTION

Texas Mutual Insurance Co. (Carrier) disputes a decision of an independent review organization (IRO) regarding medical services for ___ (Claimant). Carrier had denied reimbursement to Pain & Recovery Clinic North (Provider) for certain services provided to the Claimant between April 15, 2003, and July 10, 2003. The IRO and MRD decision found that Carrier should reimburse Provider only for the therapeutic exercise and neuromuscular reeducation services, and Carrier challenges that part of the decision.

Carrier contends that Provider failed to show that the disputed services were adequately documented. As set out below, the Administrative Law Judge (ALJ) agrees and finds that those services were not adequately documented. Specifically concerning the therapeutic exercise, there is no documentation to show which of three doctors of chiropractic assisted Claimant on any given day or that any of them recorded qualitative or quantitative measurements for any date of service. Carrier was able to show that Provider did not have records of the specific therapeutic activities performed on any given date of service, of how many repetitions and at what weight, and of the Claimant’s specific performance on the measurable activities. Carrier was also able to show Provider did not document that the activities billed under CPT code 97110 were on a one-to-one basis or that Claimant required one-on-one treatment. Finally, Carrier was able to show that Provider could not persuasively support the need for neuromuscular reeducation services billed under 97112 for this injury.

II. FINDINGS OF FACT

1. On ___, the Claimant sustained a work-related injury to his lower back.
2. On the date of injury, the Claimant’s employer held workers compensation insurance coverage with Texas Mutual Insurance Company (Carrier).
3. As a result of the compensable injury, the Claimant suffered lumbar radiculitis, and an MRI on April 29, 2003, indicated a 1-2 millimeter disk bulge slightly indenting the cal sac and unilateral sacralization of L5. No other significant findings were reported.
4. From April 15, 2003, to July 10, 2003, the Claimant received chiropractic services from Pain & Recovery Clinic North (Provider).
5. Provider sought reimbursement of $6,412.00 from the Carrier for the above services.
6. Crrier sent Explanations of Benefits (EOBs) to the Provider, denying all requests for reimbursement as AU (unnecessary) and ARG (exceeding medically accepted utilization review criteria and/or reimbursement guidelines).
7. Provider filed a request for medical dispute resolution with the TWCC.
8. As to the 97110 service and 97112 services, the IRO disagreed with the Carrier and ordered reimbursement in the amount of $2,870.00.
9. After the IRO decision and MRD order were issued, Carrier timely asked for a contested-case hearing before SOAH.
10. Required notice of a contested-case hearing concerning the above dispute was mailed to Carrier and Provider.
11. On February 24, 2005, SOAH ALJ Bill Zukauckas convened and closed 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.
12. Carrier appeared at the hearing through its attorney, Ryan T. Willett. Provider appeared at the hearing through its attorney, William Maxwell.
13. There is no documentation to show which of three doctors for Provider assisted Claimant on any given day.
14. There is no documentation showing Provider kept qualitative or quantitative reports of progress on Claimant for any date of service.
15. There was no documentation to show Provider delivered one-on-one therapeutic exercises as billed under CPT Code 97110.
16. There was no documentation to show that the more intensive one-on-one therapeutic exercises, when provided, were medically necessary.
17. There was no persuasive evidence supporting the need for neuromuscular reeducation-CPT Code 97112, for this type of lumbar back injury, for any date of service.

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) and Tex. Gov=t Code Ann. (Gov=t Code) ch. 2003.
2. Adequate and timely notice of the hearing was provided in accordance with Gov=t Code ” 2001.051 and 2001.052.
3. Based on the above Findings of Fact and 28 TAC ‘148.21(h) (2004), the Carrier has the burden of proof in this case.
4. 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).
5. Based on Findings of Fact Nos. 13-16, Carrier demonstrated Provider’s documentation was inadequate to support the medical necessity of therapeutic services on the dates of services in question.
6. Based on Finding of Fact No. 17, Carrier demonstrated that no persuasive evidence exists to show the medical necessity of neuromuscular reeducation on any date of service.
7. Based on the above Findings of Fact and Conclusions of Law, Provider’s request for reimbursement for the services in dispute in this case should be denied.

ORDER

IT IS ORDERED THAT Provider’s request for reimbursement for the services in dispute in this case is denied.

Signed April 18, 2005.

BILL ZUKAUCKAS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS