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Practice Area: Workers compensation
Outcome: Medical Provider Prevailed
Description: This was a case heard before the State Office of Administrative Hearings. The carrier appealed a medical dispute resolution finding that it was required to pay a medical provider for physical therapy. Dallas Multidisciplinary (DM) had provided physical therapy to an injured workers' low back following a work injury. The Texas workers' compensation insurance carrier denied payment arguing that the treatment was not for the compensable injury. The carrier had accepted a lumbar sprain/strain injury only. The claimant had a herniated disc and some degenerative changes in his lumbar spine. The Division of Workers' Compensation ruled that the carrier was only responsible for the sprain/strain diagnosis. Following surgery and injections, DM provided this therapy. The carrier argued that the therapy was for the herniated disc and degenerative conditions for which the claimant had surgery and injections. The provider argued that the therapy was for the low back generally, and the carrier had accepted a compensable injury to the low back, therefore the treatment was for the compensable injury. There was a question of whether the carrier waived its right to raise an extent of injury defense to reimbursement because that was not on the explanation of benefits. The judge ruled that because the EOB stated payment was not made due to a peer review, it was assumed that that meant extent of injury, as opposed to medical necessity. The ruling was that the carrier did not waive any dispute for denial of payment due to extent of injury. After reviewing the evidence, the judge determined that the treatment provided was to the low back, and the carrier had accepted an injury to the low back. The carrier had the burden of proof to show that the treatment was not related to the compensable injury. Because there was no evidence showing what treatment would be necessary for a sprain/strain as opposed to degenerative conditions, the carrier did not meet its burden of proof.