Judges: ELLA JANE P. DAVIS
Agency: Department of Management Services
Latest Update: May 16, 1985
Summary: Is Petitioner entitled to reimbursement under the State of Florida Employees Group Health Self Insurance Plan for $300.00 she spent for chiropractic treatment between 11/16/83 and 01/23/84?Allow the $300 chiropractic bills as medically necessary less the $6.44 supply charge.
84-3690STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DARA HOULISTON, )
)
Petitioner, )
)
vs. ) CASE NO. 84-3690
) DEPARTMENT OF ADMINISTRATION, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, this cause was heard by Ella Jane P. Davis, the assigned Hearing Officer of the Division of Administrative Hearings on March 21, 1985 in Tallahassee, Florida.
Thee parties were represented by:
For the Petitioner: DARA HOULISTON, pro se
2308 Motley Court
Tallahassee, Florida 32308
For the Respondent: Daniel C. Brown, Esquire
General Counsel
Department of Administration
435 Carlton Building Tallahassee, Florida 32301
Petitioner presented the testimony of herself and Steven M. Willis, D. C. and had 7 exhibits including composites admitted in evidence; only Petitioner's Exhibit 7 was not admitted. Respondent offered no witnesses but had admitted one exhibit. At the close of Petitioner's case, Respondent moved to dismiss.
That motion to dismiss is ruled upon in the course of the instant Recommended Order. No transcript and no proposed orders were submitted.
ISSUE
Is Petitioner entitled to reimbursement under the State of Florida Employees Group Health Self Insurance Plan for $300.00 she spent for chiropractic treatment between 11/16/83 and 01/23/84?
FINDINGS OF FACT
Petitioner is and has been an employee of the State of Florida for a number of years. In February of 1974, she subscribed to the general group health insurance plan offered by the State of Florida Employees Group Health Self Insurance Plan under contract no. 264158282. Blue Cross of Florida Inc. and Blue Shield of Florida Inc. are the designated claims agent/administrator for the general plan and its options/addenda.
Petitioner was first treated by Dr. Steven M. Willis, D.C., in January, 1983. She did not initially present to Dr. Willis, a chiropractor, for trauma but for symptoms of chronic sciatica and leg pain. She was treated the remainder of that month for sciatica but did not subscribe to the state group health plan until February 1, 1983.
Although her application for chiropractic coverage was not offered or admitted in evidence, Petitioner testified that she answered all questions thereon and Respondent did not affirmatively raise any issues of lack of coverage due to effective date of coverage, or due to addendum changes, or due to concealment or due to fraud and on the basis of Petitioner's exhibits as a whole, I find that she acquired chiropractic coverage during a period of open enrollment and that from February 1, 1983 on, the plan took her as it found her and provided complete chiropractic coverage.
In dispute in this cause are a series of chiropractic treatments and charges incurred by the Petitioner with Dr. Willis. Claims for the following dates of treatment were made in the name of a health care provider, Robert G. Hildreth, D.C." Dr. Hildreth made the formal claims upon Petitioner's assignment to the Centerville Road Chiropractic Clinic in which both chiropractors are partners. There is no dispute that the following treatments were rendered by Dr. Willis and properly assigned for payment by Petitioner:
11/16/83 | - $20.00 | 12/21/03 - $6.44 |
11/22/83 | - $20.00 | 12/29/83 - $20.00 |
11/28/83 | - $20.00 | 01/03/84 - $20.00 |
12/05/83 | - $20.00 | 01/06/84 - $20.00 |
12/09/83 | - $20.00 | 01/13/84 - $20.00 |
12/14/83 | - $20.00 | 01/17/84 - $20.00 |
12/19/83 | - $20.00 | 01/19/84 - $20.00 |
12/21/83 | - $20.00 | 01/23/84 - $20.00 |
Claims for some or all of these treatments/amounts were submitted by the chiropractors a number of times and rejected by Blue Cross/Blue Shield as the state administrator a number of times.
Petitioner conceded at hearing that the 12/21/83 charge in the amount of $6.44 was properly rejected for lack of coverage of supplies costs.
The first rejection of some of the other charges was for failure of the doctors' bookkeeper to include the correct diagnosis and procedure codes on the claims forms. This was corrected and resubmitted and thereafter all of the charges for treatment were rejected (either together or piecemeal) for payment upon grounds that 26 visits had already been paid for and that after the maximum number of 26 visits has been paid the state plan pays for no more chiropractic visits.
Blue Cross/Blue Shield resumed paying for chiropractic treatment for the chronic back and leg problems on 1/27/84. In light of Blue Cross/Blue Shield's earlier response, Petitioner and Dr. Willis concluded that this must be because a new year was beginning and a new 26 visits would be paid annually. However, Respondent stipulated at hearing, that although private Blue Cross/Blue Shield insurance plans may have such a maximum, the state plan has no such 26 visits annual maximum.
Petitioner and Dr. Willis questioned Blue Cross/Blue Shield about its
26 visit annual maximum reason for rejection, so Blue Cross/Blue Shield sent a "review sheet" asking Dr. Willis to justify his diagnosis and treatment. His justification was supplied on the review sheet (R-1) dated February 27, 1984. After review, Blue Cross/Blue Shield advised Petitioner and Dr. Willis that payment for these treatments had been determined not to be "medically necessary" by its chiropractic board of review. Petitioner responded with a timely request for Section 120.57(1) hearing.
Petitioner eventually paid for the treatments in question out of her own pocket.
In support of her position that her treatments (all of which may be generically described as "spine adjustments") are "medically necessary, Petitioner offered the testimony of Dr. Willis, the treating chiropractor. In addition to relating facts, I find Dr. Willis by education, training, and experience is capable of giving expert opinions in the field of chiropractic medicine.
Dr. Willis testified that he first saw Petitioner on 1/12/83 for sciatic pain in both legs. After taking a complete history revealing previous orthopedic treatment locally with Dr. Haney and previous podiatric treatment locally with Dr. Merritt, treatment with another doctor in Orlando and with another podiatrist in Texas, Dr. Willis initially diagnosed acute lumbosacral neuralgia and treated Petitioner 3 times per week for 6 weeks. He opined that Petitioner's case was unusual in that Petitioner wanted to remain as athletically active as possible, including but not limited to running 10-50 miles per week and participating in a number of sports.
Dr. Willis subsequently revised his diagnosis to make it bilateral sacrilization at the L-5/S-1 vertebrae, anterior gravitational syndrome and hyperimbrication at the L4/L5 vertebrae. Put into laymen's terms, Petitioner's L-4 / L-5 vertebrae do not have full range of motion and this results in Petitioner's low back pain at that level. In Dr. Willis' opinion, due to a congenital abnormality, in Petitioner, her condition is not fully correctable.
On 4/5/83, Petitioner came to Dr. Willis with back pain which he diagnosed as the result of a trauma occurring as a result of weight lifting Petitioner had done on 4/4/83, and subsequently she suffered a trauma to the unstable back while windsurfing. On 10/28/83, Petitioner reported pain in the medial aspect of her left foot which Dr. Willis diagnosed as tendonitis. In January, 1984 he referred her to Dr. Merritt, a local podiatrist for a severe left shin/ankle/ metatarsal problem. These various diagnoses, treatments, and referrals, are important to the instant issue involving spine adjustment treatments between 11/16/83 and 01/23/84 for chronic back pain at L-4 through S-
1 because they serve to illustrate diagnosis and treatment differences between trauma situations and continuing treatment for exacerbations of the chronic back and foot/leg problems for which cost of treatment reimbursement is sought. "Apparently, however, there was no problem with payment of any fees charged until 11/16/83 (the twenty-seventh visit in 1983), and clearly payments resumed as soon as the calendar rolled over to 1984.
Dr. Willis further diagnosed concluded that there is pedal instability of Petitioner's foot resulting in ankle and shin problems and that these problems in turn create an imbalance; the imbalance in turn causes great wear and tear in the lumbar (low back) region. The low back is again exacerbated by increased periods of activity. During these periods of exacerbation he treats
Petitioner's chronic back pain with spine adjustments. There may be long periods between exacerbations when treatments are not necessary. It is for the periods of exacerbation that the treatments in question were administered and for which Petitioner seeks reimbursement.
Although Dr. Willis conceded on cross-examination that frequency of treatment in a case like Petitioner's is a matter of chiropractic judgment and also that opinions among health care providers and especially chiropractors may differ as to whether the treatments he has provided to Petitioner are medically necessary or not, he states emphatically that in his professional opinion they are medically necessary.
Upon consideration of all the testimony and evidence, I find the treatments between 11/16/83 and 01/23/84 to be remedial as opposed to merely palliative in nature due to the considerable instability of both the back and foot which continued to be exacerbated by Petitioner's particular lifestyle. Both Petitioner and her doctor testified that chiropractic treatment sessions in her case have always included preventive counselling as well as therapeutic treatment. The goal of such counselling is to substitute non-exacerbating or less-exacerbating recreational activities for those Petitioner would otherwise pursue (i.e. weight training and swimming in place of running and wind surfing).
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this cause.
Respondent moved to dismiss upon grounds that the treatments in question had been found "not medically necessary" in the opinion of the administrator (Blue Cross/Blue Shield) and citing the definition of "medically necessary" found on page 38 of the State of Florida Employees Group Health Self Insurance Booklet. Unlike some other definitions under the state insurance program/plan this definition does not appear in Section 22K-1, Part II et seq. F.A.C:
"Medically Necessary" means in the opinion of the Administrator the service received is required to identify or treat
the illness or injury which a Physician has diagnosed or reasonably suspects. The service must (1) be consistent with the diagnosis and treatment of the patient's condition, (2) be in accordance with standards of good medical practice, and (3) be required for reasons other than convenience of the patient and his/her Physician. The fact that a service is prescribed by a Physician does not necessarily mean that such service is Medically Necessary.
Dr. Willis qualifies as a "physician' as defined on page 39 of the same booklet, and on the last page of the Addendum to Employees Group Health Self Insurance Booklet (P-4), which definition also does not appear in Section 22K-(1), Part II, et seq. F.A.C:
"Physician" shall mean the following:
. . . 2. a licensed chiropractor acting within the scope of his/her license, provided the insured receiving his/her services is covered under the chiropractic coverage option of the plan and the proper premium has been paid; . . .
Dr. Willis's testimony is the only direct, credible expert testimony before the undersigned. In the instant Section 120.57(1) proceeding the undersigned sits as the head of the executive agency to try the issues de novo. Simply because Petitioner prefers a vigorous lifestyle is not grounds to conclude that the reasons for treatment are merely for her convenience. Upon the foregoing findings of fact, I have concluded that Petitioner has met the burden of proof necessary to establish that the 15 treatments in question were "medically necessary," and Respondent has in no wise refuted that evidence.
RECOMMENDATION
Upon the foregoing findings of fact and conclusions of law it is RECOMMENDED that the Department of Administration enter a Final Order finding Petitioner's treatments in question "medically necessary and ordering the plan administrator (Blue Cross/Blue Shield) to reimburse her $300.00 therefor (amount claimed less the admittedly "not covered" $6.44 supplies charge on 12/21/83.).
DONE and ORDERED this 2nd day of May, 1985, in Tallahassee, Florida.
ELLA JANE P. DAVIS
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32301
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 2nd day of May, 1985.
COPIES FURNISHED:
Dara Houliston 2308 Notley Court
Tallahassee, Florida 32308
Daniel C. Brown, Esquire General Counsel
Department of Administration
435 Carlton Building Tallahassee, Florida 32301
Gilda Lambert, Secretary Department of Administration
435 Carlton Building Tallahassee, Florida 32301
Docket for Case No: 84-003690
Orders for Case No: 84-003690
| Issue Date |
Document |
Summary |
|
May 15, 1985 |
Agency Final Order
|
|
|
May 02, 1985 |
Recommended Order
|
Allow the $300 chiropractic bills as medically necessary less the $6.44 supply charge.
|
