| FINAL AWARD ALLOWING COMPENSATION (Modifying Award and Decision of Administrative Law Judge) |
| Employee: | Carmelita Frost |
| Employer: | Coin Acceptors, Inc./Mountain View Fabricating |
| Insurer: | Self-Insured |
| This workers’ compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by § 287.480 RSMo. We have reviewed the evidence, read the parties’briefs, and considered the whole record. Pursuant to § 286.090 RSMo, we modify the award and decision of the administrative law judge. We adopt the findings, conclusions, decision, and award of the administrative law judge to the extent that they are not inconsistent with the findings, conclusions, decision, and modifications set forth below. |
| Discussion Past medical expenses |
| The parties asked the administrative law judge to resolve the issue whether employer is liable for employee’s past medical expenses for treatment in connection with her right and left shoulder work injuries. The administrative law judge awarded employee a total of $46,164.17 in past medical expenses based on a conclusion that the disputed treatment was reasonably required to cure and relieve the effects of employee’s injuries. Employer appeals, arguing that certain of the awarded charges are not shown on the record to relate to treatment in connection with employee’s left or right shoulder.Employee, in her brief, fails to respond to employer’s argument that certain of the charges are not supported by corresponding treatment records. We have carefully reviewed the transcript, and we agree that certain of the charges awarded by the administrative law judge are not shown to correspond to treatment that was reasonably required to cure and relieve the effects of the work injury. Accordingly, we must modify the award of the administrative law judge as follows.The administrative law judge awarded $245.00 in charges from Schierling Chiropractic, LLC. The bills themselves suggest that these charges were for lumbar spine adjustments provided between October 3, 2012, and November 19, 2014, and the medical records from December 18, 2013, through March 6, 2015, do not clearly reflect any treatment for the right or the left shoulder.Transcript, pages 240, 203-09. On the other hand, employee did provide records and bills for two dates of service, January 6 and February 8, 2012, for myofascial release treatments for the right shoulder.Transcript, pages 210-15. The total of these latter charges is $114.00. Accordingly, we must modify the award of charges from Schierling Chiropractic from 245.00 to 114.00.The administrative law judge also awarded $5,378.29 in charges from Physical Therapy Specialists Clinic, Inc. The bills suggest 34 dates of service between May 4, 2012, and August 8, 2012.Transcript, pages 243-61. Employer argues that the medical records corresponding to these treatments are incomplete, as the record only contains specific notes for the following dates of service: May 4 and 29, June 28, July 2, and August 1, 2012. |
Injury No. 11-041025
Employee: Carmelita Frost
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Transcript, pages 140-72. We note, however, that the June 28, 2012, record references a total of 25 previous physical rehabilitation sessions, and the bills themselves plainly reveal that each date of service involved treatment for the shoulders. For example, the diagnostic codes and descriptions of service for July 2, 2012, (a date for which employee did provide a corresponding treatment record) and July 3, 2012, (a date for which employee did not) are identical. Given these circumstances, we deem the record sufficient to infer (and we so find) that these charges were incurred for treatment that was reasonably required to cure and relieve the effects of employee's work injury, despite the absence of notes specific to each physical therapy session.
We note also that the administrative law judge appears to have undervalued the cost of this treatment, in awarding to employee only the outstanding amount of the charges, and failing to include reimbursement for the payments employee or her insurer rendered to this provider. Specifically, our own calculations derived from the bills themselves suggest that this provider billed employee a total of $6,750.00 for these services, and that this amount was reduced to the outstanding balance of $5,378.29 as a result of a number of payments by employee and/or her insurer. Employee, however, has not filed an application for review challenging the administrative law judge's calculations, nor has she argued in her brief that we should award any additional amount. Accordingly, we will not disturb the administrative law judge's award with respect to Physical Therapy Specialists Clinic, Inc.
The administrative law judge also awarded $9,929.88 in charges from Hubbard Bone and Joint Clinic, LLC. Employer argues that this amount must be reduced because it includes $63.84 in charges for medical records. We disagree. Instead, a careful review of the bills reveals that, as with the charges from Physical Therapy Specialists Clinic, Inc., the administrative law judge has awarded the outstanding balance, and has not reimbursed employee for her out-of-pocket expenses, including the payments she made for medical records. Specifically, the bills reveal that employee made a payment of 31.92 for medical records furnished on August 22, 2012, and another payment of 31.92 for medical records furnished on September 26, 2012. Transcript, pages 271-72. These amounts are not included in the outstanding balance of $10,141.88 identified by Hubbard Bone and Joint Clinic, LLC, Transcript, page 269, which was reduced by the administrative law judge to $9,929.88 based on her finding that the April 4, 2012, treatment constituted self-directed treatment for which employer is not liable.
In fact, rather than overcharge employer for medical records, the administrative law judge appears to have once again undervalued the charges from this provider, because she did not account for the $76.12 payment employee rendered to Hubbard Bone and Joint Clinic, LLC, for the treatment date of August 8, 2012. However, as we have noted, employee does not challenge the administrative law judge's award in any respect; for this reason, we decline to modify the award with respect to these (apparent) out-of-pocket expenses.
The administrative law judge also awarded $1,518.00 in charges from Cox Regional Services. The bills themselves suggest that employee incurred $2,325.00 in charges with this provider for dates of service between December 7, 2011, and February 5, 2015.
Transcript, pages 273-95. The administrative law judge did not provide her calculations or otherwise explain how she reached the awarded amount of $\ 1,518.00. Nor has employee, in her brief, provided any itemization or other explanation identifying the charges she believes are compensable.
The notations within the bills are rather cryptic and ultimately offer no indication that these charges were incurred in connection with treatment for employee's left or right shoulder. Turning to the medical treatment records from Cox Regional Services, we find only one note, March 5, 2012, that both corresponds to a date of service listed in the bills and that pertains to treatment of employee's right shoulder. Transcript, page 217-18. Accordingly, we must modify the award of charges from Cox Regional Services from $\ 1,518.00 to $\ 261.00, the amount incurred for employee's right shoulder treatment with Dr. Laurie Clarkston on March 5, 2012.
The administrative law judge also awarded $\ 3,490.00 in charges from Ozark Medical Center. The bills themselves suggest that employee incurred $\ 7,178.48 in charges with this provider for dates of service between November 1, 2013, and March 14, 2014. Transcript, pages 296-308. As with the charges from Cox Regional Services, the administrative law judge did not provide her calculations or otherwise explain how she reached the awarded amount of $\ 3,490.00. Nor has employee, in her brief, provided any itemization or other explanation identifying the charges she believes are compensable.
The notations within the bills do not clearly suggest that any of these charges were incurred in connection with treatment for employee's left or right shoulder. Employee did not provide testimony to explain the charges from Ozark Medical Center, and after a thorough review of the transcript, we are unable to find any treatment records from this provider corresponding to the dates of service listed in the bills. We find that employee has failed to meet her burden of proof with respect to the claimed charges from Ozark Medical Center. Accordingly, we must modify the award on this point. We conclude that the charges shown in the bills from Ozark Medical Center were not incurred in connection with any treatment reasonably required to cure and relieve the effects of the work injury. Consequently, employee is not entitled to any amount in charges from Ozark Medical Center.
As a result of the foregoing modifications, we conclude that employee is entitled to, and employer is obligated to pay, a total of $\ 41,286.17 in past medical expenses, rather than the amount of $\ 46,164.17 identified by the administrative law judge.