Bond Medical Services v. Bureau of WC Fee Review Hearing Office (Travelers Casualty Ins. Co. of America)

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IN THE COMMONWEALTH COURT OF PENNSYLVANIA Bond Medical Services, : Petitioner : : v. : No. 233 C.D. 2019 : Submitted: October 11, 2019 Bureau of Workers’ Compensation : Fee Review Hearing Office (Travelers : Casualty Insurance Company of : America), : Respondent : BEFORE: HONORABLE MARY HANNAH LEAVITT, President Judge HONORABLE ANNE E. COVEY, Judge HONORABLE CHRISTINE FIZZANO CANNON, Judge OPINION NOT REPORTED MEMORANDUM OPINION BY PRESIDENT JUDGE LEAVITT FILED: July 31, 2020 Bond Medical Services (Provider) petitions for review of an adjudication of the Bureau of Workers’ Compensation (Bureau), Fee Review Hearing Office (Hearing Office) that dismissed Provider’s request for a hearing to contest a fee review determination made by the Bureau’s Medical Fee Review Section. The Hearing Office held that it lacked jurisdiction over Provider’s request for a hearing. For the reasons set forth below, we vacate the Hearing Office’s decision. On June 14, 2018, Derek Ramirez (Claimant) sustained a work-related injury while working for Cedar Farms Company, Inc. (Employer).1 In July 2018, 1 Claimant’s injury was described as: non-displaced Lisfranc fractures of the plantar and dorsal aspect of the first metatarsal base at the tarsometatarsal joint with dorsal subluxation of the first tarsometatarsal joint of the left foot; lumbar sprain and strain with L4-5 and L5 S- Michael Gonzon, D.C., prescribed durable medical equipment and supplies, including neuromuscular electrical stimulation (NMES) supplies, electrodes, lead wires, transcutaneous electrical nerve stimulation (TENS) supplies, a ventilator and biofreeze pain relieving gel to treat Claimant’s work injury. Provider dispensed the prescribed items to Claimant and billed Employer in the amount of $3,255.2 Employer denied payment on some supplies but agreed to pay $155.77. Relevant to this appeal, Employer denied payment for the NMES supplies and ventilator for the stated reasons that “the charge exceed[ed] the fee schedule/ UCR [usual and customary rates] allowance for this region” and that “the billed service require[d] the use of a modifier code.” Reproduced Record at 7a (R.R.__).3 Provider timely filed a fee review with the Bureau’s Medical Fee Review Section. On September 6, 2018, the Medical Fee Review Section determined that Employer did not owe Provider anything for two reasons. First, the Fee Review Section observed that “[a] valid prescription or certificate of medical necessity for this service was not submitted by [Provider.]” R.R. 13a. Second, the Fee Review Section observed that the Chiropractic Practice Act4 does not include the 1 disc bulges; thoracic sprain and strain; left shoulder sprain and strain; left knee sprain and strain; left ankle sprain and strain with bone marrow edema. Reproduced Record at 39a (R.R.__). 2 Employer was insured by Travelers Casualty Insurance Company of America (Insurer) for its workers’ compensation liability. 3 Employer denied payment of the electrodes for the stated reason that the Centers for Medicare and Medicaid Services (CMS) guidelines require electrodes to be billed under a separate code. Employer made partial payment on the lead wires, TENS supplies and miscellaneous durable medical equipment. It explained that per CMS guidelines, 1 additional lead wire is …

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