Carrier must reimburse chiropractor for needle procedure

In a medical fee dispute in Texas, the workers' compensation commission or other deciding forum will defer to an agency's interpretation of its own rules unless that interpretation is plainly erroneous or inconsistent with the text of the rule or underlying law.

Case name: Texas Mutual Insurance Co. v. Stelzer, No. 03-06-00675-CV (Tex. Ct. App. 01/13/10).

Ruling: The Texas Court of Appeals upheld the finding that the Texas Workers' Compensation Commission did not have to perform an independent analysis but could defer to the Texas Board of Chiropractic Examiners to determine whether a procedure was within the scope of chiropractic practice. The court affirmed the order requiring the carrier to reimburse the chiropractor for the procedure.

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What it means: In a medical fee dispute in Texas, the workers' compensation commission or other deciding forum will defer to an agency's interpretation of its own rules unless that interpretation is plainly erroneous or inconsistent with the text of the rule or underlying law.

Summary: A chiropractor performed a needle electromyography (a procedure to verify healthy nerve function) and submitted a reimbursement claim to the carrier. The carrier denied the claim, alleging the procedure was outside the scope of authorized chiropractic practice. The commission ordered reimbursement, relying on a ruling by the Texas Board of Chiropractic Examiners that the procedure was within the scope of chiropractic practice.

The carrier asserted the commission's reliance on the ruling was incorrect. The chiropractor asserted that the Texas medical fee guidelines require the commission to defer to another agency's clear announcement on the scope of practice issue. The Court of Appeals agreed, noting that to require the commission to second-guess another agency's scope of practice rule where that rule is not patently invalid or illegal would lead to confusion among health care providers. The court determined the commission would be guided by the board's determination of whether a needle electromyography is within the scope of chiropractic practice when applying the medical fee guidelines. It affirmed the decision ordering the carrier to reimburse the chiropractor for the procedure.

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February 18, 2010

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