04-001149RX Richard W. Merritt, D.C. vs. Department Of Health Status: Closed DOAH Final Order on Tuesday, January 25, 2005.

Summary: The evidence demonstrated that inclusion of surface electromyography in the proposed rule was arbitrary and capricious, since surface electromyography did not meet statutory criteria for inclusion on the list.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

RICHARD W. MERRITT, D.C., )

)

Petitioner, )

)

vs. ) Case No. 04 - 1149RX

)

DEPARTMENT OF HEALTH, )

)

Respondent, )

)

and )

)

THE FLORIDA INSURANCE COUNCIL, )

INC.; THE PROPERTY CASUALTY )

INSURERS ASSOCIATION OF )

AMERICA; THE AMERICAN INS URANCE )

ASSOCIATION; THE NATIONAL )

ASSOCIATION OF MUTUAL INSURANCE )

)

)

)

)

FINAL ORDER

Pursuant to notice, a formal admi nistrative hearing was held

in this case before Diane Cleavinger, Administrative Law Judge of

the Division of Administrative Hearings, on July 19 and 20, 2004,

in Tallahassee, Florida.

APPEARANCES

For Petitioner: E. Gary Early, Esquire

Alber t T. Gimbel, Esquire

Messer, Caparello & Self, P.A.

215 South Monroe Street, Suite 701

Tallahassee, Florida 32301

For Respondent: Lucy Schneider, Esquire

Thomas D. Koch, Esquire

Department of Health

4052 Bald Cypress Way, Bin A02

Tallahassee, Florida 32399 - 1703

For Intervenors: Cynthia S. Tunnicliff, Esquire

Brian A. Newman, Esquire

Pennington Law Firm

215 South Monroe Street, Second Floor

Pos t Office Box 10095

Tallahassee, Florida 32302 - 2095

Fernando Roig, Esquire

Roig, Kasperovich & Tutan, P.A.

1255 South Military Trail, Suite 100

Deerfield Beach, Florida 33442

STATEMENT OF THE ISSUES

Th e issue in this case is whether Florida Administrative

Code Rule 64B - 3.004(2) constitutes an invalid exercise of

delegated legislative authority.

PRELIMINARY STATEMENT

On April 2, 2004, Petitioner filed a Petition to Determine

Invalidity of Existing Rule. The Petition alleged that Florida

Administrative Code Rule 64B - 4.003, which declared certain tests

to not be medically necessary for people who have been injured in

an automobile accident, was an invalid exercise of delegated

legislative authority, and t herefore, an invalid rule.

On April 29, 2004, a Petition to Intervene was filed by the

Florida Insurance Council, Inc., the Property Casualty Insurers

Association of America, the American Insurance Association, the

National Association of Mutual Insurance Companies, the Florida

Automobile Joint Underwriting Association, State Farm Mutual

Automobile Insurance Company, Allstate Insurance Company,

Government Employees Insurance Company, the Florida Farm Bureau

Insurance Companies, Liberty Mutual Insurance Gro up, First

Floridian Auto and Home Insurance Company, and United Services

Automobile Association, alleging that their interests would be

substantially affected if the rule were stricken, in that they

would incur significantly greater expenses. On May 5, 20 04, the

Petition to Intervene was granted.

On June 6, 2004, Petitioner filed a motion to amend his

Petition. The proposed amendment limited the scope of his rule

challenge to the portion of the rule involving surface

electromyography (SEMG). On June 9, 2004, an Order Granting the

Motion to Amend was entered.

At the hearing, Petitioner presented the testimony of two

witnesses and offered 19 exhibits into evidence. Respondent

presented the testimony of three witnesses and offered 10

exhibits into evidenc e, of which Exhibits 1, and 3 through 10

were accepted. Intervenors presented the testimony of one

witness and offered 4 exhibits into evidence.

After the hearing, Petitioner, Respondent and Intervenors

filed Proposed Final Orders on October 4, 2004.

FI NDINGS OF FACT

1. In 1971, Personal Injury Protection (PIP) coverage was

required to be included in automobile insurance policies and was

required to be obtained by anyone operating a motor vehicle in

Florida. In general, PIP coverage provides payment f or medically

necessary treatment, lost wages and funeral expenses incurred by

persons involved in motor vehicle accidents. The reasons PIP

insurance coverage was made mandatory were to provide for the

speedy payment of medical expenses, lost wages and bur ial

expenses that an individual might incur as a result of being

injured in a motor vehicle accident and to reduce the amount of

litigation involved in recovering such expenses. Responsibility

for such speedy payment rested with the various insurance

comp anies involved in writing motor vehicle insurance.

2. Until 1980, the PIP system operated in a reasonably

cost - efficient manner. However, fraud and paying for medically

unnecessary medical tests or treatment were problems under the

PIP system. In t he past, at the option of a given insurance

company, such unnecessary testing or treatment resulted in

payment, denial of the claim, and perhaps litigation for the

denied claim.

3. By the mid - 1980s, for a variety of reasons, the PIP

system became les s cost efficient. The average Florida PIP claim

rose by 33 percent and the amount of premium per insured vehicle

needed to cover PIP claims rose by 35 percent. Such increases

led to higher premiums for the driving public, as well as larger

numbers of mot orists not carrying PIP coverage, estimated to be

around 22 percent of Florida drivers. Indeed since 1999, State

Farm Insurance Company, one of the largest insurers of motor

vehicles, has experienced an average $100,000,000.00 loss per

year.

4. In 2 001, the Legislature enacted a fee schedule for

certain medical services and tests, including a fee for SEMG.

The legislature did not limit the number of times a particular

service or test could be used. The 2001 legislation did not

solve the problems of continued claims and payment for tests or

services that were not medically necessary or overutilized. The

2001 legislation also did not solve the problem of the cost

ineffectiveness of companies litigating the issue of whether a

particular test was medic ally necessary or overused.

5. Consequently, during the 2003 legislative session, the

Florida Legislature enacted Section 627.736(5)(b)6., Florida

Statutes, which provides:

The Department of Health, in consultation

with the appropriate professional l icensing

boards, shall adopt, by rule, a list of

diagnostic tests deemed not to be medically

necessary for use in the treatment of persons

sustaining bodily injury covered by personal

injury protection benefits under this

section. The initial list shall be adopted by

January 1, 2004, and shall be revised from

time to time as determined by the Department

of Health, in consultation with the

respective professional licensing boards.

Inclusion of a test on the list of invalid

diagnostic tests shall be based on lack of

demonstrated medical value and a level of

general acceptance by the relevant provider

community and shall not be dependent for

results entirely upon subjective patient

response. Notwithstanding its inclusion on a

fee schedule in this subsection, a n insurer

or insured is not required to pay any charges

or reimburse claims for any invalid

diagnostic test as determined by the

Department of Health.

6. The statute was intended to relieve an insurance company

of the burden of paying for or litigating the medical necessity

of diagnostic tests that the Department listed in a to - be -

developed rule. There was no evidence suggesting that the

Legislature intended the words used in the statute to have any

meaning other than their ordinary meanings.

7. I n order to implement the statute, the Department

commenced rulemaking pursuant to the legislative directive in

Section 727.736(5)(b)6. Florida Statutes. As a starting point,

the Department asked the insurance industry to provide a list of

diagnostic tests that the insurance industry believed should be

in the rule. The list contained four tests -- Spinal Ultrasound,

Nerve Conduction Velocity (NCV) Studies, Somatosensory Evoked

Potential, and Dermatomal Evoked Potential. SEMG was not

included on the insuranc e industry’s list.

8. SEMG is a method of measuring the electrical output of

muscles through the placement of electrical sensors on the skin.

In general, a muscle at rest has a lower amount of electrical

activity than a muscle that is being worked o r contracted.

Similarly, muscle spasms have more electrical activity associated

with them than a muscle at rest. On the other hand, muscle

contracture, which is the condition of a muscle at rest that has

been permanently shortened and generally hardened through some

process, has a different level of electrical activity associated

with it than with muscle spasms.

9. There are two types of SEMG, used for different

purposes. Neither type of SEMG relies on subjective patient

input. Static EMG uses a hand - held device with probes as an

assessment (or muscle scanning) procedure to take a quick measure

of muscle tension. Although in most cases hand palpation of a

muscle gives a practitioner all the necessary information needed

to diagnose a patient, SEMG can augment hand palpation when

palpation is not determinative and help differentiate contraction

from contracture. SEMG, also can assist in determining the need

for the more comprehensive application of dynamic SEMG and

generates a graphic, recorded reading of muscle tension.

10. Dynamic SEMG is used to document and verify injury, to

determine if the patient is injured, and, in concert with other

diagnostic procedures, establish the level or the extent of

injury. Once a treatment plan is developed and imple mented, SEMG

testing is used to monitor a patient's response to treatment.

Dynamic SEMG provides an objective tool to evaluate the function

of paraspinal muscles of injured persons, including those

involved in motor vehicle accidents.

11. On July 25, 200 3, the Department published a notice for

a workshop for proposed Rule 64B - 3.004 in volume 29, no. 30 of

the Florida Administrative Weekly. On August 29, 2003, the

Department re - noticed the workshop in Volume 9, no. 35 of the

Florida Administrative Weekly. The workshop was held on

September 9, 2003.

12. The draft rule presented at the workshop listed the

four tests submitted by the insurance industry. The draft rule

did not include SEMG. However, based on comments made during the

workshop, some o f which came from a chiropractic representative

of the Florida Chiropractic Association, SEMG was included in the

next iteration of the draft Rule.

13. The next public iteration of the rule appeared in a

Notice of Proposed Rule published on Friday, Novemb er 14, 2003,

in Volume 29, No. 46 of the Florida Administrative Weekly. SEMG

appeared for the first time in the November 14, 2003 notice. The

proposed rule was, according to the Notice, based “[u]pon review

of the testimony provided at the workshop, inpu t received from

the Boards, written opinions by members of the health care and

insurance communities, and literature in support thereof.” The

Notice also announced a public hearing for 9:00 a.m. on Tuesday,

November 18, 2003.

14. Additionally, the reco rd for submitting information

regarding the proposed rule was held open for 21 days after the

November 14, 2003, publication date to give interested persons an

opportunity to submit information. During the time the record

was held open, the Department rec eived some evidence and studies

indicating that SEMG was not useful, or at a minimum,

unnecessarily redundant in the diagnosis of the type of injuries

often incurred in an automobile accident. However, the

Department also received some evidence and studie s that SEMG was

useful in the treatment of such injuries, particularly when bio -

feedback is being employed in treatment.

15. Oddly, on December 2, 2003, prior to the official

closure of the record, the final rule was transmitted to the

Secretary of the De partment for signature and approval for filing

with the Secretary of State. In due course, the rule was filed

with the Secretary of State and became effective on January 7,

2004.

16. Rule 64B - 3.004, as adopted by the Department states, in

relevant part, as follows:

64B - 3.004 Diagnostic Testing.

For the purposes of Section 627.736(5)(b)6.,

F.S. (2003), the Department of Health, in

consultation with the appropriate licensing

boards, hereby adopts the following list of

diagnostic tests based on their demonst rated

medical value and level of general acceptance

by the provider community:

* * *

(2) Surface EMG is deemed not to be

medically necessary for use in the diagnosis

of persons sustaining bodily injury covered

by personal injury protection benefits.

* * *

Specific Authority 627.736(5) FS. Law

Implemented 627.736(5) FS. History - New 1 - 7 -

04.

The rule only applies to SEMG when used for diagnostic purposes.

The rule does not apply to SEMG when used in the treatment of

PIP - covered automobile accident vic tims.

17. Petitioner, Richard Merritt, is a Doctor of

Chiropractic, licensed in Florida, Texas, and Alabama. Prior to

the adoption of Rule 64B - 3.004, Dr. Merritt billed $130,000 to

$160,000 per year for SEMG tests.

18. Dr. Merritt has used SEM G in his practice since the

1980s. Thirty - five percent of Dr. Merritt’s patients have been

involved in motor - vehicle accidents. Curiously, Dr. Merritt

performs SEMG on all of those patients for which PIP insurance

generally pays. Again, curiously, only ten percent of his

remaining patients have SEMG that may or may not be covered by

other insurance. However, the evidence was not clear as to the

differences between patients sustaining injuries in motor - vehicle

accidents and other non - accident patients. Dr. Merritt suggested

that motor - vehicle accident patients generally have more

complicated or layered medical histories than patients who have

not been involved in motor - vehicle accidents. No evidence was

presented on this alleged difference which seems to be a very

dubious distinction between patients.

19. The Florida Insurance Council, Inc.; the Property

Casualty Insurers Association of America; The American Insurance

Association; The National Association of Mutual Insurance

Companies; The Florida A utomobile Joint Underwriting Association;

State Farm Mutual Automobile Insurance Company; Allstate

Insurance Company; Government Employees Insurance Company; The

Florida Farm Bureau Insurance Companies; Liberty Mutual Insurance

Group; First Floridian Auto and Home Insurance Company; and

United Service Automobile Association have standing to intervene

in this proceeding.

20. Florida Insurance Council, Property and Casualty

Insurance Association of America, and the American Insurance

Association, all ha ve a substantial number of members affected by

the rule. These associations exist, in part, to protect their

member's interests in legislative and regulatory matters

involving insurance. The subject matter of this rule is within

the associations' scope o f interest and activity and they are

often involved in these types of rule challenges.

21. Intervenor, Florida Automobile Joint Underwriters

Association (JUA), is the automobile residual market in Florida.

The JUA makes PIP available to high - risk cu stomers and operates

as a standard insurance company under its governing statutes and

rules.

22. All the individual companies that sought to intervene

in this proceeding pay claims under PIP provisions.

23. Both the JUA and the individual compa nies are directly

affected by the rule. The rule affects rates and premiums which

are calculated based in part on loss experience. Loss costs are

affected by the rule because the rule regulates what must be paid

under PIP coverage. Additionally, the rul e affects the profits

and losses of individual companies.

24. The issue in this case is limited to a consideration of

whether the inclusion of SEMG on the “list of diagnostic tests

deemed not to be medically necessary for use in the treatment of

perso ns sustaining bodily injury covered by personal injury

protection benefits” is an invalid exercise of delegated

legislative authority. Accordingly, the place to start is

with the language of the statute being implemented.

§ 627.736(5)(b)6., Fla. Stat.

25. As indicated earlier, there was no evidence that the

Legislature intended the words used in the statute to have any

meanings other than their ordinary meanings. Thus, by reading

the statute, it is clear that the tests to be included in any

proposed rule must be “diagnostic tests.”

26. It is undisputed that “diagnosis” and “treatment” in

the medical area are different procedures and refer to different

aspects of providing medical care to a patient. When used in a

medical context, the term “diagno sis” means the art of

distinguishing one disease from another or the determination of

the nature of or cause of disease or injury, whereas the term

“treatment” means the management and care of a patient for the

purpose of combating disease or disorder. Se e Dortland’s

Illustrated Medical Dictionary , 27th Ed. (1988) and Stedman’s

Medical Dictionary, 26th Ed. (1995) . In short, there is a

diagnosis phase of medical care wherein a practitioner uses

various tests, procedures and historical information to determ ine

the nature, i.e. what the patient’s condition is and/or how

severe the condition is, and the cause, i.e. automobile accident

or fall, of a given disease or condition. Distinct from the

diagnostic phase there is a treatment phase of medical care

wherei n a practitioner, through tests, therapies, procedures and

medicines manages or cares for a patient’s condition. However,

in their ordinary usage, the terms “diagnosis” and “treatment”

can overlap. In ordinary usage, the term “diagnosis” does not

differ significantly from the medical term and means the art or

act of identifying a disease from its signs and symptoms.

Webster’s New Collegiate Dictionary (1984). The term “treatment”

means “the act or manner or an instance of treating someone or

something: HANDLING, USAGE.” Id. The term “treat” means to

“deal with.” Id. In its ordinary sense, “treatment” has a

broader meaning than it does in its medical sense and can include

diagnosis. Thus, in this case, the tests referred to in the

statute are diagno stic tests used in handling or dealing with a

person who has been physically hurt in a motor vehicle accident.

Also, by giving the term “treatment” its ordinary meaning the

Department has the authority to differentiate between the

appropriateness of a dia gnostic test used in the medical

diagnostic phase and the same test used in the medical treatment

phase.

27. In this case, SEMG, especially static SEMG, is used as

a test in both the medical diagnosis and treatment phases in

dealing with persons inju red in a motor vehicle accident.

Therefore, it is a diagnostic test that may be considered under

the other criteria of the statute.

28. For a test to be included in the rule it must be

medically unnecessary, based on a lack of demonstrated medical

v alue and a lack of general acceptance by the relevant provider

community and not be dependant for results entirely from

subjective patient response. As can be seen, the statute does

not deal with the overuse of a given test, but only defines

medical neces sity by the three criteria listed above. In

reality, some types of test overuse may only be determined on a

case - by - case basis, since whether a generally or occasionally,

medically beneficial test is useful or redundant at a particular

time in treatment o r diagnosis depends greatly on the reasons the

test is being employed. Thus, if a test has a degree of medical

value, it cannot be on the list; if a test has a level of general

acceptance by the relevant provider community which includes the

Doctors of Ch iropractic, it cannot be on the list; and if a test

is not dependent for results entirely on subjective patient

response, it cannot be on the list.

29. The medical value of any test is not related in any way

to the manner in which payment for that proce dure is made. In

that regard, the medical validity of a procedure does not vary as

to whether the patient is covered by Workers' Compensation,

Medicare, private insurance, or PIP.

30. PIP patients typically have injuries to the connecting

soft tissues of their spine as well as injuries to organs and

broken bones. Muscles, ligaments, and tendons can be stretched

or injured, which can lead to a breakdown in spinal - joint motion

or a spinal - joint misalignment. Spinal - joint misalignment may

cause interfer ence in the patient's nervous system. Soft tissue

and misalignment injuries are routinely the subject of

chiropractic care. SEMG is effective in recording changes in the

electrical activity of muscles associated with spinal injuries

known as vertebral su bluxations. Vertebral subluxations are

commonly associated with automobile accidents, and are diagnosed

and treated by chiropractic physicians.

31. In spinal injuries, there is a depolarization that

occurs at the cellular level. Electrical activity is generated

at the cellular level and runs down the muscle fiber. SEMG

measures the surface manifestation of the amount of electrical

activity generated and the depolarizations in the area. The

purpose is to measure muscle tension. SEMG is objective and

quantitative. It eliminates subjective impressions or input and

provides an objective and unbiased assessment of the electrical

activity of the patient's paraspinal muscles. It allows a

medical professional to distinguish objectively between observed

mus cle tension that is electrically active, which is associated

with spasm, from observed muscle tension that is not electrically

active, which is associated with contracture. It is debatable

whether SEMG provides no more useful information to a

practitioner than information gleaned by hand palpation of the

injured area. The problem is that hand palpation can sometimes

be inconclusive, especially in regard to determining if a muscle

is hard from spasm or contracture. The question is one of over

or redundant use of a test. Again that question is not part of

the criteria for inclusion of a test in the rule. The criteria

only include whether a test can be used by the practitioner to

make a valid diagnosis or conclusion. In regard to SEMG,

published documenta ry evidence demonstrates that spasm and

contracture share a similar physical manifestation, i.e. the

muscle is hard to the touch, and may not be distinguished through

palpation and that, in the occasional instances where had

palpation is inconclusive, SEMG can differentiate the conditions,

and “provide[] an important element of diagnostic information.”

Specific to automobile - related injuries, when hand palpation is

inconclusive, SEMG has medical value to chiropractic physicians

in that it allows the treati ng chiropractic physician to

determine if a patient has an injury or does not have an injury,

to quantify the extent of the injury, to monitor the patient's

response to treatment, and to assess the point of maximum

clinical improvement or maximum therapeut ic benefit. While its

diagnostic usefulness may be limited to certain situations when

hand palpation is inconclusive, the evidence demonstrated that

SEMG had some utility in the diagnostic phase of medical care.

Therefore, SEMG should not be included in the proposed rule.

32. Dynamic SEMG is also utilized on motor vehicle accident

victims. Its primary use is to provide the level of

documentation for services rendered a person involved in a motor -

vehicle accident required to demonstrate injury, perma nency of

injury, the need for treatment, and the response to treatment

before payment will be made under a PIP plan.

33. Overall, SEMG has advanced as a clinical tool from its

earliest, more experimental uses in which no computer support was

available, through the time in which the best technology

available was the Commodore 64 (or earlier) computer, to today,

when advances in technology and understanding have resulted in

the elimination of problems of electrical interference, bandwidth

filtering and ele ctrode placement, and have resulted in a higher

threshold of sensitivity.

34. The evidence in this case demonstrates that SEMG has

medical value for use in the treatment of persons sustaining

bodily injury covered by personal injury protection benefits.

The Department admitted and the evidence showed that some surface

EMG techniques may be useful in the treatment of persons

sustaining bodily injury in motor vehicle accidents in

appropriate circumstances. Based on the admissions of the

Department, it is clear that SEMG has a degree of demonstrated

medical value. Therefore, its inclusion on the list of medically

unnecessary tests is arbitrary and capricious; has exceeded the

Department’s grant of rulemaking authority; and has enlarged,

modified, or contra vened the specific provisions of law

implemented.

35. The Department also admitted and the evidence showed

that SEMG is not dependent for results entirely upon subjective

patient response. Therefore, under the terms of the statute, the

inclusion of SEMG on the list of medically unnecessary tests has

exceeded the Department’s grant of rulemaking authority and has

enlarged, modified, or contravened the specific provisions of law

implemented.

36. The evidence also demonstrated that SEMG is generally

accepte d in the relevant provider community. In 1996, the two

primary organizations that represent chiropractic physicians in

Florida, the Florida Chiropractic Association and the Florida

Chiropractic Society, were asked to develop a set of guidelines

to apply t o the chiropractic profession. Their work resulted in

a report and the publication of the Chiropractic Practice

Guidelines and Parameters for the State of Florida (CPG). The

CPG was unanimously accepted and endorsed by the Florida Board of

Chiropractic o n August 22, 1996. The CPG was copyrighted and

published by the Florida Chiropractic Association, Inc. and the

Florida Chiropractic Society, Inc. in 1997.

37. The CPG is a set of rules or guidelines that a

practicing chiropractic physician can follow r egarding the

treatment of chiropractic problems. The CPG constitutes the

consensus agreement of the chiropractic profession on many of the

procedures that a chiropractor might provide.

38. The CPG references SEMG both in comparison with needle

EMG and as to its own merits. As a comparative matter, the CPG

provides that “needle techniques are appropriate for the

evaluation of specific muscles, while surface electrodes are

appropriate for kinesiological studies of the “global” function

of groups of muscles .” In terms of test - retest reliability and

longitudinal muscle studies, SEMG was found to be superior to

needle EMG. The CPG also states that SEMG provides an objective

and quantifiable measure of muscular activity in areas of

vertebral subluxation. Alt hough the section discussing SEMG

concludes with language indicating a degree of qualification, the

CMG rates SEMG as “established.” An “established” rating means

that SEMG is accepted as appropriate by the practicing

chiropractic community for the given indication in the specified

patient population. The rating of “established” was made with a

Consensus Level of 1, which is the highest level of consensus

available. In addition, the rating was supported by various

categories of evidence used to analyze a given test, including

expert opinion, clinical experience or effectiveness studies

(Evidence E), refereed literature or published monographs, legal

decisions and/or authority (Evidence L) and available controlled

studies (Evidence C). The rating of “est ablished” also requires

one or more controlled trials. Therefore, read as a whole, the

CMG demonstrates the medical value of SEMG as a clinical and

diagnostic tool for evaluating paraspinal muscle activity,

quantifying palpation findings, performing longi tudinal studies,

and detecting muscle spasm.

39. Dr. Jenkins’ testimony regarding the lack of

reliability of the CPG and attempt to disown the CPG as an

authoritative statement by the Board of Chiropractors cannot be

given weight since he was on neither t he Florida Committee for

Adoption of Guidelines nor the Board of Chiropractic when the CPG

was accepted and endorsed. Additionally, during his tenure on

the Board stretching back to 1997, the Board has not rescinded or

amended the CPG.

40. Finally, the evidence did not demonstrate that the CPG

was superceded by the 1999 Universe of Florida Patients with Neck

Pain or Injury Medical Practice Guidelines. These Universe

Guidelines appear to relate only to medial doctors and not to

Chiropractic Physicians. The Guidelines state they are not

applicable to Chiropractic Physicians licensed under Chapter 460,

Florida Statutes.

41. The fact that the CPG describes SEMG as “[a]ccepted as

appropriate by the practicing chiropractic community” provides a

strong dem onstration of the medical value of the test, and strong

evidence of the high level of general acceptance of the test by

the relevant provider community.

42. Additionally, the American Medical Association Current

Procedural Terminology (CPT) 2004 Manual is a proprietary system

of the AMA for reporting medical services and procedures. CPT

Codes are the uniform, established system for reporting medical

services for reimbursement under government and private insurance

programs. CPT coding is mandatory to d escribe the services a

physician renders when submitting that service for payment to an

automobile insurance carrier.

43. In order to be assigned a five - digit CPT Code, the

procedure must be “consistent with contemporary medical practice

and be . . . pe rformed by many practitioners in clinical practice

in multiple locations.

44. Code assignment is performed by a CPT Editorial Panel,

consisting of 17 physician members, and a larger CPT Advisory

Committee of medical and allied health professionals. Among the

objectives of the CPT Advisory Committee is to “provide

documentation to staff and the CPT Editorial Board regarding the

medical appropriateness of various medical and surgical

procedures. . . .” (emphasis supplied)

45. Among the considerations for C ode assignment are the

requirements “that the service/procedure is a distinct service

performed by many physicians/practitioners across the United

States,” and “that the clinical efficacy of the service/procedure

is well established and documented in peer review literature.”

46. Dynamic SEMG has been assigned a five - digit CPT Code

96002. Similarly, The review and interpretation of dynamic SEMG

has been assigned a five - digit CPT Code 96004.

47. The fact that SEMG has been found to meet the

requireme nts of the AMA for assignment of five - digit CPT Codes

provides evidence of the medical value of the test, and strong

evidence of the high level of general acceptance of the test by

the relevant provider community.

48. Finally, the rulemaking record for Rule 64B - 3.004

contains information regarding SEMG. The literature submitted as

part of the rulemaking record reveals, by a preponderance of

competent, substantial evidence, that SEMG does not lack

demonstrated medical value, and that it has a level of g eneral

acceptance by the relevant provider community.

49. The primary documents submitted in the course of

rulemaking included the 1993 Guidelines for Chiropractic Quality

Assurance and Practice Parameters (Mercy Conference), the

National Guideline Cleari nghouse summary of the 1998 Council on

Chiropractic Practice Guideline entitled Vertebral subluxation in

chiropractic practice , a pair of AAEM Literature Reviews,

entitled The Use of Surface EMG in the Diagnosis and Treatment of

Nerve and Muscle Disorders a nd Dynamic Electromyography in Gait

and Motion Analysis ; the American Academy of Neurology study on

Clinical utility of surface EMG ; a report from Connie Coleman;

two submissions from Dr. Jerome True, and a 2003 literature

review, Surface EMG in Chronic P araspinal Pain .

50. Neither the Mercy Conference Guidelines nor the AAEM

Surface EMG Literature Reviews contained any information or

analysis more recent than 1993. Those documents did not reflect

the current state of technology or understanding of SEMG, and

could not form the sole bases for a rule based on SEMG’s

demonstrated medical value and level of general acceptance in

2003.

51. The National Guideline Clearinghouse summary of the

1998 Council on Chiropractic Practice Guidelines, and the

American Academy of Neurology study on Clinical Utility of

Surface EMG both provide support of the medical value for SEMG.

As indicated, the 1998 Council on Chiropractic Practice

Guidelines, which was subject to external peer review, and which

even critics of SEMG recognize as being authoritative, determined

that SEMG earned a rating of “established” “for recording changes

in the electrical activity of muscles associated with vertebral

subluxations” based on expert opinion, literature support, and

controlled studie s. The American Academy of Neurology study drew

three conclusions, one of which was that Surface EMG “is an

acceptable tool for kinesiologic (movement) analysis of movement

disorders because it is a method for recording and quantifying

clinically importan t muscle - related activity with the least

interference on the clinical picture,” and confirmed its

usefulness for several maladies, some of which result from

automobile accidents.

52. A report from Connie Coleman concluded that SEMG should

not be in the rule, based on the American Academy of Neurology

study, the AAEM Surface EMG Technology Literature Review, and a

position paper authored by Aetna Insurance. Ms. Coleman’s report

cannot be given any weight since she cited only the negative

recommendations of the American Academy of Neurology study

regarding SEMG, but omitted the third, positive recommendation

from the study referenced above. Furthermore, as support for her

recommendation to include spinal ultrasound in the rule,

Ms. Coleman relied on the N ational Guidelines Clearinghouse

document referenced above, which she stated was:

a comprehensive database of evidence - based

clinical practice guidelines and related

documents produced by the Agency for

Healthcare Research and Quality (AHRQ), U.S.

Departm ent of Health and Human Services, in

partnership with the American Medical

Association (AMA) and the American

Association of Health Plans (AAHP).

However, Ms. Coleman failed to note that the same National

Guidelines Clearinghouse document gave SEMG a rati ng of

established “for recording changes in the electrical activity of

muscles associated with vertebral subluxations.”

53. Of the two reports submitted by Drue, only one

recommended that SEMG should have been on the list, with that

recommendation b ased on a single journal article. Drue’s

other submission mentioned SEMG, but made no specific

recommendation regarding the test. However, Drue’s second

submission did note that allegations of over utilization and

abuse have “nothing to do with d etermining whether a test is

medically valid.” Drue also relied on the Chiropractic

Practice Guidelines and Parameters for the State of Florida,

which recognize the medical validity of SEMG.

54. Finally, David Marcarian, the developer and

manufactur er of SEMG equipment, submitted several documents,

including a literature review of journal articles ranging in

dates from 1982 to 2002. The review discussed each of the

journal articles, and concluded that “SEMG is a useful diagnostic

tool in the evaluat ion of spine pain patients, and suggests that

it be done routinely in cases where there is a need for

disability and impairment determination.” The evidence did not

demonstrate that Mr. Marcarian’s materials should be given less

weight than older material containing dated information.

55. The evidence submitted in this proceeding demonstrates

a definite trend in both the understanding of the medical

validity of SEMG and its acceptance by the chiropractic and

medical community.

56. Each of the 21 journal articles comprising Petitioner’s

Exhibit 8, ranging in dates from 1988 to 2004, used SEMG as a

tool to provide an objective measurement of muscle activity.

Although many of the articles were focused on the muscular

conditions leading to such conditions as low back pain,

fibromyalgia, and whiplash disorders, rather than the clinical

efficacy of SEMG itself, the fact that SEMG was so widely used as

a measure of muscle activity is evidence of its medical value.

Additionally, several of the articles focused o n SEMG as a

diagnostic tool in and of itself.

57. Going back as far as 1988, researchers reported that

“clear and consistent surface paraspinal EMG patterns can be

discerned between differing groups of lower back pain patients

and non - pain controls if the methodological limitations inherent

in previous studies are corrected,” and concluded that “[t]he

findings of the present study clearly point to the utility of

differential diagnosis in lower back pain surface EMG studies,”

and that “[r]esults strongly in dicate that when careful attention

is given to both diagnosis and position, surface EMG recordings

can differentiate among the various types of lower back pain, as

well as between those with and without lower back pain.”

Electromyographic recordings of 5 types of low back pain subjects

and non - pain controls in different positions , Arena, et al .,

"Pain " , 37 (1989) pp. 63, 64.

58. Through the early 1990s, researchers began noting the

effect that technological advances were having on the medical

efficacy of Surface EMG. Researchers during that period were

recognizing that advances in surface electromyography (EMG) have

prompted a renewed interest in examining the fatigue properties

of back muscles. See Fatigue, recovery and low back pain in

varsity rowers , Roy, et al ., Medicine and Science in Sports and

Exercise , vol. 22, no. 4, p. 463. As a result of those advances,

those researchers concluded that “the EMG technique is able to

correctly identify persons with LBP from two very different

populations” [ Id. at p. 467] and that “the results of this study

have verified the usefulness of a surface EMG measurement

technique to identify changes in back muscles that are

characteristic of LBP in rowers . . . The technique may be useful

to athletic trainers and other health professionals for

evaluating the muscular component of LBP in their patients.” ( Id.

at 468). During that same period, researchers were beginning to

conclude that, though not without limitations, "[e]lectromyo -

graphic spectral analysis was shown ag ain to be a highly

sensitive and highly specific diagnostic test.” Comparison of

Spinal Mobility and Isometric Trunk Extensor Forces with

Electromyographic Spectral Analysis in Identifying Low Back Pain ,

Klein, et al. , Physical Therapy, vol. 71, no. 6, p. 41 (1991).

Other groups noted that contemporaneous research studies “have

also shown the reliability of dynamic EMG measurements of

paraspinal low back muscles,” and concluded that “[w]e believe

that [EMG] is an invaluable aid in detecting and objectifyi ng

disturbed function in paraspinal muscles in back pain patients

and in general disability. This agrees with recent research

which indicates that kinetic EMG patterns (in contrast to static

levels) may best show the complex biomechanical events in the

lu mbar region.” Electric Behavior of Low Back Muscles During

Lumbar Pelvic Rhythm in Low Back Pain Patients and Healthy

Controls , Sihvonen, et al. , Arch. Phys. Med. Rehabil., vol. 72,

pp. 1080, 1086 (1991).

59. By the mid to late 1990s, the continuing res earch,

though still recognizing that there were things left to learn,

was becoming more conclusive as to the value of SEMG. In 1997,

researchers funded by the Department of Veterans’ Affairs stated

that “[w]e predict that in the future the concept of surf ace EMG -

based imbalance or load sharing parameters may provide the

clinician with important person - specific information already in

the acute stage of the injury, to help prevent the development of

a chronic disability. Surface EMG provides us with a power ful,

noninvasive tool to investigate the status and function of

muscles.” Development of new protocols and analysis procedures

for the assessment of LBP by surface EMG techniques , Oddsson, et

al. , Journal of Rehabilitation Research and Development, vol. 3 4,

no. 4, p. 425 (1997). During that same year, researchers in

California studying muscular electrical signals, noted the

technological advances that were serving to make SEMG more

effective. In their study, they found that “[s]uccessful

myoelectric reco rding with surface electrodes during dynamic

exercise of the low back is relatively recent. This is largely

due to the recent development of small high - competence

preamplifiers located close to the muscle which reduces the

electronic artifact during dynam ic activity to allow analysis of

the myoelectric signal.” Relationships Between Myoelectric

Activity, Strength, and MRI of Lumbar Extensor Muscles in Back

Pain Patients and Normal Subjects , Mooney, et al ., Journal of

Spinal Disorders, vol. 10, no. 4, p. 3 54 (1997).

60. By the early 2000s, SEMG was becoming established as a

reliable and valuable tool in the assessment and diagnosis of

automobile related injury. In a peer - reviewed study regarding

whiplash - associated disorders (WAD), the authors concluded that:

Patients with whiplash associated disorder

Grade II can be distinguished from healthy

control subjects according to the presence of

cervical muscle dysfunction, as assessed by

surface electromyography of the upper

trapezius muscles. Particulary the decreased

ability to relax the trapezius muscles seems

to be a promising feature to identify

patients with whiplash associated disorder

Grade II. Assessment of the muscle

(dys)function by surface electromyography

offers a refinement of the whiplash

associ ated disorder classification and

provides an indication to a suitable

therapeutic approach.

Cervical Muscle Dysfunction in the chronic Whiplash Associated

Disorder Grade II (WAD II) , Nederhand, et al ., Spine, vol. 25

(15), p. 8 of 10 (2000). The authors noted that “the use of

palpation to assess either muscle point tenderness or muscle

spasm is questionable because manually tested musculoskeletal

signs have shown poor interexaminer reliability, and very little

is known about its diagnostic validity.” Id . The authors found

that “SEMG as a measure of the inability to relax the upper

trapezius muscles may be useful in diagnostic testing. In the

literature this feature was shown to be related to cervical pain

and muscle fatigue and therefore supports the cl inical importance

of this study’s findings.” Id . at p. 8 of 10. Also in 2000,

researchers, while still recognizing the lack of absolute

precision with all manner of electro - diagnostic testing

(including X - rays, MRIs, CT scans, myelograms), stated that

“ surface electromyography (SEMG) is a non - invasive method of

analysis of the degree of muscular activity and function.”

Chronic Low Back Pain Assessment Using Surface Electromyography ,

Ambroz et al., JOEM, vol. 42, no. 6, p. 661 (2000). In

recognition of t he advances in technology, the authors noted that

“[r]ecent technological advancement has overcome the previous

limitations of data acquisition and processing.” Id . at 661.

That study, while noting the need for accounting for physical

conditions includin g body fat, and recognizing the advantages of

further testing and study, made the following findings:

More recent investigations have found a

significant relationship between pain and

SEMG - measured muscle activity in the upper

and lower back and have sugg ested that SEMG

can be a valid tool for objectively assessing

LBP. Also, although Biederman questioned the

reliability of SEMG reading in biofeedback

research, two subsequent studies addressing

the validity of this technique reported good

reliability for the static and dynamic SEMG

activities in the assessment of CLBP.

By using a rigorous matching protocol

that included BMI [body mass index], our

study demonstrated a statistically

significant difference between CLBP patients

and pain free controls. Thus , the results of

this study support the previous

investigations suggesting that SEMG is a

useful diagnostic tool in the assessment of

CLBP. Furthermore, in this study the use of

one of the latest and more technologically

advanced semi devices available ha s

contributed to a more reliable collection and

processing of this data, giving more strength

to this analysis.

61. Finally, in 2004, the evidence regarding the medical

value of SEMG demonstrates that it has achieved a full level of

general acceptance. In a study released in June 2004, the

authors concluded that “[s]urface electromyography has been shown

to be useful in the evaluation of spine pain in much the same way

that EKGs have become indispensable for chest pain evaluation.

SEMG testing is easy to do, inexpensive, has no morbidity, and

provides important information for the pain practitioner.”

Objective Documentation of Spine Pain, Ambroz , et al ., Practical

Pain Management, May/June 2004, p. 36

62. Thus, it is clear that the evidence in this c ase

demonstrates that there was no “lack” of demonstrated medical

value to SEMG, but, that SEMG has a level of general acceptance

for use in the treatment of patients by the relevant provider

community. The real dispute in this case is how often SEMG is

u sed in the relevant provider community. Therefore, the

inclusion of SEMG in Florida Administrative Code Rule 64B - 3.004

exceeds the Department’s grant of rulemaking authority, enlarges,

modifies, or contravenes the specific provisions of Section

627.736(5) (b)6., Florida Statutes, and is arbitrary and

capricious.

CONCLUSIONS OF LAW

63. The Division of Administrative Hearings has

jurisdiction over the parties to and the subject matter of this

proceeding. § 120.54, Fla. Stat. (2003).

64. Petitioner has the burden of proving by a preponderance

of the evidence that the challenged rule is an invalid exercise

of delegated legislative authority. § 120.56(1)(e), Fla. Stat.

(2003).

65. Consideration of the validity of a rule must

necessarily commence with an ana lysis of Respondent's rulemaking

authority in accordance with the legislative mandate set forth in

Section 120.52(8), Florida Statutes, which states:

(8) "Invalid exercise of delegated

legislative authority" means action which

goes beyond the powers, func tions, and duties

delegated by the Legislature. A proposed or

existing rule is an invalid exercise of

delegated legislative authority if any one of

the following applies:

(a) The agency has materially failed to

follow the applicable rulemaking procedu res

or requirements set forth in this chapter;

(b) The agency has exceeded its grant

of rulemaking authority, citation to which is

required by s. 120.54(3)(a)1.;

(c) The rule enlarges, modifies, or

contravenes the specific provisions of law

impleme nted, citation to which is required by

s. 120.54(3)(a)1.;

(d) The rule is vague, fails to

establish adequate standards for agency

decisions, or vests unbridled discretion in

the agency;

(e) The rule is arbitrary or

capricious;

(f) The rule impo ses regulatory costs

on the regulated person, county, or city

which could be reduced by the adoption of

less costly alternatives that substantially

accomplish the statutory objectives.

A grant of rulemaking authority is necessary

but not sufficient to al low an agency to

adopt a rule; a specific law to be

implemented is also required. An agency may

adopt only rules that implement or interpret

the specific powers and duties granted by the

enabling statute. No agency shall have

authority to adopt a rule on ly because it is

reasonably related to the purpose of the

enabling legislation and is not arbitrary and

capricious or is within the agency's class of

powers and duties, nor shall an agency have

the authority to implement statutory

provisions setting forth general legislative

intent or policy. Statutory language

granting rulemaking authority or generally

describing the powers and functions of an

agency shall be construed to extend no

further than implementing or interpreting the

specific powers and duties c onferred by the

same statute.

66. The standard of review in this proceeding has been

established in Section 120.56(1)(e), Florida Statutes (2003),

which provides, in pertinent part, that “[h]earings held under

this section shall be de novo in nature, w hich effectively

superceded the earlier standard of review set forth in Florida

Board of Medicine v. Florida Academy of Cosmetic Surgery, Inc. ,

808 So. 2d 243 (Fla. 1st DCA 2002). In that case, the First

District Court of Appeal, construing the now - repeal ed “competent

substantial evidence” rule challenge basis, opined that the

standard of review was, essentially, an appellate standard of

review, meant “to limit the scope of review by ALJ’s in rule

challenge proceedings to whether legally sufficient evidenc e

exists supporting the agency’s proposal.” Florida Academy of

Cosmetic Surgery at 257.

67. The language of the 2003 amendment is clear on its face

that the Florida Academy of Cosmetic Surgery standard has been

superceded due both to the repeal of the statutory section upon

which the opinion was based, Section 120.52(8)(f), Florida

Statutes (2002), and to the amendment of Section 120.56(1)(e),

Florida Statutes, which now specifies the de novo standard. In

addition, legislative history of the bill provi des that:

The effect of these amendments, in

combination with the bill’s removal of the

“competent substantial evidence” language

from ss. 120.52(8)(f) and 120.57(1)(e)1.,

F.S., will arguably overturn the court’s

decision in Florida Academy of Cosmetic

Su rgery, Inc . . . . Under the bill, however,

it is made clear that an ALJ’s rule challenge

hearing is de novo . . . .

Senate Staff Analysis, CS/CS/SB 1584, Judiciary Committee,

April 15, 2003 at p. 10.

68. It is well established through a long - standing l ine of

judicial opinions that “[o]nly when a statute is of doubtful

meaning should matters extrinsic to the statute be considered in

construing the language employed by the legislature.” Capers v.

State , 678 So. 2d 330, 332 (Fla. 1996), citing Florida Sta te

Racing Commission v. McLaughlin , 102 So. 2d 574, 576 (Fla. 1958);

see also Closet Maid v. Sykes , 763 So. 2d 377, 381 (Fla. 1st DCA

2000) (holding that the phrase “major contributing cause” as

applied to injuries covered by Workers’ Compensation was amen able

to construction without resort to extrinsic aides); Rhodes v.

State , 704 So. 2d 1080, 1083 (Fla. 1st DCA 1998).

69. Consideration of the legislative history of an act as

an extrinsic aid to construction has been expressly found to be

improper in con struing an unambiguous statute. Coleman v.

Coleman , 629 So. 2d 103, 104 (Fla. 1994)(holding the term

“alimony obligation” to be unambiguous, thus allowing no

consideration of legislative history); Southwest Florida Water

Management District v. Save the Ma natee Club, Inc. , 773 So. 2d

594, 599 (Fla. 1st DCA 2000)(holding that terms used in the 1999

amendments to Section 120.52(8), Florida Statutes, were clear and

capable of construction using the dictionary, thus providing “no

reason to add our own view of t he legislative intent.”); Mayo

Clinic Jacksonville v. Department of Professional Regulation ,

Board of Medicine , 625 So. 2d 918, 919 (Fla. 1st DCA 1993)

(finding no ambiguity in a facility based physician licensure

statute, and thus no need to resort to le gislative history or

other rules of construction). Also, in a case on point to this

case, the Florida Supreme Court has held that the terms

“diagnosis” and “treatment” are not ambiguous, and should be

accorded their plain meaning, without resort to legisl ative

history. Silva v. Southwest Florida Blood Bank, Inc. , 601 So. 2d

1184, 1186 - 1187, 1188 (Fla. 1992). Furthermore, the restriction

on using legislative history as an aid to construction is so

strong that the Florida Supreme Court has held that:

Where , as here, the language of a statute is

clear and unambiguous the language should be

given effect without resort to extrinsic

guides to construction. As we have

repeatedly noted, "[e]ven where a court is

convinced that the legislature really meant

and int ended something not expressed in the

phraseology of the act, it will not deem

itself authorized to depart from the plain

meaning of the language which is free from

ambiguity." (citations omitted)

Lamont v. State , 610 So. 2d 435, 437 (Fla. 1992). Accord F lorida

Department of Children and Family Services v. McKim , 869 So. 2d

760 (Fla. 1st DCA 2004).

70. Extrinsic evidence that is improper as an aid in

construing an unambiguous statute also includes the

administrative construction of the statute by the impl ementing

agency. In a recent case from the Third District Court of Appeal

construing the application of a statute affecting medical

“clinics” to portable diagnostic testing equipment, the court

held that:

State Farm points out that the Department of

Healt h has interpreted the statute to require

registration by entities such as Diagnostic.

. . . That makes no difference here, because

the statutory language is clear on its face.

"[A] court need not defer to an agency's

construction if the language of the sta tute

is clear and therefore not subject to

construction." Doyle v. Department of

Business Regulation, 794 So.2d 686, 690 (Fla.

1st DCA 2001). "[W]here the administrative

ruling or policy is contrary to the plain and

unequivocal language being interpreted, the

ruling or policy is clearly erroneous."

Eager v. Florida Keys Aqueduct Authority, 580

So.2d 771, 772 (Fla. 3d DCA 1991).

State Farm argues that it would [sic] a good

idea as a matter of policy to require

companies like Diagnostic to register. Tha t

policy determination is for the Legislature,

not for us.

Diagnostic Services of South Florida v. State Farm Mutual

Automobile Insurance Co. , 877 So. 2d 1, 3 (Fla. 3d DCA 2004); see

also Mayo Clinic Jacksonville , supra at 919 (“[c]ourts may resort

to leg islative history, administrative construction of a statute,

and rules of statutory construction only to determine the

legislative intent of an ambiguous statute.”).

71. The testimony of a witness, even expert testimony, is

equally unavailing in the face of the plain meaning of a statute.

As stated by the First District:

Expert testimony as to the meaning of an

ordinance is not appropriate when the

disputed language consists of "ordinary words

susceptible to being given plain effect

consistent with their ordinary meaning."

T.J.R. Holding Co., Inc. v. Alachua County,

617 So.2d 798, 800 (Fla. 1st DCA 1993). . .

. While expert testimony may be relevant and

helpful to the court where a statute or

ordinance contains words of art or scientific

and technical te rms, even then such testimony

cannot dictate the court's construction of

the enactment. T.J.R. Holding Co., 617 So.2d

at 799 - 800.

Lindsey v. Bill Arflin Bonding Agency Inc. , 645 So. 2d 565 (Fla.

1st DCA 1994)

72. Section 627.736(5)(b)6., Florida Statute s, is not so

unclear or ambiguous as to require or justify the consideration

of extrinsic means of construction to decipher its meaning.

Thus, recognition by the Legislature that testing can be abused

does not affect whether evidence supports the medical value of

any specific test. As stated by Drue, over - utilization and

abuse have little or nothing to do with the medical validity of a

test.

73. Section 627.736(5)(b)6., Florida Statutes, is the only

statute that authorizes the Department to prom ulgate a rule, and

establishes the criteria upon which the rule must be based. It

limits the Department’s authority to the development of “a list

of diagnostic tests deemed not to be medically necessary for use

in the treatment of persons sustaining bodil y injury covered by

personal injury protection benefits.”

74. SEMG was included in the rule because it was “deemed

not to be medically necessary for use in the treatment of persons

sustaining bodily injury covered by personal injury protection

benefits.” There is no question that “diagnosis” and

“treatment,” mean different things. However, in common usage the

term "treatment" can include diagnosis.

75. Based on a review of the entire record, Petitioner has

shown, by a preponderance of the evidence, that SEMG has

demonstrated medical value. The findings reflected in the

Chiropractic Guidelines and Parameters for the State of Florida

and the CPT Codes, combined with the advances in technology and

understanding of the process reflected in the trend of the

literature, demonstrate that SEMG has achieved a level of medical

acceptance as a valuable diagnostic tool for injuries of the

spine and upper and lower back. Therefore, Florida

Administrative Code Rule 64B - 3.004(2) exceeds the Department’s

grant of rulem aking authority conferred by Section

627.736(5)(b)6., Florida Statutes, and enlarges, modifies, or

contravenes the specific provisions of Section 627.736(5)(b)6.,

Florida Statutes.

76. Additionally, based on a review of the entire record,

the Petitioner has demonstrated, by a preponderance of the

evidence, that SEMG has a level of general acceptance by the

relevant provider community. SEMG is regularly used by

chiropractic physicians who are a part of the relevant provider

community. The Florida Chirop ractic Association and the Florida

Chiropractic Society, the leading chiropractic professional

groups in Florida, agree that SEMG is generally accepted by the

practicing chiropractic community. The basis for the rating of

“established” in the CPG, has bee n accepted and endorsed by the

Florida Board of Chiropractic, the chiropractic physician

regulatory and licensing arm of the Department of Health. The

American Medical Association had determined that SEMG is a

distinct service performed by many physicians and practitioners

across the United States. In addition, the clinical efficacy of

SEMG has become established and documented as reflected in peer

reviewed literature. Therefore, by including SEMG in Florida

Administrative Code Rule 64B - 3.004(2) the Depa rtment has exceeded

its grant of rulemaking authority conferred by Section

627.736(5)(b)6., Florida Statutes, and has enlarged, modified, or

contravened the specific provisions of Section 627.736(5)(b)6.,

Florida Statutes. As such, Florida Administrative Code Rule 64B -

3.004(2) is an invalid exercise of delegated legislative

authority.

77. Finally, Petitioner has demonstrated, by a

preponderance of the evidence, that Surface EMG is not dependent

for results entirely upon subjective patient response. The

Department’s admission of that fact is conclusive. Therefore,

Florida Administrative Code Rule 64B - 3.004(2) exceeds the

Department’s grant of rulemaking authority conferred by Section

627.736(5)(b)6., Florida Statutes, and enlarges, modifies, or

contraven es the specific provisions of Section 627.736(5)(b)6.,

Florida Statutes. As such, Florida Administrative Code Rule 64B -

3.004(2) is an invalid exercise of delegated legislative

authority.

78. In State, Board of Trustees of the Internal Improvement

Trust Fund v. Day Cruise Association, Inc. , 794 So. 2d 696 (Fla.

1st DCA 2001), the court held that:

[A]dministrative agencies are creatures of

statute and have only such powers as the

statutes confer . . . . If reasonable doubt

exists as to the "lawful existen ce of a

particular power that is being exercised, the

further exercise of the power should be

arrested." ( supra at 700 - 701)

79. In Southwest Florida Water Management District v. Save

the Manatee Club, Inc. , 773 So. 2d 594, 599 (Fla. 1st DCA 2000),

the c ourt noted:

The ordinary meaning of the term "specific"

is "limiting or limited; specifying or

specified; precise, definite, [or] explicit."

See Webster's New World College Dictionary

1287 (3rd Ed. 1996). "Specific" is used as

an adjective in the 1999 ve rsion of section

120.52(8) to modify the phrase "powers and

duties."

It is clear that the authority to adopt an administrative rule

must be based on an explicit power or duty identified in the

enabling statute. Otherwise, the rule is not a valid exercise of

delegated legislative authority.

80. The Legislature has not granted to the Department the

specific power or duty that the rule seeks to implement. The

only statute which provides the specific power or duty for the

Department to promulgate Florida Ad ministrative Code Rule 64B -

3.004(2) is Section 627.735(5)(b)6., Florida Statutes. That

statute allows the Department to place a diagnostic test on the

list only if the test is not “medically necessary for use in the

treatment of persons sustaining bodily injury covered by personal

injury protection benefits.” The statute does not allow the

Department to place a diagnostic test on the list due to its

overuse in the treatment of persons sustaining bodily injury.

The Department’s authority is limited to tho se tests that meet

the criteria of a) lack of demonstrated medical value and b) a

level of general acceptance by the relevant provider community

and c) are not dependent for results entirely upon subjective

patient response. None of those criteria apply t o SEMG. Thus,

the rule constitutes an invalid exercise of delegated legislative

authority pursuant to Section 120.52(8)(b) and (c), Florida

Statutes.

81. While the Department has asserted that allowing tests

to be included on the list when they are used for the diagnosis

of injured persons would more fully comport with its view of the

purpose of the statute, the "necessity for, or the desirability

of, an administrative rule does not, of itself, bring into

existence authority to promulgate such rule." 42 45 Corporation

v. Division of Beverage , 371 So. 2d 1032, 1033 (Fla. 1st DCA

1978). Such a rationale does not validate an otherwise invalid

rule. Therefore, the inclusion of SEMG in Florida Administrative

Code Rule 64B - 3.004 exceeds the Department’s grant of rulemaking

authority, enlarges, modifies, or contravenes the specific

provisions of Section 627.736(5)(b)6., Florida Statutes, and is

arbitrary and capricious.

ORDER

Based on the foregoing Findings of Facts and Conclusions of

Law, it is

ORDERED that the Amended Petition to Determine Invalidity of

Existing Rule challenging Florida Administrative Code Rule

64B - 3.004(2) is granted, and the rule is declared invalid.

DONE AND ORDERED this 25th day of January, 2005, in

Tallahassee, Leon County, Florida.

S

DIANE CLEAVINGER

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675 SUNCOM 278 - 9675

Fax Filing (850) 921 - 6847

www.do ah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 25th day of January, 2005.

COPIES FURNISHED :

Lucy Schneider, Esquire

Department of Health

4052 Bald Cyrpress Way, Bin A02

Tallahassee, Florida 32399 - 1703

Cynt hia S. Tunnicliff, Esquire

Pennington, Moore, Wilkinson,

Bell & Dunbar, P.A.

215 South Monroe Street, Second Floor

Post Office Box 10095

Tallahassee, Florida 32302 - 2095

E. Gary Early, Esquire

Albert T. Gimbel, Esquire

Messer, Caparello & Self, P.A.

215 South Monroe Street, Suite 701

Tallahassee, Florida 32301

Fernando Roig, Esquire

Roig, Kasperovich & Tutan, P.A.

1255 South Military Trail, Suite 100

Deerfield Beach, Florida 33442

Scott Boyd, Executive Director

and General Counsel

Joint Administrat ive Procedures Committee

120 Holland Building

Tallahassee, Florida 32399 - 1300

Liz Cloud, Program Administrator

Bureau of Administrative Code

Department of State

R.A. Gray Building, Suite 101

Tallahassee, Florida 32399 - 0250

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is entitled

to judicial review pursuant to Section 120.68, Florida Statutes.

Review proceedings are governed by the Florida Rules of Appellate

Procedure. Such proceedings are commenced by filing the original

notice of appeal with the Clerk of the Division of Administrative

Hearings and a copy, accompanied by filing fees prescribed by

law, with the District Court of Appeal, First District, or with

the District Court of Appeal i n the Appellate District where the

party resides. The notice of appeal must be filed within 30 days

of rendition of the order to be reviewed.