DECISION AND ORDER
The issue in this case is whether the Petitioner Scientific Therapy and Advanced Treatment (STAT) should be reimbursed $306.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for and provided to the workers’ compensation claimant. The Administrative Law Judge (ALJ) concludes that STAT did not meet its burden of proving that G/C 1000 and MSM were medically necessary for the treatment of the claimant’s injury. Therefore, she denies reimbursement.
I. Jurisdiction, Notice, and Procedural History
The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to §413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
The Commission’s Medical Review Division (MRD) issued its findings and decision on May 3, 2001. STAT filed a timely request for hearing. Proper and timely notice of the hearing was issued July 2, 2001. The hearing was convened on March 14, 2002. Randy Burgett appeared for STAT. Shannon Butterworth appeared for Liberty Mutual Insurance Company. The hearing was adjourned the same day and the record was closed.
II. Legal Standards
The applicable legal standards are found in Tex. Lab. CodeAnn. §§408.021 and 401.011. Section 408.021 states:
(a) An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. The employee is specifically entitled to health care that:
- cures or relieves the effects naturally resulting from the compensable injury;
- promotes recovery; or
- enhances the ability of the employee to return to or retain employment.
Section 401.011(19) defines “health care” as including “all reasonable and necessary medical . . . services.”
STAT has the burden of proof in this matter. 28 TexAdmin. Code §148.21(h).
III. Discussion
The workers’ compensation claimant was diagnosed with “lumbar HNP, muscle spasms, pain sacroiliac, stiffness of joint, and non-allopathic lesions lumbar region.”[1]
Medical Necessity
In support of its claim that the treatment was medically necessary, STAT submitted a letter dated October 4, 2000, written by Thimos Partales, D.C., the claimant’s treating doctor. In the letter, Dr. Partales states:
I have prescribed the following oral agents to [the claimant] for use as part of a complete treatment program in order to recover from injury. These agents are Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM). Although these agents have been marketed for some time now, it has come to my attention that some carriers refuse to accept the fact that these agents promote healing of joint tissues as well as reduced joint pain when used on a chronic basis. Use of these agents can reduce the overall effect of an injury and help one get back to a normal productive state. Several such products have been studied and are now with NDC registration. Beside the results from medical journals showing their effectiveness, in my own practice I have met with positive results as well. Therefore, I believe that for this patient, not only are these medications appropriate, but they are medically necessary as well.[2]
Dr. Partales’s letter is identical to that written by the doctor in Scientific Therapy and Advanced Treatmentv. Texas Workers’ Compensation Commission and Northside Independent School District, SOAH Docket No. 453-01-1958.M5 (Sept. 19, 2001), in Scientific Therapy and Advanced Treatment 2000 v. Liberty Mutual Fire Insurance Co., SOAH Docket No. 453-01-2901.M5 (February 28, 2002), and in Scientific Therapy and Advanced Treatment v. Texas Workers’ Compensation Commission and Texas Builders Insurance Company, SOAH Docket No. 453-01-3053.M5.
On May 17, 2001, Dr. Partales wrote another letter indicating that G/C 1000 and MSM “will promote healing of the joint tissues and reduce pain that is associated with this injury.”[3] While the letter is slightly more specific to this claimant’s injury than the October 2000 letter, it appears to be a form letter as well, as it quotes virtually verbatim a letter also written by the doctors in support of STAT’s claim of medical necessity in the Liberty Mutual and the Texas Builders cases referred to in the preceding paragraph.
STAT was obligated to show the efficacy of the G/C 1000 and the MSM for the purpose prescribed, and these rote, prefabricated, form letters are not persuasive. At the hearing, STAT argued that the treating doctor’s professional medical judgment should carry the day on questions of medical necessity of medications and supplements, but there appears to be very little medical judgment at work here. To the contrary, Dr. Partales’s letters carry the whiff of a mill, and when offered as evidence in support of STAT’s claim, do very little to enlighten or persuade.
Therefore, the ALJ concludes that STAT has not met its burden of proving that the G/C 1000 and the MSM were medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. CodeAnn. §§408.021.
IV. Findings of Fact
- The Petitioner Scientific Therapy and Advanced Treatment (STAT) provided $306.00 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to the workers’ compensation claimant from August 12, 2000, to October 12, 2000.
- The claimant’s treating doctor, Thimos Partales, D.C., prescribed the G/C 1000 and MSM to the claimant.
- STAT requested reimbursement from Liberty Mutual Fire Insurance Company (Liberty), which Liberty denied.
- STAT filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
- The Commission’s Medical Review Division (MRD) issued its decision, denying STAT’s request, on May 3, 2001.
- STAT filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
- Notice of the hearing was issued July 2, 2001.
- The hearing was convened March 14, 2002. STAT and Liberty appeared through their representatives. The staff of the Commission did not appear. The hearing adjourned the same day.
- The claimant suffered from lumbar pain, muscle spasms, joint stiffness and lumbar lesions.
- The mere prescribing of a substance by a medical doctor, without more, is insufficient evidence to require a finding that the substance is medically necessary.
- The evidence presented does not demonstrate the efficacy or the medical necessity of the prescribed G/C 1000 and MSM.
V. Conclusions of Law
- The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq.
- SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031(d) and Tex. Gov’t Code Ann. ch. 2003.
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
- STAT has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
- STAT has not met its burden of proving the G/C 1000 and the MSM were medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. Code Ann. §408.021.
- STAT’s request for reimbursement should be denied.
ORDER
IT IS, THEREFORE, ORDERED that Scientific Therapy and Advanced Treatment’s request for reimbursement for G/C 1000 and MSM provided to the workers’ compensation claimant from August 12, 2000, through October 12, 2000, is denied.
Signed March 20, 2002.
CATHLEEN PARSLEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS