DECISION AND ORDER

Petitioner Highpoint Pharmacy (Highpoint) seeks reimbursement of $581.04 from Lumbermens Underwriting Alliance (Carrier) for numerous medications provided to_______, an injured worker (Claimant). The Medical Review Division of the Texas Workers’ Compensation Commission (Commission) referred the matter to an Independent Review Organization (IRO) which denied reimbursement. Highpoint then appealed the IRO’s decision. After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that the prescribed medications were medically necessary and that Highpoint is entitled to reimbursement in the amount of $581.04.^[1]

I. Background Facts

Claimant suffered a compensable, work-related injury to her foot on________. As a result of her injury, one of Claimant’s toes was subsequently amputated. As part of Claimant’s follow-up treatment, Dr. Jacob Rosenstein prescribed pain and anti-depressant medications to her. Specifically, Dr. Rosenstein prescribed Topamax, Vanadom, Trazodone, and Propoxyphene/APAP. Highpoint filled the prescriptions on October 26, November 9, and December 10, 2001. Carrier reimbursed Highpoint for the Topamax and Trazodone provided on November 9, 2001, but declined to reimburse the other medications.

After Carrier denied reimbursement for some of the prescriptions, Highpoint requested medical dispute resolution. The Commission’s MRD referred the matter to the IRO, which determined that the prescriptions in issue were not medically appropriate for the Claimant’s diagnoses. Highpoint then appealed. On March 12, 2003, ALJ Craig R. Bennett convened a hearing on these issues. Highpoint appeared and was represented by Nicky Otts, via telephone.

Carrier did not appear and was not represented. The Commission’s staff did not appear nor participate. The hearing concluded and the record closed the same day.

II. Analysis

The sole issue in this case is whether the numerous prescription drugs provided to Claimant in October, November, and December 2001 were medically necessary to treat her work-related injury. Because the Carrier did not appear nor participate, the only evidence introduced in the record was offered by Highpoint. That evidence shows that Claimant’s physician, Dr. Rosenstein, determined that the prescriptions were medically necessary treatment for Claimant’s compensable injury. In particular, Dr. Rosenstein provided two initial one-page reports of medical necessity and a follow-up three-page report explaining the medical necessity of the prescriptions.^[2] Moreover, the record contains Dr. Rosenstein’s treatment notes, which document the reasons the prescriptions were given to Claimant. While the Carrier denied reimbursement on the basis of two codes, U (unnecessary treatment without peer review) and V (unnecessary treatment per peer review), the record contains neither any peer review reports nor any physician opinions indicating the prescriptions were not medically necessary. The record reflects that Carrier initially reimbursed Highpoint for the Trazodone and Topamax provided on November 9, 2001, so Carrier must have initially thought the medications were necessary.^[3] The totality of evidence in the record supports only the conclusion that Propoxyphene/APAP, Topamax, Vanadom, and Trazodone were appropriate and necessary medical treatment for Claimant’s work-related injury.

In conclusion, the ALJ finds that the preponderance of the evidence establishes that the prescribed medications were medically necessary for treatment of Claimant’s work-related injury. Therefore, Carrier is liable to reimburse Highpoint the sum of $581.04 for the Propoxyphene/APAP, Topamax, Vanadom, and Trazodone provided to Claimant on the dates of service of October 26, November 9, and December 10, 2001. In support of this conclusion, the ALJ makes the following findings of fact and conclusions of law.

III. Findings of Fact

1. On________, ________ (Claimant) suffered a compensable, work-related injury. At the time that she suffered her injury, Lumbermens Underwriting Alliance (Carrier) was the provider of workers’ compensation insurance covering Claimant.
2. As a result of her injury, Claimant had one of her toes amputated.
3. As follow-up care after her surgery, Claimant was seen by Jacob Rosenstein, M.D.
4. October 26, 2001, Dr. Rosenstein prescribed Topamax, Vanadom, and Propoxyphene/APAP for Claimant, and Highpoint Pharmacy (Highpoint) filled the prescriptions for Claimant.
5. Highpoint billed Carrier $300.31 for the Topamax, Vanadom, and Propoxyphene/APAP provided to Claimant on October 26, 2001.
6. On November 9, 2001, Highpoint filled additional prescriptions for Topamax, Vanadom, Trazodone, and Propoxyphene/APAP for Claimant, all of which were prescribed by Dr. Rosenstein.
7. Highpoint billed Carrier $384.25 for the Topamax, Vanadom, Trazodone, and Propoxyphene/APAP provided to Claimant on November 9, 2001.
8. On December 10, 2001, Highpoint filled an additional prescription for Trazodone for Claimant, pursuant to the prescription of Dr. Rosenstein.
9. Highpoint billed Carrier $69.20 for the Trazodone provided to Claimant on December 10, 2001.
10. Carrier reimbursed Highpoint for the Topamax and Trazodone provided on November 9, 2001, but otherwise declined to reimburse Highpoint for the other medications provided.
11. It was appropriate, and medically necessary, to treat Claimant’s work-related injury with the medications Topamax, Vanadom, Trazodone, and Propoxyphene/APAP on the dates in issue.
12. The maximum allowable reimbursement for the disputed medications provided by Highpoint to Claimant is $581.04.
13. Highpoint requested medical dispute resolution with the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission, and MRD referred the matter to an Independent Review Organization (IRO).
14. After conducting dispute resolution, the IRO issued a decision on November 18, 2002, denying reimbursement to Highpoint for the prescriptions.
15. MRD adopted the IRO decision and issued an order on December 10, 2002, denying reimbursement in accordance with the IRO determination.
16. On December 17, 2002, Highpoint appealed the IRO decision and requested a hearing before the State Office of Administrative Hearings.
17. Notice of the hearing in this case was mailed to the parties on January 21, 2003. The notice contained a statement of the time, place, and nature of the hearing; a statement of the legal authority and jurisdiction under which the hearing was to be held; a reference to the particular sections of the statutes and rules involved; and a short, plain statement of the matters asserted. In the notice, the Commission’s staff indicated that it would not participate in the hearing.
18. On March 12, 2003, ALJ Craig R. Bennett convened the hearing in this docket. Highpoint appeared and was represented by Nicky Otts, via telephone. Carrier did not appear and was not represented at the hearing. The Commission’s staff did not appear nor participate. The hearing concluded and the record closed the same day.

IV. Conclusions of Law

1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. §413.031.
2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to §413.031 of the Act and Tex. Gov’t Code Ann. ch. 2003.
3. Highpoint timely filed its request for a hearing pursuant to 28 Tex. Admin. Code § 148.3.
4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code § 2001.052 and 28 Tex. Admin. Code § 148.4.
5. Highpoint has the burden of proof in this matter by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code §148.21(h).
6. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
7. Highpoint established, by a preponderance of the evidence, that the dispensed drugs Topamax, Vanadom, Trazodone, and Propoxyphene/APAP were medically necessary for the treatment of Claimant’s work-related injury.
8. Highpoint’s request for reimbursement should be granted as to the prescriptions in issue.

ORDER

IT IS ORDERED that Lumbermens Underwriting Alliance reimburse Highpoint Pharmacy the sum of $581.04 plus interest for the medications Topamax, Vanadom, Trazodone, and Propoxyphene/APAP dispensed to Claimant on October 26, November 9, and December 10, 2001.

Signed this 13^th day of March 2003.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Highpoint also requests a refund of the amount it paid for the IRO fee. The ALJ agrees that Highpoint is entitled to reimbursement of the IRO fee as the prevailing party to this dispute. However, the Commission’s rules provide that such a refund is not ordered by the State Office of Administrative Hearings (SOAH) ALJ, but by the Commission after the SOAH decision is issued. 28 Tex. Admin. Code § 133.308(r)(10); also Decision and Order, SOAH Docket No. 453-02-3525.M5 (Oct. 15, 2002). Accordingly, in this decision, the ALJ is not ordering a refund of the IRO fee.↑
2. Ex. 1, pp. 1-3 and 7-8.↑
3. Ex. 2, p. 17 (although, on re-evaluation at Highpoint’s request, Carrier apparently determined that the medications should not have been reimbursed. See Ex. 2, pp. 14-15).↑