DECISION AND ORDER

I. DISCUSSION

Insurance Company of Pennsylvania (Petitioner or Carrier) requested a hearing before the State Office of Administrative Hearings (SOAH) following the decision of April 23, 2004, by the Texas Workers’ Compensation Commission (Commission) acting through Medical Review of Texas, an Independent Review Organization (IRO). The Commission’s Order found that the request for reimbursement filed by ___ (Respondent or Claimant) was reasonable and necessary. On May 12, 2004, Carrier filed a request for hearing, on June 17, 2004, the Commission sent the parties a notice of hearing.

This decision denies the relief requested by Carrier and finds that Respondent’s request for reimbursement is reasonable and necessary.

A hearing was convened on November 29, 2004. John Fundis appeared as counsel for Petitioner, and ___ appeared pro se by telephone with the assistance of Luz Loza, an ombudsman provided through the Commission. Ms. Loza appeared at the hearing. Zvi Kalisky, M.D., a physiatrist, testified by telephone on behalf of Petitioner.

There were no contested issues of notice or jurisdiction.The record closed upon adjournment of the hearing on November 29, 2004.

The issue in this hearing is whether the medications for which Claimant seeks reimbursement are medically necessary. Pursuant to the Texas Workers Compensation Act, an employee who has sustained a compensable injury is entitled to all health care reasonably required by the nature of the injury as and when needed. Under the Act, 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. As Petitioner, Carrier had the burden of proof to show that the medications for which reimbursement is sought were not medically necessary.

Claimant sustained a work-related injury to her neck, back, and shoulders on ___, prior to which she had no history of significant cervical or lumbar problems or neuropathic pain. On June 26, 1996, she was examined by a physician and diagnosed with cervical and thoracic strain. Subsequent to that diagnosis, she was also diagnosed with bilateral carpal and cubital tunnel

syndrome, multilevel lumbar and cervical disc disease, lumbar and cervical radiculopathy, lumbar and cervical disc disruption, depression, and anxiety. Claimant underwent anterior lumbar interbody fusion (ALIF) with implants, as well as bilateral carpal and cubital tunnel release, each of which were preauthorized by the Carrier as related to her original injury. Following her ALIF, Claimant continued to have significant bilateral upper extremity neuropathic pain and functional loss.

Dr. Kalisky, Carrier’s witness, reviewed Claimant’s medical records and testified that: (1) Claimant’s medical status is unrelated to her injury of 1996, (2) the mechanism of the injury does not correlate with the diagnosis and objective exam findings, (3) the injury did not exacerbate Claimant’s pre-existing medical conditions, (4) continuing treatment is not related, reasonable, or necessary as a result of the injury of 1996, (5) Claimant should be weaned from addictive drugs and placed on low key maintenance care, (6) most of Claimant’s medications can be discontinued, and (7) the effects of the injury of 1996 have not resolved because of severe iatrogenesis (unintended injury caused by medical intervention) introduced by the unsuccessful back surgery.

Claimant’s physician is Aaron Calodney, M.D., who provided non-testimonial documentary evidence in the form of five written reports (March 27, June 3, July 8, August 20, and September 11, 2003) on his patient’s history and condition. Dr. Calodney’s evidence was that: (1) Claimant’s present medical condition is directly related to her injury of 1996, (2) Claimant’s condition is not the result of pre-existing ordinary diseases of life, (3) Claimant’s care has been disrupted because Carrier has terminated reimbursement for her medications, (4) her medications have been helpful in improving her overall ability to function, (5) Claimant takes her medication properly and responsibly, and (6) Claimant is exhibiting symptoms or depression/anxiety that are the direct result of her injury of ___.

Although Dr. Kalisky’s testimony was compelling, Dr. Calodney’s treatment of the patient and knowledge of her pain levels and responses were more persuasive.

Between May 28, 2003, and July 22, 2004, Claimant paid $1,184.58 for prescriptions for Ambien, Hydrocodone, Carisoprodol, Buspirone, and Duragesic for the purpose of pain relief, sleep assistance, control of anxiety and associated symptoms. Carrier had paid for these medications for seven years, after which time Carrier denied benefits.

Petitioner failed to prove by a preponderance of the evidence that the medications prescribed were not reasonable or necessary for the treatment of Claimant’s condition.

II. FINDINGS OF FACT

1. ___ (Respondent or Claimant) sustained a work-related injury on ___.
2. Before Claimant’s injury, she had no history of significant cervical or lumbar problems or neuropathic pain.
3. On June 26, 1996, she was examined by a physician and diagnosed with cervical and thoracic strain.
4. Later, Claimant was also diagnosed with bilateral carpal and cubital tunnel syndrome, multilevel lumbar and cervical disc disease, lumbar and cervical radiculopathy, lumbar and
5. cervical disc disruption, depression, and anxiety.
6. Claimant underwent anterior lumbar interbody fusion (ALIF) with implants, as well as bilateral carpal and cubital tunnel release, each of which were preauthorized by the Carrier as related to her original injury.
7. Following her ALIF, Claimant continued to have significant bilateral upper extremity neuropathic pain and functional loss.
8. Claimant’s present medical condition is directly related to her injury of ___.
9. Claimant’s care has been disrupted because Carrier has terminated reimbursement for her medications.
10. Claimant’s medications has been helpful in improving her overall ability to function.
11. Claimant takes her medication properly and responsibly.
12. Claimant is exhibiting symptoms or depression/anxiety which are the direct result of her injury of 1996.
13. Between May 28, 2003, and July 22, 2004, Claimant paid $1,184.58 for prescriptions for Ambien, Hydrocodone, Carisoprodol, Buspirone, and Duragesic for the purpose of pain relief, sleep assistance, control of anxiety and associated symptoms.
14. Carrier had paid for these medications for seven years, after which time Carrier denied benefits.
15. In a decision dated April 23, 2004, the Texas Workers Compensation Commission’s Medical Review Division confirmed the decision of Medical Review of Texas, an independent review organization (IRO), that concluded that the prescription medications were medically necessary for the treatment of Claimant’s conditions.
16. Carrier had paid for these medications for seven years, after which time Carrier denied benefits.
17. The management of Claimant’s pain through medication was reasonable and necessary.
18. On May 12, 2004, Petitioner requested a hearing before the State Office of Administrative Hearings.
19. By letter dated June 17, 2004, the Texas Workers’ Compensation Commission (Commission) issued a notice of hearing.
20. A hearing was convened by the Administrative Law Judge on November 29, 2004, in the hearing rooms of SOAH.
21. John Fundis appeared as counsel for Petitioner, and ___ appeared pro se by telephone with the assistance of Luz Loza, an ombudsman provided through the Commission.
22. There were no contested issues of notice or jurisdiction.
23. The record closed upon adjournment of the hearing on November 29, 2004.

III. CONCLUSIONS OF LAW

1. The IRO decision is deemed a Decision and Order of the Texas Workers Compensation Commission.
2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in 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.
3. Petitioner timely requested a hearing in this matter pursuant to 28 Tex. Admin. Code (TAC) §§ 102.7 and 148.3.
4. Notice of the hearing was proper and complied with the requirements of Tex. Gov’t. Code Ann. ch. 2001.
5. Petitioner had the burden of proof in this matter, which was the preponderance of evidence standard. 28 TAC §§ 148.21(h) and (i).
6. An employee who has sustained 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. Tex. Lab. Code Ann. § 408.021(a).
7. The treatment of Claimant’s condition was medically necessary.

ORDER

THEREFOREIT IS ORDERED that Petitioner’s request for relief is GRANTED and that Carrier shall reimburse Petitioner the sum of $1,184.58, plus any applicable interest.

Signed January 5, 2005.

PAUL D. KEEPER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS