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At a Glance:
Title:
453-01-0281-m4
Date:
July 24, 2003
Status:
Medical Fees

453-01-0281-m4

July 24, 2003

DECISION AND ORDER

Petitioner, Harris County, sought reversal of the amended decision issued by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) that awarded an injured worker, (Claimant), $1,859.61 for her out-of-pocket payments for numerous prescription medications. The decision reverses the MRD based on Petitioner’s evidence proving lack of medical necessity presented at the hearing, which the Claimant failed to attend.

I. PROCEDURAL HISTORY

Originally, this case was remanded back to the MRD by agreement of all parties. This appeal concerns the amended decision by MRD issued on October 18, 2002.

Administrative Law Judge (ALJ) Deborah Ingraham convened the hearing on May 29, 2003. Petitioner was represented by Mark H. Sickles, attorney. The Claimant failed to appear.[1] The Commission did not participate in the hearing. The hearing was concluded and the record closed on the same date.

ALJ Bill Zukauckas reviewed the entire record and wrote the decision, as permitted under Tex. Gov’t Code Ann. art. 2001.062(c).

II. DISCUSSION

A. BackgroundFacts[2]

Claimant sustained a compensable injury on, as an employee of the Harris County Sheriff’s Office. An inmate struck her five or six times in her left temple, causing her to sustain a closed head injury. The Claimant did not lose consciousness.

Eventually, the Claimant came under the care of Dr. Ninan Mathew, a neurologist and headache specialist, after she complained of headaches. Dr. Mathew administered three MRI scans on Claimant in1992 and 1993 and found her brain stable with no evidence of a pathological lesion or other injury related to the compensable injury.

Claimant has been referred three times for required medical examinations (RMEs) by Dr. Martin Steiner, a board-certified neurologist. At the first neurological evaluation on July 28, 1993, Dr. Steiner found Claimant had a history of headaches beginning when she was 18 years old - 22 years before her compensable injury occurred. Additionally, Dr. Steiner found Claimant had a history of temporal lobe epilepsy that started in 1985, when Claimant was 34 years old. Dr. Steiner’s evaluation found no evidence of a neurological abnormality. He concluded that in all reasonable probability, any type of traumatic injury she received from the work incident would have resolved itself within six - eight weeks, and in rare cases, within a year. He gave her a 0% impairment rating and determined that she had reached maximum medical improvement. At the RME’s on January 2, 1998, and October 12, 1999, Dr. Steiner reached the same conclusion; i.e., that the Claimant’s symptoms were not related to her 1992 injury at the Sheriff’s Office.

Based largely on the above-described evidence, the ALJ in the Claimant’s previous appeal

denied her request for reimbursement for her out-of-pocket expenses totaling $4,395.04 for 110 separate prescriptions obtained within an 11 - month period for the treatment of migraine headaches, epileptic seizures, and arthritic pain. The ALJ found the medications were not reasonable and necessary for the treatment of her compensable injury.[3]

B. Testimonial Evidence

Petitioner called Dr. Steiner to testify at the hearing. His testimony reaffirmed the conclusions he reached in the referenced RMEs. Dr. Steiner explained that the Claimant’s complaints are subjective, and that there is no objective evidence of any permanent harm done by the 1992 injury. He explained that trauma does not cause migraine headaches, and, of course, Claimant’s migraine headaches started 22 years before she was injured on-the-job. He concluded that her current symptoms are not related to her injury. Therefore, he testified the Claimant’s prescriptions for the following drugs between February 11, 1998 and April 27, 1999, were not reasonable or necessary for treatment of Claimant’s 1992 injury: Carisoprodol, Depakote, Diclofenac, APAP with Codeine, Methylpred, Meduretic, Lodine, Propranolol, Cimetidine, Methylpred, Amiloride, and Etodolac.

C. Analysis and Conclusion

Nothing in the record supports a conclusion that the referenced drugs were reasonable and necessary to treat the Claimant’s compensable injury. Therefore, Petitioner’s appeal is granted, and payment for the medications is denied.

III. FINDINGS OF FACT

  1. (____________ (Claimant) received notice of the hearing in this matter.
  2. Luz Loza, Ombudsman, stated at the initial phase of the hearing that the Claimant had spoken to her the day before and planned to appear telephonically at the scheduled hearing. However, when the ALJ telephoned the Claimant and found that she did not answer, the hearing proceeded in the Claimant’s absence.
  3. 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.
  4. Claimant sustained a compensable injury on, when an inmate of the Harris County Jail struck her five or six times in her left temple, causing her to sustain a closed head injury. The Claimant did not lose consciousness.
  5. Three MRI scans on Claimant in 1992 and 1993 found her brain stable with no evidence of a pathological lesion or other injury related to the compensable injury.
  6. Claimant has been referred three times for required medical examinations (RME’s) by Dr. Martin Steiner, a board-certified neurologist. At the first RME in 1993:
    1. Dr. Steiner found Claimant had a history of headaches beginning when she was 18 years old - 22 years before her compensable injury occurred.
    2. Additionally, Dr. Steiner found Claimant had a history of temporal lobe epilepsy that started in 1985, when Claimant was 34 years old.
    3. Dr. Steiner found no evidence of a neurological abnormality.
    4. He gave her a 0% impairment rating and determined that she had reached maximum medical improvement.
  7. Dr. Steiner reached the same conclusions referenced in Finding 4 at the 1998 and 1999 RMEs.
  8. The Claimants headaches are not related to the injury referenced in Finding 2.
  9. Headaches related to trauma would have resolved within six - eight weeks, and in rare cases, within a year.
  10. The Claimant’s complaints are subjective, and there is no objective evidence of any permanent harm done by the injury.
  11. Based on the foregoing, the prescriptions for the following drugs obtained between February 11, 1998 and April 27, 1999, were not reasonable or necessary for treatment of Claimant’s injury: Carisoprodol, Depakote, Diclofenac, APAP with Codeine, Methylpred, Meduretic, Lodine, Propranolol, Cimetidine, Methylpred, Amiloride, and Etodolac.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. CodeAnn. §413.031.
  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 §413.031 of the Act and Tex. Gov’t Code ch. 2003.
  3. 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 injury, promotes recovery, or enhances the ability to return to or retain employment. Act §408.021.
  4. The prescribed medications purchased by the Claimant were not reasonable or necessary for treatment of her injury, and, therefore, are not compensable pursuant to§408.021 of the Act.

ORDER

IT IS THEREFORE, ORDERED that the decision rendered by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) awarding ________(Claimant) $1,859.61 for her out-of-pocket payments for prescription medications is reversed. Harris County is not required to pay for the medications.

Issued this 24th day of July, 2003.

Bill Zukauckas
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Luz Loza, Ombudsman, appeared at the initial phase of the hearing. She stated that the Claimant had spoken to her the day before and planned to appear telephonically. Once the ALJ telephoned the Claimant and determined that she was not available to testify, Ms. Loza excused herself from the proceeding.
  2. At Petitioner’s request, the ALJ took official notice of a prior decision involving the Claimant and the medical necessity of medications similar to those at issue in this case. See, H.C. v. Texas Workers’ Compensation Commission and J.G., Docket No. 453-01-2563.M5 (April 11, 2002).
  3. Id. at 3.
End of Document
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