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At a Glance:
Title:
453-01-0909-m5
Date:
February 12, 2002
Status:
Retrospective Medical Necessity

453-01-0909-m5

February 12, 2002

DECISION AND ORDER

This case is a dispute over the decision by the Insurance Company of the State of Pennsylvania (Carrier) not to reimburse VONO the sum of $279.97 for medication provided to_____, an injured employee.[1]

The Administrative Law Judge (ALJ) finds that Carrier is liable to reimburse VONO for the medication provided. Specifically, the ALJ notes that Carrier denied reimbursement because (1) the physician prescribing the medication was not____’s treating physician and (2) the medication was not medically necessary treatment for____’s underlying compensable injury. On review of the evidence, the ALJ concludes that____.’s treating physician, Dr. David Nelson, referred ____ to Dr. David M. Hirsch, the physician prescribing the medication in issue. Under Tex. Lab. Code §408.021(c), all non-emergency health care must be provided by the employee’s treating doctor. However, under Tex. Lab. Code §408.022(e)(1) and 28 Tex. Admin. Code §§ 133.3 and 133.4, the treating doctor may refer an injured employee to another physician for additional treatment. Where a physician provides care pursuant to the treating doctor’s referral, the Carrier cannot refuse to reimburse the services simply because the referral physician is not the designated treating doctor.

Further, the ALJ concludes that Carrier has failed to meet its burden of proving that the medications in issue were not medically necessary for____.’s compensable injury. Specifically, the ALJ finds that Dr. Hirsch’s opinion that____.’s symptoms were the result of the compensable injury to be equally persuasive as Dr. Taylor’s opinion that they were not. Under the circumstances, therefore, the ALJ concludes that Carrier has not met its burden of proving that the medication was not medically necessary for____’s injury. As set forth below in the Findings of Fact and Conclusions of Law, VONO’s request for reimbursement is granted, and Carrier is to reimburse VONO the sum of $248.39.

I. Findings of Fact

  1. ____ suffered an injury on or about______. At all times relevant herein, the Insurance Company of the State of Pennsylvania (Carrier) was the workers’ compensation insurance carrier for _____.
  2. As part of her treatment,____. was seen by Dr. David Nelson as her treating physician. Dr. Nelson referred_____ to Dr. David M. Hirsch for additional treatment.
  3. As part of his treatment of_____., Dr. Hirsch prescribed the medications Relafen and Ambien for_____ on February 8, 2000, April 17, 2000, and May 16, 2000. VONO provided the medications to_____, pursuant to Dr. Hirsch’s prescription, and billed Carrier the sums of $98.55, $74.92, and $74.92 respectively for the three medications. These amounts are all within the Commission’s maximum allowable reimbursement amounts for the medications.
  4. Carrier denied reimbursement on the grounds that Dr. Hirsch was not the treating doctor and that the medications were not medically necessary treatment for_____’s compensable injury.
  5. VONO a filed a Request for Medical Dispute Resolution with the Commission, seeking reimbursement for the medications.
  6. On October 9, 2000, the Commission’s Medical Review Division (MRD) determined that VONO was entitled to reimbursement in the amount of $248.39.
  7. On October 16, 2000, Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  8. Notice of the hearing was initially sent on November 14, 2000.
  9. 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.
  10. The hearing was continued by written order and all parties received notice of the reset date.
  11. The hearing was held February 6, 2002, with Administrative Law Judge Craig R. Bennett presiding and representatives of the Carrier and VONO participating. The hearing was adjourned and the record closed the same day.

II. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. ch. 401 et seq.
  2. 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.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §
  4. Carrier has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Under the Act and the Commission’s rules,_____ is entitled to obtain treatment from a physician other than her treating physician, provided her treating physician refers her to the other physician. Tex. Lab. Code § 408.022(e)(1) and 28 Tex. Admin. Code §§133.3.
  6. Carrier has failed to show that the medications in issue were not medically necessary treatment for_____’s compensable injury.
  7. Carrier has not met its burden of proving VONO is not entitled to reimbursement for the disputed charges.
  8. VONO’s request for reimbursement in the amount of $248.39 should be granted.

ORDER

IT IS, THEREFORE, ORDERED that the request by VONO for reimbursement in the amount of $248.39 from the Insurance Company of the State of Pennsylvania (Carrier) for medications provided to ______ an injured employee, is GRANTED. Carrier is ordered to pay that sum to VONO pursuant to this order.

Signed February 12, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CRAIG R. BENNETT
Administrative Law Judge

  1. The amount in dispute in this proceeding is only $248.39. The amount billed for the medications in issue was $279.97, but the Commission’s Medical Review Division denied reimbursement for some disputed items, and VONO did not request a hearing on that determination.
End of Document
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