DECISION AND ORDER

Continental Casualty Company (Petitioner) has appealed the decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordering payment to _____(Respondent and Claimant) for medical services provided in the amount of $209.12. In this decision, the Administrative Law Judge (ALJ) finds that Petitioner has shown that the medical services in question were not related to the compensable injury and therefore not medically necessary. The ALJ finds Petitioner owes nothing further to Respondent for the dates of service in question.

I. Discussion

It is uncontroverted that ________suffered a compensable injury in ________and an aggravating compensable injury on_______. The only medical services considered for review are for medications prescribed on May 19, 2000, and extending to August 30, 2000. During the SOAH hearing on July 5, 2001, the parties noted that the issue of compensability had not yet been decided. The ALJ announced that he would wait to make a decision until the issue of compensability was resolved by TWCC. In a status report dated October 2, 2002, Petitioner reported that TWCC had finally determined “the causes of _____complaints are either congenital or degenerative with no causal relationship shown between the laundry list of complaints and the compensable injury of_____________.” No party challenged that finding. Accordingly, the ALJ finds that because the complaints that caused the medical services to be rendered cannot be tied to the compensable injury, those services are not medically necessary.

II. Findings of Fact

1. _____. (Claimant and Respondent) sustained a compensable, work-related re-injury on______, at which time his employer’s workers’ compensation carrier was Continental Casualty Company (Petitioner).
2. ______. received medical services consisting of prescription medications considered for this review between May 19, 2000, and August 30, 2000.
3. A MRD decision rendered on November 22, 2000, ordered Petitioner to reimburse_____. for $209.12 of the medical services disputed in Finding No. 2.
4. Petitioner timely filed an appeal.
5. Petitioner was able to show that there was no causal relationship between the Petitioner’s laundry list of complaints leading to the medical services in question and the compensable injury.

A. An order issued after a TWCC benefits review conference held accordingly.

B. Respondent exhibited only mild stenosis at the L5-S1 region in his back immediately subsequent to the___________, compensable reinjury.

C. Any subsequent diagnosis showing more severe stenosis in the L5-S1 region of Respondent’s back was caused by something other than the compensable injuries and may likely have been caused by Respondent’s weight.

III. 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. Petitioner timely filed its notice of appeal, as specified in 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 ANN. §2001.052 and 28 Tex. Admin. Code § 148.4 and a hearing was held on July 5, 2001.
5. Carrier had the burden of proof on its appeal by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. §413.031 and 28 Tex. Admin. Code §148.21(h).
6. The amount ordered by the MRD to be reimbursed treatment between May 19, 2000, and

August 30, 2000, was not reasonable and necessary to treat the compensable injury. ______. is not entitled to reimbursement in the amount of $209.12 for this treatment. Tex. Lab. Code Ann. § 408.021.

ORDER

IT IS ORDERED THAT the appeal by Continental Casualty Company is GRANTED and that no reimbursement for the dates of service are due.

Issued THIS 5th DAY OF DECEMBER 2002

STATE OFFICE OF ADMINISTRATIVE HEARINGS

BILL ZUKAUCKAS
Administrative Law Judge