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At a Glance:
Title:
453-01-2096-m5
Date:
January 18, 2002
Status:
Retrospective Medical Necessity

453-01-2096-m5

January 18, 2002

DECISION AND ORDER

I. SUMMARY

Texas Mutual Insurance Company (Carrier or Petitioner) disputes a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (Commission or MRD) recommending reimbursement of $460.40 to Los Ebanos Pharmacy (Pharmacy) for the prescription drug Axid dispensed to_______ (Claimant), an injured worker. Contending Axid was not medically necessary, Carrier challenges MRD’s decision.

The Administrative Law Judge (ALJ) convened a hearing on the matter on September 20, 2001, and the record closed the same day. After receiving proper notice, Pharmacy failed to appear at the hearing. The Commission also did not appear. The only evidence was presented by Carrier. Based on the evidence, the ALJ concludes that Pharmacy is not entitled to reimbursement from Carrier in the amount of $460.40.

II. EVIDENCE

The evidence in this case consists of the certified record (Ex. No. 1), the deposition of Mitchell Lestico, Pharm.D. (Ex. No. 2), the deposition of Nicholas Tsourmas, M.D. (Ex. No. 3), and the testimony of Rick Ball, R.N.

The principal issue in this case is whether the drug Axid, dispensed by Pharmacy with the drug Celebrex, was medically necessary to treat Claimant’s injury. Dr. Lestico testified that Axid is an H2 blocker generally used to suppress stomach acid production. Dr. Lestico pointed out that Axid used along with Celebrex has been shown to be effective in preventing ulcers in high risk patients, but has not been proven to be of any benefit to patients who are not considered high risk.

Dr. Tsourmas testified Celebrex is a nonsteroidal anti-inflammatory drug (NSAID) used to treat inflammatory disorders of the musculoskeletal system. Dr. Tsourmas asserted, although some doctors routinely prescribe acid inhibitors, such as Axid, with NSAIDs, that routine practice is not reasonable or necessary because NSAIDs are generally well tolerated, with little or no side effects. Dr. Tsourmas testified, because Claimant’s medical records indicated he did not fall into any of the high risk groups, there was absolutely no indication for prescribing Axid with Celebrex to treat Claimant’s injury. For this reason, Dr. Tsourmas contended prescribing Axid was unreasonable and medically unnecessary treatment for Claimant.

The only evidence indicating that prescribing the drug Axid was medically necessary is a letter from Claimant’s physician, Dr. Ruben Pechero, stating the following:

. . . Axid is used for patients who are on nonsteroidal anti-inflammatory drug therapy to prevent the complication of gastritis and peptic ulcer disease. Studies have shown that the use of these medications reduce the occurrence of gastritis and peptic ulcer disease on patients on frequent [NSAID] therapy. The use of this medication should be regarded as appropriate adjunctive therapy in the total care of this patient.

III. FINDINGS OF FACT

  1. ____________(Claimant) sustained a work-related injury to his neck on_____________
  2. Claimant’s injury is covered by Texas Mutual Insurance Company (Carrier) for worker’s compensation insurance.
  3. As directed by Dr. Ruben Pechero, Claimant’s treating physician, Los Ebanos Pharmacy (Pharmacy) dispensed 150 mg (30-day supply) of the prescription drug Axid to Claimant on the following dates: March 10, 1999, at a cost of $112.88; April 14, 1999, at a cost of $112.88; May 7, 1999, at a cost of $116.32; and June 3, 1999, at a cost of $118.32, for a total cost of $460.40.
  4. Carrier denied Pharmacy’s request for reimbursement of $460.40, stating that the use of Axid or similar medications are unreasonable or unnecessary as they are not efficacious for the intended use of preventing nonsteroidal anti-inflammatory side effects.
  5. Pharmacy requested dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) in a letter dated October 7, 1999.
  6. MRD issued its findings and decision on January 12, 2001, determining that Carrier should reimburse Pharmacy for $460.40, plus all accrued interest.
  7. On February 1, 2001, Carrier appealed the findings and decision of MRD.
  8. Administrative Law Judge Carol Wood convened a hearing on the disputed issues on September 20, 2001.
  9. Celebrex is a nonsteroidal anti-inflammatory drug (NSAID) used to treat inflammatory disorders of the musculoskeletal system.
  10. Axid is an H2 blocker used to suppress stomach acid production.
  11. Axid is effective in the prevention of gastritis and peptic ulcer disease due to NSAIDs, but only in those patients who are considered high risk.
  12. Claimant does not fall into any of the high risk groups.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to TEX. LABOR CODE (LABOR CODE) § 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 LABOR CODE § 413.031 and TEX. GOV’T CODE (GOV’T CODE) ch. 2003.
  3. The notice of hearing issued by the Commission conformed to the requirements of GOV’T CODE § 2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. Under LABOR CODE § 408.021(a), 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.
  5. Petitioner proved by a preponderance of the evidence that Axid was not reasonably or medically necessary to treat Claimant.
  6. Los Ebanos Pharmacy is not entitled to reimbursement from Carrier in the amount of $460.40.

ORDER

THEREFORE, IT IS ORDERED that Los Ebanos Pharmacy shall not recover from Texas Mutual Insurance Company the amount of $460.40.

Issued this 18th day of January, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CAROL WOOD
Administrative Law Judge

End of Document
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