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At a Glance:
Title:
453-01-2335-m5
Date:
December 10, 2001
Status:
Retrospective Medical Necessity

453-01-2335-m5

December 10, 2001

DECISION AND ORDER

Scientific Therapy and Advanced Treatment (Provider) appealed the findings of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD), which found it should not be reimbursed for a knit garment electrode glove in the amount of $495. This decision finds that the Provider should be reimbursed for the cost of the glove.

I. PROCEDURAL HISTORY AND NOTICE

The hearing convened before Janet R. Dewey, Administrative Law Judge (ALJ) with the State Office of Administrative Hearings (SOAH), on October 10, 2001 in the Stephen F. Austin Building, 1700 North Congress, Austin, Texas. Attorney Jane Lipsomb Stone appeared on behalf of the Texas Association of School Boards (Carrier). The Texas Workers’ Compensation Commission (Commission) did not appear at the hearing. Nicky Otts appeared on behalf of the Provider via telephone. The record closed the day of the hearing.

II. FACTUAL BACKGROUND

___________ (Claimant) sustained a compensable worker’s compensation injury on ______. As a result of her injury the Claimant suffers from reflex sympathetic dystrophy (RSD) in her left hand. Dr. Ben Wiseman, a pain management specialist, prescribed an electrode glove to be used in conjunction with a neuromuscular stimulator. Provider billed the Carrier $495 for the electrode glove. The Carrier denied the claim as unnecessary medical treatment.

III. LEGAL STANDARD

Workers’ compensation insurance covers all medically necessary health care, which includes all reasonable and necessary medical aid, examinations, treatments, diagnoses, evaluations and services. Texas Workers Compensation Act, Tex. Lab. Code Ann. § 401.011 (19)(A) (Vernon Supp. 2001). An employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the compensable injury, as and when needed. Tex. Lab. Code Ann. §408.021 (Vernon 1996). The employee is specifically entitled to health care that: (1) cures or relieves the effects naturally resulting from the injury; (2) promotes recovery; or (3) enhances the ability to return to or retain employment. Id.

IV. THE PARTIES’ POSITIONS

The Provider

Mr. Otts, a pharmacist and president of Scientific Therapy and Advanced Treatment testifying on behalf of the Provider, argued that the electrode glove used in combination with the neuromuscular stimulator has proven effective in treating the patient’s pain, muscle spasms and edema. According to Mr. Otts, use of the electrode glove prevents the need to use sticky gummed electrodes that could be painful for a person suffering from RSD. He argued the glove is cost-effective and reduces the Claimant’s need for medication. Mr. Otts submitted documentation demonstrating that other Carriers had reimbursed the Provider $495 for the glove.

Dr. Wiseman, a pain management specialist prescribed the electrode glove to treat Claimant’s RSD. Dr. Wiseman’s letters dated July 9, 1999 and May 21, 2001, reflect that use of the stimulator and glove have provided the Claimant pain relief and reduced her muscle spasms and swelling. Ex. 1 at 10 and Ex. 2 at 1. He explains that he glove, being moistened at specific trigger points, is more effective at reducing swelling than an oval electrode because it covers a larger area and efficiently increases circulation. Ex. 1 at 10. He stated in May 2001 that with continued use of the stimulator and glove the Claimant’s prognosis was good. Use of the glove, Dr. Wiseman hoped, would alleviate the need for pain medications as well as supervised clinical therapies, thereby providing cost effective care to the Claimant.

The Carrier

The Carrier argues that the electrode glove, while possibly medically necessary in certain circumstances, is not appropriate for a person suffering from RSD. The Carrier further argues the glove is not cost-effective. Dr. Tsourmas, the medical director for the Carrier, testified that a tight fitting glove is not appropriate treatment for RSD because of severe touch sensitivity. Instead, he recommended the use of electrode pads instead of an electrode glove, which have a monthly resupply charge of $100 if used continually. He also testified that if severe edema, or swelling is the problem, then it would be appropriate for the Claimant to be treated with an edema glove, which would effectively reduce swelling.

The Carrier does not dispute the cost of the glove and did not provide any evidence that $495 is not a fair and reasonable charge for this equipment.

The Commission

The MRD reviewed the Provider’s claims and found that he was not entitled to any reimbursement for the electrode glove. The MRD found that it was unable to determine the effectiveness of the glove because progress notes were not submitted supporting the claimed medical benefits. The MRD relied upon the 1996 Medical Fee Guideline, adopted under 28 Tex. Admin. Code (TAC) § 134.201.

V. ANALYSIS AND RECOMMENDATION

The ALJ agrees with the Provider and finds that he should be reimbursed $495 for the cost of the glove.

Based upon the evidence in the record, the glove has provided consistent relief for the Claimant’s pain, swelling, and muscle spasms since July1999 when Dr. Wiseman wrote the first letter. Ex. 1 at 10. In a letter dated May 21, 2001 provided at the hearing, Dr. Wiseman again confirmed the Claimant’s consistent positive experience using the glove. Ex. 2 at 1.

Dr. Tsourmas testified that electrode pads would be a more cost-effective approach. He also believed the pad would be less painful than a tight-fitting electrode glove. There is no evidence in the record that the Claimant has used more than one electrode glove or that additional reimbursement has been sought since the glove was initially prescribed in April of 1999. Clearly, a $495 glove is more cost-effective than pads assuming the glove does not have to be replaced and that it is used regularly. While it is unclear whether the Claimant uses the glove on a daily basis, it can be inferred from Dr. Wiseman’s letters that the Claimant regularly uses the glove and stimulator to control her RSD symptoms. Therefore, the ALJ finds the glove is a more cost-effective method for treating the Claimant’s RSD. There was conflicting testimony as to whether the glove or the pads would be more comfortable for the Claimant. The Claimant’s success with the glove indicates its use has not been painful, but rather, to the contrary, her pain has lessened with its use.

Dr. Tsourmas also testified that if the Claimant’s swelling needs to be addressed, as Dr. Wiseman indicates, then a tight-fitting edema glove would be more effective. Dr. Tsourmas, however, contradicts his own testimony. While there is no evidence that the electrode glove is tight, an edema glove is designed to be tight to alleviate swelling. Based upon Dr. Tsourmas’ testimony, wearing a tight-fitting edema glove could be painful for an RSD patient. According to the July 9, 1999 letter from Dr. Wiseman, the electrode glove reduces swelling by increasing circulation through electrical stimulation, not constriction. Ex. 1 at 10. The evidence before the ALJ does not support the use of an edema glove, as it could be painful. Instead it shows the electrode glove has achieved good results, with no evidence of increased pain to the Claimant. Further, the electrode glove has reduced the Claimant’s pain and muscle spasms as well as swelling.

The MRD found tht the Provider’s documentation was insufficient to support payment for the electrode glove under the MFG. The ALJ, however, finds the documentation sufficient to meet the requirements of the MFG’s durable medical equipment rule covering non-listed items. See MFGat 253, Part IV. This part of the MFG, which deals with durable medical equipment, merely requires that the provider bill the carrier its usual and customary rate for unlisted durable medical equipment, such as the electrode glove. The Carrier is then required to reimburse the Provider the Afair and reasonable rate for the item. In this matter, the Carrier does not dispute the cost of the item, but rather its medical necessity; therefore, Part IV of the MFG is inapplicable to this dispute. The MRD also found that the documentation failed to meet the requirement of the MFG’s general instructions contained in Part III because it did not supply progress notes to support claims of medical benefits. Contrary to the MRD’s assertion, the MFG does “not generally require detailed clinical records.” MFG at 1-2, Part III, emphasis supplied. Therefore, the ALJ finds the Provider’s documentation to be sufficient to establish the medical necessity of the electrode glove.

The ALJ finds on balance that a preponderance of the evidence supports reimbursement for the glove. It appears to be more cost-effective than alternative therapies, and the letters from Dr. Wiseman establishes that the glove has been successful in treating the Claimant’s RSD. The Provider demonstrated that the glove is medically necessary and has achieved substantial relief for the Claimant in a cost-effective manner.

VI. FINDINGS OF FACT

  1. The Commission issued notice of the hearing in this matter on March 20, 2001.
  2. _______ (Claimant) sustained a compensable worker’s compensation injury on ________
  3. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by the Texas Association of School Boards (Carrier).
  4. As a result of her injury, the Claimant suffers from reflex sympathetic dystrophy (RSD) in her left hand.
  5. Dr. Ben Wiseman, a pain management specialist, prescribed an electrode glove to be used in conjunction with a neuromuscular stimulator.
  6. Scientific Therapy and Advanced Treatment (Provider) billed the Carrier $495 for the electrode glove. The Carrier denied the claim as unnecessary medical treatment.
  7. Use of the stimulator and electrode glove have provided the Claimant pain relief and reduced her muscle spasms and swelling since July of 1999.
  8. The Claimant has used one glove since July of 1999.
  9. Electrode pads cost $100 per month if the patient uses them on a daily basis.
  10. The electrode glove is more cost-effective than alternative therapies and should reduce the Claimant’s need for supervised medical therapies as well as prescription medications.
  11. The Provider’s documentation was sufficient to demonstrate the medical necessity of the electrode glove and to establish the Provider’s fair and reasonable charge for the glove.
  12. The electrode glove is a medically necessary and cost-effective treatment for the Claimant.

VI. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction to decide the issue presented pursuant to Tex. Lab. Code Ann. §413.031 (Vernon 1996).
  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. §§402.073(b) and 413.031(d) (Vernon Supp. 2001) and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2001).
  3. Adequate and timely notice of hearing was provided in accordance with Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
  4. The Provider’s documentation meets the requirements of the Texas Workers’ Compensation Commission’s 1996 Medical Fee Guideline, adopted pursuant to 28 Tex. Admin. Code § 134.201.
  5. The electrode glove is health care that relieves the effects naturally resulting from the injury in accordance with Tex. Lab. Code Ann. § 408.021 (Vernon Supp. 2001).
  6. The Provider is entitled to reimbursement for the electrode glove in the amount of $495.

ORDER

IT IS, THEREFORE, ORDERED that Scientific Therapy and Advanced Treatment is entitled to $495 reimbursement from the Texas Association of School Boards for medical equipment provided to ____________

Signed this 10th day of December, 2001.

JANET R. DEWEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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