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At a Glance:
Title:
453-01-2428-m4
Date:
January 17, 2002
Status:
Medical Fees

453-01-2428-m4

January 17, 2002

DECISION AND ORDER

Petitioner,____________, seeks reimbursement of $871.84 for costs incurred for prescription medications. Respondent United States Fire Insurance Company (U.S. Fire) contends_______ medical documentation failed to establish medical necessity for the medications. Although a party to the proceeding, the Texas Workers= Compensation Commission did not appear at the hearing, which convened and closed on December 10, 2001.

As reflected in the Findings of Fact and Conclusions of Law, the Administrative Law Judge denies reimbursement. While_______ compensable injury may have warranted the disputed prescription drug treatments, such treatments were not supported in the evidentiary record. The record did not show that the treatments were adequately documented, cost effective, or consistent with the Commission's Spine Treatment Guideline, or that functional gains in_______ condition were objectively measured.

I. Findings of Fact

  1. Petitioner,___________, suffered a compensable injury in____________
  2. __________reached maximum medical improvement status in 1994.
  3. __________did not receive treatment for the injury from December 1994 to December 1997.
  4. __________seeks reimbursement for prescription drug expenses incurred by him from July 1, 1998, through July 1, 1999, to treat his 1993 work-related injuries.
  5. Notice of the hearing in this case was sent to all parties more than 10 days before the hearing. 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.
  6. ________paid $871.84 for the prescription drugs from July 1, 1998, through July 1, 1999.
  7. The evidentiary record contains no documentation reflecting medical necessity to treat __________injury between July 1998 and July 1999.
  8. There is no evidence indicating_________ prescription drug treatment was evaluated for effectiveness.
  9. There is no evidence indicating________ prescription drug treatment was consistent with the Spine Treatment Guideline of the Texas Workers= Compensation Commission.
  10. There is no evidence indicating_________ prescription drug treatment was objectively measured and that it resulted in functional improvement in________ medical condition.
  11. _________condition has remained unchanged for three to four years.

II. Conclusions of Law

  1. 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. '413.031(D) and Tex. Gov=t Code Ann. ch. 2003.
  2. The hearing was conducted pursuant to the Administrative Procedure Act (APA), Tex. Gov=t Code Ann. ch. 2001 (Vernon 2000) and 28 Tex. Admin. Code (TAC) ''133.305.
  3. The parties received notice of the hearing in accordance with '' 2001.051 and 2001.052 of the APA.
  4. Based on Finding 7, the treatment of_________ injury was not adequately documented, as required by ' (e)(2)(A)(I) of the Commission's Spine Treatment Guideline.
  5. Based on Finding 8, the treatment of________ injury was not evaluated for effectiveness, as required by ' (e)(2)(A)(ii) of the Spine Treatment Guideline.
  6. Based on Finding 9,________ failed to prove the prescription drug treatment was consistent with the Spine Treatment Guideline.
  7. Based on Finding 10,_________ failed to prove the prescription drug treatment was objectively measured and that it resulted in functional improvement to his medical condition.
  8. Based on the Findings and Conclusions,_________ is not entitled to reimbursement for the prescription drug expenses incurred by him from July 1, 1998, through July 1, 1999.

ORDER

IT IS, THEREFORE, ORDERED that_________ shall not be reimbursed for those prescription drug expenses at issue incurred from July 1, 1998, through July 1, 1999.

Signed this 17the day of January, 2002.

GARY W. ELKINS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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