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At a Glance:
Title:
453-01-2563-m5
Date:
April 11, 2002

453-01-2563-m5

April 11, 2002

DECISION AND ORDER

This case is a dispute over whether reimbursement for prescription drugs is appropriate_________. (Claimant) purchased prescription drugs with her personal funds between November 23, 1999, and October 25, 2000. Claimant requested reimbursement from Harris County (Carrier) for her out-of-pocket expenses. Carrier asserts Claimant’s prescriptions were not reasonable or necessary according to the Medical Fee Guideline. The amount in controversy is $4,395.04.

The Administrative Law Judge (ALJ) concludes the Carrier met its burden of proving the Claimant’s prescriptions were not reasonable or necessary. Therefore, the ALJ finds Carrier is not required to reimburse Claimant for the prescriptions.

I.

DISCUSSION

Background Facts

Claimant sustained a compensable injury on __________She was 40 years old at the time and employed with the Harris County Sheriff’s Office. Claimant was involved in an altercation with an inmate where she sustained a closed head injury as a result of the inmate striking her five or six times in her left temple. Following the incident, Claimant was treated at the Office’s clinic and released.

Claimant’s personal doctor referred her to Dr. Ninan Mathew, a neurologist and headache specialist, after she complained of headaches. Dr. Mathew administered three MRI scans on Claimant in1992 and 1993 and found her brain stable with no evidence of a pathological lesion or other injury related to the compensable injury.

Claimant was then referred to Dr. Martin Steiner for a neurological evaluation on July 28, 1993. Dr. Steiner found Claimant had a history of headaches beginning when Claimant was 18 years old, 22 years before her compensable injury. Additionally, Dr. Steiner found Claimant had a history of temporal lobe epilepsy which started in 1985 when Claimant was 34 years old. Dr. Steiner’s evaluation found no evidence of neurological abnormality.

On November 23, 1999, Claimant made the first of many prescription drug purchases. Claimant claimed she suffered from migraine headaches resulting from her compensable injury in_____. At this time, Dr. E. Floyd Robinson was Claimant’s treating doctor. Claimant visited Dr. Stephen Waller as well.

Drs. Robinson and Waller prescribed several medications to Claimant for treatment of her migraine headaches.

Dr. Wayne Gordon conducted a peer review of Claimant using records of Drs. Steiner, Robinson and Waller. Dr. Gordon found the medication purchased by Claimant between November 23, 1999, and October 25, 2000, was not reasonable or necessary for treatment of Claimant’s 1992 injury.

Claimant requested reimbursement of the prescriptions. Carrier denied reimbursement.

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the “Act”) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. § 408.021 provides in pertinent part:

(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. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

Under Tex. Lab. Code Ann. §401.011(19) health care “includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.”

Analysis

The compensable injury in this case occurred in____. Seven years following the injury, Claimant continued to suffer from migraine-type headaches. Claimant admits she has a history of migraine headaches beginning 22 years before her compensable injury. However, even as Claimant admits her preexisting condition, Dr. Steiner, on repeated occasions has found no neurological abnormality stemming from the compensable injury that would cause migraine headaches. The Claimant suffered from migraine headaches before the ____ injury. The evidence presented by Claimant was not compelling enough to establish Claimant’s _____ injury aggravated Claimant’s condition or otherwise caused Claimant’s headaches to last seven years following the compensable injury. In eleven months, Claimant purchased 110 separate prescriptions for the treatment of migraine headaches, epileptic seizures, and arthritic pain. The medications purchased by Claimant probably comfort Claimant, but are not reasonable and necessary for the treatment of her compensable injury.

II.

FINDINGS OF FACT

  1. Claimant, __________, sustained a compensable closed head injury on____________, while working for the Harris County Sheriff’s Office. Claimant was struck by a prisoner five or six times in her left temple.
  2. Immediately after the altercation, Claimant visited the Office’s clinic and was given an ice pack.
  3. Claimant then saw her personal physician who gave her a pain injection and Vicodin for her headache.
  4. After visiting her personal physician, Claimant was referred to Dr. Ninan Mathew, a neurologist and headache specialist.
  5. Dr. Mathew administered three MRI scans to Claimant and found no evidence of the cause of her headaches.
  6. Dr. Martin Steiner examined Claimant on July 28, 1993, and found Claimant had a history of headaches before the date of her compensable injury.
  7. Dr. Steiner found no evidence of “neurologic abnormality” that would cause Claimant’s headaches.
  8. On January 2, 1998, Dr. Steiner again examined Claimant and reissued the same diagnosis as in 1993 - that there was no objective evidence to account for Claimant’s headaches.
  9. Dr. Steiner concluded Claimant’s complaints of migraine-type headaches were not likely in this situation where Claimant sustained a closed head injury.
  10. Dr. Steiner administered another neurological examination on Claimant on October 12, 1999, and again found Claimant to have no evidence of “objective abnormality” that would cause any ongoing headaches.
  11. In his report dated October 12, 1999, Dr. Steiner expressed his concern over Claimant’s addiction to Soma.
  12. The only dates eligible for review in this dispute are November 23, 1999, through October 25, 2000.
  13. Between November 23, 1999, and October 25, 2000, Claimant made 110 purchases of various prescription drugs including: Propranolol, Acetaminophen with Codeine #4, Carisoprodol, Imitrex, Lidocaine, Depakote, Topamax, Zomig, and Zanafelx. These medications were prescribed by Dr. Robinson and Dr. Waller.
  14. On October 8, 2001, Dr. Wayne Gordon prepared a peer review of Claimant. Dr. Gordon reviewed medical records from Dr. Steiner, Dr. Stephen Waller, and Dr. E. Floyd Robinson.
  15. Dr. Gordon concluded the medication purchased by Claimant between November 23, 1999, and October 25, 2000, was not reasonable or necessary in the treatment of Claimant’s injury of _________.
  16. Dr. Stephen Waller began treating Claimant on July 30, 1997, for complaints of headaches.
  17. Dr. Waller never prescribed Carisoprodol to Claimant. Carisoprodol is a muscle relaxant.
  18. Dr. Waller prescribed Topamax to Claimant to treat Claimant’s seizures and migraine headaches.
  19. Dr. Waller prescribed Diclofenac (generic for Voltaren) to Claimant to treat Claimant’s arthritis. Diclofenac can also treat inflammation of small joints and discs in the back of the neck.
  20. Dr. Waller prescribed Zanaflex to Claimant. Zanaflex is a muscle relaxant.
  21. Claimant has a history of migraine headaches starting 22 years before the date of her compensable injury. The migraine headaches occurred near the time of her menstrual cycle.
  22. Claimant’s migraine headaches disappeared during her pregnancies.
  23. Claimant’s migraine headaches occurring between November 23, 1999, and October 25, 2000, were likely the result of her menstrual cycle and not as a result of the compensable injury of ____________.
  24. Claimant requested reimbursement of $4,395.04 from Carrier for the prescriptions.
  25. Carrier refused to reimburse Claimant for the prescriptions.
  26. Provider filed a Request for Medical Dispute Resolution with the Medical Review Division of the Texas Workers’ Compensation Commission (Commission), seeking reimbursement for the $4,395.04 in prescriptions.
  27. On March 12, 2001, the Commission’s Medical Review Division found Claimant was entitled to full reimbursement for the prescriptions.
  28. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  29. Notice of the hearing was sent December 6, 2001.
  30. 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.
  31. The hearing was held February 11, 2002, with ALJ Steven M. Rivas presiding and representatives of the Carrier and the Claimant participating. The hearing was adjourned the same day.
  32. The prescribed medication between November 23, 1999, and October 25, 2000, is not reasonable or necessary.
  33. Claimant is not entitled to reimbursement for the prescriptions.

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. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
  4. The Carrier, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. 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 in accordance with TEX. Lab. Code Ann. § 408.021.
  6. Health care includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services, under Tex. Lab. Code Ann. §401.011(19).
  7. The prescriptions purchased by Claimant between November 23, 1999, and October 25, 2000, was not reasonable or necessary for the treatment of Claimant’s compensable injury.
  8. Claimant is not entitled to reimbursement from Carrier for the prescriptions purchased between November 23, 1999, and October 25, 2000.

ORDER

IT IS, THEREFORE, ORDERED that Claimant, __________, is not entitled to reimbursement of $4,395.04 from the Carrier, Harris County, for the prescriptions purchased between November 23, 1999, to October 25, 2000.

Signed April 11, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

End of Document
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