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At a Glance:
Title:
453-01-2731-m5
Date:
February 4, 2002
Status:
Retrospective Medical Necessity

453-01-2731-m5

February 4, 2002

DECISION AND ORDER

Wausau Business Insurance Company (Petitioner) appealed the Findings and Decision of the Texas Workers' Compensation Commission (Commission) Medical Review Division (MRD) in its Medical Dispute Resolution Docket No. M5-01-1247-01. The decision found that prescriptions of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) were medically necessary.

The Administrative Law Judge (ALJ) finds that Petitioner failed to meet its burden of proving, by a preponderance of the evidence, that the prescription of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) was not medically reasonable and necessary and ,therefore, not reimbursable.

I. STATEMENT OF THE CASE

ALJ John Beeler of the State Office of Administrative Hearings convened an evidentiary hearing in this matter on December 4, 2001, in the Stephen F. Austin State Office Building, 1700 Congress Avenue, Austin, Texas. Petitioner was represented by attorney Mahon Gerry, Jr. Respondent Scientific Therapy and Advanced Treatment (STAT) appeared and was represented by Randy Burgett, COO. The Commission’s Medical Review Division did not appear and was not represented.

Petitioner seeks to reversal of the decision of the Commission’s MRD requiring reimbursement for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) in the amount of $408.00.

II. NOTICE, JURISDICTION AND VENUE

There were no contested issues regarding notice of hearing or venue. Therefore, those matters are addressed in the Findings of Fact and Conclusions of Law without further discussion here.

III. LEGAL AUTHORITY

Entitlement to Medical Benefits - Section 408.021 of the Act provides that: an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury to cure or relieve the effects naturally resulting from the compensable injury, to promote recovery, or to enhance his ability to return to or retain employment.

Section 401.011(19) of the Act defines “health care” to include "all reasonable and necessary medical . . . services.”

IV. BACKGROUND, ISSUE TO BE DECIDED, AND PARTIES’ POSITIONS

Background

On, _______, ____ (Claimant) sustained cervical and lumbar sprain in a work related injury and seeks reimbursement for over-the-counter medications it provided to the Claimant, prescribed by Dr. Alan Delgado, M. D., in the amount of $408.00.

  1. The issue to be decided is whether the Petitioner should be reimbursed $408.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) it provided for the Claimant.
  2. Petitioner billed the Carrier for pharmaceuticals provided to the Claimant between February 2, 2000, and August 8, 2000. Petitioner denied reimbursement for the G/C 1000 and MSM on the basis that they were not medically necessary. The MRD of the Commission issued a order on March 23, 2001, ordering Petitioner to remit $408.00 for reimbursement. Petitioner appealed.

V. ANALYSIS AND DECISION

Petitioner offered one document and no testimony at the hearing. Respondent STAT relied on the evidence presented to the MRD and the MRD decision. Petitioner’s document is an affidavit prepared by Nick Tsourmas, M.D. and was prepared at the request of Petitioner specifically for the purpose of being offered into the record in this hearing. The gist of the affidavit is that Dr. Tsourmas has reviewed medical literature and does not believe that G/C 1000 and MSM have been shown to be effective in treatment for back injuries.

The ALJ reviewed the affidavit and the evidence presented to the MRD. The affidavit, at best, merely states the opinion of Dr. Tsourmas without reference to any specific studies, or any reference to Ms. Wilson’s specific injuries and condition. Further, the affidavit does not address the evidence presented to the MRD and relied upon by STAT. Based on the review of all of the evidence available, the ALJ does not find that Petitioner met its burden of establishing, by a preponderance of the evidence, the decision of the MRD should be reversed. The affidavit is simply inadequate to be persuasive.

VI. FINDINGS OF FACT

  1. On_______, ____ (Claimant) sustained cervical and lumbar sprain in a work related injury.
  2. The Claimant’s workers’ compensation Carrier for the work-related injury is Wausau Business Insurance Company (Wausau).
  3. Notice of the contested hearing in this matter was provided to all parties. The notice included a statement of the time, place, and nature of the hearing, a short plain statement of the matters asserted, and legal authority and jurisdiction under which the hearing would be held and the matter decided.
  4. Administrative Law Judge John Beeler convened a hearing on December 4, 2001, in the Stephen F. Austin State Office Building, 1700 Congress Avenue, Austin, Texas. Petitioner, Wausau and Respondent Scientific Therapy and Advanced Treatment (STAT) appeared to present evidence and argument.
  5. STAT provided the Claimant Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) between February 2, 2000, and August 8, 2000.
  6. The pharmaceuticals provided Claimant were medically necessary to treat her injuries.

VII. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers’ Compensation Act (Act). Tex. Labor Code Ann. § 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. Tex. Labor Code Ann. § 413.031(d); Tex. Gov't Code Ann. Ch. 2003.
  3. Adequate and timely notice of hearing was provided pursuant to the Administrative Procedure Act § 2001.052, Tex. Gov’t Code Ann. (Vernon 2001).
  4. Pursuant to Tex. Labor Code Ann. § 408.021(a), an employee who sustains a compensable injury is entitled to health care that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment.
  5. The prescriptions for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) were shown to be medically reasonable and necessary and, therefore, reimbursable.

ORDER

IT IS, THEREFORE, ORDERED that Liberty Mutual pay Petitioner $408.00 for providing Claimant prescriptions of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM).

Issued the 4th day of February, 2002.

JOHN BEELER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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