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At a Glance:
Title:
453-01-2770-m4
Date:
January 16, 2002
Status:
Medical Fees

453-01-2770-m4

January 16, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner American Home Assurance Company (the Carrier), seeks reversal of a decision of the Texas Workers’ Compensation Commission’s Medical Review Division (MRD) ordering the Carrier to reimburse _________$541.06 in out-of-pocket expenses she incurred purchasing prescription drugs prescribed by her physician from September 19, 2000, to February 19, 2001.

The Administrative Law Judge convened a hearing on these issues on December 11, 2001. The hearing was concluded and the record closed that date. Respondent ____appeared by telephone and represented herself with the assistance of Commission Ombudsman Anthony Walker.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in this case consisted of the 25-page certified record of the MRD proceeding and additional medical reports and documents submitted by the Carrier______ also testified on her own behalf, and the Carrier called Dr. Gary N. Pamplin, who examined ____on August 3, 2000. Based on the evidence, the ALJ concludes that the Carrier’s petition should be granted, and that the Carrier should not be required to reimburse _______for the prescription drugs in dispute. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law. In summary, however, the ALJ accepts Dr. Pamplin’s testimony that the powerful and addictive drugs prescribed are not a medically necessary, ongoing treatment for _______________, workers compensation injury, which no longer exhibits objective symptoms.

III. FINDINGS OF FACT

  1. On_________, Claimant ________suffered a compensable injury to her back and neck when she fell backwards into a door while carrying two heavy boxes.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by American Home Assurance Company (the Carrier).
  3. Claimant seeks reimbursement from the Carrier for $541.06 in out-of-pocket expenses she incurred purchasing prescription drugs prescribed by her physician from September 19, 2000, to February 19, 2001.
  4. The Carrier denied reimbursement of the expenses identified in Finding of Fact No. 3.
  5. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  6. The MRD issued its findings and decision on March 30, 2001, concluding that the disputed expenses should be paid, and the Carrier timely appealed this decision.
  7. The prescription medications in dispute are hydrocodone, a narcotic analgesic, to be taken four times daily; diazepam, a sedative -hypnotic, to be taken twice daily; and promethazine, an anti-emetic, to be taken once daily as needed.
  8. Hydrocodone and diazepam are each central nervous system depressants that should not normally be taken together.
  9. Hydrocodone and diazepam are highly addictive drugs and should be used for an extended period only after careful evaluation and as a last resort.
  10. The Claimant’s treating physician did not document a baseline for the Claimant’s pain on any sort of scale.
  11. The Claimant’s treating physician did not document the Claimant’s range of motion or the Claimant’s functional level of pain with respect to daily activities such as walking and standing.
  12. By August 3, 2001, the claimant’s injury manifested no objective symptoms.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. 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 Tex. Labor Code §413.031 and Tex. Gov’t Code ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. 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. The Carrier has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. The treatment provided to the Claimant was not reasonably required by Tex. Lab. Code Ann. §408.021.
  6. Petitioner should not be reimbursed $541.06 in out-of-pocket expenses she incurred purchasing prescription drugs prescribed by her physician from September 19, 2000, to February 19, 2001.

ORDER

IT IS THEREFORE, ORDERED that ________request for reimbursement of $541.06 from American Home Assurance Company for prescription drugs prescribed by her physician from September 19, 2000, to February 19, 2001, is denied.

Issued January 16, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Kerry D. Sullivan
Administrative Law Judge

End of Document
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