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At a Glance:
Title:
453-01-2884-m5
Date:
January 31, 2002
Status:
Retrospective Medical Necessity

453-01-2884-m5

January 31, 2002

DECISION AND ORDER

I. SUMMARY

Hassle Free Pharmacy Services (the Petitioner) sought reimbursement from Dallas Independent School District (the Respondent) for medication provided to _____________ (the Claimant). The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) found that there was insufficient documentation substantiating the necessity for the medications. MRD denied reimbursement for the medications. The Petitioner challenges the MRD’s decision and requests reimbursement for the medications.

The Administrative Law Judge (ALJ) convened a hearing on December 17, 2001, and the record closed the same day. The Texas Workers’ Compensation Commission (Commission) waived its appearance. W. Jon Grove, attorney appeared on behalf of the Respondent. The Petitioner did not appear at the hearing after receiving proper notice. Based on the evidence, the ALJ recommends that reimbursement to the Petitioner for the medications be denied. Prior to the MRD decision, the Respondent had agreed that Tylenol #4 and Neurontin were reasonable and necessary, and it agreed to pay for these medications. The particular facts and reasoning in support of this decision are set forth below in the Findings of Fact, and the legal conclusions derived from those facts appear in the Conclusions of Law.

II. EVIDENCE

The evidence in this case consists of notice to the Petitioner, which the ALJ takes judicial notice of (ALJ Ex. 1) and the certified record (Respondent Ex. 1). Based on the evidence, the ALJ finds that there is not sufficient documentation to support reimbursement to the Petitioner for medications provided to the Claimant.

III. FINDINGS OF FACT

  1. On _________, __________ (the Claimant) suffered a compensable injury.
  2. The Claimant’s injury is covered by worker’s compensation insurance written for the Claimant’s self-insured employer, Dallas Independent School District (the Respondent).
  3. The Respondent denied payment for Prozac (an anti-depressant), Welbutrin (an anti-depressant), Baclofen (a muscle relaxant), and Clonazepam (an anti-convulsant)
  4. The Respondent agreed that Tylenol #4 and Neurontin were reasonable and necessary, and it agreed to pay for these medications.
  5. The Petitioner requested dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (the MRD) on January 9, 2001.
  6. The MRD issued its findings and decision on March 9, 2001, denying reimbursement for the medications.
  7. On April 9, 2001, the Petitioner appealed the findings and decision of the MRD, seeking reimbursement for the medications.
  8. The Texas Workers’ Compensation Commission (Commission) issued the notice of the hearing on May 11, 2001.
  9. Administrative Law Judge Michael J. O’Malley convened the hearing on the disputed issues on December 17, 2001, and the record closed the same day. The Petitioner did not appear at the hearing nor did it request to appear by telephone.
  10. The Petitioner’s medical documentation, for the medication provided to the Claimant, does not support reimbursement nor does it show that the medications are medically necessary.

IV. CONCLUSIONS OF LAW

  1. The 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 Petitioner 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 Petitioner did not prove by a preponderance of the evidence that additional reimbursement was warranted for the medications provided to the Claimant.
  6. The Petitioner is not entitled to reimbursement for Prozac, Welbutrin, Baclofen, or Clonazepam provided to the Claimant.

ORDER

IT IS, THEREFORE, ORDERED, that Hassle Free Pharmacy Services shall not recover from Dallas Independent School District for the medications provided to __________.

Issued January 31, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Michael J. O’malley
Administrative Law Judge

End of Document
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