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At a Glance:
Title:
453-01-2901-m5
Date:
January 24, 2002
Status:
Retrospective Medical Necessity

453-01-2901-m5

January 24, 2002

DECISION AND ORDER

The issue in this case is whether the Petitioner, Scientific Therapy and Advanced Treatment (STAT), should be reimbursed $510.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for and provided to the workers’ compensation claimant. The Administrative Law Judge (ALJ) concludes that STAT did not meet its burden of proving that G/C 1000 and MSM were medically necessary for the treatment of the claimant’s injury. Therefore, she denies reimbursement.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code Ann. ch. 401 et seq. The State Office of Administrative Hearings (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.

The Commission’s Medical Review Division (MRD) issued its amended findings and decision March 29, 2001. STAT filed a timely request for hearing. Proper and timely notice of the hearing was issued May 17, 2001. The hearing was convened December 19, 2001, with the undersigned ALJ presiding. Randy Burgett appeared for STAT. Dan Flanagan appeared for Respondent Travelers Indemnity Company of Connecticut (Travelers). Tim Riley appeared on behalf of the Commission. The hearing was adjourned the same day. The ALJ admits into evidence a copy of the TWCC-62 form as Exhibit No. 2.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. Code Ann. §§408.021 and 401.011. Section 408.021 states:

(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.

Section 401.011(19) defines “health care” as including "all reasonable and necessary medical . . . services."

The Petitioner has the burden of proof in this matter. 28 TAC §148.21(h).

III. Discussion

The only reference to the apparent injury is to a sprain at page 19 of Exhibit 1.

A. Scope of Dispute

STAT contends that Travelers is prohibited from raising the issue of medical necessity in this proceeding because it may not assert new reasons for denial other than those reasons asserted in the Form TWCC-62 or similar form.[1] Accordingly, STAT argues that the Medical Dispute Resolution Officer (MDRO) erroneously expanded the scope of review in this case by denying payment on the ground that “[t]he letter of medical necessity dated 8/11/00 is not patient specific and does not substantiate medical necessity of the prescribed product. . . .” Ex. 1 at 3-4.

The record shows that Travelers denied reimbursement with the explanation “U - These services are not reimbursable under [the] Texas Workers Compensation Program.” Ex. 1 at 31-35. According to the TWCC-62 form, the letter “U” represents unnecessary treatment. Although STAT argues that Travelers is being inconsistent in the reasons it expresses for rejecting reimbursement, the added sentence does not contradict the clear meaning of the letter U. STAT was put on notice from the outset that medical necessity was an issue and was not precluded from providing documentation and explanations in support of its position. As the Commission argued, the MDRO reasonably interpreted the dispute to be one of medical necessity.

B. Medical Necessity

In support of its claim that the treatment was medically necessary, STAT submitted a letter dated August 11, 2000, written by Michael Rihn, D.C., the Claimant’s treating doctor. In the letter, Dr. Rihn states:

I have prescribed the following oral agents . . . for use as part of a complete treatment program in order to recover from injury. These agents are Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM). Although these agents have been marketed for some time now, it has come to my attention that some carriers refuse to accept the fact that these agents promote healing of joint tissues as well as reduced joint pain when used on a chronic basis. Use of these agents can reduce the overall effect of an injury and help one get back to a normal productive state. Several such products have been studied and are now with NDC registration. Beside the results from medical journals showing their effectiveness, in my own practice I have met with positive results as well. Therefore, I believe that for this patient, not only are these medications appropriate, but they are medically necessary as well.

Ex. 1 at 25.

The letter written by Dr. Rihn is virtually identical to that written by the doctor in Scientific Therapy And Advanced Treatmentv. Texas Workers’ Compensation Commission & Northside Independent School District, SOAH Docket No. 453-01-1958.M5 (Sept. 19, 2001). As noted by ALJ Earl Corbitt, “The mere prescribing of a substance by a medical doctor, without more, is not sufficient evidence to require a finding that the substance is medically necessary. . . .[H]is conclusory statement is insufficient to demonstrate the effectiveness of the prescribed nutritional supplements.” Id. at 5. After Travelers questioned the medical necessity of the G/C 1000 and the MSM, Petitioner was obligated to show the efficacy of the G/C 1000 and the MSM for the purpose prescribed, which it has not done.

Therefore, the ALJ concludes that STAT has not met its burden of proving that the G/C 1000 and the MSM were medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. Code Ann. §408.021.

IV. Findings of Fact

  1. The Petitioner, Scientific Therapy and Advanced Treatment (STAT), provided $510.00 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to the workers’ compensation claimant.
  2. STAT provided the G/C 1000 and MSM on several dates from March 18, 2000, through July 18, 2000.
  3. The claimant’s treating doctor, Michael Rihn, D.C., prescribed the G/C 1000 and MSM.
  4. STAT requested reimbursement from Travelers Indemnity Company of Connecticut (Travelers).
  5. Travelers denied reimbursement with the explanation: “U - These services are not reimbursable under [the] Texas Workers Compensation Program.”
  6. STAT filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  7. The Commission’s Medical Review Division (MRD) issued its decision, denying STAT’s request, on March 29, 2001.
  8. STAT filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  9. Notice of the hearing was issued May 17, 2001.
  10. 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.
  11. The hearing was convened December 19, 2001, with Administrative Law Judge (ALJ) Katherine L. Smith presiding. Randy Burgett appeared for STAT. Dan Flanagan appeared for Travelers. Tim Riley appeared for the Commission. The hearing adjourned the same day.
  12. The Claimant suffered from a sprain.
  13. STAT was given notice from the outset that medical necessity was an issue and was not prevented from providing documentation and explanations in support of its position.
  14. The mere prescribing of a substance by a medical doctor, without more, is insufficient evidence to require a finding that the substance is medically necessary.
  15. The evidence presented does not demonstrate the efficacy of the prescribed G/C 1000 and MSM.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation 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 Petitioner has the burden of proof in this matter. 28 TAC §148.21(h).
  5. STAT has not met its burden of proving the G/C 1000 and the MSM were medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. Code Ann. §408.021.
  6. STAT’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Scientific Therapy and Advanced Treatment’s request for reimbursement for G/C 1000 and MSM provided to the workers’ compensation claimant from March 18, 2000, through July 18, 2000, is denied.

Signed January 24, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

KATHERINE L. SMITH
Administrative Law Judge

  1. See SOAH Docket No. 453-01-0309.M5 (February 7, 2001) (carrier’s failure to assert lack of medical necessity as a reason for denying payment resulted in medical necessity not being properly within the scope of the dispute before the MRD or an issue to be decided before SOAH.)
End of Document
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