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At a Glance:
Title:
453-01-3053-m5
Date:
March 20, 2002

453-01-3053-m5

March 20, 2002

DECISION AND ORDER

The issue in this case is whether the Petitioner Scientific Therapy and Advanced Treatment (STAT) should be reimbursed $302.00 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 claiman’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 §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 on April 4, 2001. STAT filed a timely request for hearing. Proper and timely notice of the hearing was issued May 30, 2001. The hearing was convened January 28, 2002. Randy Burgett appeared for STAT. John Gillespie appeared for Texas Builders Insurance Company (Builders). The hearing was adjourned the same day, and the record was closed.

At the hearing, STAT attempted to introduce into evidence a letter from Salvador Baylan, M.D., the claimant’s treating doctor regarding the medical necessity of the G/C 1000 and MSM. The letter was marked for identification as Petitioner’s Exh. 1. Builders objected to the admission of the exhibit on the grounds that it had never seen the letter prior to the hearing and that there was no showing why STAT had not submitted it to the Commission in time for it to be made a part of the certified record. The ALJ took a ruling on the admissibility of the exhibit under advisement and left the hearing record open until January 29, 2002, for STAT to submit evidence indicating that Dr. Baylan’s letter had been sent to Builders.

On January 29, 2002, STAT submitted copies of return receipt cards indicating that the letter was mailed to Builders on June 13, 2001, and that it was delivered to an agent of Builders on June 18, 2001. These copies have been marked as Petitioner’s Exh. 2, and the exhibit is admitted.

After consideration of the parties’ arguments regarding Petitioner’s Exh. 1, Builders’ objections are overruled, and Petitioner’s Exh. 1 is also admitted.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. CodeAnn. §§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."

STAT has the burden of proof in this matter. 28 TexAdmin. Code §148.21(h).

III. Discussion

The workers’ compensation claimant was diagnosed with lumbar radiculitis.

Medical Necessity

In support of its claim that the treatment was medically necessary, STAT submitted a letter dated November 29, 2000, written by Salvador Baylan, M.D., the claimant’s treating doctor. In the letter, Dr. Baylan states:

I have prescribed the following oral agents to [the claimant] 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.[1]

The letter written by Dr. Baylan is identical to that written by the doctor in Scientific Therapy and Advanced Treatmentv. Texas Workers’ Compensation Commission and Northside Independent School District, SOAH Docket No. 453-01-1958.M5 (Sept. 19, 2001) and in Scientific Therapy and Advanced Treatment 2000 v. Liberty Mutual Fire Insurance Co., SOAH Docket No. 453-01-2901.M5 (February 28, 2002). As noted by ALJ Earl Corbitt in the former case, “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.”[2]

On May 17, 2001, Dr. Baylan wrote another letter indicating that G/C 1000 and MSM “will promote healing of the joint tissues and reduce pain that is associated with this injury.”[3] While the letter is a bit more specific to this claimant’s injury than the November 29, 2000, letter, it appears to be a form letter as well, as it quotes virtually verbatim a letter also written by Dr. Baylan in support of STAT’s claim of medical necessity in the Liberty Mutual case referred to in the preceding paragraph.

STAT was obligated to show the efficacy of the G/C 1000 and the MSM for the purpose prescribed, and these rote, prefabricated, form letters are not persuasive. They do little or nothing to demonstrate why these substances should be given to this patient for the condition he has. 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. CodeAnn. §408.021.

IV. Findings of Fact

  1. The Petitioner Scientific Therapy and Advanced Treatment (STAT) provided $302.00 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to the workers’ compensation claimant from January 7 to April 7, 2000.
  2. The claimant’s treating doctor, Salvador Baylan, M. D., prescribed the G/C 1000 and MSM to the claimant.
  3. STAT requested reimbursement from Texas Builders Insurance Company (Builders), which Builders denied.
  4. STAT filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  5. The Commission’s Medical Review Division (MRD) issued its decision, denying STAT’s request, on April 4, 2001.
  6. STAT filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  7. Notice of the hearing was issued May 30, 2001.
  8. The hearing was convened January 28, 2002. STAT and Builders appeared through their representatives. The staff of the Commission did not appear. The hearing adjourned the same day.
  9. The claimant suffered from lumbar radiculitis.
  10. 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.
  11. The evidence presented does not demonstrate the efficacy or the medical necessity of the prescribed G/C 1000 and MSM.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to § 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. STAT has the burden of proof in this matter. 28 Tex. Admin. Code §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 January 7, 2000, through April 7, 2000, is denied.

Signed March 20, 2002.

CATHLEEN PARSLEY
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Carrier’s Exh. 1, p. 25.
  2. Judge Corbitt’s Decision and Order, p. 5.
  3. Petitioner’s Exh. 2.
End of Document
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