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At a Glance:
Title:
453-01-3082-m5
Date:
March 11, 2002
Status:
Retrospective Medical Necessity

453-01-3082-m5

March 11, 2002

DECISION AND ORDER

The issue in this case is whether the Petitioner, Scientific Therapy and Advanced Treatment (STAT), should be reimbursed $322.65 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000), Methyl Sulfonyl Methane (MSM), and aloe liniment prescribed for and provided to the workers’ compensation claimant. The Administrative Law Judge (ALJ) concludes that STAT met its burden of proving that G/C 1000 and MSM were medically necessary for the treatment of the claimant’s injury, but that the aloe liniment was not. Therefore, she grants partial reimbursement in the amount of $306.00.

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 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 §413.031(d) and Tex. Gov’t Code ch. 2003.

The Commission’s Medical Review Division (MRD) issued its amended findings and decision on April 11, 2001. STAT filed a timely request for hearing. Proper and timely notice of the hearing was issued May 31, 2001. The hearing was convened January 31, 2002, with the undersigned ALJ presiding. Randy Burgett appeared for STAT. Shannon Buttersworth appeared for Liberty Mutual Fire Insurance Company (Liberty). The hearing was adjourned the same day.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. Code §§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 Tex.Admin. Code “148.21(h).

III. Discussion

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 . . . 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 factthat these agents promotehealingof joint tissues as well as reduced joint painwhen 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 November 29, 2000 letter written by Dr. Baylan 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 (September 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.

On December 17, 2001, Dr. Baylan wrote another letter indicating that G/C 1000 and MSM “will promote healing of their [the claimant’s] joint tissues and reduce pain that is associated with this injury.”[2] After Liberty 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 done. Although Liberty argued that Dr. Baylan’s second letter was substantially similar to his first letter, the ALJ finds otherwise. The December 17, 2001 letter specifically indicates that the G/C 1000 and MSM will promote healing of the claimant’s injury. The letter does not, however, address the aloe liniment.

Therefore, the ALJ concludes that STAT has 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 §408.021. The ALJ concludes that STAT has not met its burden with respect to the aloe liniment.

IV. Findings of Fact

  1. The Petitioner, Scientific Therapy and Advanced Treatment (STAT), provided $322.65 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000), Methyl Sulfonyl Methane (MSM) and aloe liniment to the workers’ compensation claimant from March 28, 2000, through August 28, 2000.
  2. The claimant’s treating doctor, Salvador Baylan, M. D., prescribed the G/C 1000, MSM, and aloe liniment.
  3. STAT requested reimbursement from Liberty Mutual Fire Insurance Company (Liberty), which Liberty 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 11, 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 31, 2001.
  8. 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.
  9. The hearing was convened January 31, 2001, with Administrative Law Judge (ALJ) Wendy K. L. Harvel presiding. Randy Burgett appeared for STAT. Shannon Buttersworth appeared for Liberty. The hearing adjourned the same day.
  10. The Claimant suffered from a lumbosacral strain.
  11. G/C 1000 and MSM will promote healing of the claimant’s joint tissues and reduce pain that is associated with the claimant’s injury.
  12. Use of G/C 1000 and MSM can reduce the overall effect of an injury and help the claimant return to a normal productive state.
  13. The evidence presented does not demonstrate the efficacy of the prescribed aloe liniment.

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 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 §413.031(d) and Tex. Gov’t Code ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code '2001.052.
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. STAT has 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 '408.021.
  6. STAT has not met its burden of proving the aloe liniment was medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. Code §408.021.
  7. STAT’s request for reimbursement should be granted in part in the amount of $306.00.

ORDER

IT IS, THEREFORE, ORDERED that Scientific Therapy and Advanced Treatment’s request for reimbursement for G/C 1000, MSM, and aloe liniment provided to the workers’ compensation claimant from March 28, 2000, through August 28, 2000, is granted in part in the amount of $306.00.

Signed March 11th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WENDY K. L. HARVEL
Administrative Law Judge

  1. Ex. 1 at 11.
  2. Ex. 2
End of Document
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