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At a Glance:
Title:
453-01-3246-m5
Date:
March 27, 2003
Status:
Retrospective Medical Necessity

453-01-3246-m5

March 27, 2003

DECISION AND ORDER

I. SUMMARY

Scientific Therapy and Advanced Treatment (Petitioner or STAT) appealed a decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denying reimbursement of $306.00 from Insurance Company of the State of Pennsylvania (Carrier) for glucosamine hydrochloride and chondroitin sulfate (G/C 1000) and methyl sulfonyl methane (MSM) prescribed for and provided to injured worker _____ (Claimant). The Administrative Law Judge (Judge) concludes that Petitioner has failed to meet its burden of proving that the medications were medically necessary for the treatment of Claimant’s compensable injury.

Judge Carol Wood convened a hearing on this matter on May 6, 2002, at the State Office of Administrative Hearings (SOAH) facility in Austin, Texas. Petitioner appeared through its representative, Randy Burgett. Attorney Craig Courville represented Carrier. The Commission did not appear. In order to allow the Commission an opportunity to locate the MRD record[1] and later to have the parties provide the misplaced hearing exhibits,[2] the record remained open to December 9, 2002.

II. DISCUSSION

Claimant sustained a compensable worker’s compensation injury to her lower back on______. On May 6, June 6, and July 6, 2000, Petitioner provided Claimant the medications G/C 1000 and MSM Plus that had been prescribed by Claimant’s treating physician, Scott Harris, D.C. Carrier denied reimbursement with the explanations that the treatment was medically unnecessary (Denial Code U); Petitioner failed to appropriately document medical necessity (Denial Code N); and Petitioner failed to preauthorize the treatment in accordance with Commission rules (Denial Code A). Petitioner submitted a request to MRD for dispute-resolution review.

MRD issued a decision denying reimbursement, finding that (1) the letter of medical necessity failed to indicate the injured worker’s diagnosis, prognosis, and expected duration of the treatment in accordance with the Medical Fee Guideline; and (2) Petitioner failed to submit office notes substantiating Claimant’s ongoing progress in relation to the treatment, as required in the Spine Treatment Guideline.[3] Petitioner filed a timely request for hearing.

In support of its claim that the treatment was medically necessary, STAT submitted a letter dated May 17, 2001, written by Dr. Harris. In the letter, Dr. Harris stated the following:

. . . [Claimant’s] diagnosis consists of Lumbar Myofacial Pain. I have prescribed [G/C 1000 and MSM] for use as part of a complete treatment program in order to recover from the injury. These agents will promote healing of the joint tissues and reduce pain that is associated with this injury. [Claimant’s] prognosis is good with the use of these agents. She should be expected to use these agents for a period up to six months.

In my opinion these items are medically necessary and are related to the injury she received while on the job. (Exhibit No. 1)

Carrier asserts the prescribed medications are nutritional supplements that were medically unnecessary for treating Claimant. In support of its argument, Carrier submitted an affidavit by Nick Tsourmas, M.D., who is board certified in orthopedic surgery. Dr. Tsourmas attested, in pertinent part, as follows:

. . . I understand that [Claimant] suffered a low back injury . . . that she has received physical therapy, chiropractic manipulation, spinal injections, and an IDET (intradiscal electrothermal annuloplasty) procedure.

A review of the medical literature does not show that either [G/C] or [MSM] has been proven to be effective in the treatment of injuries to the spine, including the intravertebral disks, or to the soft tissue surrounding the spine.

Specifically, there has been some research suggesting that glucosamine might have some beneficial effect in the treatment of osteoarthritis of the knee; however, that research has been inconclusive. . . I am not aware of any study that even attempts to find a beneficial effect from the use of glucosamine or chondroitin on disk disease or other disorders of the spine. Generally, however, it is believed that, if glucosamine and/or chondroitin have any beneficial effect on osteoarthritis, it is because of its effect on articular cartilage. This effect would not address the common mechanisms that produce disk pain or muscular back pain.

I am not aware of any research that would indicate that Methyl Suflonyl [sic] Methane, or any similar product, is effective for the treatment of low back pain, regardless of the mechanism. (Exhibit No. 2)

STAT was obligated to prove the efficacy of G/C 1000 and MSM for the purposes prescribed, that is, to treat Claimant’s lumbar myofacial pain. Dr. Harris stated that, in his opinion, “these items are medically necessary” because they will “promote healing of the joint tissues and reduce pain” associated with Claimant’s injury. Without further explanation, however, Dr. Harris’ opinion is unconvincing, particularly in light of Dr. Tsourmas’ affidavit.

Dr. Tsourmas’ opinion that neither G/C 1000 nor MSM has been proven effective in treating injuries to the spine, including the intravertebral disks, or to the soft tissue surrounding the spine, is persuasive. The Judge finds Dr. Tsourmas’ opinion is convincing because, not only is Dr. Tsourmas board certified in orthopedic surgery, he provided the basis for his opinion that the prescribed medications are ineffective in treating Claimant’s lumbar myofacial pain. Dr. Tsourmas noted that any beneficial effect of glucosamine and chondroitin on osteoarthritis is due to its effect on articular cartilage; however, this effect does not address the common mechanism that produces disk pain or muscular back pain. Additionally, Dr. Tsourmas pointed out that no research indicates MSM is effective for the treatment of low back pain, regardless of the mechanism.

Therefore, the Judge concludes that STAT has failed to meet its burden of proving that the medications G/C 1000 and MSM Plus were medically necessary for the treatment of Claimant’s compensable injury within the meaning of TEX. LAB. CODE §§ 401.011(19) and 408.021(a).

III. FINDINGS OF FACT

  1. Injured worker____ (Claimant) sustained a compensable worker’s compensation injury to her lower back on_____.
  2. On May 6, June 6, and July 6, 2000, Scientific Therapy and Advanced Treatment (STAT) provided Claimant $306.00 worth of glucosamine hydrochloride and chondroitin sulfate (G/C 1000) and methyl sulfonyl methane (MSM) that had been prescribed by Claimant’s treating physician, Scott Harris, D.C.
  3. STAT requested reimbursement from Insurance Company of the State of Pennsylvania (Carrier), which Carrier denied.
  4. STAT timely submitted a request for dispute-resolution review to the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission).
  5. MRD issued its findings and decision on May 11, 2001, concluding that the disputed expenses should be denied.
  6. STAT filed a timely request for a hearing.
  7. Notice of the hearing was issued June 21, 2001.
  8. The hearing was convened on May 6, 2002. STAT and Carrier appeared through their representatives. The staff of the Commission did not appear. The hearing adjourned that same day.
  9. Claimant’s diagnosis is lumbar myofacial pain.
  10. Neither G/C 1000 nor MSM has been proven effective in treating injuries to the spine, including the intravertebral disks, or to the soft tissue surrounding the spine.

a.Any beneficial effect of glucosamine and chondroitin (G/C) on osteoarthritis is because of G/C’s effect on articular cartilage, and this effect does not address the common mechanisms that produce disk pain or muscular back pain.

b.Methyl sulfonyl methane is ineffective for the treatment of low back pain, regardless of the mechanism.

  1. G/C 1000 and MSM are ineffective in treating Claimant’s lumbar myofacial pain.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to TEX. LAB. CODE (Labor Code) § 413.031.
  2. The State Office of Administrative Hearings has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Labor Code § 413.031 and TEX. GOV’T CODE (Gov’t Code) ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Gov’t Code §2001.052.
  4. STAT has the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 TEX. ADMIN. CODE § 148.21(h).
  5. Based upon Findings of Fact Nos. 10 and 11, STAT failed to prove by a preponderance of the evidence that G/C 1000 and MSM were medically necessary for the treatment of Claimant’s compensable injury within the meaning of Labor Code § 408.021.
  6. STAT is not entitled to reimbursement of $306.00 from Carrier.

ORDER

Scientific Therapy and Advanced Treatment’s request for reimbursement of $306.00 from Insurance Company of the State of Pennsylvania is denied.

Issued this 27th day of March, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CAROL WOOD
Administrative Law Judge

  1. The Commission was unable to locate the documents upon which MRD based its decision.
  2. The exhibits were eventually discovered in another SOAH case file.
  3. MRD did agree with Petitioner that preauthorization is not required on DME items of less than $500.00.
End of Document
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