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At a Glance:
Title:
453-01-3298-m5
Date:
April 23, 2002
Status:
Retrospective Medical Necessity

453-01-3298-m5

April 23, 2002

DECISION AND ORDER

The issue in this case is whether Plaza Pharmacy should be reimbursed $705.35 for the cost of a two Valium prescriptions provided to a workers’ compensation claimant (Claimant) during August and October 2000. The Administrative Law Judge (ALJ) concludes that Plaza Pharmacy did not meet its burden of proving that the Valium was medically reasonable and necessary, as required by the Texas Workers’ Compensation Commission’s Spine Treatment Guidelines. Therefore, Plaza Pharmacy’s claim for reimbursement is denied.

I. Discussion

Claimant sustained a compensable back and neck injury on_____________. He has been treated primarily with medications B Valium, Vicodin, Celebrex, and Elavil B and has not undergone any type of surgery. Although the City of Fort Worth paid many of Claimants prescriptions, it declined to pay for Valium prescriptions dated August 2, 2000 (120 tablets, 10 mg), and October 23, 2000 (360 tablets, 10 mg). The City of Fort Worth contends that continued use of Valium is not medically reasonable or necessary. Plaza Pharmacy, which filled the prescriptions, filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (the Commission). The Commission’s Medical Review Division (MRD) found in favor of the City of Fort Worth. Plaza Pharmacy appealed that decision and has the burden of proof in this proceeding. 28 Tex. Admin. Code (TAC) §148.21(h).

Claimant’s treating physician, Dr. Bill E. Weldon of Fort Worth, prescribed Valium for treatment of Claimant’s compensable injury. Plaza Pharmacy provided a “Letter of Medical Necessity” from Dr. Weldon, dated October 26, 2000, which states that Claimant sustained back, neck, and arm injuries, and that Claimant continued to experience pain and rigidity in his neck and arm. Concerning the Valium prescription, Dr. Weldon’s letter states:

Mr. RC has been prescribed Valium for treatment of muscle spasms related to spinal disc injuries. This medication is necessary to reduce excessive muscle tension and spasms related to Mr. RC’s injuries. This medication does reduce muscle spasms and stiffness and improve Mr. RC’s mobility and ability to perform normal daily activities.

The MRD record contains office notes from Dr. Weldon dated April 3, June 2, and August 2, 2000. These sparse notes list Claimant’s complaints, note the drugs prescribed, and recommend rest and “exercise as tolerated,” but they do not indicate that Dr. Weldon performed any type of physical examination of Claimant. They also show that Dr. Weldon repeatedly prescribed Vicodin, Celebrex, and Elavil, in addition to Valium. Plaza Pharmacy offered no other evidence in support of its claim.

The City of Fort Worth pointed out other medical reports contained in the MRD official record that show a consistent pattern of symptom exaggeration by Claimant with secondary gain patterns. Secondary gain refers to a patient exaggerating complaints for ulterior motives, such as seeking sympathy, financial gain, obtaining narcotic drugs, not returning to work, etc. Dr. Alan B. Hurschman, a designated doctor, issued a report on March 12, 1996, concerning a prior injury to Claimant that occurred on ____:

This [Psychological Pain Inventory] score suggests the patient is primarily an exaggerating pain patient and that preexisting personality characteristics have contributed to a more extreme response than would have otherwise occurred.

On July 15, 1998, Dr. Hooman Sedighi examined Claimant on behalf of the City of Fort Worth and reported the following:

There are definite signs of psychological overlay with the patient having multiple positive Waddell’s signs[1] on exam today. . . . I would strongly recommend against using Valium which is a central nervous system depressant and has significant side effects as well as the issue of dependency formation; therefore, I would recommend that the patient be tapered off the Valium as soon as possible. . . .

On February 18, 1999, Dr. Robert T. Myles consulted with Claimant upon referral by the treating physician, Dr. Weldon. Dr. Myles reported:

The patient failed the distraction test for straight leg test and also failed the distraction test for rotation of his body through his ankles [indicating exaggeration of symptoms.] . . . He also has some hyperexaggeration of his symptoms. . . . I think the patient is showing some supra tentorial or secondary gain patterns in his presentation of the description of his pathology and his physical exam . . . It is difficult to determine how much of this patient’s pain is realistic. . . .

On March 24, 1999, Dr. Sedighi saw Claimant a second time and reported:

Significant pain behavior during the entire exam. . . . [E]ssentially all Waddell signs positive. . . . Symptom magnification. . . . [S]ubjective complaints extremely out of proportion to objective findings . . . .The patient needs to be tapered off Valium and Vicodin. Use of these two addictive medications would not be considered medically necessary nor appropriate in this setting. . . .

Finally, on August 23, 1999, Claimant was seen by Dr. Steven D. Cohen, the designated doctor for Claimant’s__________, injury. Dr. Cohen reported:

Lumbar flexion and extension measurements were invalid based on significant variance between supine measurement and observed sitting straight leg raises [indicating symptom exaggeration.] . . . A Maximum Voluntary Effort Hand Grip Strength Test was administered. Both MVE curves for the right and left hand were considered inappropriate. . . . Overall, this would suggest that Mr. RC was giving sub-maximal effort. . . . He was unable to identify pinprick anywhere below his neck, tested with a pinwheel. . . . Waddell’s test was positive on five out of ten.

The City of Fort Worth also called Dr. Sedighi as a witness. Dr. Sedighi practices pain management in the Dallas - Fort Worth area and has been Board Certified in Physical Medicine and Rehabilitation Medicine for ten years. As discussed previously, Dr. Sedighi has examined Claimant two times and he reviewed the medical records and reports contained in the MRD official record. Dr. Sedighi testified that Claimant has a consistent history of symptom exaggeration for secondary gain. He also stated that Dr. Weldon has written repeated prescriptions for Valium for Claimant without any physical examination, without a treatment plan, without evaluating or considering the effectiveness of the medication, and apparently without considering the addictive nature of Valium.

Dr. Sedighi testified that the primary purpose of Valium in a case of this type is for muscle spasms. But Dr. Sedighi never observed muscle spasms in Claimant and Dr. Weldon never documented spasms in his office notes that are contained in the Official Record. Dr. Sedighi noted that Claimant also indicated that he was suffering from adverse side effects of Valium such as depression, fatigue, and weakness. These side effects hinder rather than enhance a claimant’s ability to return to work. Dr. Sedighi also stated that Valium can become addictive when taken regularly for as short a time as four months. In this case, Claimant had been taking Valium for over two years when the City of Fort Worth declined to pay for any additional Valium prescriptions.

The Commission concurs with the City of Fort Worth’s conclusion that the Valium was not medically reasonable or necessary for Claimant, and the Commission argues that the MRD decision should be affirmed.

III. ALJ’s Analysis

The ALJ denies Plaza Pharmacy’s claim for reimbursement. The overwhelming evidence showed that Claimant has consistently exaggerated his symptoms, apparently for secondary gain purposes. In addition, the evidence does not show that Dr. Weldon has ever evaluated the effectiveness of the Valium prescription, nor has he documented any improvement in Claimant’s condition as a result of taking Valium. Indeed, the evidence showed that Claimant is suffering from side effects of Valium that are hindering his ability to return to work.

Plaza Pharmacy contends that Dr. Weldon’s “Letter of Medical Necessity” establishes that the Valium was properly prescribed. But the ALJ finds that Dr. Weldon’s letter only contains conclusory statements that are contrary to the overwhelming weight of the evidence. Plaza also states that it filled a valid prescription issued by Claimant’s treating physician and that it is unfair to deny it payment for the drugs. But when called as an adverse witness by the City of Fort Worth, Plaza’s representative testified that Plaza is not required to fill Workers Compensation prescriptions, and it understood that payment for prescriptions could be denied if they were determined not to be medically reasonable and necessary. Under the Worker Compensation rules, Plaza is not entitled to payment merely because it filled a prescription in good faith. Rather, it must, like all other providers, establish that it is entitled to payment under the Commission’s rules. In this case, Plaza Pharmacy did not establish that it was entitled to payment. Therefore, the ALJ denies Plaza’s appeal and affirms the MRD decision to deny reimbursement.

III. Findings of Fact

  1. The Claimant sustained a compensable back injury on ___________The Claimant’s treating physician, Bill E. Weldon, D.O., continuously prescribed Valium, Vicodin, Celebrex, and Elavil for Claimant after December 4, 1997.
  2. The City of Fort Worth declined to pay for two Valium prescriptions dated August 2, 2000, and October 23, 2000. The total charge for the two prescriptions was $705.35.
  3. Plaza Pharmacy of Fort Worth, Texas, which filled the prescriptions, filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission.
  4. The Commission’s Medical Review Division (MRD) found in favor of the City of Fort Worth.
  5. Plaza Pharmacy filed a timely appeal of the MRD decision.
  6. Notice of the hearing was sent January 14, 2001. 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. At the request of Plaza Pharmacy, the hearing was continued and rescheduled from March 5, 2002, until April 16, 2002.
  7. The hearing was held April 16, 2002, with Administrative Law Judge (ALJ) Thomas H. Walston presiding and representatives of the Plaza Pharmacy and the City of Fort Worth participating. The hearing adjourned and the record closed the same day.
  8. The amount in controversy is $705.35.
  9. In his office notes and a Letter of Medical Necessity, Dr. Weldon did not document any improvement for Claimant as a result of his taking Valium.
  10. Dr. Weldon prescribed Valium for Claimant for muscle spasms, but Claimant did not have muscle spasms.
  11. Claimant has displayed adverse side effects of Valium, including depression, fatigue, and weakness. Valium is also an addictive drug. Continued use of Valium by Claimant will hinder Claimant’s ability to return to work.
  12. The evidence did not demonstrate that continued use of Valium would be medically reasonable, necessary, or beneficial for Claimant.

III. 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. Plaza Pharmacy has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. Plaza Pharmacy did not meet its burden of proving that Valium was medically reasonable or necessary for the treatment of Claimant’s compensable injury.
  6. Plaza Pharmacy’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Plaza Pharmacy’s request for reimbursement of $705.35 from the City of Fort Worth for two prescriptions for Valium dated August 2, 2000, and October 23, 2000, is DENIED, and Plaza Pharmacy shall have and recover nothing from the City of Fort Worth for the claims brought in this proceeding.

Signed April 23, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

THOMAS H. WALSTON
Administrative Law Judge

  1. Waddell signs are tests that a physician can perform during an examination to determine if a patient is faking or exaggerating symptoms.
End of Document
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