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At a Glance:
Title:
453-01-3445-m5
Date:
May 16, 2002
Status:
Retrospective Medical Necessity

453-01-3445-m5

May 16, 2002

DECISION AND ORDER

I. SUMMARY

Petitioner Alpha Pharmacy seeks reimbursement for prescription medications from Reliance National Indemnity Company (Carrier). The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement of $633.84 for the following prescription medications: Neurotin ($237.84); Trazodone ($104.32); Hydrocodone ($4); and Effexor-XR ($161.24). These medications were prescribed to alleviate lower back pain allegedly associated with a September 12, 1996, injury suffered by workers’ compensation Claimant, ____. Petitioner challenges that denial. Based on the evidence, the Administrative Law Judge (ALJ) concludes that Petitioner’s claim for reimbursement should be denied.

The ALJ convened a hearing on these issues on March 28, 2002. The hearing concluded and the record closed that day. The Petitioner was represented by Nicky Otts; the Carrier was represented by Steven Tipton; the Commission did not participate in the hearing.

II. EVIDENCE AND BASIS FOR DECISION

The record in this case consisted of the 47-page certified record of the MRD proceeding and additional documentation submitted by the Carrier. No additional evidence was offered during the hearing.

The ALJ finds that the Petitioner failed to establish that the disputed items were medically necessary. The only supporting documentation offered by Petitioner is a rather conclusory letter dated January 4, 2001, from the prescribing doctor, the substantive portion of which provides:

(The Claimant) was treated by me in regards to a _____ work injury to the lower back. He presented with severe lower back pain with pain radiating down the left lower extremity. In addition, he has associated burning, numbness, and tingling with his radiating pain. He carries diagnoses of lumbar radiculitis, cervicalgia and cervical myofascial pain.

I prescribed Celebrex as an anti-inflammatory, Hydrocodone for pain, Neurotin for the neuropathic components of his pain, Trazodone to help him sleep and Effexor-XR for his depression relative to his chronic pain syndrome. These medications have been of good benefit in helping to control his pain.

This statement, which stands alone in the record in support of the prescribed suite of medications, provides inadequate documentation to establish the medical necessity for these items for a four and one half year old injury to the Claimant. There are no office visit progress notes to indicate that the medications were promoting recovery or enhancing the Claimant’s ability to return to work or maintain employment. There is no indication the pain was being charted on any kind of scale over the extensive period of time since the injury to assess the need and effectiveness of the medications on this claimant, and there is no indication of the expected duration of the ongoing treatment regime.

In addition to this lack of documented justification for the prescribed medications, there are also affirmative indications in the record that the medication was unnecessary. The documentation offered by the Carrier indicates the extent of the Claimant’s 1996 injury was a lumbosacral strain and that an MRI indicated no objective abnormalities. Additionally, a March 2000 examination of the Claimant revealed signs of symptom magnification. Given this state of the record, the ALJ cannot conclude that the Petitioner has shown the prescribed medications to be medically necessary.[1]

III. FINDINGS OF FACT

  1. On_________, ______ (Claimant) suffered a compensable injury to his back.
  2. The Claimant’s injury is covered by worker’s compensation insurance written for the Claimant’s employer by Reliance National Indemnity Company (Carrier).
  3. Petitioner Alpha Pharmacy seeks reimbursement of $633.84 from the Carrier for the following prescription medications it filled for the Claimant: Neurotin ($237.84); Trazodone ($104.32); Hydrocodone ($130.44); and Effexor-XR ($161.24).
  4. The Carrier denied reimbursement of the amounts identified in Finding of Fact No. 3.
  5. Petitioners timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  6. The MRD issued its findings and decision on May 17, 2001, concluding that the disputed expenses should be denied, and Petitioner timely appealed this decision.
  7. There is inadequate documentation in support of the prescribed medications to establish their medical necessity for a four and one half year old injury to the Claimant.
  8. There are no office visit progress notes to indicate that the medications are promoting recovery or enhancing the Claimant’s ability to return to work or maintain employment.
  9. There is no indication the Claimant’s pain was being charted on any kind of scale over the extensive period of time since the injury to assess the need for and effectiveness of the medications on the Claimant, and there is no indication of the expected duration of the ongoing treatment regime.
  10. The Claimant’s ____ injury consisted of a lumbosacral strain. An MRI indicated no objective abnormalities.
  11. A March 2000 examination of the Claimant revealed signs of symptom magnification.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code §413.031.
  2. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a Decision and Order, pursuant to Tex. Labor Code §413.031 and Tex. Govt. Code ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements of Tex. Govt. Code §2001.052 in that it 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 section of the statutes and rules involved; and a short plain statement of the matters asserted.
  4. Petitioner 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. Petitioner did not prove by a preponderance of the evidence that the disputed items provided to the Claimant were medically necessary. Tex. Labor Code §408.021.
  6. Petitioner is not entitled to reimbursement.

ORDER

The claim by Petitioner, Alpha Pharmacy, for payment from Reliance National Indemnity Company is denied.

Issued May 16, 2002.

Kerry D. Sullivan
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. As has been expressed in other SOAH dockets, the ALJ is sympathetic to the plight of the pharmacy in this proceeding. It appears to have acted in good faith and in reliance on a valid prescription by a medical doctor. Nevertheless, the Commission’s rules place the burden of proof in this proceeding squarely upon the Petitioner, and the ALJ cannot relieve the Petitioner of this regulatory responsibility. 28 Tex. Admin. Code §148.21(h)
End of Document
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