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At a Glance:
Title:
453-01-3447-m5
Date:
May 22, 2002
Status:
Retrospective Medical Necessity

453-01-3447-m5

May 22, 2002

DECISION AND ORDER

The issue in this case is whether Petitioner, Scientific Therapy and Advanced Treatment 2000 (STAT), should be reimbursed $ 204.00[1] for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for the workers’ compensation claimant on May 6 and July 6, 2000. The Administrative Law Judge (ALJ) concludes STAT met its burden of proving it should be reimbursed.

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 (the 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 decision May 29, 2001. STAT filed a timely request for hearing. Proper and timely notice of the hearing was issued July 11, 2001. The hearing itself was convened April 1, 2002, with the undersigned Administrative Law Judge (ALJ) presiding. Randy Burgett appeared for STAT, and Dan Flanagan appeared for Respondent Travelers Indemnity Company of Connecticut (Travelers). The Commission did not participate in the hearing. The hearing was adjourned the same day.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. Code Ann. §§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.

The Petitioner has the burden of proof in this matter. 28 TAC §148.21(h).

III. Discussion

On_______, the workers’ compensation claimant suffered a compensable spinal injury. In the spring and summer of 2000, the claimant’s treating doctor, Scott Harris, D.C., prescribed G/C 1000 and MSM to aid in the claimant’s recovery. STAT provided those products to the claimant and submitted claims for reimbursement to Travelers. See TWCC Ex. 1, pp. 16, 19. The claims used Procedure Code E1399 - Durable Medical Equipment, but also included a description of the products provided. Travelers refused to reimburse, citing Remark Code “Misc,” and adding the remark, “These services are not reimbursable under Texas Worker’s Compensation program.” TWCC Ex. 1, pp. 14, 17.

After unsuccessfully resubmitting its claims, STAT filed a Request for Medical Dispute Resolution with the Commission. The MRD denied the request on the grounds that STAT had not shown medical necessity for the prescribed products, and that the Spine Treatment Guideline does not list nutritional supplements as one of the interventions at any level of care.

Travelers argues that the MRD was correct in finding no showing of medical necessity and in determining that these kinds of products are not reimbursable at all. In addition, Travelers asserts that STAT’s use of a code for durable medical equipment was improper.

Are Nutritional Supplements Reimbursable?

The ALJ reads the carrier’s statement that “these services” are not reimbursable under the workers’ compensation program to constitute a rationale for denial separate from, and broader than, a denial based on the provider’s failure to demonstrate medical necessity. The language of Traveler’s denial implies that G/C 1000 and MSM are never reimbursable in a workers’ compensation context because they belong to a category of items not included with the universe of coverage under the workers’ compensation scheme. Questions of medical necessity, by contrast, are case-by-case inquiries, the answer to which may vary according to the facts underlying each claim.

This is a difficult issue. The nutritional supplements at issue in this case apparently do not require prescriptions, and yet treating doctors do in fact “prescribe” them for some patients with joint injuries. And the MRD is correct that the Spine Treatment Guideline does not refer specifically to the use of such products. However, since the Labor Code provides that an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury, and the definition of “health care” includes "all reasonable and necessary medical treatments . . . and medical services," the ALJ cannot say that nutritional supplements are not reimbursable as a matter of law. Further, the Spine Treatment Guideline does include “medication” as a possible treatment intervention at all levels of care; nutritional supplements, if designed to promote healing and recovery, could arguably constitute “medication.” Finally, the ALJ notes that in the Spine Treatment Guideline, the list of acceptable interventions for each stage of care is preceded by the phrase “may include but not limited to.”

The applicable statute and regulations do not support the basis of Traveler’s denial of reimbursement in this case.

B. Medical Necessity

In denying STAT’s appeal, the MRD stated concerning medical necessity, “Letter of Medical Necessity dated October 26, 2000, does not support the medical necessity of the use [sic] G/C 1000. The letter does not provide information addressing the claimant’s diagnosis, prognosis, and the expected duration these nutritional supplements will be required.”

At hearing, STAT offered an additional letter from the provider, dated June 13, 2001, providing the information the MRD had identified as missing. The letter, signed by Scott Harris, D.C., states that the G/C 1000 and MSM were prescribed in connection with the claimant’s headaches, neck strain/sprain, and panniculitis. Petitioner Ex. 1. The letter goes on to state that the patient’s prognosis was good with the use of these agents, and that he could be expected to use them for up to six months. While the letter is not extremely detailed, it addresses the deficiencies noted by the MRD, and is sufficient to provide a prima facie showing of medical necessity.

Coding

In general, it is established at SOAH that a carrier is limited to the explanation or explanations it provides when denying a claim, and cannot raise new reasons before the MRD or at SOAH. See, e.g., Docket No. 453-96-1446.M4 (Nov. 12, 1996, ALJ Corbitt); Docket No. 453-97-0973.M4 (May 14, 1998, ALJ Card); Docket No. 453-01-0309.M5 (February 7, 2001, ALJ Doherty). In this case, Travelers denied the claims solely on the grounds that G/C 1000 and MSM are not reimbursable in the workers’ compensation context. The ALJ will not, therefore, address the issue whether the claims were properly coded. [2]

IV. Findings of Fact

  1. On _______, the workers’ compensation claimant suffered a compensable spinal injury.
  2. On May 6 and July 6, 2000, the claimant’s treating doctor, Scott Harris, D.C., prescribed Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to aid in the claimant’s recovery.
  3. Scientific Therapy and Advanced Treatment 2000 (STAT) provided G/C 1000 and MSM to the claimant and submitted claims for reimbursement to Respondent Travelers Indemnity Company of Connecticut (Travelers).
  4. STAT’s claims used Procedure Code E1399 - Durable Medical Equipment, but also included a description of the products provided.
  5. Traveler’s denied reimbursement, asserting, “These services are not reimbursable under the Texas Workers Compensation program.”
  6. The amount in dispute for May 6 and July 6, 2000, is $ 204.00.
  7. After unsuccessfully resubmitting its claims, STAT filed a Request for Medical Dispute Resolution with the Commission’s Medical Review Division (MRD).
  8. The MRD denied the request on the grounds that STAT had not shown medical necessity for the prescribed products, and that the Spine Treatment Guideline does not list nutritional supplements as one of the interventions at any level of care.
  9. STAT filed a timely request for hearing.
  10. Notice of the hearing was issued July 11, 2001.
  11. 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.
  12. The hearing was convened April 1, 2002, with ALJ Shannon Kilgore presiding. Randy Burgett appeared for STAT, and Dan Flanagan appeared for Travelers. The Commission did not participate in the hearing. The hearing was adjourned, and the record closed, the same day.
  13. Dr. Harris prescribed G/C 1000 and MSM in connection with the claimant’s headaches, neck strain/sprain, and panniculitis.
  14. Claimant’s prognosis was good with the use of G/C 1000 and MSM, which promote healing and reduce pain.
  15. Claimant could be expected to use the products for up to six months.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act (the 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 TAC §148.21(h).
  5. Nothing in the Labor Code or the rules of the Texas Workers’ Compensation Commission (including the Spine Treatment Guideline) requires denial of claims for reimbursement for G/C 1000 and MSM.
  6. STAT has met its burden of proving that the G/C 1000 and MSM were medically necessary for the treatment of claimant’s compensable injury, within the meaning of Tex. Labor Code § 408.021.
  7. Since Travelers did not originally cite miscoding as grounds for denial of payment, it may not raise that issue for the first time at hearing. See, e.g., Docket No. 453-96-1446.M4 (Nov. 12, 1996, ALJ Corbitt); Docket No. 453-97-0973.M4 (May 14, 1998, ALJ Card); Docket No. 453-01-0309.M5 (February 7, 2001, ALJ Doherty).
  8. STAT is entitled to reimbursement of $ 204.00 for the products in question.

ORDER

IT IS, THEREFORE, ORDERED that Travelers Indemnity Company of Connecticut reimburse Scientific Therapy and Advanced Treatment 2000 (STAT) $ 204.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for the workers’ compensation claimant on May 6 and July 6, 2000.

Signed this 22nd of May, 2002.

Shannon Kilgore
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The record indicates that STAT is seeking review of claims relating to two separate prescribing events, one on May 6, 2000, and one on July 6, 2000 - each involving $102.00. See TWCC Ex. 1, pp. 2, 8. The decision of the Medical Review Division (MRD), however, inexplicably only addressed the claim concerning July 6, 2000. See TWCC Ex. 1, p. 3. The MRD’ failure to address the May 6, 2000, claim appears to have been an inadvertent error. Therefore, the Administrative Law Judge will consider the amount in controversy to be $ 204.00.
  2. Traveler’s did not raise the issue of medical necessity when it originally denied these claims. However, the ALJ does not find that the carrier has waived the requirement that STAT show medical necessity, since the question of medical necessity is the fundamental basis for reimbursement.
End of Document
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