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At a Glance:
Title:
453-01-3457-m5
Date:
June 5, 2002
Status:
Retrospective Medical Necessity

453-01-3457-m5

June 5, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner Plaza Pharmacies (Provider) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC) denying reimbursement from Respondent, Federal Insurance Company (Carrier), for prescription medication provided to Claimant. This decision orders the Carrier to reimburse the Provider $768.10[1] for the medication.

The Administrative Law Judge convened a hearing on April 10, 2002. The hearing was concluded and the record closed that date. The Petitioner appeared by telephone through its president, Nicky Otts. The Carrier was represented Robert Josey, attorney.

II. EVIDENCE AND BASIS FOR DECISION

The issue presented in this preceding is whether the Carrier should reimburse the Provider $768.10 plus interest for prescription medications consisting of Lortab, a narcotic analgesic; Celebrex, a Cox-2 inhibitor (pain reliever); and Vanadom, a skeletal muscle relaxant. The Carrier denied reimbursement on the basis the prescriptions were unnecessary for the treatment of the Claimant's compensable injury per peer review. The Provider argued that the Carrier did not comply with TWCC rules which require:

  1. A peer review must be conducted by a licensed health care provider of the same or similar speciality as the performing health care provider; and
  2. The Carrier must provide a copy of the peer reviewer's report to the Provider.[2]

The documentary record in this case consisted of the 94-page certified record of the MRD proceeding (Exh. 1). Neither Party offered oral testimony.

The certified record contained TWCC-62 forms which provided that payment for the prescriptions was denied because a peer review found that the prescriptions were unnecessary treatment. The certified record also contained several utilization reviews conducted by a registered nurse. There was not a peer review in the certified record.

Based on the evidence, the ALJ concludes that consistent with Petitioner's arguments, the appeal should be granted. The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law.

III. FINDINGS OF FACT

  1. On (date of injury) (Claimant) suffered a compensable injury to her lumbar spine.
  2. Claimant's injury is covered by worker's compensation insurance provided for Claimant's employer by Federal Insurance Company (Carrier).
  3. Claimant's treating physician prescribed Lortab, a narcotic analgesic; Celebrex, a Cox-2 inhibitor (pain reliever); and Vanadom, a skeletal muscle relaxant.
  4. Plaza Pharmacies (Provider) filled the prescriptions referred to in Finding of Fact No. 3.
  5. Payment for the prescriptions referred to in Finding of Fact No. 3 was denied by the Carrier on the basis that the prescriptions were unnecessary treatment per peer review.
  6. A peer review was not conducted by a health care provider who was licensed in the same or similar speciality as the Provider.
  7. The Carrier failed to provide a copy of a peer reviewer's report to the Provider.
  8. The Provider timely requested dispute resolution by the Texas Workers= Compensation Commission Medical Review Division (MRD).
  9. The MRD issued its findings and decision on May 31, 2001, concluding that the disputed expenses should not be paid, and the Petitioner timely appealed this decision.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers= Compensation Commission (TWCC) 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. Gov=t Code ch. 2003.
  3. The Notice of Hearing issued by TWCC conformed to the requirements of Tex. Gov=t 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. 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. Tex. Labor Code '408.021 (a).
  5. The Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code '413.031.
  6. Based on Findings of Fact Nos. 5 - 7, the Carrier failed to properly deny payment based on a peer review. 28 Tex. Admin. Code ' 133.304 (g) and (h).
  7. The Carrier should reimburse the Petitioner for prescriptions filled to treat the Claimant in the amount of $768.10 plus interest.

ORDER

IT IS, THEREFORE, ORDERED that the Federal Insurance Company reimburse Plaza Pharmacies for prescriptions filled in treating the Claimant in the amount of $768.10.

Issued this 5th day of June 2002.

MICHAEL J. BORKLAND
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The Commission Statement of Matters Asserted filed in this cause provided that the amount in dispute is $768.10. The MRD Decision indicated that the amount billed is $768.10, while the MAR is $760.30. The Provider placed the amount of $762.32 in dispute when medical dispute resolution was requested. The Parties did not mention a particular amount at the hearing and the ALJ assumes that the amount stated in the Commission Statement of Matters Asserted is the amount in controversy.
  2. 28 TEX. ADMIN. CODE ' 133.304 (G) AND (H).
End of Document
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