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At a Glance:
Title:
453-01-3468-m5
Date:
June 12, 2002
Status:
Retrospective Medical Necessity

453-01-3468-m5

June 12, 2002

DECISION AND ORDER

This case is a dispute over whether reimbursement is appropriate (Claimant) sustained a compensable injury on. On January 19, 2001, EZ Rx Pharmacies (Provider) furnished a prescription of Viagra for Claimant. Provider billed Employers Insurance of Wausau (Carrier) for this prescription. Carrier denied payment to Provider. The amount in controversy is $3.

Provider appeared and was represented by Nicky Otts. Carrier appeared and was represented by Shannon P. Butterworth, attorney. The Administrative Law Judge (ALJ) concludes the Provider is not entitled to any reimbursement.

I.

DISCUSSION

Background Facts

Claimant, __________ , sustained a compensable injury on, as a result of someone pulling a chair from under Claimant as he was attempting to sit down. Claimant was diagnosed with a lumbar strain and underwent treatment from 1992 to 1994. During his years of treatment for lumbar strain, Claimant did not complain of erectile dysfunction. At some point in time, Claimant began suffering from erectile dysfunction; however, the record is not clear when he first complained of these symptoms. Claimant received a medical prescription for Viagra to treat his erectile dysfunction. Provider filled the prescription.

B. Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the Act) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. §408.021 provides in pertinent part:

(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.

Analysis

Although it is not clear when Claimant first complained of erectile dysfunction, it is clear that Claimant began treating this condition almost nine years after his compensable injury. Provider asserts it is owed $103.33 for filling a prescription of Viagra to treat Claimant’s erectile dysfunction which was caused by the compensable injury. The only evidence supporting Provider’s position is a letter from Dr. Salvador P. Baylan, dated January 18, 2001. In this letter, Dr. Baylan asserts the problem of erectile dysfunction places a strain on Claimant’s rehabilitation because Claimant is no longer able to maintain a healthy relationship.

The record does not sufficiently reflect how the Claimant’s current erectile dysfunction is a result of his compensable injury of May 4, 1992.

In this proceeding, Provider has the burden of proving the medical prescription of Viagra cures or relieves the effects of his compensable injury. There simply is no evidence to support Provider’s position that the lumbar strain injury sustained in ______is a direct cause of Claimant’s erectile dysfunction almost nine years later. Consequently, the claim should be denied.

II.

FINDINGS OF FACT

  1. Claimant, ______ suffered a compensable injury on.
  2. From 1992 to 1994, Claimant was treated for lumbar strain.
  3. At an unspecified time, Claimant began suffering from erectile dysfunction.
  4. Claimant did not complain of erectile dysfunction during his 1992 - 1994 treatment for lumbar strain.
  5. On January 19, 2001, Claimant received a medical prescription for Viagra to treat his erectile dysfunction.
  6. EZ Rx Pharmacies (Provider) filled the prescription of Viagra.
  7. Provider billed Employers Insurance of Wausau (Carrier) for the Viagra prescription it filled on January 19, 2001.
  8. Carrier denied reimbursement for the prescription, claiming it was not medically necessary.
  9. Provider filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the prescription.
  10. On June 8, 2001, the Commission’s Medical Review Decision (MRD) found Provider was not entitled to reimbursement for the Viagra prescription.
  11. Carrier timely filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  12. Notice of the hearing was sent July 16, 2001.
  13. 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.
  14. The hearing was held April 16, 2002, with ALJ Steven M. Rivas presiding and representatives of the Carrier and Provider participating. The hearing was adjourned the same day.
  15. There is no evidence Claimant’s erectile dysfunction is related to his compensable injury.

III.

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. The Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code § 148.21(h).
  5. 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 in accordance with Tex. Lab. Code Ann. § 408.021.
  6. Provider failed to offer sufficient evidence that it is entitled to reimbursement for the Viagra prescription filled on January 19, 2001.
  7. Pursuant to the foregoing Findings of Facts and Conclusions of Law, Provider is not entitled to any reimbursement.

ORDER

IT IS, THEREFORE, ORDERED that Provider, EZ Rx Pharmacies, is not entitled to any reimbursement from Carrier, Employers Insurance of Wausau, for the Viagra prescription filled on January 19, 2001.

Signed this 12th day of June, 2002.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

End of Document
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