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At a Glance:
Title:
453-02-0510-m2
Date:
January 10, 2002
Status:
Pre-Authorization

453-02-0510-m2

January 10, 2002

DECISION AND ORDER

Before me, on December 17, 2001, came on to be heard the above-referenced medical benefit dispute and after hearing the evidence and arguments by the parties the Administrative Law Judge finds as follows:

I. FINDINGS OF FACT

  1. On May 15, 2001 David Suchowiecky, M.D. requested preauthorization for 30 sessions of chronic pain management to be provided to ___________ (Claimant).
  2. The Carrier denied the request for preauthorization of 30 sessions of chronic pain management. On June 25, 2001 the Provider filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission’s Medical Review Division.
  3. On September 12, 2001 a Medical Dispute Resolution Officer with the Division issued her Findings and Decision, concluding that the proposed chronic pain management sessions were medically necessary.
  4. On October 4, 2001 the Carrier filed a timely request for hearing before the State Office of Administrative Hearings.
  5. The Claimant sustained an injury in the course and scope of her employment on _________, the extent of which injury was disputed by the carrier on June 4, 2001, June 28, 2001 and July 6, 2001.
  6. An excess of six years elapsed from the date of injury to the date the request for chronic pain management was made.
  7. There is no evidence that out patient psychotherapy was ever provided to the Claimant as required by the Mental Health Treatment Guidelines in advance of qualifying for chronic pain management under those guidelines.
  8. There is no expectation that the chronic pain management sessions would improve the Claimant’s functioning or her perception of pain at this stage of her treatment.

II. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issue of the medical necessity of the proposed treatment presented, pursuant to the Texas Workers’ Compensation Act.
  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 Section 413.031(D) of the Act and the Texas Administrative Procedures Act, Chapter 2003.
  3. The proposed 30 sessions of chronic pain management are not medically necessary or reasonably required to treat __________ compensable injury and do not meet the parameters of the Commission’s Mental Health Treatment Guidelines.
  4. Based on the foregoing, the Carrier is not liable to pay for the requested chronic pain management on behalf of the Claimant.

ORDER

IT IS ORDERED THAT the Carrier is not liable to pay for the requested chronic pain management on behalf of the Claimant.

Signed this 10th day of January, 2002.

Bill Zukauckas
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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