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At a Glance:
Title:
453-02-0521-m5
Date:
August 29, 2002
Status:
Retrospective Medical Necessity

453-02-0521-m5

August 29, 2002

DECISION AND ORDER

I. SUMMARY

This case involves a dispute over the decision by Texas Mutual Insurance Company (Carrier) to not reimburse James Woessner, M.D (Provider) for treatment provided to ___, an injured employee. After considering the evidence and legal arguments, the Administrative Law Judge (ALJ) finds that Carrier is not liable to reimburse Provider for the treatment in issue because the steroidal injections given were not medically necessary.

I. Discussion

Nine steroidal injections are in dispute for the following dates in 2000: April 3, 10, 17, and 25; May 2,15, 18, 22, and 30, and June 6 and 12. During each office visit, Provider gave steroidal injections to ___. to help alleviate pain resulting from a compensable injury. After considering the evidentiary record, the ALJ concludes that Provider has not shown by a preponderance of the evidence that the steroidal injections were reasonable and necessary medical treatment for ___

Provider testified that the injections were a proper course of treatment and helped alleviate D. E.’s pain. The treatment notes reflect that ___’s pain was alleviated for short periods of time (up to three or four days, in general) after the injections. The injections were not done under fluoroscopic control. In response, Carrier presented the testimony of Dr. Robert Joyner who concluded that the injections were not having any meaningful benefit to ___and should be discontinued because they posed a risk of harm. Dr. Joyner clearly stated his conclusion that the injections were not medically necessary, were not standard medical care, and were not reasonable in their frequency. Carrier also presented the deposition testimony of Dr. Brian Buck, who testified that the injections would have to have been done under x-ray fluoroscopic control to be effective at all. Further, Dr. Buck concurred with Dr. Joyner’s conclusion that the injections were not medically necessary, pointing out that the injections did not result in long-lasting improvement to ___.’s pain levels.

After considering all of the testimony, the ALJ finds Dr. Joyner’s testimony and Dr. Buck’s detailed deposition testimony to be more persuasive than Provider’s summary conclusions. Therefore, the ALJ concludes that because the steroidal injections did not provide ___ with significant medical benefit, they were not medically necessary.

For the reasons identified above, and as set forth in the findings of fact and conclusions of law below, Provider has not shown by a preponderance of the evidence that the treatments in issue were medically reasonable and necessary. Therefore, reimbursement is denied as to all amounts sought.

II. Findings of Fact

  1. ___ suffered a compensable injury to his back on or about_________. At the time of the injury Texas Mutual Insurance Company (Carrier) was the workers’ compensation insurance carrier for ___’s employer.
  2. ___underwent surgery for his injury. After his surgery, ___was seen by James Woessner, M. D., (Provider) for pain relief and management for his’s injury.
  3. ___saw Provider on the following dates in issue in 2000: April 3, 10, 17, and 25; May 2,15, 18, 22, and 30, and June 6 and 12.. On each of those dates Provider provided steroidal injections to ___
  4. The steroidal injections given to D. E by Provider were not medically necessary because they did not provide significant benefits and posed a significant risk of substantial harm to ___.
  5. Provider billed Carrier the total sum of $2,442.00 for the steroidal injections provided to ___.
  6. Carrier denied reimbursement for the injections on the basis that they were not medically necessary.
  7. Provider filed a Request for Medical Dispute Resolution with the Commission, seeking reimbursement for the treatment of ___
  8. The Commission’s Medical Review Division (MRD) determined that Provider was not entitled to any reimbursement.
  9. Carrier filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  10. Notice of the hearing was sent on November 7, 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 held on June 4, 2002, with Administrative Law Judge John H. Beeler presiding and representatives of the Carrier and Provider participating. The hearing was adjourned the same day but the record was left open through July 2, 2002, for the filing of briefs.

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. The Provider timely filed its notice of appeal, as specified in 28 Tex. Admin. Code §148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code Ann.§2001.052 and 28 Tex. Admin. Code §148.4.
  5. The Provider has the burden of proof on its appeal by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. §413.031 and 28 Tex. Admin. Code §148.21(h).
  6. Provider is not entitled to be reimbursed for the steroidal injections given between April 3, 2000, and June 12, 2000, because such injections were not medically necessary.

ORDER

IT IS ORDERED that the appeal by is James Woessner, M.D DENIED. Texas Mutual Insurance Company is not required to reimburse James Woessner, M.D for any of the services in issue in this proceeding.

Signed August 29th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JOHN H. BEELER
Administrative Law Judge

End of Document
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