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At a Glance:
Title:
453-02-0526-m5
Date:
January 16, 2002
Status:
Retrospective Medical Necessity

453-02-0526-m5

January 16, 2002

DECISION AND ORDER

I. PROCEDURAL HISTORY

Petitioner, EZ RX Pharmacies, seeks reimbursement from Colonial Casualty Insurance Company (the Carrier) for $828.12 for prescription medications provided to workers compensation claimant ___. The Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement for the charges, and Petitioner appealed the denial.

The Administrative Law Judge (ALJ) convened a hearing on the appeal on January 3, 2002. The hearing was concluded and the record closed on that date. Randy Burgett, Petitioner’s chief operating officer, represented Petitioner; the Carrier was represented by attorney Dan Kelley.

II. EVIDENCE AND BASIS FOR DECISION

The documentary record in the case consisted of the 20-page certified record of the MRD proceeding. Mr. Burgett testified and argued on behalf of Petitioner. Based on the evidence, the ALJ concludes that Petitioner’s claim should be approved. The particular facts, reasoning, and legal analysis in support of this decision are set forth in the Findings of Fact and Conclusions of Law. In summary, however, the ALJ accepts Mr. Burgett’s testimony that treating physician Bill E. Weldon prescribed the medications that were medically necessary to relieve Claimant’s symptoms that resulted from the compensable injury. Petitioner provided the medications to Claimant pursuant to Dr. Weldon’s prescription. The ALJ agrees that (a) medical necessity was established; (b) the Carrier did not comply with Commission rule 133.304(g) related to peer reviews; and (c) the MRD erred when it denied reimbursement.

III. FINDINGS OF FACT

  1. On _________, ___________ (Claimant) suffered a compensable injury to his neck, back and upper extremities when he slipped off a ladder, seven to eight feet high, landing on his left side. He used his arms or hands to break his fall.
  2. Claimant’s injury was covered by worker’s compensation insurance written for Claimant’s employer by Colonial Casualty Insurance Company (the Carrier).
  3. Bill E. Weldon, D.O., treated Claimant for the neck and back injury that he sustained. He administered prescription medications to Claimant, in addition to other treatments.
  4. On August 25, 2000, Petitioner EZ RX Pharmacies supplied Claimant hydrocodone, vanadom and valium as prescribed by Dr. Weldon.
  5. Petitioner submitted a charge to the Carrier for the cost ($828.12) of the medications.
  6. In September 2000, the Carrier denied reimbursement of the charge indicated above as unnecessary medical treatment per peer review by a doctor of chiropractic. The Carrier did not send Petitioner a copy of the peer review report.
  7. Dr. Weldon submitted a letter dated October 2, 2000, indicating the medications described in Finding No. 4 were medically necessary to treat Claimant’s neck and back pain and rigidity, the weakness and paresthesias in his limbs, the muscle spasms in his back, as well as Claimant’s anxiety due to chronic pain syndrome.
  8. Petitioner sent a copy of Dr. Weldon’s letter to the Carrier.
  9. In November 2000, the Carrier denied reimbursement of the expenses as a duplicate charge.
  10. The Petitioner timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  11. The MRD issued its findings and decision on September 21, 2001, concluding the disputed expenses should be denied because the documentation did not substantiate the necessity for the medication.
  12. Petitioner timely appealed the MRD’s decision.
  13. Prior to the MRD’s decision, Petitioner had not been advised the documentation submitted to justify the charges for the prescription medications was insufficient.
  14. The peer review conducted at the request of the Carrier was done by a doctor of chiropractic; Claimant’s treating doctor was an osteopath.
  15. The medications prescribed by Dr. Weldon and provided by Petitioner were medically necessary treatment for Claimant’s symptoms identified in Finding 7.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Lab. CodeAnn. §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 §413.031 of the Act and Tex. Gov’t Code ch. 2003.
  3. The notice of hearing issued by the Commission 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. Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter pursuant to 28 Tex. Admin. Code §148.21(h) and (i).
  5. The prescribed medications provided to the Claimant by Petitioner were medically necessary and permitted by§408.021 of the Act.
  6. The documentation supplied by Petitioner was sufficient to establish medical necessity.
  7. The Carrier did not comply with 28 TAC §133.304(g) related to disputing a claim based on a peer review.
  8. Pursuant to § 408.027(d) of the Act, the Carrier waived any grounds for non-reimbursement that it did not raise at the time medical dispute resolution was requested.
  9. Petitioner should be reimbursed $828.12 for the prescription medications it provided to Claimant.

ORDER

IT IS THEREFORE, ORDERED that Colonial Casualty Insurance Company reimburse Petitioner for the prescription medications provided to Claimant in the amount of $828.12 plus accrued interest.

Issued this 16th day of January 2002.

RUTH CASAREZ
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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