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At a Glance:
Title:
453-02-0527-m5
Date:
April 15, 2002
Status:
Retrospective Medical Necessity

453-02-0527-m5

April 15, 2002

DECISION AND ORDER

I. SUMMARY

Highpoint Pharmacy (Petitioner or Highpoint) seeks reimbursement of $243.65 from Insurance Company of the State of Pennsylvania (Carrier). for glucosamine hydrochloride and chondroitin sulfate (G/C 1000) and methyl sulfonyl methane (MSM) prescribed for and provided to injured worker ___(Claimant). The Administrative Law Judge (ALJ) concludes Highpoint failed to meet its burden of proving that G/C 1000 and MSM were medically necessary or that the requested amounts were fair and reasonable.

II. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

This proceeding presented no contested issues of jurisdiction or notice. Therefore, those matters are set out in the findings of fact and conclusions of law without further discussion here.

The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) issued its amended findings and decision on September 19, 2001. MRD denied reimbursement to Highpoint for G/C 1000 and MSM supplied Claimant on September 8, 2000, determining Petitioner failed to prove those items were medically necessary for the treatment of Claimant’s injury. MRD denied reimbursement to Highpoint for G/C 1000 and MSM supplied Claimant on October 27, 2000, determining Petitioner failed to prove fair and reasonable reimbursement. Highpoint filed a timely request for hearing.

The undersigned ALJ convened a hearing on those issues on February 4, 2002. Randy Burgett appeared for Petitioner. Scott Bouton, attorney, appeared for Carrier. The hearing was adjourned the same day and the record was closed.

III. DISCUSSION

Fair and Reasonable

Highpoint submitted a claim for G/C 1000 and MSM supplied Claimant on September 8, 2000. Carrier denied the claim with the explanation “M - Services or supplies not normally charged for.” (Ex. No. 1, p. 27). Because no maximum allowable reimbursement (MAR) for G/C 1000 and MSM has been set by the Commission, Highpoint has the burden to prove the amounts billed are fair and reasonable. There is no evidence demonstrating the amounts billed on September 8, 2000, are fair and reasonable. The ALJ, therefore, concludes Highpoint has failed to meet its burden.

Medical Necessity

Highpoint submitted a claim for G/C 1000 supplied Claimant on October 27, 2000. Carrier denied the claim with the explanation “R - Reimbursement withheld - Charge unrelated to compensable injury.” (Ex. No. 1, p. 24). In support of its claim that G/C 1000 was medically necessary, Highpoint submitted a letter dated January 17, 2001, written by Johann Van Beest, D.C., Claimant’s treating doctor. In the letter, Dr. Van Beest states:

In the case of [Claimant], an injury has occurred to the right wrist. Damaged tissue and joint structure has resulted.

* * *

Patients who are given the use of [G/C] for the treatment of joint and spinal damage will experience regeneration of the damaged joint and cartilagenous [sic] areas, as well as pain relief. . . . (Ex. No. 1, pp.30 - 31).

Highpoint also submitted a claim for MSM supplied Claimant on October 27, 2000, and Carrier denied that claim for the same reason as above. (Ex. No. 1, p. 24). In support of its claim that MSM was medically necessary, Highpoint submitted a letter dated January 17, 2001, written by Dr. Van Beest. In the letter, Dr. Van Beest states:

The following is to note that we have requested for the patient,___., MSM Plus to ease in particular the ongoing pain levels that the patient does have. These pain levels do involve the right wrist area. The patient does have ongoing levels of pain which thus far do remain strong. The purpose and intent of the oral agent, is that it has in clinical trails shown favorable and positive effects on conditions similar to that of [Claimant].

It is known further that [MSM] is known to promote the healing of joint tissues, as well as reduce joint pain when used on an ongoing basis. In particular, joint pain due to injury is addressed, as is muscle pain and cramping.

* * *

MSM is known to relieve pain and inflammation, which [Claimant] is experiencing in the area of the right wrist. . . . (Ex. No. 1, pp. 32 - 33).

The ALJ concludes Highpoint has failed to meet its burden of proving that G/C 1000 and MSM were medically necessary for the treatment of Claimant’s compensable injury.[1] Although the parties apparently agree Claimant has a compensable injury, the record is unclear what that injury actually is. Dr. Van Beest’s letter concerning G/C 1000 indicates Claimant has sustained an injury to the right wrist. However, “wrist injury” is an insufficient diagnosis of Claimant’s condition. Without a specific diagnosis of Claimant’s condition, Dr. Van Beest’s letter fails to prove G/C 1000 is medically necessary to treat Claimant’s compensation injury. And Dr. Van Beest’s letter regarding MSM fails to explain why MSM is more effective than any other pain reliever, and thus medically necessary, for treating Claimant’s injury.

IV. FINDINGS OF FACT

  1. Highpoint Pharmacy (Highpoint) provided $54.50 worth of glucosamine hydrochloride and chondroitin sulfate (G/C 1000) and $90.00 worth of methyl sulfonyl methane (MSM) to injured worker ___(Claimant) on September 8, 2000.
  2. Highpoint provided $45.65 worth of G/C 1000 and $53.50 worth of MSM to Claimant on October 27, 2000.
  3. Claimant’s treating doctor, Johann Van Beest, D.C., prescribed G/C 1000 and MSM for Claimant.
  4. Highpoint requested reimbursement totaling $243.65 from Insurance Company of the State of Pennsylvania (Carrier) for the items identified in Findings of Fact Nos. 1 and 2. Carrier denied reimbursement.
  5. Highpoint filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission (Commission).
  6. On September 19, 2001, the Commission’s Medical Review Division (MRD) issued its amended decision, determining Highpoint should not be reimbursed.
  7. Highpoint filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  8. Notice of hearing was issued November 7, 2001.
  9. A hearing was convened February 4, 2002, with Highpoint and Carrier appearing through their representatives. Staff of the Commission did not appear. The hearing adjourned the same day.
  10. The record is unclear what compensable injury Claimant has sustained.
  11. No documentation or other evidence was in the record to establish that the amounts billed for the G/C 1000 and MSM prescribed and provided Claimant on September 8, 2000, were fair and reasonable.
  12. The evidence failed to demonstrate the medical necessity of the prescribed G/C 1000 and MSM provided Claimant on October 27, 2000.

a.“Wrist injury” is an insufficient diagnosis of Claimant’s condition.

b.Without a specific diagnosis of Claimant’s condition, Dr. Van Beest’s letter of January 17, 2001, is insufficient to prove G/C is medically necessary to treat Claimant’s compensable injury.

c.Dr. Van Beest’s letter of January 17, 2001, fails to explain why MSM is more effective than any other pain reliever, and thus medically necessary, for treating Claimant’s compensable injury.

V. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. Labor Code (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 Labor Code §413.031 and Tex. Gov’t Code (Gov’t Code) ch. 2003.
  3. The Notice of Hearing issued by the Commission conformed to the requirements ofGov’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. Highpoint Pharmacy (Highpoint) has the burden of proving by a preponderance of the evidence that it should prevail in this matter. 28 TEX. ADMIN. CODE §148.21(h).
  5. Based upon Findings of Fact Nos. 10 - 12, Highpoint failed to prove by a preponderance of the evidence that the disputed items prescribed and provided to Claimant were medically necessary or that the requested amounts were fair and reasonable within the meaning of Labor Code §408.021.
  6. Highpoint failed to show it is entitled to reimbursement.

ORDER

The claim by Petitioner, Highpoint Pharmacy, for payment of $243.65 from Insurance Company of the State of Pennsylvania is denied.

Issued this 15th day of April, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CAROL WOOD
Administrative Law Judge

  1. In its Explanation of Reimbursement, Carrier’s only reason for denying Highpoint’s October 27, 2000, claim was that the charges were “unrelated to compensable injury.” Neither party at the hearing argued medical necessity was not properly before MRD and the ALJ. Instead, both parties’ arguments pertained solely to the issue of medical necessity. Therefore, the ALJ’s decision regrading that claim is limited to the issue of medical necessity.
End of Document
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