Your FREE and easy resource for all things Texas workers' compensation
At a Glance:
Title:
453-02-0532-m5
Date:
February 11, 2002
Status:
Retrospective Medical Necessity

453-02-0532-m5

February 11, 2002

DECISION AND ORDER

This case involves a dispute over four prescription drugs, Neurontin, Vicoprofen, Vanadom, and Diazepam. The total amount in dispute is $466.63. The Administrative Law Judge (ALJ) finds that Continental Casualty Company (the Carrier or CCC) met its burden of proof; therefore, Plaza Pharmacies (the Provider) should not be reimbursed for the prescription drugs dispensed on June 13, 2000.

I. Jurisdiction and Notice

The Texas Workers’Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the Act), Tex. Lab. Code Ann. chapter 401 et seq. The State Office of Administrative Hearings (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. chapter 2003.

Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.

II. Procedural History

The hearing was held January 8, 2002. The Carrier was represented by David L. Swanson. The Provider was represented by Randy Burgett, who appeared by telephone. The Commission did not participate in the hearing. The certified record that was before the Medical Review Division (MRD) was admitted into evidence as CCC Ex. 1. Portions of the Physician’s Desk Reference were admitted as CCC Ex. 2. Finally, chart notes from A.J. Morris, M.D. were admitted as CCC Ex. 3. Neither party presented any witnesses. After arguments from the parties, the hearing was adjourned the same day.

III. Discussion

____ (the Claimant) suffered a compensable injury on______. She injured her right index finger, underwent surgery, and suffered complications as a result of the surgery. She was treated by A.J. Morris, M.D. Dr. Morris recommended the Claimant treat her pain with four prescription drugs.

The following charges are in dispute:

Date of ServiceItemAmt. BilledAmt. Paid

6-13-00 Neurontin $118.92 $0.00

6-13-00 Vicoprofen[1] $76.68 $0.00

6-13-00 Vanadom $250.44 $0.00

6-13-00 Diazepam $20.59$0.00

Totals $466.63 $0.00

A. Parties’ Positions

The Carrier denied reimbursement for the medications because it contends that Dr. Morris did not demonstrate that the medications were medically necessary. The Carrier also asserts that Dr. Morris did not document the benefits of the medications as required by the Upper Extremities Treatment Guideline.

The Provider claims that, at the hearing, the Carrier presented additional reasons for denying reimbursement that were not initially the basis for denial. The Provider also asserts that it relies on the doctor’s documentation when it dispenses medication and assumes that the doctor as determined the medical necessity of the medications.

B. ALJ’s Analysis

The Carrier satisfied its burden of proof by showing that the medications were not medically necessary, and further by showing that the benefits of the medications were not properly documented as required by the Upper Extremities Treatment Guideline. Because the Carrier met its burden of proof, the ALJ finds that the Provider should not be reimbursed for the four medications dispensed on June 13, 2000.

Under Tex. Lab. Code Ann. §408.021(a)(1-3),

(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.

“Health care,” under Tex. Lab. Code Ann. §401.011(19),

includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

Dr. Morris’ March 19, 2001, letter[2] does not show that the four medications were medically necessary. In the letter, he states that Neurontin causes a reduction in pain and burning in the extremities. He states that Diazepam controls the anxiety in this patient. He further states that Vicoprofen is needed to relief the pain from the Claimant’s injury. Finally, he states that the Vanadom is a skeletal muscle relaxant. The letter does not indicate why these medications were medically necessary for more than two years after the compensable injury. The letter merely provides an explanation as to what the medications should accomplish. Further, Dr. Morris’ chart notes from December 15, 1998, through March 16, 2000, do not indicate that these medications were medically necessary or that they benefitted the Claimant. The notes only state that Dr. Morris prescribed these medications, but the notes offer no explanation as to how these medications benefitted the Claimant as required by the Upper Extremities Treatment Guideline. CCC Ex. 2; 28 Tex. Admin. Code § 134.1002(e)(2)(A) and (e)(3)(B).

Additionally, the Carrier arranged for the Claimant’s records to be reviewed by physician advisor Curtis Spier, M.D. Dr. Spier opined that the medications were not medically necessary. He further stated that Dr. Morris had been prescribing the medications since early 1998, but there was no documentation showing that the medications benefitted the Claimant in any way. Dr. Spier concluded that the Claimant had developed a dependency on these medications and should discontinue use of these medications immediately.

Based on the evidence, the Provider is not entitled to reimbursement for the four medications dispensed on June 13, 2000.

IV. Findings of Fact

  1. The Claimant suffered a compensable injury to her right index finger on________.
  2. The Claimant was treated by A.J. Morris, M.D. for her injury.
  3. Dr. Morris recommended the Claimant treat her recurring pain with four prescription drugs, Neurontin, Vicoprofen, Vanadom, and Diazepam, which the Provider dispensed.
  4. The Carrier declined to reimburse the Provider for the four prescription drugs dispensed on June 13, 2000.
  5. The Provider filed a request for dispute resolution.
  6. The MRD ordered payment in a decision issued October 3, 2001, whereupon the Carrier requested a hearing.
  7. Notice of the hearing was mailed to the parties November 6, 2001.
  8. 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.
  9. The hearing was held January 8, 2002. The Carrier was represented by David Swanson. The Provider was represented by Randy Burgett, who appeared by telephone. The Commission did not participate in the hearing. The hearing was adjourned the same day.
  10. The following charges are in dispute:

Date of ServiceItemAmt. BilledAmt. Paid

6-13-00 Neurontin $118.92 $0.00

6-13-00 Vicoprofen $76.68 $0.00

6-13-00 Vanadom $250.44 $0.00

6-13-00 Diazepam $20.59 $0.00

Totals $466.63 $0.00

  1. The medications, Neurontin, Vicoprofen, Vanadom, and Diazepam, dispensed by the Provider on June 13, 2000, were not medically necessary to treat the compensable injury.
  2. Dr. Morris did not properly document how the Claimant benefitted from Neurontin, Vicoprofen, Vanadom, and Diazepam.

V. 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. chapter 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. chapter 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. The charges for the four prescription medications, Neurontin, Vicoprofen, Vanadom, and Diazepam, should not be reimbursed because the Carrier proved that the medications were not medically necessary, and the Carrier further demonstrated that there was no documentation showing that these medications benefitted the Claimant. 28 Tex. Admin. Code §134.1002(e)(2)(A) and (e)(3)(B).
  5. The Provider not should be reimbursed for the medications, Neurontin, Vicoprofen, Vanadom, and Diazepam, dispensed on June 13, 2000.

ORDER

IT IS, THEREFORE, ORDERED that the Petitioner, Continental Casualty Company, shall not reimburse the Respondent, Plaza Pharmacies, in the amount of $466.63, for the medications, Neurontin, Vicoprofen, Vanadom, and Diazepam, dispensed on June 13, 2000.

Signed February 11th, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Michael J. O’Malley
Administrative Law Judge

  1. Norco is a brand name for Vicoprofen.
  2. Dr. Morris’letter was written nine months after the medications were dispensed.
End of Document
Top