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At a Glance:
Title:
453-02-0774-m5
Date:
April 15, 2002
Status:
Retrospective Medical Necessity

453-02-0774-m5

April 15, 2002

DECISION AND ORDER

The issue in this case is whether the Petitioner, Highpoint Pharmacy (Highpoint), should be reimbursed $198.30 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for and provided to a workers’ compensation claimant. The Administrative Law Judge (ALJ) concludes that Highpoint failed to prove by a preponderance of the evidence that G/C 1000 and MSM were related to the claimant’s compensable injury. Therefore, she denies reimbursement.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. ch. 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. ch. 2003.

The Commission’s Medical Review Division (MRD) issued its findings and decision on September 6, 2001. Highpoint filed a timely request for hearing. Proper and timely notice of the hearing was issued November 15, 2001. The hearing was convened February 13, 2002, with the undersigned ALJ presiding. Randy Burgett appeared for Highpoint. Allain Collins appeared for Respondent, American Home Assurance Company (Carrier). The ALJ admitted into evidence the Commission’s certified record.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. Code Ann§§408.021 and 401.011. Section 408.021 states:

(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.

Section 401.011(19) defines “health care” as including “all reasonable and necessary medical . . . services”

The Petitioner has the burden of proof in this matter. 28 TAC §148.21(h).

III. Discussion

Highpoint seeks reimbursement for prescriptions dispensed on January 29 and February 23, 2001, for G/C 1000 and MSM in the total amount of $198.30. Highpoint conceded that G/C 1000 and MSM are over-the-counter vitamin supplements not approved by the Federal Drug Administration. The Carrier denied reimbursement under denial code R- Information Received from the Adjuster Does Not Indicate That the Condition/Diagnosis Is Related to the Compensable Injury and argued several grounds for the denial, including that G/C 1000 and MSM are used to treat arthritis. Both parties agreed that the Medical Dispute Resolution Officer (MDRO) erroneously expanded the scope of review in this case to medical necessity and that the proper scope of dispute was whether the prescriptions were related to the compensable injury.

The only information in the certified record about the claimant’s compensable injury is that he injured his left shoulder. Although the record includes two letters from the claimant’s treating chiropractor discussing the benefits of the prescribed vitamin supplements to joints and cartilage, nothing in those letters or the remainder of the record discloses the nature of the claimant’s shoulder injury. The ALJ could not tell from the evidence whether the claimant tore his rotator cuff or dislocated his shoulder or broke a bone or suffered some other injury. Because the ALJ could not

discern even the basic nature of the injury[1], she could not determine whether the prescribed vitamin supplements were related to the compensable injury. Therefore, the ALJ concludes that Highpoint has not met its burden of proving that the G/C 1000 and the MSM were treatments related to the compensable injury within the meaning of Tex. Lab. Code Ann. §§408.021. Because this evidentiary insufficiency disposes of the case, the ALJ need not address the other grounds the parties urged to support their respective positions.

IV. Findings of Fact

  1. The Petitioner, Highpoint Pharmacy (Highpoint), dispensed Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to a workers’ compensation claimant on January 29 and February 23, 2001.
  2. Highpoint requested reimbursement for the prescriptions from Respondent, American Home Assurance Company (Carrier) in the amount of $198.30.
  3. The Carrier denied reimbursement under denial code R with the explanation: Information Received from the Adjuster Does Not Indicate That the Condition/Diagnosis Is Related to the Compensable Injury.
  4. Highpoint filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  5. The Commission’s Medical Review Division (MRD) issued its decision denying Highpoint’s request on September 6, 2001.
  6. Highpoint filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  7. Notice of the hearing was issued November 15, 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 convened February 13, 2002, with Administrative Law Judge (ALJ) Deborah L. Ingraham presiding. Randy Burgett appeared for Highpoint. Allain Collins appeared for the Carrier. The hearing adjourned the same day.
  10. The Claimant suffered from a compensable injury to his shoulder, but no evidence was presented to describe the injury or to explain the nature or extent of the injury.
  11. The evidence presented does not demonstrate that the prescribed G/C 1000 and MSM were prescription treatments related to the compensable injury.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation 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. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.
  4. The Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Highpoint has not met its burden of proving the G/C 1000 and the MSM were treatments related to the compensable injury within the meaning of Tex. Lab. Code Ann. §§408.021.
  6. Highpoint’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Highpoint Pharmacy’s request for reimbursement for Glucosamine Hydrochloride, Chondroitin Sulfate, and Methyl Sulfonyl Methane provided to the workers’ compensation claimant on January 29 and February 23, 2001, is denied.

Issued this 15th of April, 2002.

Deborah L. Ingraham
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. In argument, Highpoint’s representative did state that the diagnosis code on the prescription indicated the claimant suffered a left sprain/strain to his shoulder or arm, but that prescription form was not offered into evidence. Moreover, had that evidence been proffered, the ALJ would have then found unconvincing Highpoint’s argument that the chiropractor’s letters establish that the treatments were related to the compensable injury. The letters state that the supplements help repair and replace damaged cartilage, which is not a treatment that appears related to healing a sprain.
End of Document
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