DECISION AND ORDER
Plaza Pharmacies (Petitioner or Provider) has appealed the decision of the Texas Workers’ Compensation Commission (Commission) Medical Review Division (MRD) denying its request for reimbursement of $ 255.50 from the City of Fort Worth (Carrier) for the cost of two prescriptions for the medication Meridia, which were prescribed by Claimant’s physician. The only issues are whether the prescriptions were medically necessary and reasonable.
As set out below, the Administrative Law Judge (ALJ) finds that the prescriptions were both medically necessary and reasonable and that reimbursement of $ 255.50 is due. The particular facts and reasoning in support of this decision are set forth below in the Findings of Fact, and the legal conclusions derived from those facts appear in the Conclusions of Law.
The ALJ convened a hearing on these issues on January 24, 2002, and the record closed January 24, 2002. Petitioner appeared and was represented by Nicky Otts. Respondent City of Fort Worth appeared and was represented by Shonna Macaulay of Barron Risk Management Services. The Commission did not participate in the hearing. The evidence consisted of the certified record from the MRD proceeding.
II. Findings of Fact
- The Claimant, ______, sustained a compensable work-related injury on _______, while employed by the City of Fort Worth, Texas. She suffered injuries to her neck, knee and ankle.
- On_________, more than two years after the injury, Claimant was examined by Dr. Bill E. Weldon, D.O., for treatment of persistent pain and swelling in her right knee and left foot relating to her compensable injury. Claimant was found to be 5'9" tall and weighed 304 pounds.
- On October 27, 2000, Claimant was examined again by Dr. Weldon. Dr. Weldon noted that Claimant had received prior extensive evaluation and treatment for her compensable injuries. Dr. Weldon discussed a weight reduction program with Claimant and advised her that her excessive weight would delay improvement of, and possibly aggravate, problems with her knee and ankle.
- Dr. Weldon prescribed Meridia, a medication used in weight reduction, for a period of six months.
- Plaza Pharmacies (Provider) filled the prescription ordered by Dr. Weldon on October 27, 2000, and December 21, 2000.
- The cost of those prescriptions was $ 127.75 per prescription.
- The Carrier refused to reimburse the Provider for the cost of the two prescriptions for Meridia, claiming that the weight loss medications were unrelated to the Claimant’s injury.
- Provider filed a request for reconsideration by the Carrier and forwarded a letter of medical necessity from Dr. Weldon, the treating physician.
- In the letter of medical necessity provided to Provider, Dr. Weldon noted that the Meridia medication was necessary for Claimant, who was morbidly obese, in order to reduce her weight, thereby reducing strain and wear and tear on her ankle and knee.
- Dr. Weldon’s letter justified the need for the Claimant’s weight loss, citing to medical studies that indicated even a modest weight loss of 15 pounds could reduce the Claimant’s need for a second knee arthroscopy by thirty to forty percent.
- Dr. Weldon noted a causal connection between Claimant’s weight and her lack of recovery from the injury she had sustained.
- The Claimant’s weight affects her ability to recover from her compensable injury and is an intercurrent condition.
- The Carrier did not respond to the request for reconsideration.
- On May 9, 2001, the Provider filed a request for medical dispute resolution with the MRD, asking for reimbursement of $ 255.50 for the above-described prescriptions.
- On October 10, 2001, the MRD denied the Provider’s request for reimbursement.
- On November 14, 2001, the Provider appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
- On November 15, 2001, notice of a January 24, 2002, hearing in this case was mailed to the Carrier, the Provider, and the TWCC APA Litigation Section.
- On January 24, 2002, Suzanne Formby Marshall, a SOAH ALJ, held a hearing on the Provider’s appeal at the Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas. Representatives of the Provider and the Carrier attended the hearing through a telephone appearance. The TWCC staff did not attend the hearing. The hearing concluded and the record closed on that same day.
III. Conclusions of Law
- The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented in this case, pursuant to the Texas Workers’ Compensation Act (the Act), Tex. Labor Code Ann. § 413.031 (Vernon 2001).
- SOAH has jurisdiction over matters related to the hearing in this case, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 413.031(d) and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2001).
- Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. § 2001.052.
- As the party appealing the MRD decision, the Provider has the burden of proof in this matter, pursuant to 28 Tex. Admin. Code (TAC) §148.21(h).
- Under Tex. Labor Code § 408.021 (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:
- (i)Cures or relieves the effects naturally resulting from the compensable injury;
- (ii)Promotes recovery; or
- (iii)Enhances the ability of the employee to return to or retain employment.
- Since the prescriptions at issue were prescribed and filled before March 1, 2002, the Medical Fee Guideline for Medical Treatments and Services is applicable. 28 TAC § 134.500(b).
- Because the prescriptions at issue were for treatment of a body area that was not part of the original injury, the Commission’s rule for treatment of an unrelated or intercurrent illness, 28 TAC 134.1003(e)(4), contains the relevant standards for documentation of the treatment.
- The statement of medical necessity provided by Dr. Weldon satisfies the requirements of 28 TAC § 134.1003(e)(4), wherein the doctor documented the need for treatment of Claimant’s weight loss through the use of weight loss prescription(s) since Claimant’s excessive weight prevented her lack of recovery from her compensable injury.
- The MRD findings state that there is no MAR (maximum allowable rate) for the prescriptions. Therefore, reimbursement at the amount charged for the prescriptions ($225.50) is reasonable and necessary.
- Based on the above Findings of Fact and Conclusions of Law Petitioner proved by a preponderance of the evidence that the two prescriptions for Meridia were health care services that were reasonably required and medically necessary to promote her recovery from the effects of a compensable injury suffered by Claimant, within the meaning of Tex. Labor Code §§ 408.021 and 401.011(19)(E).
- Petitioner is entitled to reimbursement for the prescriptions under Tex. Labor Code § 413.015.
- Based on the above Findings of Fact and Conclusions of Law, the Provider’s appeal and request for reimbursement of $ 225.50 for two prescriptions of Meridia for a period of six months under CPT Code 99999 should be granted.
IT IS ORDERED THAT the Petitioner’s request for reimbursement of $ 255.50 from the Carrier is granted and the City of Forth Worth is ORDERED to reimburse Plaza Pharmacies this amount.
Signed this 22nd day of March, 2002.
STATE OFFICE OF ADMINISTRATIVE HEARINGS
SUZANNE FORMBY MARSHALL
Administrative Law Judge
- These types of cases are especially difficult. Here, the pharmacy filled a prescription that was issued by a physician who is treating the Claimant for her worker’s compensation injury. The Carrier’s dispute over whether the medication is reimbursable really relates to whether, and with what amount of supporting documentation, the treating physician should have prescribed the medication in the first place. The pharmacy is merely the means of delivery of the medication to the patient. It is caught between the proverbial rock and hard place: if the pharmacist fills the prescription, the pharmacy runs the risk that it won’t be reimbursed by the Carrier; if the pharmacist makes substantive decisions about whether or not the medication should have been prescribed at all, the pharmacist may be accused of practicing medicine without a license.↑
- The only information about Claimant’s original injury and treatment is found in Dr. Weldon’s letter of medical necessity contained within the MRD file. It is unclear whether, in addition to the neck injury, Claimant sustained injuries to both legs or only her left knee and ankle. Dr. Weldon’s letter discusses the need for weight loss to alleviate problems with her knee and ankle. It appears that Claimant received arthroscopic surgery on her left knee and ankle sometime after the injury, but the record does not reflect whether treatment was provided to her right knee and ankle.↑
- There is no evidence in the record of Claimant’s weight loss before the compensable injury or during the course of treatment so it is unknown whether her excessive weight was a pre-existing condition. It is clear from Dr. Weldon’s letter, however, that her weight negatively affects her ability to recover from her injury.↑
- The MRD Officer found that the Provider “failed to submit documentation to show the relatedness of [the weight loss] treatment to the compensable injury.” The decision indicates that the letter of medical necessity was admitted as an exhibit but does not otherwise discuss this letter as it relates to the need for documentation.↑
- There is no evidence in the record of Claimant’s weight before the compensable injury so it is unknown whether her excessive weight was a pre-existing condition.↑