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At a Glance:
Title:
453-02-1001-m5
Date:
June 4, 2002
Status:
Retrospective Medical Necessity

453-02-1001-m5

June 4, 2002

DECISION AND ORDER

I. SUMMARY

Petitioner Scientific Therapy and Advanced Treatment (STAT) seeks reimbursement for medicine and medical supplies from Texas Mutual Insurance Company (Carrier). Texas Workers’ Compensation Commission’s Medical Review Division (MRD) denied reimbursement of $234.63 for aloe liniment ($54.73) and for a hot/cold knee wrap ($179.90) prescribed to Claimant ___. Both of these items were prescribed for the treatment of a meniscus and cartilage damage and were denied on the basis that the doctor’s statements of medical necessity failed to meet the criteria established for durable medical equipment. Petitioner challenges that denial. Based on the evidence, this decision concludes that Petitioner’s claim for reimbursement of $234.63 should be denied.

Administrative Law Judge, Stephen J. Pacey, convened a hearing on these issues on April 2, 2002. The hearing concluded that day, and the record remained open until April 9, 2002 to allow for the filing of additional documents. The Petitioner was represented by Paula Sadovsky; the Carrier was represented by Patricia Eads.

II. EVIDENCE AND BASIS FOR DECISION

The record in this case consisted of the certified record of the MRD proceeding; two additional letters from Claimant’s treating physician supporting the disputed items; the testimony of Mitchell R. Lestico, PhD, disputing the medical necessity of the aloe liniment; the deposition of John Pearce, M.D., disputing the medical necessity of the aloe liniment; and, the testimony of Richard Ball concerning the fair and reasonable price of the hot/cold knee wrap.

Petitioner’s letters lacked objective findings and did not address the expected duration for equipment or supplies, both of which are required by the Commission’s Durable Medical Equipment

Ground Rules. In addition Mitchell Lestico, who has a doctorate of pharmacy, testified that once the arthroscopy wound is healed, aloe liniment has no medical benefit.

The particular facts, reasoning, and legal analysis in support of this decision are set forth below in the Findings of Fact and Conclusions of Law. In summary, however, the ALJ finds that the Petitioner failed to establish that the disputed items were medically necessary because aloe liniment has not been shown to be of benefit in treating injuries to the knee, and the hot/cold knee brace was not proved to be medically necessary.

III. FINDINGS OF FACT

  1. On______, ___(Claimant) suffered a compensable injury to his back.
  2. Claimant’s injury is covered by worker’s compensation insurance written for Claimant’s employer by Texas Mutual Insurance Company (Carrier).
  3. Petitioner Scientific Therapy and Advanced Treatment (STAT) requests reimbursement from the Carrier for the aloe liniment and the hot/cold knee brace that STAT provided to the Claimant.
  4. The Carrier denied reimbursement of the equipment expenses identified in Finding of Fact No. 3.
  5. STAT timely requested dispute resolution by the Texas Workers’ Compensation Commission Medical Review Division (MRD).
  6. The MRD issued its findings and decision on November 1, 2001, concluding that the disputed expenses should be denied, and STAT timely appealed this decision.
  7. Topical aloe vera application was not be shown to be of benefit for the treatment of a knee injury once the arthroscopy wound has healed.
  8. The hot/cold knee brace prescribed was not shown to be medically necessary because the documents provided did not contain objective findings and did not address the expected duration.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction to decide the issues presented pursuant to Tex. 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 Tex. Labor Code §413.031 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.
  4. Petitioner has the burden of proving by a preponderance of the evidence that it should prevail in this matter. Tex. Labor Code §413.031.
  5. Petitioner did not prove by a preponderance of the evidence that the disputed items provided to the Claimant are medically necessary. Tex. Labor Code §408.021.
  6. Petitioner is not entitled to reimbursement.

ORDER

The claim by Petitioner, Scientific Therapy and Advanced Treatment, for payment from Texas Mutual Insurance Company is denied.

Issued June 4TH, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Stephen j. pacey
Administrative Law Judge

End of Document
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