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At a Glance:
Title:
453-02-1063-m5
Date:
April 26, 2002

453-02-1063-m5

April 26, 2002

DECISION AND ORDER

This is a dispute over whether Scientific Therapy and Advanced Treatment, Inc. (STAT) should be reimbursed for the cost of monthly supplies for a neuromuscular stimulator and aloe vera liniment it provided the workers’ compensation claimant. The amounts in dispute are $425.00 for the stimulator supplies and $83.25 for the liniment, for a total of $508.25.

The Administrative Law Judge (ALJ) concludes the Petitioner proved the supplies for the neuromuscular stimulator were medically necessary, but did not prove the liniment was medically necessary. Therefore he orders reimbursement of $425.00.

I. Discussion

The Claimant sustained a compensable back injury[1] in __of__. In October of 1998, her treating physician, Dennis R. Gutzman, M.D., prescribed for her the NT 2000 neuromuscular stimulator. At some point, apparently in the year 2000, the Claimant also began receiving massage therapy with aloe vera liniment. Dr. Gutzman prescribed 8-ounce bottles of aloe vera liniment for that purpose.

Federated Mutual Insurance Company (the Carrier) paid for both the stimulator supplies and the liniment until the November 8, 2000, date of service, when it began to refuse those payments as medically unnecessary. This controversy concerns five monthly dates of service, from November 8, 2000, through March 8, 2001.

The Texas Workers’ Compensation Commission’s (the Commission’s) Medical Review Division (MRD) issued its decision, which denied reimbursement, on October 3, 2001. The evidence in this case consists of the 64-page record that was before the MRD and a subsequent letter of medical necessity from Dr. Gutzman. The most informative pieces of evidence are Dr. Gutzman’s original letter of medical necessity (Exhibit 1, page 43), a peer review conducted by Aaron Combs, M.D. (Exhibit 1, pages 61-63), and Dr. Gutzman’s second letter of medical necessity (Exhibit 2).

Dr. Gutzman’s first letter, dated December 21, 2000, describes the Claimant’s use of the stimulator unit and observes she is receiving relief from it. According to Dr. Gutzman, the unit has reduced the Claimant’s muscle spasms and improved her quality of sleep. The unit enables her to treat herself at home.

The second letter, dated December 14, 2001, states the unit has decreased the Claimant’s pain from a level of 10 to a level of 6, and has increased her range of motion. Dr. Gutzman states the long-term objective is to reduce or alleviate the need for pain medications and other ongoing long-term supervised therapies. In both letters, he emphasizes the supplies are needed for the stimulator to work. The supplies consist of batteries and electrode pads. Ex. 2.

The MRD decision (Ex. 1, pages 1-3) states the liniment is used with the neuromuscular stimulator. However, the record suggests otherwise. Dr. Gutzman’s first letter talks about massage therapy using the liniment, and his second letter mentions the liniment and the stimulator supplies as separate items. Although he states the liniment is medically necessary, neither letter explains how it is improving the Claimant’s health, other than in the most general terms.

Dr. Combs’ peer review states continued treatment of the Claimant is not reasonable or necessary and is not consistent with the Commission’s Spine Treatment Guidelines. However, the only treatment Dr. Combs discusses in any detail is the use of narcotic analgesics. Dr. Combs’ review was not enlightening regarding the issues in dispute in this case.

In summary, Dr. Gutzman provided specific and convincing documentation for the medical necessity of the neuromuscular stimulator and the necessary supplies. There was no persuasive evidence to the contrary. Neither Dr. Gutzman nor STAT provided adequate documentation for the medical necessity for the aloe vera liniment, however. Therefore, the ALJ orders the Carrier to reimburse STAT for the cost of the supplies for the neuromuscular stimulator, in the amount of $425.00.

The Carrier argued aloe vera liniment is not “health care” under Tex. Lab. Code Ann. §401.011(19)(E) and therefore STAT is not a “health care provider”under §401.011(22). That issue need not be addressed, however, because STAT did not prove the liniment was medically necessary. Clearly, the neuromuscular stimulator and the requisite supplies are medical supplies under §401.011(19)(F), which qualifies STAT as a health care provider for those items.

II. Findings of Fact

  1. The Claimant sustained a compensable back injury in __of___.
  2. In October of 1998, the Claimant’s treating physician, Dennis R. Gutzman, M.D., prescribed for her the NT 2000 neuromuscular stimulator (the stimulator).
  3. At some point, apparently in the year 2000, the Claimant also began receiving massage therapy with aloe vera liniment. Dr. Gutzman prescribed 8-ounce bottles of aloe vera liniment for that purpose.
  4. Federated Mutual Insurance Company (the Carrier) paid for both the stimulator supplies and the liniment until the November 8, 2000, date of service, when it began to refuse those payments as medically unnecessary.
  5. This controversy concerns five monthly dates of service, from November 8, 2000, through March 8, 2001.
  6. The amounts in dispute are $425.00 for the stimulator supplies and $83.25 for the liniment, for a total of $508.25.
  7. Scientific Therapy and Advanced Treatment, Inc. (STAT), which provided the stimulator supplies and the liniment, filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  8. The Commission’s Medical Review Division (MRD) issued its decision, which denied reimbursement, on October 3, 2001.
  9. STAT filed a timely request for a hearing regarding the MRD decision.
  10. Notice of the hearing was sent December 6, 2001.
  11. 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.
  12. The hearing was held March 26, 2002, with Administrative Law Judge (ALJ) Henry D. Card presiding and representatives of STAT and the Carrier participating. The hearing was adjourned the same day.
  13. Use of the stimulator has reduced the Claimant’s muscle spasms and improved her quality of sleep.
  14. The stimulator enables the Claimant to treat herself at home.
  15. Use of the stimulator has decreased the Claimant’s pain from a level of 10 to a level of 6, and has increased her range of motion.
  16. The stimulator is likely to reduce or alleviate the Claimant’s need for pain medications and other ongoing long-term supervised therapies.
  17. The supplies, which consist of batteries and electrode pads, are needed for the stimulator to work.
  18. The liniment is used for massage therapy and was not shown to be a necessary supply for the stimulator.
  19. The evidence does not show the liniment is improving the Claimant’s health, except in the most general terms.

III. 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. 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. STAT has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. The neuromuscular stimulator and the requisite supplies are medical supplies underTex. Lab. Code Ann§401.011(19)(F), which qualifies STAT as a health care providerfor thoseitems under §401.011(22).
  6. STAT met its burden of proving the neuromuscular stimulator supplies were medically necessary under Tex. Lab. Code Ann. §408.021(a).
  7. STAT did not meet its burden of proving the liniment was medically necessary under Tex. Lab. Code Ann. §408.021(a).
  8. The Carrier should be required to reimburse STAT for the cost of the stimulator supplies, in the amount of $425.00.
  9. The Carrier should not be required to reimburse STAT for the cost of the liniment.

ORDER

IT IS, THEREFORE, ORDERED that Federated Mutual Insurance Company (the Carrier) shall reimburse Scientific Therapy and Advanced Treatment, Inc. (STAT) $425.00 for neuromuscular stimulator supplies for five dates of service from November 8, 2000, through March 8, 2001. The Carrier shall not be required to reimburse STAT for the cost of aloe vera liniment provided for those dates of service.

Signed this 26th day of April 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. The Claimant suffers from a herniated cervical intervertebral disc.
End of Document
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