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At a Glance:
Title:
453-02-1215-m4
Date:
July 10, 2002
Status:
Medical Fees

453-02-1215-m4

July 10, 2002

DECISION AND ORDER

I. Procedural History

Petitioner Plaza Pharmacies (Provider or Petitioner) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC or Commission) denying reimbursement from Employers Insurance of Wausau (Carrier) for prescription medication provided to ___ (Claimant). This decision denies Provider’s request for reimbursement of $106.34 for medication.

Administrative Law Judge (ALJ) Howard S. Seitzman convened a hearing on June 3, 2002. The Petitioner appeared by telephone through its representative, Nicky Otts. The Carrier was represented by attorney Mahon B. Garry, Jr. The Commission did not enter an appearance. The hearing was concluded that day. Subsequently, the case was reassigned to the undersigned ALJ, who listened to a tape recording of the hearing and read the record before preparing this decision.

II. Evidenceand Discussion

The issue presented in this proceeding is whether Carrier should reimburse Provider $106.34 plus interest for three prescriptions filled on January 23 and February 9, 2001, for the drug Sonata (sleeping aid) and on February 12, 2001, for the drug Lortab (pain medication). The MRD found that the medical documentation did not show the treatment was related to the compensable injury. Carrier concurs with this finding.

Claimant suffered compensable injury to her right knee on______. Carrier does not dispute that the medication is necessary for an injury-rather, it disputes whether the medication (the treatment for the torn meniscus) is related to the compensable injury. Provider argues it relied upon Dr. Selod’s prescription as a determination that the medication was needed for the compensable injury.

The only evidence in this proceeding consists of the 64-page certified record of the MRD proceeding. Provider relies on a letter written on or about April 27, 2001, by Claimant’s treating physician, Dr. Farooq I. Selod, which states the patient has a torn meniscus and indicates the doctor is “appealing the denial since we had pre-cert to do surgery on her.” Petitioner’s Ex. 1 at 13.

In contrast, a letter from Liberty Mutual indicates Claimant’s compensable injury occurred on__________. Claimant was treated from this date until 1994. During that time period, two MRI’s did not show a “torn medical meniscus.” Petitioner’s Ex. 1 at 26. The letter, dated October 16, 2001, further states:

In December of 2000, it appears the claimant presented again for treatment with the diagnosis of tear of the medical cartilage or meniscus of the knee. This was confirmed by the 12/15/00 MRI. Attached is a copy of the TWCC 21 that was filed disputing current treatment as a new injury, unrelated to the initial incident of 1/16/92.

Petitioner’s Ex. 1 at 26. The TWCC 21 filled out by Carrier in this case indicates Claimant did not sustain injury to the meniscus area during the scope of her employment and any such injury did not arise from the original injury.

The ALJ is aware of the on-going controversy arising from instances where a pharmacy relies upon a prescription issued by a treating physician and, in good faith, supplies a claimant with the prescription medication. In this instance, the pharmacy could not have known the facts behind this case, which indicate the torn meniscus manifested itself long after the original, compensable injury. As argued by Petitioner, pharmacies do not have access to medical records, rather they must rely on the doctor’s prescription that the injury being treated is a work-related injury. However, at the hearing, Petitioner did not argue that a good faith presumption is implied by statute or by case precedent. Thus, the ALJ looks only to the evidence and applicable law. Petitioner bears the burden of proving that the treatment would cure or relieve the naturally occurring effects of the compensable injury.

The ALJ finds that the small amount of evidence related to the disputed issue weighs in favor of Carrier. Dr. Selod’s letter indicates the date of injury was January 16, 1992, (the date of the compensable injury), but provides no information as to why a torn meniscus manifested in 2001. Two MRIs (taken some time before or during 1994) did not show such an injury. The torn meniscus then appears on an MRI taken approximately eight years post-injury. Absent any evidence or testimony from Petitioner explaining how this particular injury can manifest eight years after Claimant’s compensable injury, the ALJ must concur with Carrier that Petitioner failed to meet its burden of proof to show the medication (the treatment at issue) is related to the compensable injury. Therefore, the ALJ denies Plaza Pharmacies’ appeal and affirms the MRD decision to deny reimbursement.

IV. Findings of Fact

  1. On or about________, ___(Claimant) suffered a compensable injury to her right knee.
  2. Claimant’s injury is covered by worker’s compensation insurance provided for Claimant by the Employers Insurance of Wausau (Carrier).
  3. Claimant was treated from the date of injury until 1994, including surgery and physical therapy. Two MRI’s during that time period did not show a torn medical meniscus in the area of the knee.
  4. During December of 2000, Claimant was diagnosed with a tear of the meniscus of the knee. An MRI dated December 15, 2000, confirmed this diagnosis.
  5. On January 23 and February 9, 2001, Plaza Pharmacies (Petitioner) filed prescriptions for Claimant for the drug Sonata. Petitioner filed a prescription for the drug Lortab on February 12, 2001. The cost of the three prescriptions totaled $106.34.
  6. Dr. Farooq I. Selod prescribed the medication referenced in the above Finding of Fact No.5 in order to treat Claimant’s injury, a torn meniscus, which occurred or manifested over eight years post-injury.
  7. The medication prescribed by Dr. Selod and filled by Petitioner is for an injury that is unrelated to the compensable injury.
  8. Petitioner Plaza Pharmacies timely submitted a request for dispute-resolution review to the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (TWCC), after being denied payment by Carrier.
  9. Notice of the hearing was sent January 3, 2002.
  10. 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.
  11. The original hearing date of March 18, 2002, was continued by written order dated March 6, 2002.
  12. The hearing was held June 3, 2002 with Administrative Law Judge (ALJ) Howard S. Seitzman presiding and representatives of the Plaza Pharmacies and Employers Insurance of Wausau participating. The hearing was adjourned and the record closed the same day.
  13. Subsequent to the hearing, this case was reassigned to ALJ Lilo D. Pomerleau, who read the record and listened to a tape recording of the proceeding.

V. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to § 413.031 of the Texas Workers' Compensation Act (the Act), Tex. Labor Code Ann. ch. 401 et seq.
  2. The State Office of Administrative Hearings (SOAH) 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 Ann. § 413.031 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. Petitioner failed to establish that the prescribed medication provided to Claimant by Petitioner would cure or relieve the naturally occurring effects of the compensable injury and is therefore not reimbursable pursuant to § 408.021 of the Act.
  5. Petitioner should not be reimbursed for the cost of the prescriptions filled to treat Claimant.

ORDER

IT IS, THEREFORE, ORDERED that Plaza Pharmacies’ request for reimbursement of $106.34, for prescription medication for Claimant D.S.M., from the Employers Insurance of Wausau is denied.

Signed July 10, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

LILO D. POMERLEAU
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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