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At a Glance:
Title:
453-02-1286-m2
Date:
February 11, 2002
Status:
Pre-Authorization

453-02-1286-m2

February 11, 2002

DECISION AND ORDER

I. Introduction

Travelers Indemnity Company of Connecticut (Carrier) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) preauthorizing and ordering Carrier to pay the reasonable and necessary costs to removes a lesion mass in the wrist of ____ (Claimant) that resulted from a compensable injury. Specifically, the following services would be provided to the Claimant: ambulatory surgical care use, excision of the mass, modified tenosynovectomy right wrist, and tenolysis-extension of right index and middle fingers (collectively “the surgery”). The only disputed issue is whether the surgery is reasonably medically necessary.

As set out below, the Administrative Law Judge (ALJ) finds that the surgery is reasonably medically necessary, preauthorizes it, and orders the Carrier to pay for its reasonable and necessary cost. The Carrier introduced uncontroverted evidence that the Claimant’s hand and wrist are fully functional. However, Dr. Varon, an expert hand surgeon who would perform the surgery, convincingly testified that the lesion in the Claimant’s wrist will tend to grow and interfere with the function of the Claimant’s wrist tendons unless it is surgically removed.

II. FINDINGS of Fact

  1. The Claimant sustained a work-related injury to his wrist on______, while his employer was______ and the Carrier was its workers compensation insurance carrier.
  2. As a result of the compensable injury, the Claimant developed a one centimeter lesion mass in his right wrist, which causes him pain, is likely to grow, and will likely interfere with the function of his wrist tendons unless it is surgically removed.
  3. Brent Powell, D.C., referred the Claimant to Jacob Varon, M.D., who prescribed the surgery. Dr. Powell sought preauthorization from the Carrier for the surgery.
  4. The Carrier denied the requested preauthorization, maintaining that it was not medically necessary.
  5. Dr. Powell filed a request for medical dispute resolution with the TWCC, seeking preauthorization for the surgery.
  6. MRD reviewed the dispute and preauthorized and ordered the Carrier to pay the reasonable and necessary cost of the surgery
  7. The Carrier appealed the MRD decision to the State Office of Administrative Hearings (SOAH).
  8. Notice of a February 7, 2002 hearing on the dispute was mailed to the Carrier and Dr. Powell on January 9, 2002.
  9. On February 7, 2002, William G. Newchurch, an ALJ with SOAH, held a hearing on the appeal at the Stephen F. Austin Building, Suite 1100, 1700 North Congress Avenue, Austin, Texas. The Carrier attended the hearing through its attorney, and Dr. Varon attended by telephone on behalf of Dr. Powell. The hearing concluded and the record closed on that same day.

III. CONCLUSIONS of Law

  1. 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 Ann. §§ 402.073(b) and 413.031(d) and Tex. Gov’t Code Ann. ch. 2003. (Vernon 2001).
  2. Adequate and timely notice of the hearing was provided in accordance with TexGov’t. Code Ann. §§2001.051 and 2001.052 (Vernon 2001).
  3. As the party appealing the MRD decision, the Carrier has the burden of proof in this matter pursuant to 28 Tex. Admin. Code §'148.21(h).
  4. 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.
  5. Based on the above Findings of Fact and Conclusions of Law, the surgery is reasonably medically necessary and should be preauthorized as required by 28 TAC § 134.600(h).

ORDER

IT IS ORDERED THAT the above-described surgery on the Claimant is preauthorized and the Carrier shall pay the reasonable and necessary costs of the surgery.

Signed February 11, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

End of Document
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