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At a Glance:
Title:
453-02-1312-m5
Date:
June 7, 2002
Status:
Retrospective Medical Necessity

453-02-1312-m5

June 7, 2002

DECISION AND ORDER

This case is a dispute over whether Highpoint Pharmacy (Pharmacy) should be reimbursed $537.51 for prescriptions dispensed for Zonegran, Methocarbamal and Naproxen between March 1, 2001 and April 4, 2001.

Continental Casualty Company contends the prescriptions were not medically necessary and there was insufficient documentation provided to justify exceeding the level of treatment set forth in the spine treatment guidelines, 28 Tex. Admin. Code (TAC) § 134.1001 et. seq. The Pharmacy maintains that the prescriptions were medically necessary and appropriate for the injured worker’s condition, and that the Carrier violated 28 TAC § 133.304(h)(i), which requires the Carrier to provide a copy of a peer review if it was the basis of a denial for reimbursement.

Based upon the evidence presented, the ALJ finds that the prescriptions were medically necessary, and the Carrier is required to pay the Pharmacy $537.51. The ALJ’s reasoning is detailed in the Findings of Fact and Conclusions of Law.

I. Findings of Fact

  1. The injured worker suffered a compensable back injury on______.
  2. Continental Casualty Company (Carrier) provided workers’ compensation insurance coverage to the injured worker’s employer on the date of the injury.
  3. The injured worker underwent a fusion in June of 1999 at the L5-S1 level of her spine.
  4. Between March 1, 2001 and April 4, 2001, the Highpoint Pharmacy (Pharmacy) dispensed the following prescriptions:
  5. Date of ServicePrescriptionAmount BilledMAR[1]

3/1/01 Zonegran (40) $83.45 $82.71

3/1/01 Methocarbamal (40) $33.85 $34.42

3/1/01 Naproxen (60) $76.99 $80.45

3/7/01 Methocarbamal (40) $33.85 $34.42

3/16/01 Zonegran (40) $83.45 $82.71

3/16/01 Methocarbamal (40) $33.85 $34.42

3/23/01 Methocarbamal (40) $33.85 $34.42

3/27/01 Naproxen (60) $76.99 $80.45

4/4/01 Zonegran (40) $83.45 $82.71

Total $546.31 $539.73

  1. The Carrier denied payment of the prescriptions on the basis of medical necessity. On April 24, 2001, the Pharmacy requested reconsideration of the denial for the dates of service listed in finding of fact number four.
  2. At the Carrier’s request, a peer review of treatment provided to the injured worker was issued on May 21, 2002 by Dr. Aaron Combs.
  3. The Pharmacy appealed the Carrier’s denial to the Medical Review Division of the Texas Workers’ Compensation Commission (MRD). The MRD found that the Carrier was not required to reimburse the Pharmacy for the prescriptions because the documentation was insufficient as it did not justify exceeding the treatment recommended by the Spine Treatment Guidelines.
  4. The Pharmacy appealed the decision of the MRD.
  5. The original notice of hearing was issued on January 11, 2002.
  6. 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.
  7. The hearing was held May 7, 2002, with Administrative Law Judge (ALJ) Janet Dewey presiding, the Carrier participating and the Pharmacy appearing via telephone. The hearing was adjourned and the record closed the same day.
  8. The patient has had continued pain following her surgery in 1999. The screws used in the fusion at the S1 level of the spine project too far anteriorly.
  9. Naproxen is a non-steroidal anti-inflammatory drug. Zonegran is a non-narcotic anti-seizure medication commonly used to treat neuropathic pain. Methocarbamal is a non-narcotic muscle-relaxant.
  10. Dr. Combs’ peer review does not define “current treatment,” clarify the period of treatment to which it applies, or discuss the positioning of the screws used in the fusion.
  11. At the time of the prescriptions, the drugs were reasonable and necessary to treat the injured worker’s pain and complications of surgery, notwithstanding her subsequent allergic reaction to Zonegran and Naproxen.
  12. In some instances the Pharmacy billed the Carrier less than the MAR. The total of either the amount billed by the Pharmacy, or the MAR, whichever is lower, the amount reimbursable to the Pharmacy equals $537.51.

II. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to section 413.031 of the Texas Workers’Compensation 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. The Pharmacy has the burden of proof in this matter. 28 TAC § 148.21(h).
  5. The Carrier did not violate 28 TAC 133.304(i), as the peer review was performed after the denials for reimbursement for the dates of service at issue in this proceeding.
  6. The documentation provided by the Pharmacy satisfies the requirements of the Spine Treatment Guidelines, 28 TAC § 134.1001 (e)(3)(A).
  7. Prescriptions identified in finding of fact four were reasonably required health care under Tex. Lab. Code Ann. § 401.011 (19)(A).

Order

IT IS, THEREFORE, ORDERED that Continental Casualty Company is required to pay Highpoint Pharmacy $537.51.

Signed this 7th day of June, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

JANET R. DEWEY
Administrative Law Judge

  1. Maximum amount reimbursable under the Medical Fee Guideline adopted pursuant to 28 TAC §' 134.201.
End of Document
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