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At a Glance:
Title:
453-02-1324-m5
Date:
March 28, 2002
Status:
Retrospective Medical Necessity

453-02-1324-m5

March 28, 2002

DECISION AND ORDER

The issue in this case is whether the Petitioner, Scientific Therapy and Advanced Treatment (STAT), should be reimbursed $204.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for and provided to __________ (Claimant) on August 26, 2000 and September 26, 2000. The Administrative Law Judge (ALJ) concludes STAT met its burden of proving that G/C 1000 and MSM were medically necessary for the treatment of Claimant’s injury. Therefore, reimbursement in the amount of $204.00 is granted.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (the Commission) has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers' Compensation Act, Tex. Lab. Code ch. 401 et seq. The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code §413.031(d) and Tex. Gov’t Code ch. 2003.

The Commission’s Medical Review Division (MRD) issued its findings and decision on November 8, 2001, denying STAT’s reimbursement request. On November 26, 2001, STAT filed a timely request for hearing before SOAH. Proper and timely notice of the hearing was issued on January 14, 2002 . The hearing convened March 21, 2002, with ALJ Sharon Cloninger presiding. Randy Burgett appeared via telephone for STAT. Dan Kelley appeared for North River Insurance Company of NE (Carrier). The hearing adjourned and the record closed the same day.

II. Legal Standards

The applicable legal standards are found in Tex. Lab. Code §§408.021 and 401.011. Section 408.021 states:

(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. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

Section 401.011(19) defines “health care” as including “all reasonable and necessary medical . . . services.”

The Medical Fee Guideline’s Durable Medical Equipment Ground Rule (IX)(B)(1-3) requires the billing statement to include :

A. . . the medical necessity and specify the following:

  1. claimant’s diagnosis;
  2. prognosis; and
  3. the expected duration the equipment or supplies will be required.

The Petitioner has the burden of proof in this matter. 28 Tex.Admin. Code §148.21(h).

III. Discussion

In support of its claim that the treatment was medically necessary, STAT submitted a letter to the MRD dated November 22, 2000, written by Alan E. Delgado, D.C., Claimant’s treating doctor. In the letter, Dr. Delgado states:

I have prescribed the following oral agents to _________for use as part of a complete treatment program in order to recover from injury. These agents are Glucosamine Hydochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM). Although these agents have been marketed for some time now, it has come to my attention that some carriers refuse to accept the fact that these agents promote healing of joint tissues as well as reduced joint pain when used on a chronic basis. Use of these agents can reduce the overall effect of an injury and help one get back to a normal productive state. Several such products have been studied and are now with NDC registration. Beside [sic] the results from medical journals showing their effectiveness, in my own practice I have met with positive results as well. Therefore, I believe that for this patient, not only are these medications appropriate, but they are medically necessary as well.[1]

The November 22, 2000 letter written by Dr. Delgado is virtually identical to that written by the doctor in Scientific Therapy And Advanced Treatmentv. Texas Workers’ Compensation Commission & Northside Independent School District, SOAH Docket No. 453-01-1958.M5 (September 19, 2001). As noted by ALJ Earl Corbitt, “The mere prescribing of a substance by a medical doctor, without more, is not sufficient evidence to require a finding that the substance is medically necessary. . . .[H]is conclusory statement is insufficient to demonstrate the effectiveness of the prescribed nutritional supplements.” Id. at 5.

On January 2, 2002, Dr. Delgado wrote another letter, which was admitted at the hearing, which states:

I have been treating __________for an on the job injury she sustained on _________. __________’s diagnosis consists of lumbosacral sprain/strain, disturbance of skin sensation, lumbosacral neuritis, and postlaminectomy syndrome, lumbar region. I have prescribed Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) for use as part of a complete treatment program in order to recover from the injury. These agents will promote healing of their joint tissues and reduce pain that is associated with this injury. ___________’s prognosis is good with use of these agents. They should be expected to use the agents for a period up to six months.

In my opinion the items are medically necessary and are related to the injury she received while on the job.[2]

After Carrier questioned the medical necessity of the G/C 1000 and the MSM, Petitioner was obligated to show the efficacy of the G/C 1000 and the MSM for the purpose prescribed, which it has done. Unlike the November 22, 2000 letter, the letter of January 2, 2002 specifically sets out Claimant’s diagnosis; prognosis; and the expected duration the G/C 1000 and MSM will be required. The second letter also states that the G/C 1000 and MSM will promote healing of Claimant’s injury.

Therefore, the ALJ concludes that STAT has met its burden of proving that the G/C 1000 and the MSM were medically necessary for the treatment of Claimant’s compensable injury within the meaning of Tex. Lab. Code §408.021.

IV. Findings of Fact

  1. The Petitioner, Scientific Therapy and Advanced Treatment (STAT), provided $204.00 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to ___________(Claimant) on August 26, 2000 and September 26, 2000.
  2. Claimant’s treating doctor, Alan Delgado, D.C., prescribed the G/C 1000 and MSM.
  3. STAT requested reimbursement from North River Insurance Company of NE (Carrier), which Carrier denied.
  4. STAT filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission).
  5. The Commission’s Medical Review Division (MRD) issued its decision, denying STAT’s request, on November 8, 2001.
  6. On November 26, 2001, STAT filed a timely request for a hearing before the State Office of Administrative Hearings (SOAH).
  7. Notice of the hearing was issued on January 14, 2002.
  8. 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.
  9. The hearing convened March 21, 2002, with Administrative Law Judge (ALJ) Sharon Cloninger presiding. Randy Burgett appeared for STAT. Dan Kelley appeared for Carrier. The hearing adjourned and the record closed the same day.
  10. Claimant’s diagnosis consists of lumbosacral sprain/strain, disturbance of skin sensation, lumbosacral neuritis, and postlaminectomy syndrome, lumbar region.
  11. Claimant’s prognosis is good with use of these G/C 1000 and MSM.
  12. Claimant is expected to use G/C 1000 and MSM for up to six months.
  13. G/C 1000 and MSM will promote healing of Claimant’s joint tissues and reduce pain that is associated with Claimant’s injury.
  14. Use of G/C 1000 and MSM can reduce the overall effect of an injury and help Claimant return to a normal productive state.

V. 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 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 §413.031(d) and Tex. Gov’t Code ch. 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code §2001.052.
  4. Petitioner has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. STAT has met its burden of proving the G/C 1000 and the MSM were medically necessary for the treatment of the claimant’s compensable injury within the meaning of Tex. Lab. Code §408.021.
  6. STAT’s request for reimbursement should be granted in the amount of $204.00.

ORDER

IT IS, THEREFORE, ORDERED that North River Insurance Company of NE is to reimburse Scientific Therapy and Advanced Treatment in the amount of $204.00 for G/C 1000 and MSM provided to Claimant on August 26, 2000 and September 26, 2000.

Signed March 28, 2002.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Petitioner’s Exhibit 2, 23.
  2. Petitioner’s Exhibit 1.
End of Document
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