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At a Glance:
Title:
453-02-1325-m5
Date:
June 18, 2002
Status:
Retrospective Medical Necessity

453-02-1325-m5

June 18, 2002

DECISION AND ORDER

I. Introduction

Plaza Pharmacies (Provider) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) denying its request for reimbursement of $1,810.59 from Lumbermen’s Underwriting Alliance (Carrier) for drugs that it provided to__. (Claimant) between October 23, 2000, and January 10, 2001, almost two years after the Claimant’s compensable injuries. The only disputed issue is whether the provided drugs-Remeron, Methylpred, Effexor-XR, Hydro-APAP, Diazepam, and Celebrex (collectively “the Drugs”)-were reasonably medically necessary to treat the Claimant’s compensable injuries.

The Claimant was injured when he fell over a barrel at work. In letters that were admitted into evidence, Bill E. Weldon, D.O., the Claimant’s treating physician (Treating Physician), indicated that as a result of the compensable injuries, the Claimant suffered from degenerative disc disease, muscle spasms in his back, chronic back pain, and-due to that pain-depression. The Treating Physician claimed that the Drugs were necessary to treat those problems. Aside from his conclusory statements to that effect, there is no objective evidence to support the Treating Physician’s diagnoses or prescriptions.

Instead, the great weight of the evidence shows that the Claimant sustained only a minor strain of soft tissue in his back and a minor contusion to his right elbow. These compensable injuries should have resolved themselves, even without treatment, within six to eight weeks. The evidence indicating only minor and short-lived compensable injuries includes electrodiagnostic testing of the Claimant’s right arm, x-rays and magnetic resonance images (MRIs) of his back, and the more thoughtful and thorough analyses by both a Carrier-retained and a peer-review physician who examined the Claimant. The Claimant also had a very mild degenerative disc disease and a history of depression that existed before the compensable injuries occurred.

It is not credible to suggest that the Claimant’s very mild injuries would have caused pain and depression that would have required the Drugs almost two years after the injuries. Moreover, some of the Drugs are addictive narcotics that should not be taken for prolonged periods of time.

Based on the evidence and as set out below, the Administrative Law Judge (ALJ) finds that the Drugs were not reasonably medically necessary to treat the Claimant’s compensable injuries. Accordingly, the Provider’s request for reimbursement is denied.

II. FINDINGS OF FACT

  1. The Claimant sustained work-related injuries to his right elbow and back on_____, while his employer was _____ and its workers’ compensation insurance carrier was the Carrier.
  2. The compensable injuries were a minor contusion to the Claimant’s right elbow and a soft‑tissue strain to his lumbar spine.
  3. As a result of the compensable injuries, the Claimant suffered a mild loss of flexion in his right elbow.
  4. Even without treatment, the Claimant’s injuries would have resolved within six to eight weeks after they occurred without any medication.
  5. Prior to his compensable injury, the Claimant had mild degenerative disc disease of his spine and suffered from depression.
  6. The Claimant’s Treating Physician prescribed the following Drugs for the Claimant for the following purposes:
  7. Remeron to treat chronic pain syndrome and secondary depression;
  8. Effexor-XR to treat chronic pain and depression;
  9. Methylpred for an unspecified purpose;
  10. Diazepam to treat muscle spasms in the Claimant’s back;
  11. Celebrex to treat swelling; and
  12. Hydrocodone to relieve pain.
  13. Remeron is used to treat depression.
  14. Effexor‑XR is used to treat depression.
  15. The Claimant was taking Effexor-XR prior to his compensable injury.
  16. Methylpred, also known as Medrol or Methylprednisolone, is a corticosteroid used as an anti-inflammatory.
  17. Diazepam, also known as Valium, is used to treat anxiety and acute muscle spasms.
  18. Celebrex is a non‑steroidal anti‑inflammatory drug that is used to treat pain caused by arthritis.
  19. Hydrocodone, also known as Vicodin and Lortab, is a habit‑forming narcotic used to treat severe pain.
  20. The Provider, a pharmacy, furnished the above-described Drugs to the Claimant between October 23, 2000, and January 10, 2001, and sought reimbursement of $1,810.59 from the Carrier for the Drugs.
  21. The Carrier timely denied the requested reimbursement, maintaining that the Drugs were not medically necessary to treat the compensable injuries.
  22. The Provider timely filed a request for medical dispute resolution with the TWCC.
  23. MRD reviewed the dispute and denied the Claimant’s request for reimbursement, finding that the Drugs were not reasonably medically required by the compensable injuries.
  24. The Provider timely appealed the MRD’s decision to the State Office of Administrative Hearings (SOAH).
  25. Notice of a March 21, 2002, hearing in this case was mailed to the Carrier and the Provider on January 14, 2002.
  26. The hearing was continued by a SOAH Administrative Law Judge (ALJ) to June 11, 2002, and the Provider and Carrier were given written notice of that continuance.
  27. On June 11, 2002, William G. Newchurch, a SOAH ALJ, held a hearing on the Provider’s appeal at the William P. Clements Office Building, Fourth Floor, 300 West 15th Street, Austin, Texas. Representatives of the Carrier and the Provider attended that hearing. 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 Tex Gov’t. Code Ann. §§2001.051 and 2001.052 (Vernon 2001).
  3. As the party appealing the MRD’s decision, the Provider 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. The above Findings of Fact do not show that the symptoms and conditions for which the Treating Physician prescribed the Drugs stemmed from the Claimant’s compensable injuries.
  6. The above Findings of Fact do not show that the Drugs were reasonably required by the nature of the compensable injuries as and when needed.
  7. Based on the above Findings of Fact and Conclusions of Law, the Provider’s request for reimbursement of $1,810.59 from the Carrier for the Drugs it provided to the Claimant between October 23, 2000, and January 10, 2001, should be denied.

ORDER

IT IS ORDERED THAT the Provider’s request for reimbursement of $1,810.59 from the Carrier for the Drugs provided to the Claimant between October 23, 2000, and January 10, 2001, is denied.

Signed June 18, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

WILLIAM G. NEWCHURCH
Administrative Law Judge

End of Document
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