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At a Glance:
Title:
453-02-1327-m5
Date:
April 18, 2002
Status:
Retrospective Medical Necessity

453-02-1327-m5

April 18, 2002

DECISION AND ORDER

This case is a dispute over whether Oxymed, Inc., should be reimbursed for the cost of a water circulating unit, with lumbar cooler wrap and pad, provided to the workers’ compensation claimant. The amount in controversy is $724.00.

The Administrative Law Judge (ALJ) concludes the Petitioner did not meet its burden of proving the equipment and supplies were medically necessary under the Texas Workers’ Compensation Commission (the Commissions) Spine Treatment Guidelines. Therefore he denies additional reimbursement.

I. Discussion

The Claimant sustained a compensable back injury on_______, and subsequently underwent a lumbar fusion. Her treating physician, Robert J. Henderson, M.D., prescribed cryotherapy in the form of a water circulating unit, with a lumbar cooler wrap and pad ,[1] to decrease the Claimant’s pain and allow her to perform daily activities more easily.

Southwestern Bell Telephone Company (Southwestern Bell) declined to pay for the cold therapy unit. Oxymed, Inc., which had provided the unit, filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission. The Commission’s Medical Review Division (MRD) found in favor of Southwestern Bell. Oxymed appealed that decision. As the Appellant, Oxymed has the burden of proof. 28 Tex. Admin. Code (TAC) §148.21(h).

Southwestern Bell’s refusal to pay for the cold therapy unit was based on a records review conducted by William D. Abraham, M.D., an orthopedic surgeon. Dr. Abraham did not question the need for pain relief, but stated there is no benefit to a cold therapy unit over the traditional use of ice bags. The Commission’s Spine Treatment Guidelines, at 28 TAC §134.1001 (e)(2)(A)(4), state that treatment of a work-related injury must be, among other things, cost effective. Based on Dr. Abraham’s assessment, Southwestern Bell contended the cold therapy unit was not cost effective.

Dr. Henderson did not address the benefits of the cold therapy unit over ice bags, however. In his letter of medical necessity, Robert J. Henderson, M.D., the Claimant’s treating physician, convincingly described why cryotherapy was necessary

Ms. Kristen Moore of Oxymed, in a letter dated July 3, 2001, did discuss several reasons the cold therapy unit would be preferable to ice bags. Ms. Moore is an accounts employee with Oxymed, however, and apparently has no medical training. Therefore, although her letter was articulate and thorough, it did not convince the ALJ of the medical necessity of the cold therapy unit.

If Ms. Moore were medically trained, or if Dr. Henderson had addressed the benefits of the cold therapy unit over the ice bags, the ALJ might have found that equipment to be medically necessary. Based on the evidence in the record, however, he does not.

II. Findings of Fact

  1. The Claimant sustained a compensable back injury on_______, and subsequently underwent a lumbar fusion.
  2. The Claimant’s treating physician, Robert J. Henderson, M.D., prescribed cryotherapy in the form of a water circulating unit, with a lumbar cooler wrap and pad (cold therapy unit), to decrease the Claimant’s pain and allow her to perform daily activities more easily.
  3. Southwestern Bell Telephone Company (Southwestern Bell) declined to pay for the cold therapy unit.
  4. Oxymed, Inc., which had provided the unit, filed a request for medical dispute resolution with the Texas Workers’ Compensation Commission.
  5. The Commission’s Medical Review Division (MRD) found in favor of Southwestern Bell.
  6. Oxymed filed a timely appeal of the MRD decision.
  7. Notice of the hearing was sent 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 was held March 26, 2002, with Administrative Law Judge (ALJ) Henry D. Card presiding and representatives of the Oxymed and Southwestern Bell participating. The hearing was adjourned the same day.
  10. The amount in controversy is $724.00.
  11. In his letter of medical necessity, Robert J. Henderson, M.D., the Claimant’s treating physician, did not address the benefits of the cold therapy unit over ice bags.
  12. Ms. Kristen Moore, who addressed the benefits of the cold therapy unit over ice bags, is an accounts employee with Oxymed, and apparently has no medical training.
  13. The evidence does not demonstrate that the use of the cold therapy unit would be medically more beneficial to the Claimant than the use of ice bags.

III. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to Section 413.031 of the Texas Workers’ Compensation Act (the 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. Oxymed has the burden of proof in this matter. 28 Tex. Admin. Code (TAC) §148.21(h).
  5. Oxymed did not meet its burden of proving the cold therapy unit was cost effective pursuant to 28 TAC §134.1001(e)(2)(A)(4).
  6. Oxymed’s request for additional reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Oxymed, Inc.s request for additional reimbursement of $724.00 from Southwestern Bell Telephone Company for a water circulating unit, with lumbar cooler wrap and pad, is denied.

Signed April 18, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

  1. For ease of reference, the ALJ will refer to the water circulating unit with the lumbar wrap and the pad as a “cold therapy unit,” although they were requested and billed as separate items.
End of Document
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