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At a Glance:
Title:
453-02-2078-m5
Date:
July 3, 2002

453-02-2078-m5

July 3, 2002

DECISION AND ORDER

The issue in this case is whether Petitioner Scientific Therapy and Advanced Treatment (STAT) should be reimbursed $216.00 for Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) prescribed for and provided to ___, an injured employee (Claimant), between April 20, 2000, and July 20, 2000. The Administrative Law Judge (ALJ) concludes STAT has not 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 $216.00 is denied.

In support of its claim that the treatment was medically necessary, STAT submitted a letter dated May 10, 2002, written by Donald Dutra, M.D., Claimant’s treating doctor. In the letter, Dr. Dutra states:

I have been treating [___] for an on the job injury she sustained on___________. [___’s] diagnosis consists of lumbar invertebral disc displacement and disorder of the sacrum. 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.[1]

After Carrier questioned the medical necessity of the prescribed agents, STAT was obligated to show the efficacy and necessity of the G/C 1000 and the MSM for the purpose prescribed. The ALJ finds that STAT’s evidence is unpersuasive and does not meet this burden. The only significant evidence offered by STAT is the May 10th letter from Dr. Dutra. However, the ALJ notes that letter by Dr. Dutra appears to be nothing more than a conclusory form letter, and contains numerous typographical errors (such as the inconsistent usage of the terms “their” and “they” throughout the letter to refer to the Claimant, a lone individual).[2] Moreover, the language of the letter is identical to the language of letters submitted by other doctors, in regard to other patients, in other cases before SOAH.[3]

While the ALJ recognizes that physicians may sometimes use forms as a matter of efficiency, the wholesale use of detailed form letters that contain typographical errors and form language regarding the time period for usage of a prescribed product and the reason such product is being prescribed for a particular patient is troubling. These are matters that are supposed to be addressed by the physician’s independent judgment and the patient’s particular circumstances. When a physician simply plugs in a different name, injury, and treatment date into a form letter, this leads the ALJ to find the letter to be of little or no persuasive value and of no use in evaluating the true medical necessity of the prescribed agents for the patient’s specific condition. Therefore, because the ALJ gives no persuasive weight to the letter written by Dr. Dutra, the ALJ concludes that STAT has not 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.

I. Findings of Fact

  1. The Petitioner Scientific Therapy and Advanced Treatment (STAT) provided $216.00 worth of Glucosamine Hydrochloride and Chondroitin Sulfate (G/C 1000) and Methyl Sulfonyl Methane (MSM) to ___, an injured employee from April 20, 2000 to July 20, 2000.
  2. ___’s treating doctor, Donald Dutra, M.D., prescribed the G/C 1000 and MSM to her.
  3. STAT requested reimbursement from Travelers Indemnity Company (Carrier) for the G/C 1000 and MSM, and Carrier denied the request.
  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 findings and decision on March 22, 2001, denying STAT’s reimbursement request.
  6. On April 2, 2001, STAT filed a request for a hearing before the State Office of Administrative Hearings (SOAH).
  7. Notice of the hearing was issued on March 8, 2002.
  8. The hearing convened June 10, 2002, with Administrative Law Judge Craig R. Bennett presiding. Randy Burgett appeared via telephone for STAT. Dan Flanagan appeared for Carrier. The hearing adjourned and the record closed the same day.
  9. ___ suffered from lumbar invertebral disc displacement and disorder of the sacrum.
  10. The evidence presented does not demonstrate the efficacy or the medical necessity of the prescribed G/C 1000 and MSM.

II. Conclusions of Law

  1. The Commission has jurisdiction over this matter pursuant to §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. STAT has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. STAT has not 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 Ann. §408.021.
  6. STAT’s request for reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Scientific Therapy and Advanced Treatment’s request for reimbursement for G/C 1000 and MSM provided to the workers’ compensation claimant

from April 20, 2000 to July 20, 2000, is denied.

Signed the 3rd day of July, 2002.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. Exhibit 2.
  2. While, arguably, the typographical errors are not substantive in nature, they do raise serious questions as to whether the statements contained are actually the result of independent medical determination related specifically to the patient. When the physician refers on at least two occasions to a lone individual with the terms “they” or “their” it raises questions as to the validity of the physician's determination relating to the specific patient.
  3. See, e.g., the Decision and Order in SOAH Docket No. 453-02-1324.M5 which discusses a letter by a different physician which contains the exact language (including typographical errors) of Dr. Dutra’s letter. Also, see the Decision and Order in SOAH Docket No. 453-01-3369.M5, wherein the ALJ discusses the use of the same or similar form medical necessity letters in numerous proceedings before SOAH.
End of Document
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