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At a Glance:
Title:
453-02-2300-m2
Date:
August 27, 2002
Status:
Pre-Authorization

453-02-2300-m2

August 27, 2002

DECISION AND ORDER

American Home Assurance Company (Petitioner) appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in MDR Docket No. M2-01-0990-01, which granted preauthorization of a thoracic discogram with CT scan by Dr. Charles R. Gordon, M.D. (Provider) for a worker’s compensation claimant (Claimant). This decision finds the requested procedure should not be preauthorized because the evidence established it was not medically necessary.

I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY

There were no contested issues of jurisdiction, notice or venue. Therefore, those issues are addressed in the findings of fact and conclusions of law without further discussion here.

The hearing in this matter convened and closed on July 3, 2002, at the State Office of Administrative Hearings, 300 W. 15th Street, Austin, Texas, with Administrative Law Judge (ALJ) Ann Landeros presiding. Attorney Dan Kelley represented Petitioner. Provider appeared through his designated representative and employee Bridget Shelton. The Commission was not a party to this matter.

II. DISCUSSION

The sole issue in this case was whether the requested thoracic discogram with CT scan was medically necessary. Petitioner introduced a copy of its Requests for Disclosure, which was delivered to Provider on April 4, 2002. Petitioner asserted, and Provider did not dispute, that Provider had never filed responses to the Request for Disclosure. The Request for Disclosure contained the following Request for Admission:

Admit there is no medical necessity for a Thoracic Discogram with CT scan when there is an MRI of the thoracic spine that reveals only small disc protrusions at T6-7 & T7-8 without severe canal stenosis.

The Request for Disclosure also contained the following interrogatory:

If you have denied Request for Admission No. 1, then please identify all facts upon which you base your denial to Request for Admission No. 1.

Petitioner asked that its Request for Admission No. 1 be deemed admitted, pursuant to 1 TEX. ADMIN. CODE (TAC) 155. 31.(d), which requires unanswered admissions to be deemed true. Provider asserted that its failure to answer the Request for Disclosure was inadvertent but did not provide any factual support for that conclusion. Upon request by the Petitioner, the ALJ found that the facts alleged in Petitioner’s Request for Admission No. 1 were true. The SOAH procedural rules also mandated that any evidence contradicting the facts in Petitioner’s Request for Admission No. 1 had to be excluded. 1 TAC § 155.31(d). Provider did not offer any evidence.

Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i). Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a). Health care includes all reasonable and necessary medical services including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A). A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31). Pursuant to TEX. LAB. CODE ANN. §413.014 and 34 TAC § 134.600(h)(5), a discogram requires preauthorization.

Petitioner correctly asserted that no evidence contravening the deemed fact could be admitted. Thus, the only evidence admitted in this case, the deemed admission that the thoracic discogram with CT scan was not medically necessary, established Petitioner’s case. The facts in Petitioner’s Request for Admission, once deemed true, established as a matter of law that the thoracic discogram with CT scan was not medically necessary healthcare in this case.

III. FINDINGS OF FACT

  1. American Home Assurance Company (Petitioner) appealed the decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) granting preauthorization to Dr. Charles R. Gordon, M.D. (Provider) for a thoracic discogram with CT scan for a workers’ compensation claimant.
  2. Pursuant to the notice of hearing sent by Commission Staff, both Petitioner and Provider were represented at the hearing held in this matter on July 3, 2002.
  3. During the discovery process in this contested case, Petitioner sent Provider a Request for Disclosure that contained the following Request for Admission:
  4. Admit there is no medical necessity for a Thoracic Discogram with CT scan when there is an MRI of the thoracic spine that reveals only small disc protrusions at T6-7 & T7-8 without severe canal stenosis.
  5. Provider received Petitioner’s Request for Admission on April 4, 2002, but failed to answer it.
  6. Provider admitted it failed to answer Petitioner’s discovery but did not provide evidence in the form of facts to explain this failure.
  7. Petitioner’s request that the facts contained in its Request for Admission be deemed true was granted.
  8. The thoracic discogram with CT scan requested by Provider for the claimant was not medically necessary.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission (Commission) has jurisdiction related to this matter pursuant to the Texas Workers' Compensation Act (Act), TEX. LABOR CODE ANN. § 413.031.
  2. 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 § 413.031(d) of the Act and TEX. GOV'T CODE ANN. ch. 2003.
  3. The hearing was conducted pursuant to the Administrative Procedure Act, TEX. GOV'T CODE ANN. ch. 2001 and the Commission’s rules, 28 TEX.ADMIN.CODE (TAC) §133.305(g).
  4. Adequate and timely notice of the hearing was provided in accordance with TEX. GOV’T CODE ANN. §§ 2001.051 and 2001.052.
  5. Petitioner has the burden of proof in this proceeding. 28 TAC §§ 148.21(h) and (i).
  6. Pursuant to the Act, an employee who has sustained 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 cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances the ability of the employee to return to or retain employment. TEX. LAB. CODE ANN. § 408.021(a).
  7. Health care includes all reasonable and necessary medical services, including a medical appliance or supply. TEX. LAB. CODE ANN. §401.011(19)(A).
  8. A medical benefit is a payment for health care reasonably required by the nature of the compensable injury. TEX. LAB. CODE ANN. § 401.011(31).
  9. Pursuant to TEX. LAB. CODE ANN.§ 413.014 and 34 TAC § 134.600(h)(5), a discogram requires preauthorization.
  10. Because the thoracic discogram with CT scan is not medically necessary healthcare for the claimant, it should not be preauthorized.

ORDER

IT IS ORDERED that the request for preauthorization of a thoracic discogram with CT scan by Dr. Charles R. Gordon, M.D., for the claimant in this matter is denied.

Signed this 27TH day of August 2002.

ANN LANDEROS
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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