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At a Glance:
Title:
453-02-2310-m5
Date:
September 3, 2002

453-02-2310-m5

September 3, 2002

DECISION AND ORDER

I. SUMMARY

Respondent, Highpoint Pharmacy, sought reimbursement of $1,426.36 from Home Indemnity Company (Carrier) for medications prescribed for and provided to ___(Claimant). The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) ordered reimbursement of $1,300.25. Carrier has appealed MRD’s decision. The Administrative Law Judge (Judge) concludes MRD correctly determined that the medications prescribed for Claimant and provided by Respondent were medically necessary and that Respondent is entitled to reimbursement.

II. BACKGROUND

Claimant suffered a compensable work-related injury on ___. On April 3, April 24, and June 13, 2001, Respondent provided medications (Ultram, Neurontin, Celexa, Vioxx, and quinine sulfate) prescribed by Claimant’s treating physician, Jacob Rosenstein, M.D., a board-certified neurological surgeon. Carrier denied reimbursement as medically unnecessary, based on a peer review (Denial Code V). Respondent requested medical dispute resolution and furnished MRD with letters of medical necessity from Dr. Rosenstein. MRD found that the letters adequately documented the medical necessity of the medications, “particularly when no opposing information is offered by the carrier,” and ordered reimbursement.

Judge Carol Wood convened a hearing on these issues on July 3, 2002. The hearing concluded, and the record closed the same day. Carrier was represented by Steven M. Tipton, attorney; Respondent was represented by Nicky Otts; the Commission did not appear.

III. DISCUSSION

Carrier asserts the prescribed medications were medically unnecessary. Carrier contends the medications were for multiple problems not related to the compensable injury, such as depression and trochanteric bursitis. In support, Carrier offered a peer review by J. Martin Barrash, M.D., dated February 2, 2000 (Exhibit No. P-3), and another peer review by Dr. Barrash dated June 25, 2002 (Exhibit No. P-1).

Respondent argues there is nothing in Dr. Rosenstein’s letters of medical necessity that indicates he is treating Claimant for depression or trochanteric bursitis. Additionally, Respondent asserts Carrier failed to follow 28 TEX. ADMIN. CODE (TAC) §133.304(h)[1] by denying payment based on a peer review that was never sent with the explanation of benefits (EOB). The Judge concurs.

Section 133.304(h) requires a carrier who reduces or denies payment for a treatment or service on the recommendation of a peer review to provide a copy of the peer reviewer’s report to the sender of the bill with the EOB. The evidence shows that Dr. Barrash completed his peer review of Claimant’s records in February, 2000, more than a year before Respondent filled the prescriptions at issue. Although Carrier denied payments using Denial Code V, nothing in the EOBs or the peer review letter indicates that a copy of the review was sent to Respondent with the payment denials.[2] Had Carrier sent the peer review to Respondent as required by 28 TAC § 133.304(h), Respondent would have had more complete information to communicate to Dr. Rosenstein, Claimant’s treating physician, about the reason for the denials, and subsequently to Carrier, about the necessity of the medications.

However, Dr. Rosenstein’s letters of medical necessity clearly establish the medications prescribed for Claimant were reasonably required by the nature of Claimant’s injury. Dr. Rosenstein’s letter of medical necessity dated May 4, 2001, indicates Claimant has had a chronic lumbar radiculopathy and chronic low back pain since being injured in 1992, and Dr. Rosenstein prescribed Ultram as an analgesic for treatment of Claimant’s low back pain. And Dr. Rosenstein’s letter dated July 11, 2001, states Claimant was prescribed the following medications for treatment of radiculopathy: Neurontin for its neuropathic pain effects, Celexa for its chronic pain effects, Vioxx for its anti-inflammatory effects, and quinine sulfate for Claimant’s leg spasms and cramps.

Based on the evidence, the Judge concludes MRD correctly determined that the medications prescribed for Claimant and provided by Respondent were medically necessary and that Respondent is entitled to reimbursement from Carrier in the amount of $1,300.25, plus all accrued interest due.

FINDINGS OF FACT

  1. On ___, (Claimant) suffered an injury compensable under the Texas Workers’ Compensation Act, TEX. LABOR CODE ch. 401 et seq.
  2. Claimant’s injury is covered by Home Indemnity Company (Carrier) for workers’ compensation insurance.
  3. On April 3, April 24, and June 13, 2001, Highpoint Pharmacy provided Claimant medications (Ultram, Neurontin, Celexa, Vioxx, and quinine sulfate) prescribed by Claimant’s treating physician, Jacob Rosenstein, M.D., a board-certified neurological surgeon.
  4. Carrier denied reimbursement as medically unnecessary, based on a peer review (Denial Code V).
  5. On August 15, 2001, Highpoint Pharmacy filed a request with the Medical Review Division (MRD) of the Workers’ Compensation Commission (Commission) for medical dispute resolution and furnished MRD with letters of medical necessity from Dr. Rosenstein.
  6. On January 26, 2002, MRD issued a decision that found that the letters from Dr. Rosenstein adequately documented the medical necessity of the medications, “particularly when no opposing information is offered by the carrier,” and ordered Carrier to reimburse Highpoint Pharmacy $1,300.25.
  7. Carrier on February 13, 2002, filed a request for hearing to contest the findings and decision of MRD.
  8. On April 2, 2002, the Commission provided notice of the contested hearing in this matter to all parties. 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 to be considered.
  9. On July 3, 2002, Administrative Law Judge Carol Wood convened a hearing on the matter in Austin, Texas, and both Carrier and Highpoint Pharmacy appeared.
  10. Carrier denied payments based on a peer review prepared by J. Martin Barrash, M.D., dated February 2, 2000, and a peer review dated February 18, 2000.
  11. When Carrier sent Highpoint Pharmacy the explanation of benefits (EOB) forms denying the April 3, April 24, and June 13, 2001, prescription claims, Carrier failed to send copies of the peer reviews with the EOBs.
  12. The medications Ultram, Neurontin, Celexa, Vioxx, and quinine sulfate prescribed for Claimant by Claimant’s treating physician, Dr. Rosenstein, and provided by Highpoint Pharmacy were medically necessary for treating Claimant’s chronic lumbar radiculopathy and chronic low back pain: Ultram as an analgesic for Claimant’s low back pain; Neurontin for its neuropathic pain effects; Celexa for its chronic pain effects; Vioxx for its anti-inflammatory effects; and quinine sulfate for Claimant’s leg spasms and cramps.

CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented, pursuant to the Texas Workers’ Compensation Act, TEX. LABOR CODE (Labor Code) § 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. Labor Code § 413.031(d) and TEX. GOV’T CODE (Gov’t Code) ch. 2003.
  3. Adequate and timely notice of hearing was provided pursuant to the Administrative Procedure Act, Gov’t Code § 2001.052.
  4. 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. Labor Code § 408.021(a).
  5. Carrier had the burden of proving by a preponderance of the evidence that it should prevail in this matter. Labor Code § 413.031.
  6. Based on Findings of Fact Nos. 10 and 11, Carrier failed to follow 28 TEX. ADMIN. CODE (TAC) § 133.304(c) by not providing a sufficient explanation to allow the provider, Highpoint Pharmacy, to understand the reason for Carrier’s actions.
  7. Based on Findings of Fact Nos. 10 and 11, Carrier failed to follow 28 TAC § 133.304(h) by not sending Highpoint Pharmacy copies of the peer review reports with the explanation of benefits forms denying payments for the medications.
  8. The medications provided by Highpoint Pharmacy were for health care reasonably required by the nature of the injury. Labor Code § 408.021(a).

Issued this 3rd day of September, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

CAROL WOOD
Administrative Law Judge

  1. The rule applies to all dates of service on or after July 15, 2000.
  2. Indeed, the Carrier’s re-evaluation of the prescriptions filled by Respondent for Claimant on April 24, 2001, indicates Carrier’s denial of payment was based on a peer review dated February 18, 2000, that stated “No further treatment including medications is necessary” (p.17 of the certified record from MRD, Exhibit No. 1).
End of Document
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