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At a Glance:
Title:
453-02-2847-m5
Date:
December 12, 2002
Status:
Retrospective Medical Necessity

453-02-2847-m5

December 12, 2002

DECISION AND ORDER

The issue in this case is whether Petitioner, Hassle Free Pharmacy Services (Hassle Free), should be reimbursed $356.12 for medications prescribed for the workers’ compensation claimant in August and September 2001. The Administrative Law Judge (ALJ) concludes that Hassle Free should be reimbursed for the disputed claims.

I. Jurisdiction, Notice, and Procedural History

The Texas Workers’ Compensation Commission (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. The State Office of Administrative Hearings (SOAH) has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Lab. Code Ann. §413.031and Tex. Gov’t Code Ann. ch. 2003.

The Commission’s Medical Review Division (MRD) issued its decision March 13, 2002. Hassle Free filed a timely request for hearing. Proper and timely notice of the hearing was issued May 6, 2002. Following a continuance, the hearing was convened October 22, 2002, with the undersigned Administrative Law Judge (ALJ) presiding. John V. Fundis appeared for Hassle Free, and Paige Duncan, Assistant Attorney General, appeared for the _________________. The hearing was adjourned and the record closed the same day.

II. Legal Standards

The applicable legal standards are found in sections 408.021 and 401.011 of the Texas Labor Code. Section 408.021 states:

(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. The employee is specifically entitled to health care that:

  1. cures or relieves the effects naturally resulting from the compensable injury;
  2. promotes recovery; or
  3. enhances the ability of the employee to return to or retain employment.

Section 401.11(19) defines "health care" to include “all reasonable and necessary medical aid, medical examinations, medical treatments, medical diagnoses, medical evaluations, and medical services.”

The Commission’s Spine Treatment Guideline, though abolished effective January 1, 2002, was in effect at all times relevant to this case. 28 Tex. Admin. Code § 134.1001 (West 2002) (abolished by statute effective January 1, 2002).

Hassle Free, the petitioner, has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).

III. Discussion

Factual background. The claimant worked as a ___ at _________________ in Tyler. On_______, she suffered a compensable injury when she fell, resulting in lumbar strain and contusion of her right sacroiliac area. Provider Exhibit 1. She has experienced long-term pain in her lower back, hip, and leg that has been described as lumbar myofascial pain and chronic pain syndrome. Id., pp. 10, 150, 171. Her treating doctor has stated that her pain may be permanent. Id., p. 10. She has undergone spinal injections, physical therapy, and work conditioning, but the pain has persisted. Provider Exhibit 1.

The medications at issue in this case are:

Medication Date[1] Amount billed

Neurotin 8-8-01 $43.17

Skelaxin 9-10-01 $93.11

Clorazepate 9-11-01 $113.82

Mobic 9-19-01 $74.14

Ultram 9-24-01 $31.88 Total: $ 356.12

All the prescriptions were written by Kenneth Cushman, M.D., of the University of Texas Health Center in Tyler. TWCC Exhibit 1, pp. 11 - 18. _________ denied reimbursement for all as medically unnecessary. Id., pp. 19 - 28. Hassle Free sought MRD review. The MRD determined that medical necessity had not been established by the records before it, and ordered no reimbursement. Id., pp. 1 - 3.

Analysis and recommendation. The medical records show that the claimant’s doctors were experimenting with a number of different medications to try to treat her pain without causing troublesome side effects. See Provider Exhibit 1. Dr. Cushman’s documentation shows that in 2001 he had “tried Neurotin as an attempt to abate the neuropathy component of her pain,” but the claimant had trouble tolerating the medication.[2] Provider Exhibit 1, p. 7. The record shows that Dr. Cushman treated the claimant’s muscle spasms with Skelaxin in 2001. Id., pp. 5, 14, 34, 48. Dr. Cushman’s notes explain that he also treated the claimant with Mobic, an anti-inflammatory, and Clorazepate, a muscle relaxer, in 2001. Id., pp. 47, 145. The record further shows that Dr. Cushman attempted to treat the claimant’s pain with Ultram, but she could not tolerate its side effects. Id., p. 4.

The documentation in evidence is sufficient to demonstrate the claimant’s condition and the purposes of the prescribed medications (e.g., pain reduction and inhibition of muscle spasms). Post-tertiary management of symptoms is authorized by the Spine Treatment Guideline. The provider has established medical necessity, and these claims should be reimbursed.

IV. Findings of Fact

  1. The claimant worked as a ___ at__________. On_______, she suffered a compensable injury when she fell, resulting in lumbar strain and contusion of her right sacroiliac area.
  2. _____________ is the workers’ compensation insurer with respect to the claims at issue in this case.
  3. The claimant has experienced long-term pain in her lower back, hip, and leg that has been described as lumbar myofascial pain and chronic pain syndrome.
  4. The claimant has undergone spinal injections, physical therapy, and work conditioning, but her pain has persisted. It may be permanent.
  5. The claimant’s treating physician, Kenneth Cushman, M.D., of the University of Texas Health Center in Tyler, experimented with a variety of medications in 2001 to try to treat his patient’s pain effectively without causing intolerable side effects.
  6. In 2001, Dr. Cushman prescribed Neurotin as an attempt to abate the neuropathy component of the claimant’s pain.
  7. On August 8, 2001, the claimant filled a prescription for Neurotin through Hassle Free Pharmacy Services (Hassle Free) for $43.17.
  8. Dr. Cushman treated the claimant’s muscle spasms with Skelaxin, a muscle relaxer, in 2001.
  9. On September 10, 2001, the claimant filled a prescription for Skelaxin through Hassle Free for $93.11.
  10. Dr. Cushman prescribed Clorazepate, a muscle relaxer, to treat the claimant’s back and hip condition.
  11. On September 11, 2001, the claimant filled a prescription for Clorazepate for $113.82.
  12. Dr. Cushman prescribed Mobic, an anti-inflammatory medication, for claimant’s back and hip condition.
  13. On September 19, 2001, the claimant filled a prescription for Mobic through Hassle Free for $74.14.
  14. Dr. Cushman attempted to treat the claimant’s pain with Ultram.
  15. On September 24, 2001, the claimant filled a prescription for Ultram through Hassle Free for $31.88.
  16. Hassle Free filled the prescriptions and submitted claims for reimbursement to the ________. The total amount claimed for all the medications at issue was $356.12.
  17. _______ denied reimbursement, asserting a lack of medical necessity.
  18. Hassle Free filed a Request for Medical Dispute Resolution with the Commission’s Medical Review Division (MRD).
  19. The MRD denied the request on the grounds that Hassle Free had not shown medical necessity for the medications in the documentation presented to the MRD.
  20. Hassle Free filed a request for hearing.
  21. Notice of the hearing was issued May 6, 2002.
  22. 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.
  23. Following a continuance, the hearing was convened October 22, 2002, with Administrative Law Judge Shannon Kilgore presiding. John V. Fundis appeared for Hassle Free, and Paige Duncan, Assistant Attorney General, appeared for_____________. The hearing was adjourned and the record closed the same day.

V. 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 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 and Tex. Gov’t Code ch. 2003.
  3. 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. Tex. Lab. Code § 408.021.
  4. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code § 2001.052.
  5. Hassle Free has the burden of proof in this matter. 28 TAC §148.21(h).
  6. Based on Findings of Fact 1, 3, 4, 5, 6, 8, 10, 12, and 14, the medications provided on August 8 and September 10, 11, 19, and 24, 2001, were reimbursable under § 408.021 of the Texas Labor Code.
  7. Hassle Free is entitled to reimbursement of $356.12, plus accrued interest, for the claims at issue in this case.

ORDER

IT IS THEREFORE ORDERED that _____________ reimburse Hassle Free Pharmacy Services $356.12, plus accrued interest, for medications provided to the workers’ compensation claimant on August 8 and September 10, 11, 19, and 24, 2001.

Signed this 12th of December, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Shannon Kilgore
Administrative Law Judge

  1. These appear to be the dates the prescriptions were filled, not written.
  2. The date of service for this medication was one month later than Dr. Cushman’s note saying that the drug had been discontinued. However, given that the evidence shows the medication was prescribed for a legitimate medical purpose, and the patient and doctor were struggling and experimenting to find a treatment regimen the patient could tolerate, the ALJ does not conclude that the short time lapse has any significance with respect to medical necessity.
End of Document
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