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At a Glance:
Title:
453-02-3130-m5
Date:
December 4, 2002

453-02-3130-m5

December 4, 2002

DECISION AND ORDER

The Petitioner in this case, Plaza Pharmacies (Plaza), seeks reimbursement of $2,573.49 for prescription medications it provided the workers’ compensation claimant (Claimant). Reliance Insurance Company (the Carrier) and its successor, Texas Property and Casualty Insurance Guaranty Association (TPCIGA), refused to reimburse Plaza for those medications.

The Administrative Law Judge (ALJ) concludes Plaza did not prove it was entitled to reimbursement, and denies its request.

I. Discussion of the Evidence

The Claimant sustained a compensable injury to her back________. She was treated with physical therapy, medications and muscle stimulation. She continued to have back pain, however. Her treating doctor, Bill E. Weldon, D.O., prescribed several medications that Plaza provided in October and December 2000 and March 2001.

The Carrier declined to reimburse Plaza for those medications. After requesting reconsideration, Plaza filed a Request for Medical Dispute Resolution with the Texas Workers’ Compensation Commission (TWCC or the Commission). On April 23, 2002, the Commission’s Medical Review Division (MRD) issued a decision in favor of TPCIGA, which had succeeded the Carrier.

Plaza requested a hearing before the State Office of Administrative Hearings (SOAH). After the appropriate notice had been provided, the hearing was held September 3, 2002, before ALJ Henry D. Card, with representatives of Plaza and TPCIGA participating. The hearing was adjourned the same day.

The medications, dates of service, and amounts in dispute are set forth below:

DOS

10/13/00

12/13/00

03/23/01

03/23/01

03/23/01

03/23/01

Total

Medication

Vanadom

Vanadom

Hydrocodone/APAP

Vanatrip

Piroxicam

Vanadom

Amount Billed

$ 665.93

665.93

144.94

206.01

224.75

665.93

$2,573.49

Dr. Weldon provided letters of medical necessity for the prescriptions. Dr. Weldon stated the Claimant’s diagnosis at the time of the first date of service was cervical and lumbar intervertebral disc syndrome and tendonitis of the left shoulder. Dr. Weldon observed the Claimant was continuing to experience pain, rigidity, and decreased range of motion in her neck, shoulder, and lower back. He prescribed Vanadom, a skeletal muscle relaxer, to reduce excessive muscle tension and muscle spasms related to the Claimant’s symptoms, which were directly related to her compensable injury.

For the later dates of service, the Claimant’s symptoms and diagnosis were much the same, although Dr. Weldon described them in slightly different language. He prescribed Peroxicam, a non-steroidal anti-inflammatory, to reduce pain, swelling and inflammation. He described hydrocodone/APAP as a narcotic painkiller used to treat moderate to severe pain related to musculoskeletal injuries. Vanatrip is a generic brand of Amyltryptoline, a tricyclic anti-depressant medication used to treat patients with chronic pain and related depression. Dr. Weldon stated the medications at issue are routinely used for patients with symptoms such as the Claimant’s, that those symptoms were directly related to the Claimant’s injuries, and that the Claimant had shown no tendency to abuse those medications.

Plaza also provided notes from the Claimant’s visits with Dr. Weldon that stated she was experiencing continuing pain and stiffness during the period in question.

Two peer reviews and a physician’s examination disputed the need for the medications. The first peer review in the record was unsigned, and the ALJ therefore has given it no weight. The second, dated January 2, 2001, was provided by Charles R. Crane, M.D. Dr. Crane observed that the Claimant’s compensable injury was a soft tissue injury sustained in__________. In his opinion, treatment for such injuries usually lasts three to six months, not three and a half years. He believed none of the medications was needed.

Jeffrey P. Pardee, M.D., examined the Claimant ___. Dr. Pardee summarized the Claimant’s diagnostic testing and medical history. An MRI conducted March 30, 1998, showed a disc bulge at C4-5, and disc herniation at L3-4 and L5-S1. Radiographs of the lumbar spine showed the lumbar interspaces to be normal, other than mild disc space narrowing at L5-S1, along with normal degenerative changes. The Claimant’s history included another work-related injury and several traffic accidents in ____ and____, before the compensable injury in question here. At the time of Dr. Pardee’s examination, the Claimant was working as a grocery store cashier and stocker. She was still taking pain medications, though not the particular ones at issue here.

After examining the Claimant, Dr. Pardee concluded her temporary total disability had long since ended. He cited Dr. Crane’s conclusion that treatment for the Claimant’s type of injury typically would last from three to six months. He stated the Claimant’s symptoms could be controlled successfully by over-the-counter anti-inflammatories such as Aleve. He believed there was “absolutely no indication for the use of narcotic medications and sleeping pills in the treatment of chronic pain.”

II. Analysis

Although Dr. Pardee examined the Claimant almost two years after the first date of service in dispute, nothing in the record suggested her medical situation had changed significantly. Dr. Pardee’s report was detailed and convincing. Although the evidence suggested the Claimant was still experiencing pain from her injury, the diagnostic testing did not show the injury to be structurally severe. Dr. Weldon’s letter of medical necessity did not adequately explain why the prescription medications at issue were needed to treat the Claimant more than three years after such an injury.

Because Plaza requested the SOAH hearing, it has the burden of proof under 28 Tex. Admin. Code §148.21(h). The ALJ concludes it did not meet that burden and denies its request for reimbursement.

III. Findings of Fact

  1. The Claimant sustained a compensable injury to her back on__________
  2. The Claimant was treated with physical therapy, medications and muscle stimulation. She continued to have back pain, however.
  3. The Claimant’s treating doctor, Bill E. Weldon, D.O., prescribed several medications that Plaza provided in October and December 2000 and March 2001.
  4. The Carrier declined to reimburse Plaza for those medications.
  5. After requesting reconsideration, Plaza filed a Request for Medical Dispute Resolution with the Commission.
  6. On April 23, 2002, the MRD issued a decision in favor of TPCIGA, which had succeeded the Carrier.
  7. Plaza requested a hearing before SOAH.
  8. The hearing was held September 3, 2002, before ALJ Henry D. Card, with representatives of Plaza and TPCIGA participating, and was adjourned the same day.
  9. The medications, dates of service, and amounts in dispute are set forth below:

DOS

10/13/00

12/13/00

03/23/01

03/23/01

03/23/01

03/23/01

Total

Medication

Vanadom

Vanadom

Hydrocodone/APAP

Vanatrip

Piroxicam

Vanadom

Amount Billed

$ 665.93

665.93

144.94

206.01

224.75

665.93

$2,573.49

  1. The Claimant’s compensable injury was a soft tissue injury.
  2. Treatment for soft tissue injuries usually lasts three to six months, not three and a half years.
  3. The Claimant’s symptoms could be controlled successfully by over-the-counter anti-inflammatories such as Aleve.
  4. The prescription medications at issue were not medically necessary for the treatment of the Claimant’s compensable injury.

IV. 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. Plaza has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Plaza did not prove it was entitled to additional reimbursement.
  6. Plaza’s request for additional reimbursement should be denied.

ORDER

IT IS, THEREFORE, ORDERED that Plaza Pharmacies’ request for reimbursement of $2,573.49 for prescription medications provided the Claimant on October 13, 2000, December 13, 2000, and March 23, 2001, is denied.

Signed this 4th day of December, 2002.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Henry D. Card
Administrative Law Judge

End of Document
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