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At a Glance:
Title:
453-02-3288-m2
Date:
September 6, 2002
Status:
Pre-Authorization

453-02-3288-m2

September 6, 2002

DECISION AND ORDER

_________ has appealed a decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission). MRD ordered preauthorization for the reasonable and necessary costs for a motorized wheelchair for____ (Respondent/Claimant), suffering from Reflex Sympathetic Dystrophy (RSD).[1] In this decision, the Administrative Law Judge (ALJ) finds that _________ has failed to meet its burden of showing that the requested equipment was not reasonable and medically necessary for Claimant’s compensable injury. Therefore, the ALJ concurs with the MRD decision which preauthorized a new wheelchair for Claimant, and orders _________ to authorize and reimburse the reasonable and necessary costs associated with the requested equipment.

The hearing was convened on August 9, 2002, before Steven M. Rivas, ALJ. ___________was represented by Todd Clark, attorney. Claimant appeared and was assisted by Luz Loza, Ombudsman. The record closed the same day.

I. DISCUSSION

Background Facts

Claimant was an employee of _____________ for 14 years, was promoted to the rank of Lieutenant, and worked in the corrections division. On________, Claimant suffered a compensable injury to her knee during a shooting range exercise. She received treatment for her injuries and subsequently developed RSD, a condition that affects the sympathetic nervous system. Claimant currently suffers from RSD as a direct result of her ____injury. Claimant was out of work three-to-four months following the injury and later returned to work with________. After a couple of years, Claimant found she was unable to perform her duties as a result of her injury and resigned. Claimant moved to Ohio where she attended school and later obtained employment commensurate with her physical capabilities.

Reflex Sympathetic Dystrophy (RSD

RSD is a medical condition yet to be fully understood by the medical industry. From the testimony of Michael Harris, M.D., it is a pain condition that affects patients who typically sustain a relatively minor injury and later complain of symptoms that far outweigh what one would expect following a minor injury. In this case, Claimant suffered an injury to her knee when she knelt down on top of a small stone while performing an exercise at a firing range. After a reasonable amount of treatment which included an invasive procedure in 1995, Claimant began suffering from symptoms of RSD, specifically, an extreme sensitivity to touch. As a result of her extreme sensitivity, Claimant now suffers from severe pain in her lower extremities. According to Dr. Harris, very few people return to work after the onset of RSD symptoms. It was undisputed that Claimant’s symptoms of RSD are a direct and proximate result of Claimant’s injury. It was further noted that the surgical procedure in 1995 temporarily relieved Claimant’s pain caused by her injury, but soon after the procedure, her RSD symptoms recurred.

Applicable Law

The Texas Labor Code contains the Texas Workers’ Compensation Act (the Act) and provides the relevant statutory requirements regarding compensable treatment for workers’ compensation claims. In particular, Tex. Lab. Code Ann. §408.021 provides in pertinent part:

(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.

* * *

Under Tex. Lab. Code Ann. §401.011(19) health care includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

A. Analysis

Claimant began suffering from RSD in 1995 and was provided a wheelchair in 1996 by______. Presently, Claimant is employed as a ___ in Ohio.[2] Her primary job responsibility is to assist homeless families obtain housing and employment as a means to become self-sufficient. Although Claimant’s actual job duties are sedentary in nature, she is required to move about her office freely to retrieve case files and copy large amounts of documents. Claimant asserts she is unable to adequately move about her work area due to the restrictions placed on her by her current wheelchair.

Claimant asserts the wheelchair provided by _________causes her pain and restricts her movements in her office. Claimant asserted she is entitled to a new wheelchair in order to retain employment because her current wheelchair restricts her mobility and thereby reduces her productivity. Although Claimant is somewhat mobile at home without use of the wheelchair, she uses her current wheelchair 100% of time at work.

Two years ago, Claimant’s request to modify her current wheelchair was denied by ________[3] At this time, the wheelchair manufacturer has determined modifications to Claimant’s present wheelchair are not possible.[4] Claimant therefore asserts a new wheelchair is the only proper remedy to retain employment.

Dr. Harris has been Claimant’s treating doctor since 1997. On several occasions, Dr. Harris has physically examined Claimant and made recommendations regarding her treatment including the acquisition of the requested motorized wheelchair. Dr. Harris believes a new wheelchair is reasonable and necessary because it will allow Claimant to work and function properly in society. He believed if Claimant is denied a new wheelchair, she will most certainly go on disability. This ALJ found the testimony of Dr. Harris quite compelling because he has been Claimant’s treating doctor for several years and has personally examined Claimant.

The issue here is whether or not the new wheelchair will assist Claimant to retain employment. Under Tex. Lab. Code Ann. § 408.021(a)(3), a claimant is entitled to all health care that enhances the ability of the employee to return to or retain employment. Even though the wheelchair will not cure Claimant’s condition, it will, in this case, enhance the Claimant’s ability to retain employment by allowing Claimant to be a productive employee without further accommodations from her current employer.[5]

________ relied on the report and opinion of John Yatsu, M.D., in denying Claimant’s new wheelchair. Dr. Yatsu’s main argument is that the wheelchair is not medically necessary because it merely contributes to Claimant’s work accommodations. Dr. Yatsu agreed with Dr. Harris that the new wheelchair would not assist in Claimant’s recovery from RSD symptoms. Dr. Yatsu did not address whether the new wheelchair will assist Claimant in retaining employment by allowing Claimant to become a productive employee.

Dr. Yatsu further testified the responsibility of Claimant’s work accommodations should rest with the Claimant’s present employer. Dr. Yatsu did not address why _________should avoid responsibility for a compensable injury that occurred while Claimant was a ________ employee.

Finally, _______wants this ALJ to consider what, if anything, Claimant’s current employer has done to accommodate Claimant’s condition. Dr. Harris has not contacted Claimant’s employer to research how much her employer can accommodate Claimant, if at all. It seems unreasonable and unrealistic to expect a treating doctor to contact a patient’s employer to address accommodation issues. Treating doctors are charged with treating patients and recommending treatment in the best interest of the claimant. Furthermore, this ALJ was not presented with any statute that requires a treating doctor to contact Claimant’s employer regarding accommodation issues.

Claimant repeatedly testified how she wanted to be employed and would rather work with the assistance of a wheelchair rather than claim disability and/or draw social security. The testimony of Claimant and Dr. Harris was much more persuasive than Dr. Yatsu who admitted never examining Claimant personally. Since the new wheelchair will assist Claimant in retaining employment, Claimant is entitled to the new wheelchair.

After reviewing the evidentiary record, this ALJ finds that_________, as the party appealing the MRD decision, has not met its burden of proof. Specifically, ________ has failed to establish that the requested equipment is not medically reasonable nor necessary for Claimant’s RSD.

For the foregoing reasons, the ALJ concludes that the requested equipment is reasonable and medically necessary for Claimant________ compensable injury, and should be authorized.

II. FINDINGS OF FACTS

  1. ____ (Claimant), was an employee of ________as a corrections officer for 14 years.
  2. On_________, Claimant sustained a compensable work-related injury while employed by_________.
  3. At the time of Claimant’s compensable injury, ________was self-insured under the Texas Workers’ Compensation Act.
  4. Claimant received treatment for her injuries and returned to work with__________.
  5. After two years back with_________, Claimant resigned because she was unable to perform the required duties as a corrections officer.
  6. In 1995, as a result of the compensable injury, Claimant began suffering from symptoms of Reflex Sympathetic Dystrophy (RSD), a condition that affects the sympathetic nervous system.
  7. In 1996, ___________ provided Claimant with a wheelchair. In the years following 1996, Claimant repeatedly requested _____________to authorize modifications to Claimant’s wheelchair to improve Claimant’s mobility at work. All requests for modifications were denied by_________.
  8. In 1997, Michael Harris, M.D., became Claimant’s treating doctor.
  9. At some point between 1997 and 2002, it was discovered that modifications to Claimant’s current wheelchair could not be implemented by the manufacturer.
  10. Dr. Harris recommended Claimant receive a new motorized wheelchair to use at work. __________ denied Claimant’s request for a new wheelchair as not medically necessary.
  11. Claimant requested medical dispute resolution through the Commission’s Medical Review Division (MRD).
  12. MRD reviewed the dispute and issued a decision on February 15, 2002, finding that the requested wheelchair was medically necessary and ordered _____________to authorize purchase of the wheelchair.
  13. ___________ appealed the MRD decision to the State Office of Administrative Hearings (SOAH).
  14. Notice of the hearing in this case was mailed to the parties on July 29, 2002. 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. In the notice, the Commission’s staff indicated that it would not participate in the hearing.
  15. The hearing was held on August 9, 2002, with Administrative Law Judge (ALJ) Steven M. Rivas presiding. ________ appeared through its attorney, Todd Clark. Claimant____., appeared with Luz Loza, Ombudsman. The hearing was adjourned and the record closed the same day.
  16. Claimant presented evidence that the requested wheelchair would enhance her ability to retain employment by allowing her to move freely about her work environment thereby making her a productive employee.
  17. _________ did not establish that the requested wheelchair was not medically necessary.

III. CONCLUSIONS OF LAW

  1. The Commission has jurisdiction over this matter pursuant to Tex. Lab. Code § 413.031.
  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. _______filed its notice of appeal, as specified in 28 Tex. Admin. Code § 148.3.
  4. Proper and timely notice of the hearing was effected upon the parties according to Tex. Gov’t Code § 2001.052 and 28 Tex. Admin. Code § 148.4.
  5. _________ had the burden of proof on its appeal by a preponderance of the evidence, pursuant to Tex. Lab. Code Ann. § 413.031 and 28 Tex. Admin. Code § 148.21(h).
  6. Under Tex. Labor Code § 408.021(a)(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 that enhances the ability of the employee to retain employment.
  7. _________ did not prove that the requested wheelchair is not medically necessary for treating Claimant’s compensable injury.
  8. Based on the above Findings of Fact and Conclusions of Law, _________ appeal should be denied, and the request for preauthorization should be granted.

ORDER

IT IS ORDERED THAT the wheelchair requested by Claimant be preauthorized and ________ is ordered to reimburse all reasonable and necessary covered expenses associated with the requested wheelchair.

Signed this 6TH day of September, 2002.

Steven M. Rivas

State office of administrative hearings
Administrative Law Judge

  1. Also known as Complex Regional Pain Syndrome (CRPS), a chronic neurological syndrome characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch. Reflex Sympathetic Dystrophy Syndrome Association of America - 1999.
  2. Claimant’s entire employment and education history was not addressed at the hearing, nor is it a central or controlling issue.
  3. Claimant first requested modifications to her current wheelchair while she was employed at another job. She contended her mobility is similarly restricted by the wheelchair at her present job.
  4. Claimant and Claimant’s treating doctor testified the wheelchair manufacturer, Rascal, has determined modifications are not possible with Claimant’s current wheelchair. This ALJ heard no controverting or supporting testimony from either Rascal or Travis County, therefore, the testimony regarding the impossibility of modifications will be taken as accurate.
  5. Claimant’s current employer rearranged the office in an attempt to accommodate Claimant’s condition, to no avail.
End of Document
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