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At a Glance:
Title:
453-02-3492-m5
Date:
October 11, 2002

453-02-3492-m5

October 11, 2002

DECISION AND ORDER

Petitioner VONO seeks reimbursement of $1,006.99 from Zurich American Insurance Company (Carrier) for numerous medications prescribed for and provided to _____ an injured worker (Claimant). The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denied reimbursement. VONO has appealed MRD’s decision. The Administrative Law Judge (ALJ) concludes that only one of the prescribed medications was medically necessary and that VONO is entitled to reimbursement of $422.66.

I. Background Facts

Claimant suffered a compensable, work-related injury to her lower back and upper leg areas on_________. Claimant was initially seen at Med Alert Industrial Health Center, where she was given a shot of Toradol for pain control and muscle relaxants. She then underwent a short course of physical therapy. On April 4, 2000, Claimant was seen by Dr. A.J. Morris, who noted that Claimant had low back pain and left hip and leg radiation connected with her compensable injury. Dr. Morris prescribed medications for Claimant’s pain and muscle spasms. On August 8, 2000, Dr. Morris determined that Claimant could return to light duty with restrictions, noting that Claimant was diagnosed with a lumbar sprain/strain. Approximately two months later, Dr. Morris determined that Claimant had reached maximum medical improvement and assigned Claimant a 10% Whole Person Impairment rating. On November 16, 2000, an independent medical examination was conducted by Dr. Wright Singleton, who agreed that Claimant was at maximum medical improvement. However, Dr. Singleton found that Claimant had no impairment and should have a 0% impairment rating.

In December 2000, Dr. Morris saw Claimant again and concluded that she continued to suffer pain in her back and legs. At that time, Dr. Morris prescribed Lortab and Prozac for Claimant. Thereafter, he continued to treat Claimant for her injury through 2001. In October 2001, Dr. Morris prescribed Prozac, Hydrocodone/APAP, and Vanadom for Claimant, and VONO filled the prescriptions. On November 7, 2001, VONO filled additional prescriptions for Prozac and Hydrocodone/APAP for Claimant. Carrier refused to reimburse VONO for the prescriptions filled in October and November, 2001, relying on a peer review conducted by Dr. William Culver. In his peer review, dated October 13, 2001, Dr. Culver found that there was no objective evidence to support anything beyond a soft tissue injury and degenerative spine disease for Claimant. Dr. Culver noted that the degenerative spine disease was an ordinary disease of life, pre-existing, and not related to the compensable injury. Further, Dr. Culver noted that it was inappropriate to treat Claimant’s soft-tissue injury on a chronic basis with medications such as Lortab or Prozac.

After Carrier denied reimbursement, VONO requested medical dispute resolution by the Commission’s MRD. After conducting medical dispute resolution, MRD denied reimbursement to VONO for the prescriptions. VONO then appealed. On October 1, 2002, ALJ Craig R. Bennett convened a hearing on these issues. VONO appeared and was represented by Nicky Otts, via telephone. Carrier appeared and was represented by Steven M. Tipton, attorney. The Commission’s staff did not appear nor participate. The hearing concluded and the record closed the same day.

II. Analysis

The sole issue in this case is whether the numerous prescription drugs provided to Claimant in October and November 2001 were medically necessary to treat her work-related injury. In this regard, there are only three medical opinions that are particularly relevant: the statements of medical necessity by Dr. Morris, the peer review by Dr. Culver, and the independent medical examination report by Dr. Singleton-this last one being only moderately helpful. Dr. Singleton disagreed with Dr. Morris’s impairment conclusions, but acknowledged that it might be appropriate for Dr. Morris to continue to prescribe medications for Claimant. In his statements of medical necessity, Dr. Morris provided only limited reasons for the prescriptions, without providing much substantive explanation to support his specific recommendations for the medications in issue. On the other hand, in his peer review, Dr. Culver provided specific reasons why he believed that Claimant’s injury would not require ongoing treatment with some of the medications prescribed.

The ALJ has no reason to doubt the veracity of any of the physicians. But, ultimately, the ALJ is most persuaded by the reports of Dr. Culver and Dr. Singleton, who provide more supporting detail for their conclusions. After considering the evidence, the ALJ is particularly persuaded by the peer review of Dr. Culver, who found that neither Prozac nor Lortab were medically necessary for treatment of Claimant’s injury. While Dr. Culver did not mention Hydrocodone/APAP specifically, his conclusion that Lortab would not be appropriate applies also to Hydrocodone/APAP. The ALJ takes official notice of the Physician’s Desk Reference, which indicates that Lortab is a Hydrocodone-based, brand name pharmaceutical with the same essential properties as Hydrocodone/APAP.[1] Therefore, the ALJ understands Dr. Culver’s conclusion regarding Lortab to apply equally to the Hydrocodone/APAP that was prescribed. Because the ALJ finds Dr. Culver’s peer review to be persuasive, the ALJ determines that neither Prozac nor Hydrocodone/APAP were medically necessary treatment for Claimant.

However, Dr. Culver’s peer review does not address Vanadom or similar medications. In fact, Dr. Culver indicated that it might be appropriate to treat a soft tissue injury (like that suffered by Claimant) with medication on a chronic, ongoing basis. Further, as noted above, Dr. Singleton also concluded that additional medications might be necessary treatment for Claimant. Dr. Morris specifically states that Vanadom is medically necessary for treatment of Claimant’s work-related injury. Therefore, the evidence in the record supports only the conclusion that Vanadom was appropriate and necessary for treatment of Claimant’s work-related injury. As such, the ALJ finds that it was medically necessary and that Carrier is liable to reimburse VONO for it.

In conclusion, the ALJ finds that the preponderance of the evidence establishes that Vanadom was medically necessary for treatment of Claimant’s work-related injury, but that Prozac and Hydrocodone/APAP were not. Therefore, Carrier is liable to reimburse VONO the sum of $422.66 for the Vanadom provided to Claimant. In support of this, the ALJ makes the following findings of fact and conclusions of law.

III. Findings of Fact

  1. On________,____ (Claimant) suffered a compensable, work-related injury. At the time that she suffered her injury, Zurich American Insurance Company (Carrier) was the provider of workers’ compensation insurance covering Claimant.
  2. Claimant was initially seen at Med Alert Industrial Health Center, where she was given muscle relaxants and a shot of Toradol for pain control. She then underwent a short course of physical therapy.
  3. On April 4, 2000, Claimant was seen by Dr. A.J. Morris, who noted that Claimant had low back pain and left hip and leg radiation connected with her compensable injury. Dr. Morris prescribed medications for Claimant’s pain and muscle spasms.
  4. On August 8, 2000, Claimant was diagnosed with a lumbar sprain/strain and was allowed to return to light duty work with restrictions.
  5. Claimant’s injury was a soft tissue injury. Claimant also had a degenerative spine disease which was an ordinary disease of life, pre-existing, and not related to the compensable injury.
  6. By November 16, 2000, Claimant had reached maximum medical improvement with no impairment.
  7. Dr. Morris continued to treat Claimant for her injury through 2001.
  8. In October 2001, Dr. Morris prescribed Prozac, Hydrocodone/APAP, and Vanadom for Claimant, and VONO filled the prescriptions for Claimant.
  9. On November 7, 2001, VONO filled additional prescriptions for Prozac and Hydrocodone/APAP for Claimant.
  10. VONO billed Carrier $1,009.54 for the Vanadom, Prozac, and Hydrocodone/APAP provided to Claimant in October and November 2001. Of that, $428.73 was billed for the provision of Vanadom.
  11. Carrier refused to reimburse the prescriptions filled in October and November, 2001, relying on a peer review conducted by Dr. William Culver.
  12. It was inappropriate, and not medically necessary, to treat Claimant’s soft-tissue injury on a chronic basis with medications such as Hydrocodone/APAP or Prozac.
  13. It was appropriate, and medically necessary, to treat Claimant’s soft-tissue injury with the medication Vanadom.
  14. On December 26, 2001, VONO requested medical dispute resolution with the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission.
  15. After conducting medical dispute resolution, MRD issued a decision on May 13, 2002, denying reimbursement to VONO for the prescriptions.
  16. On May 30, 2002, VONO requested a hearing before the State Office of Administrative hearings.
  17. On October 1, 2002, ALJ Craig R. Bennett convened a hearing on these issues. VONO appeared and was represented by Nicky Otts, via telephone. Carrier appeared and was represented by Steven M. Tipton, attorney. The Commission’s staff did not appear nor participate. The hearing concluded and the record closed the same day.

IV. Conclusions of Law

  1. The Texas Workers' Compensation Commission has jurisdiction to decide the issue presented pursuant to the Texas Workers' Compensation Act (the Act), Tex. Labor Code Ann. §413.031 (Vernon Supp. 2002).
  2. SOAH has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to §413.031 of the Act and Tex. Gov’t Code Ann. ch. 2003 (Vernon 2002).
  3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 (Vernon 2002) and 28 Tex. Admin. Code ch. 148.
  4. VONO has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. VONO failed to establish, by a preponderance of the evidence, that the dispensed drugs Prozac and Hydrocodone/APAP were medically necessary for the treatment of Claimant’s work-related injury.
  6. VONO did establish, by a preponderance of the evidence, that the dispensed drug Vanadom was medically necessary for the treatment of Claimant’s work-related injury.
  7. VONO’s request for reimbursement should be granted as to the Vanadom dispensed by VONO to Claimant. In all other respects, VONO’s request for reimbursement should be denied.
  8. The maximum allowable reimbursement for the Vanadom prescribed by Dr. Morris and provided by VONO to Claimant is $422.66.

ORDER

IT IS ORDERED that Zurich American Insurance Company is to reimburse VONO the sum of $422.66 for the medication Vanadom dispensed to claimant on October 10, 2001.

Signed this 11th day of October, 2002.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

  1. The parties may contest the material of which official notice is taken, i.e., the Physician’s Desk Reference and the facts recognized from such document. Any challenge to the ALJ’s taking of official notice shall be filed with the State Office of Administrative Hearings within 10 days of the date of this decision.
End of Document
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