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At a Glance:
Title:
453-02-3606-m5
Date:
January 15, 2003
Status:
Retrospective Medical Necessity

453-02-3606-m5

January 15, 2003

DECISION AND ORDER

I.

SUMMARY

Ez Rx Pharmacies (Provider) sought reimbursement from State Office of Risk Management (Carrier) in the amount of $1,757.68 for prescription drugs it provided to____ (Claimant). The Medical Review Division (MRD) held Provider was not entitled to reimbursement. In this Order, the ALJ concludes Provider is not entitled any reimbursement. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH). Based on the evidence, the ALJ concludes that Provider’s claim for reimbursement of $1,757.68 for the prescription drugs provided to Claimant should be denied. The particular facts and reasoning in support if this decision are set forth below in the Findings of Facts, and the legal conclusions derived from those facts appear in the Conclusions of Law. The ALJ convened a hearing on these issues on November 21, 2002, and the record closed the same day.

II.

EVIDENCE

Claimant sustained a compensable injury on_____; however, the circumstances of Claimant’s injury were not addressed at the hearing. The only evidence presented at the hearing was the Certified Record that contained the bills for the medication and a peer review. Claimant’s medical records from her treating doctor(s) were not contained in the Certified Record.

On April 23, May 22, June 21, and July 19, 2001, Provider filled prescriptions for Vicodin, Celebrex, and Effexor for Claimant. The total amount of the prescriptions billed to the Carrier was $1,757.68. Carrier denied reimbursement as not medically necessary and attached a peer review in support of its denial.

The peer review was completed by Charles Graham, M.D., on April 12, 2001.[1] Dr. Graham stated that based on the documentation he reviewed, Claimant sustained a lumbar sprain which should have healed within three months following the injury. Dr. Graham also concluded the complaints of pain Claimant presented were related to “disease and activities of daily living” and not related to the compensable injury. Finally, Dr. Graham stated the appropriate treatment plan for Claimant is a home exercise program and not a prescription program.[2]

Provider argued Carrier should not have relied on Dr. Graham’s opinion because he was merely a peer reviewer and not Claimant’s treating doctor who prescribed the medication. Provider further argued Claimant was entitled to the prescription drugs because they relieved the pain she experienced from the compensable injury. Provider finally asserted the burden of medical necessity was met because Claimant complained of pain to her treating doctor and her treating doctor prescribed the drugs. Therefore, Provider asserted, it should be reimbursed for providing the medication to Claimant.

Carrier argued the presence of pain alone did not entitle Claimant to the prescription drugs. The ALJ found Carrier’s argument more persuasive especially since Dr. Graham noted Claimant’s injury should have healed three years before she filled the prescriptions for this medication. The Carrier further argued any drugs or treatment rendered to any claimant must be related to the compensable injury. Although Provider asserted Claimant’s pain was related to the compensable injury, it presented no evidence that this was the case.

The Provider presented no evidence from any treating doctor that Claimant’s pain was related to her compensable injury. Carrier’s evidence of Dr. Graham’s peer review, which concluded the medication program was not medically necessary, was more persuasive considering the amount of time that has passed since the date of Claimant’s injury. For these reasons, Carrier should not be ordered to reimburse Provider for the medication it provided to Claimant.

III.

FINDINGS OF FACT

  1. Claimant, ___ sustained a compensable injury on_________.
  2. In 2001, Claimant was prescribed Vicodin, Celebrex, and Effexor.
  3. On April 23, May 22, June 21, and July 19, 2001, Ez Rx Pharmacies (Provider) filled the prescriptions and billed State Office of Risk Management (Carrier) a total amount of $1,757.68 for the prescriptions.
  4. Carrier denied reimbursement as not medically necessary and attached a peer review in support of its denial.
  5. Provider filed a Request for Medical Review Dispute Resolution with the Texas Workers’ Compensation Commission (the Commission), seeking reimbursement for the treatment rendered to Claimant.
  6. On May 31, 2002, the Commission’s Medical Review Decision (MRD) concluded Provider was not entitled to any reimbursement.
  7. Provider filed a request for hearing before the State Office of Administrative Hearings (SOAH) seeking reimbursement.
  8. Notice of the hearing was sent July 15, 2002.
  9. 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.
  10. The hearing was held November 21, 2002, with Administrative Law Judge (ALJ) Steven M. Rivas presiding, and representatives of the Provider, and Carrier participating. The hearing was adjourned the same day.
  11. Claimant sustained a lumbar sprain which should have completely healed in 1998.
  12. There was no evidence Claimant’s pain complaints were related to her 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. The Provider, as Petitioner, has the burden of proof in this matter under 28 Tex. Admin. Code§ 148.21(h).
  5. Under Tex. Lab. Code Ann. §408.021(a), an employee who sustains a compensable injury is entitled to all health care reasonably required by the nature of the injury that cures or relieves the effects naturally resulting from the compensable injury, promotes recovery, or enhances an employee’s ability to return to or retain employment.
  6. Provider is not entitled to reimbursement for any of the prescriptions it filled for Claimant because it was not shown that the medication rendered was medically necessary.
  7. Pursuant to the foregoing Findings of Fact and Conclusions of Law, Provider is not entitled to any reimbursement.

ORDER

IT IS, THEREFORE, ORDERED that Provider, Ez Rx Pharmacies, is not entitled to receive any reimbursement from the Carrier, State Office of Risk Management, for the prescriptions it filled for Claimant on April 23, May 22, June 21, and July 19, 2001.

Signed this 15th day of January 2003.

State office of administrative hearings

Steven M. Rivas Administrative Law Judge

  1. Dr. Graham. Pages 26 - 37 of the Certified Record.
  2. See Id“program is not reasonable and necessary and appropriate, especially in view of the fact that she is not participating in a home exercise program trying to re-condition her back which obviously has undergone some atrophy due to her inactivity”
End of Document
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