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At a Glance:
Title:
453-02-3924-m5
Date:
March 14, 2003
Status:
Retrospective Medical Necessity

453-02-3924-m5

March 14, 2003

DECISION AND ORDER

Zurich Insurance Company (Carrier) has appealed a decision of the Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) requiring it to pay Plaza Pharmacies (Provider) $1587.70 for drugs provided to ____ (Claimant) in accordance with a prescription written by the Claimant’s treating physician. The Administrative Law Judge (ALJ) finds that the Carrier met its burden of proof; therefore the Provider should not be reimbursed for the drugs.

I. Jurisdiction and Notice

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. chapter 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. §413.031(d) and Tex. Gov’t Code Ann. chapter 2003.

Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann. §2001.052.

II. Procedural History

The hearing was held January 16, 2003 by Administrative Law Judge (ALJ) John Beeler. The Carrier was represented by Stephen Tipton. The Provider was represented by Nicky Otts, who appeared by telephone. The Commission did not participate in the hearing. The certified record that was before the Medical Review Division (MRD) was admitted into evidence as Carrier’s Ex. 4. Documents submitted to the MRD were admitted into evidence as Carrier’s Ex.1. A position statement by the Carrier which was tendered to the MRD, but which was not entered into that record was admitted into evidence as Carrier’s Ex. 2. Further documents which were tendered to the MRD were admitted into evidence as Carrier’s Ex. 3. Neither party presented any witnesses. After arguments from the parties, the hearing was adjourned the same day. This case was subsequently transferred to ALJ Melissa M. Ricard, who reviewed the record and issues this decision.

III. Discussion

The Claimant suffered a compensable injury on______. He suffered a soft tissue injury to the spinal area. He was treated by A.J. Morris, M.D. Dr. Morris recommended the Claimant treat his pain with the Drugs at issue.

The following charges are in dispute:

Date of ServiceItemAmt. BilledAmt. Paid

7/16/01 Hydrocodone $ 67.17 $0.00

7/16/01 Vanadom $ 639.33 $0.00

8/5/01 Hydrocodone $ 67.17 $0.00

8/5/01 Vanadom $ 288.31 $0.00

10/1/01 Hydrocodone $ 96.99 $0.00

10/1/01 Vanadom $ 428.73$0.00

Totals $1587.70 $0.00

Hydrocodone is a narcotic analgesic that acts on the central nervous system to relievepain.Vanadom is a skeletal muscle relaxant used to relax certain muscles and relieve the stiffness, pain, and discomfort caused by strains, sprains, or other injury to muscles.[1]

A. Parties’ Positions

The Carrier denied reimbursement for the medications because it contends that Dr. Morris did not demonstrate that the medications were medically necessary.

The Provider asserts that the Claimant is entitled to all heath care that is reasonable and necessary in treating the compensable injury. The Provider also asserts that 28 Tex. Admin. Code § 134.001(e) requires that the treatment of spinal injuries be based upon the needs of the Claimant and the treating physician’s professional judgement and that both of those considerations were met with regard the drugs at issue.

The Provider also argued that the Carrier did not timely provide the peer review that it now relies upon as required by 28 Tex. Admin. Code § 133.304(h), arguing that only received the peer review in April of 2002.

B. ALJ’s Analysis

The Carrier has the burden of proof to show that the medications were not medically necessary.

Under Tex. Lab. Code Ann. §408.021(a)(1-3),

(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.

“Health care,” under Tex. Lab. Code Ann. §401.011(19),

includes all reasonable and necessary medical aid, medical examinations, medical treatment, medical diagnoses, medical evaluations, and medical services.

The Carrier arranged for the Claimant’s records to be reviewed by Aaron L. Combs, M.D. On August 15, 2001, Dr. Combs opined that the medications were not medically necessary. Dr. Combs stated that his review of the records showed that Dr. Morris gave the Claimant a Maximum Medical Improvement (MMI) rating of 9% on July 18, 2001. Dr. Combs further stated that under the relevant treatment guidelines, the Claimant should have reached MMI within 8 weeks of the injury, by March 17, 2001, and that any additional treatment beyond the recommended care should be documented to justify additional treatment. Dr. Combs stated that intermediate strength or potent analgesics are not recommended for patients with chronic musculoskeletal pain. Also, Dr. Combs found that continued treatment with muscle relaxants like Vanadom is not medically necessary, reasonable, nor causally related to the compensable event. Dr. Combs did not perform a physical examination of the Claimant.[2]

The only evidence that the drugs at issue were medically necessary is Dr. Morris’ September 18, 2001 letter in which he stated:

  • As a result of a January ________ work related accident the Claimant was being treated;
  • The Claimant continued to suffer intolerable, severe and intractable and increasing lumbar pain;
  • Despite conservative treatment, the Claimant had no significant improvement in his injuries;
  • The use of Vanadom and Hydrocondone were medically necessary to allow the Claimant to function and cope with his pain while performing his limited daily activities.[3]

The letter does not indicate the nature of the injury or why these medications were medically necessary for more than eighteen months after the compensable injury. In fact, there is a dearth of information regarding the injury, the treatment plan, expected outcomes and probable duration of the treatment and all other documentary requirements required by the Spinal Treatment Guideline (Guideline), 28 Tex. Admin. Code § 134.1001. The Provider correctly points out that the Guideline states that treatment should be based on the Claimant’s needs and the doctor’s professional judgement 28 Tex. Admin. Code § 134.1001(e). However, as analyzed in Dr. Comb’s peer evaluation, the Guideline also requires that treatment beyond standard treatment must be adequately documented, evaluated for effectiveness, provided in the least intrusive setting, cost effective, consistent with the Guideline, objectively measured and show ongoing progress.[4] Since the short, three paragraph letter provided by the Provider does none of these, the Carrier met its burden of proof.

With regard to 28 Tex. Admin. Code § 138.304(h), Carrier’s Exhibit No. 3 shows that the Provider was provided a copy of the peer review with the denial of payment on September 17, 2001. The date precedes the date of the last prescription filled by the Provider.

Based on the evidence, the Provider is not entitled to reimbursement for the drugs at issue.

IV. Findings of Fact

  1. The Claimant suffered a compensable injury to the lumbar region on________.
  2. The Claimant was treated by A.J. Morris, M.D. for his injury.
  3. Dr. Morris recommended the Claimant treat his recurring pain with two prescription drugs, Hydrocodone and Vanadom.
  4. The Carrier declined to reimburse the Provider for the two prescription drugs dispensed on July 16, 2001, August 5, 2001 and October 1, 2001.
  5. Intermediate strength or potent analgesics is not recommended for patients with chronic musculoskeletal pain.
  6. The Carrier provided a copy of the peer review it based its denial of reimbursement to the Provider on September 17, 2001.
  7. The Provider filed a request for dispute resolution.
  8. The MRD ordered payment in a decision issued June 27, 2002, whereupon the Carrier requested a hearing.
  9. Notice of the hearing was mailed to the parties on August 15, 2001.
  10. 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.
  11. The hearing was held January 16, 2003. The Carrier was represented by Stephen Tipton. The Provider was represented by Nicky Otts, who appeared by telephone. The Commission did not participate in the hearing. The hearing was adjourned the same day.
  12. The following charges are in dispute:

Date of ServiceItemAmt. BilledAmt. Paid

7/16/01 Hydrocodone $ 67.17 $0.00

7/16/01 Vanadom $ 639.33 $0.00

8/5/01 Hydrocodone $ 67.17 $0.00

8/5/01 Vanadom $ 288.31 $0.00

10/1/01 Hydrocodone $ 96.99 $0.00

10/1/01 Vanadom $ 428.73$0.00

Totals $1587.70 $0.00

  1. The medications, Hydrocodone and Vanadom, dispensed by the Provider on July 16, 2001, August 5, 2001 and October 1, 2001, were not medically necessary to treat the compensable injury.
  2. Dr. Morris did not properly document his rationale and other necessary facts for the treatment of the Claimant’s injury with Hydrocodone and Vanadom.

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 Ann. chapter 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. chapter 2003.
  3. Adequate and timely notice of the hearing was provided in accordance with Tex. Gov’t Code Ann.§2001.052.
  4. The Carrier proved that the medications were not medically necessary, and the Carrier further demonstrated that there was no documentation showing that these medications properly treated the Claimant. 28 Tex. Admin. Code § 134.1001.
  5. The Provider not should be reimbursed for the medications, Hydrocodone and Vanadom dispensed by the Provider on July 16, 2001, August 5, 2001 and October 1, 2001.

[Remainder of this page left intentionally blank]

ORDER

IT IS, THEREFORE, ORDERED that the Petitioner, Zurich Insurance Company, shall not reimburse the Respondent, Plaza Pharmacies, in the amount of $1587.70, for the medications, Hydrocodone and Vanadom dispensed by the Provider on July 16, 2001, August 5, 2001 and October 1, 2001.

Signed March 14, 2003.

STATE OFFICE OF ADMINISTRATIVE HEARINGS

Melissa M. Ricard
Administrative Law Judge

  1. U.S. National Library of Medicine, MEDLINEplus Health Information (21 May 2001) <http://www.nlm.nih.gov/medlineplus/druginfo/.
  2. Carrier’s Ex. 2
  3. Carrier Ex.4, pg. 26
  4. Carrier Ex. 2
End of Document
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