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At a Glance:
Title:
453-02-3925-m5
Date:
December 11, 2002
Status:
Retrospective Medical Necessity

453-02-3925-m5

December 11, 2002

DECISION AND ORDER

This case involves a dispute over the decision by Continental Casualty Company (Carrier) not to reimburse EZ Rx Pharmacy (Pharmacy) for a prescription the Pharmacy filled for a workers’ compensation claimant (Claimant). The amount in dispute is $461.14, and the Pharmacy has appealed the decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission), which denied reimbursement. The hearing in this case convened on November 19, 2002; it adjourned and the record closed the same day. The Texas Workers’ Compensation Commission (TWCC) did not participate in the hearing. In this decision, the Administrative Law Judge (ALJ) concludes the prescribed medications were medically necessary treatment for the claimant’s compensable injury and, therefore, Carrier must reimburse the Pharmacy for such medication.

I. Background Facts

Claimant sustained a work related injury to his back while lifting a sink on ___________. He began receiving treatment for his injury almost immediately. He underwent conservative treatment for almost two years with little improvement. In September 1998, he underwent a laminectomy and framinotomy, lateral fusion, and posterior segmental instrumentation. A bone growth stimulator was implanted at the same time. The bone growth stimulator was removed during a second surgery on August 10, 2000.

Following removal of the bone growth stimulator, Claimant was placed on muscle relaxants and narcotic pain killers (Soma and Vicodin). He remained on both medications until January 2001, when he began treatment with Celebrex, a non-steroidal anti-inflammatory drug (NSAID).

Carrier does not dispute the medical necessity of the narcotic pain killers and muscle relaxants immediately following the surgery to remove the bone stimulator. The two prescriptions Carrier disputes are the ones filled on December 22, 2000, and January 5, 2001. These prescriptions were filled by the Pharmacy, which then billed Carrier for the medications. Carrier denied reimbursement, asserting the medications were not medically necessary treatment for Claimant’s compensable injury. After conducting medical dispute resolution, MRD upheld Carrier’s denial. Pharmacy then appealed.

II. Analysis

The sole issue in this case is whether the prescription drugs provided to Claimant on December 22, 2000, and January 5, 2001, were medically necessary to treat his work-related injury of 1996. After considering the evidence, the ALJ concludes that both the Vicodin and Soma were medically necessary to treat the Claimant’s compensable injury.

The Pharmacy argues that the medical documentation, particularly the statement of medical necessity submitted by Dr. Gutzman, establishes the medical necessity of the prescribed medications.

In response, Carrier asserts the evidence in this case shows that the prescribed medications were not medically necessary for Claimant’s injury. Dr. Bierner, Carrier’s expert, testified that following the removal of the bone stimulator, he recommends patients take narcotics for no longer than three months. He did not specifically testify about the medical necessity of the muscle relaxant, other than to say it is used for acute muscle spasms.

This is not a case where a physician prescribed a medication that is clearly not indicated for the Claimant’s condition. In this case, following back surgery, the Claimant was prescribed Vicodin and Soma. Carrier did not dispute the medical necessity of the first several prescriptions. Furthermore, on January 23, 2001, Claimant’s treating physician, Dr. Gutzman, discontinued the Soma and Vicodin prescriptions, switching Claimant to Celebrex, a non-steroidal anti-inflammatory drug. Dr. Gutzman stated that the Vicodin and Soma prescriptions at issue were medically necessary. The two medications were prescribed for five months post-surgery only. Following the discontinuation of those medications, Claimant remained on other pain medications, the medical necessity of which was not disputed in this case. The ALJ finds the Claimant’s treating physician more credible than Carrier’s expert, who did not examine the Claimant, especially with respect to which pain medications were medically necessary. Because Claimant had an ongoing need for pain medications well past the dates in controversy in this case, and based on the statement of Dr. Gutzman, the ALJ finds that the Pharmacy demonstrated by a preponderance of the evidence that the prescribed medications were medically necessary, and the pharmacy is entitled to reimbursement.

III. Findings of Fact

  1. A worker (Claimant) suffered compensable injuries to his back in __________
  2. At the time of Claimant’s injuries, Continental Casualty Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
  3. In 1996, Claimant began receiving ongoing treatment for his injury. He underwent physical therapy and other conservative treatment without significant improvement.
  4. In September 1998, Claimant underwent back surgery for his injury, which included the implantation of a bone growth stimulator.

.

  1. On August 10, 2000, Claimant underwent another back surgery to remove the bone growth stimulator.
  2. Following the surgery to remove the bone growth stimulator, Claimant was prescribed muscle relaxants and narcotic pain killers (Soma and Vicodin).
  3. Carrier denied reimbursement for the prescriptions filled on December 22, 2000, and January 5, 2001, asserting the medications were not medically necessary treatment for Claimant’s compensable injury.
  4. On December 27, 2001, EZ Rx Pharmacy (Pharmacy) filed a request for medical dispute resolution with the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission.
  5. On July 3, 2002, after conducting medical dispute resolution, MRD upheld the Carrier’s denial of reimbursement.
  6. On July 15, 2002, the Pharmacy filed a request for hearing before the State Office of Administrative Hearings (SOAH).
  7. Proper notice of the hearing was sent on August 15, 2002.
  8. A hearing was conducted on November 19, 2002. Representatives of Carrier and the Pharmacy appeared and participated. The hearing adjourned and the record closed the same day.
  9. The Vicodin and Soma prescribed on December 22, 2000 and January 5, 2001, were medically necessary treatment of Claimant’s compensable injury.

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. Pharmacy has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
  5. Pharmacy established, by a preponderance of the evidence, that the dispensed drugs were medically necessary for the treatment of Claimant.
  6. Pharmacy’s request for reimbursement should be granted.

ORDER

IT IS ORDERED that EZ Rx Pharmacy is entitled to reimbursement in the amount of $461.14 from Continental Casualty Company for medications dispensed to Claimant on December 22, 2000, and January 5, 2001.

Signed this 11th day of December, 2002.

WENDY K. L. HARVEL
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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