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At a Glance:
Title:
453-03-0094-m5
Date:
March 26, 2003
Status:
Retrospective Medical Necessity

453-03-0094-m5

March 26, 2003

DECISION AND ORDER

Oxymed, Inc., (Provider) has appealed the decision of an independent review organization (IRO) regarding durable medical equipment provided to _______(Claimant). The IRO found and the Texas Workers’ Compensation Commission’s (TWCC) Medical Review Division (MRD) directed that reimbursement be denied. The only disputed issue is whether the equipment was medically necessary.

As set out below, the Administrative Law Judge (ALJ) finds the durable medical equipment was medically necessary. Therefore, Liberty Mutual Insurance Company (Carrier) is to reimburse Provider $769.00 for the cold circulating unit, wrap, pad, and auto adapter provided to Claimant on February 27, 2001.

I. JURISDICTION AND VENUE

TWCC has jurisdiction to consider appeals from decisions of its MRD pursuant to Tex. Labor Code Ann. § 413.031. The State Office of Administrative Hearings (SOAH) has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 413.031(d) and Tex. Gov't Code Ann. ch. 2003. Venue is established in this matter in accordance with 28 Tex. Admin. Code § 148.6.

II. DISCUSSION OF ISSUES

Claimant sustained a compensable injury on_______, when she stepped in a space between the dock and a trailer while unloading packages on a roller for her employer,_______. She strained her right hip, right wrist, right shoulder, and right leg. She subsequently underwent two-level lumbar fusion surgery.

The post-operative treatment included a cold circulating unit, wrap, pad, and auto adapter, prescribed to Claimant by her treating physician, Robert Henderson, M.D., and provided to her by Provider. Testimony by Keith Payne, Provider’s employee, established that it is Dr. Henderson’s practice to prescribe the cold therapy unit prior to surgery, so that it is available to a patient immediately following surgery; the cold therapy unit is either delivered to the patient in the hospital or at home. Dr. Henderson’s letter of medical necessity regarding Claimant’s treatment stated in part that use of the cold therapy unit decreases pain and inflammation, and is in accordance with accepted medical standards for treating post-operative pain. (Provider’s Ex. 1 at 11).

The IRO determined the cold circulating unit, wrap, pad, and auto adapter were not medically necessary, in part because most patients who have two-level lumbar fusion usually remain hospitalized for five-to-seven days, after which ice has no significant effect on healing of the fusion mass.

III. FINDINGS OF FACT

  1. On_______, ______(Claimant) sustained a work-related injury to her right hip, right wrist, right shoulder, and right leg. On the date of the injury, Claimant’s employer was _________ and its workers’ compensation insurance carrier was Liberty Mutual Insurance Company (Carrier). As a result of the compensable injury, Claimant required a two-level lumbar fusion.
  2. Claimant’s treating physician prescribed a cold circulating unit, wrap, pad, and auto adapter to relieve her post-operative pain. Oxymed, Inc. (Provider) provided the durable medical equipment to Claimant, as prescribed.
  3. On March 14, 2001, Provider sought reimbursement from Carrier for the durable medical equipment. Carrier sent an explanation of benefit (EOB) to Provider denying the requested reimbursement because the durable medical equipment was not medically necessary. When the bill was resubmitted for reconsideration, payment was denied again as not pre-authorized.
  4. On January 22, 2002, Provider filed a request for medical dispute resolution with TWCC. An independent review organization (IRO) reviewed the medical dispute, and found the durable medical equipment was not medically necessary and that Carrier should not reimburse Provider. Based on the IRO’s July 9, 2002 decision, TWCC’s MRD directed on July 12, 2002, that reimbursement was not warranted, and declined to issue an order.
  5. On July 24, 2002, Provider asked for a contested case hearing before the State Office of Administrative Hearings (SOAH). Notice of a contested case hearing concerning the dispute was mailed to the Carrier and Provider on September 16, 2002.
  6. The notice of hearing 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.
  7. On January 21, 2003, ALJ Sharon Cloninger held a hearing on the Provider’s appeal in the William Clements Building, 300 West 15th Street, Fourth Floor, Austin, Texas. Provider appeared by telephone through its attorney Peter N. Rogers. Carrier appeared through its attorney Mahon B. Garry, Jr. The hearing concluded that same day and the record closed January 28, 2003.
  8. Robert J. Henderson, M.D., Claimant’s treating physician, prescribed a cold therapy unit for Claimant on February 26, 2001, prior to her two-level fusion surgery, for use immediately after surgery, either in the hospital or at home.
  9. The cold therapy unit was used in conjunction with Claimant’s post-operative recovery from her two-level fusion surgery, which was related to her compensable injury.
  10. The cold therapy unit was necessary to relieve Claimant’s post-operative pain.

IV. CONCLUSIONS OF LAW

  1. The Texas Workers’ Compensation Commission has jurisdiction to decide the issues presented pursuant to the Texas Workers' Compensation Act (the Act), Tex. Labor Code Ann. § 413.031.
  2. The Commission assigned this matter to the Texas Medical Foundation for an independent review in accordance with Tex. Labor Code Ann. § 413.031 and 28 Tex. Admin. Code (TAC) §§ 133.305 and 133.308 which allows for medical dispute resolution by an independent review organization (IRO).
  3. The State Office of Administrative Hearings has jurisdiction over matters related to the hearing in this proceeding, including the authority to issue a decision and order, pursuant to § 413.031(d) of the Act and Tex. Gov't Code Ann. ch. 2003.
  4. Venue is established in this matter in accordance with 28 TAC § 148.6 and 1 TAC § 155.13.

.5. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001, the Commission’s rules, 28 TAC § 133.305(g) and §§ 148.001-148.028, and the rules of the State Office of Administrative Hearings, 1 TAC §§155.1 et seq.

  1. Petitioner timely appealed the decision of the Medical Review Division and appealed the decision in accordance with 28 TAC §§ 102.7 and 148.3.
  2. Adequate and timely notice of the hearing was provided in accordance with 28 TAC § 148.4.
  3. Provider, as the party seeking relief, bore the burden of proof in this case, pursuant to 28 TAC § 148.21(h).
  4. Pursuant to Tex. Labor Code Ann. § 408.021(a)(1)(2), and based on Findings of Fact Nos. 8-10, Provider established the cold therapy unit was medically necessary.

ORDER

IT IS, THEREFORE, ORDERED that Liberty Mutual Fire Insurance Company shall be required to pay Oxymed, Inc., $769.00 for the cold therapy unit provided to ________on February 27, 2001.

Signed this 26th day of March, 2003.

SHARON CLONINGER
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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