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At a Glance:
Title:
453-03-1105-m5
Date:
March 27, 2003
Status:
Retrospective Medical Necessity

453-03-1105-m5

March 27, 2003

DECISION AND ORDER

This case involves a dispute over the decision by Royalty Indemnity Company (Carrier) not to pay for prescriptions filled for a workers’ compensation claim filed _________ (Claimant). The amount in dispute is $2. The Claimant has appealed the decision of the Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission), which denied reimbursement. In this decision, the Administrative Law Judge (ALJ) concludes the prescribed medications were medically necessary treatment for the Claimant’s compensable injury.

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 in this case was convened on January 27, 2003 by Administrative Law Judge (ALJ) John Beeler; it adjourned and the record closed the same day. The Claimant appeared by telephone. The Carrier was represented by Mark H. Sickles. Barton Levy from the Ombudsman Services of the Texas Workers’ Compensation Commission (TWCC) was also present to assist the Clamant. The Claimant testified on his own behalf. After arguments from the parties, the hearing adjourned the same day. This case was subsequently transferred to ALJ Melissa M. Ricard who reviewed the entire record and issues this decision.

III. Background Facts

Claimant sustained a work related injury to his back on ________ when he was sitting at work and the legs of his chair collapsed, resulting in a fall. He began receiving treatment for his injury immediately.

From January 2002 to March 2002, the Claimant underwent lumbar epidural injections, behavioral modification, and the use of a neuromuscular stimulator for pain control. At least as far back as May 2001, the Claimant was prescribed many medications, including Soma and Vicodin, among other medications, to treat his pain by his treating physician, Robert J. Kilian, M.D.

On March 11, 2002, a peer review was conducted by Mark A. Doyne, M.D. at the Carrier’s request. Dr. Doyne reviewed the Claimant’s medical records. Dr. Doyne reviewed the medication history and recommended that the Claimant “be weaned to a non-narcotic analgesic.” He also stated that there was no indication for the long-term administration of Soma.

Dr. Kilian’s notes from a visit on March 12, 2002 indicate the Claimant was suffering low back pain which was alleviated by the medications.

On March 13, 2002, Dr. Kilian wrote a letter to the Carrier wherein he stated that the Claimant’s dosage of medications provided adequate pain relief, and that after discussion with the Claimant, he did not feel that it was in the Claimant’s best interest to decrease the dosage.

On March 20, 2002 the Claimant filled three prescriptions for pain: Vicodin costing $41.37; Xanax costing $59.38; and Soma costing $55.37, for a total of $156.12. The Claimant purchased the medications himself. These are the prescriptions at issue in this case.

On June 10, 2002, John C. Anigbogu, M.D., M.P.H., designated that the Claimant reached Maximum Medical Improvement (MMI) as of March 31, 2002 with a 0% whole person impairment rating.

The Medical Dispute Resolution request filed by the Claimant is not dated. In the request, the Claimant seeks reimbursement for the Vicodin, Xanax, and Soma prescriptions filled on March 20, 2002.

On October 4, 2002, the Texas Medical Foundation, an independent review organization (IRO), issued a decision determining that prescriptions provided on March 20, 2002 for Hydrocodone/APAP, Alprazolam, and Carisoprodol were not medically necessary.

On October 17, 2002 the Medical Review Division (MRD) issued its Findings and Decision, finding that, based upon the above IRO decision, the claim should be denied.

The Claimant now appeals this decision.

IV. Analysis

The sole issue in this case is whether the prescription drugs Vicodin, Xanax, and Soma provided to Claimant on March 20, 2002, were medically necessary to treat his work-related injury of 2002. After considering the evidence, the ALJ concludes that the Vicodin, Xanax, and Soma were medically necessary to treat the Claimant’s compensable injury.

Although the Claimant has the burden of proof, something in this case is very amiss. The Carrier somehow succeeded at the MRD, because the MRD relied solely upon the IRO. The IRO only determines that other prescriptions, rather than the prescriptions at issue in this case, are not medically necessary. The medications analyzed in the IRO appear to have the same date, but they are not the same medicines.

The only evidence remotely favorable to the Carrier’s position is the March 11, 2002 peer review by Dr. Doyne, which recommends that the Claimant be weaned to a non-narcotic analgesic. This recommendation implicitly acknowledges a period of continuation of the medications for a weaning process to occur.

On the other hand, Dr. Kilian’s notes dated March 12, 2002 and his letter dated March 13, 2002 establish the necessity for the medications to treat the Claimant’s pain at the time the prescriptions were filled. Therefore, the Claimant met his burden of proof and he should be reimbursed for the prescriptions at issue in this matter.

V. Findings of Fact

  1. The Claimant suffered a compensable injury to his back in__________.
  2. At the time of Claimant’s injuries, Royalty Indemnity Company (Carrier) was the workers’ compensation insurance carrier for Claimant’s employer.
  3. In 2000, Claimant began receiving ongoing treatment for his injury. He underwent lumbar epidural injections, behavioral modification, the use of a neuromuscular stimulator and was prescribed various medications for pain control.
  4. The Claimant saw his treating physician, Robert J. Kilian, M.D., on March 12, 2002. Dr. Kilian found that the Claimant suffered from low back pain and that he needed various medications to control the pain. Treatment continued through March of 2002.
  5. On March 13, 2002, Dr. Kilian opined that the Claimant was on a dosage of medications that provided adequate pain relief and that a decreased dosage was not in the Claimant’s best interest.
  6. The Claimant was prescribed and filled prescriptions for Vicodin, Xanax, and Soma as treatment for his pain on March 20, 2002.
  7. The Carrier denied reimbursement for the prescriptions filled on March 20, 2002, asserting the medications were not medically necessary treatment for Claimant’s compensable injury.
  8. The Claimant purchased the three medications using his own funds for a total of $156.12.
  9. On October 17, 2002, after conducting medical dispute resolution, the MRD upheld the Carrier’s denial of reimbursement.
  10. On October 28, 2002 the Claimant filed a request for hearing.
  11. Proper notice of the hearing was sent on November 18, 2002.
  12. A hearing was conducted on January 27, 2003. Representatives of the Carrier and the Claimant appeared and participated. The hearing adjourned and the record closed the same day.
  13. The Vicodin, Xanax and Soma medications prescribed and filled on March 20, 2002, were medically necessary treatment of Claimant’s compensable injury.

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

ORDER

IT IS ORDERED that _________ is entitled to reimbursement in the amount of $156.12, plus interest, from Royalty Indemnity Company for the Vicodin, Xanax, and Soma medications dispensed to Claimant on March 20, 2002.

Signed this 27th day of March, 2003.

Melissa M. Ricard
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

End of Document
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