DECISION AND ORDER

____ (Claimant) appealed the decision by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) in a medical fee dispute. MRD found that TPCIGA for Reliance Insurance Company (Carrier) properly denied reimbursement to Claimant for prescriptions filled between February 5, 2002, and January 28, 2003, based upon the lack of evidence that Carrier timely received Claimant’s request for reimbursement. Claimant requested a hearing on MRD’s decision. At the hearing, Claimant asked for additional payment for office visits and laboratory testing, and submitted additional documentation in support of her request for reimbursement. After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Claimant is not entitled to further reimbursement and denies Claimant’s appeal.

I. DISCUSSION

The issue initially appealed in this case is whether Claimant properly submitted documentation supporting the right to reimbursement for prescriptions purchased between February 5, 2002, and January 28, 2003. At the hearing, however, Claimant also asked to be reimbursed for office visits and laboratory work done between July 23, 2002, and April 7, 2003. The Carrier did not object to the inclusion of the office visits and laboratory work in this appeal. The reimbursementsought for the office visits is $777.80, and for the prescriptions is $207.33, making the total of $985.13.^[1]

Claimant injured her lower back while at work on ____. Claimant was treated with epidural injections and prescriptions. Under cross-examination, Claimant agreed that the Carrier paid for her treatment for two years following the injury. Nonetheless, Claimant explained, her back has gotten worse since the date of injury, and she now has pain in her upper back. Her current doctor has diagnosed her condition as osteo-arthritis/arthritis, which Claimant contends is related to her compensable injury.

The prescriptions Claimant is requesting payment for include Hydrocodone, Prednisone, and Amitriptyline. Claimant testified that she took Amitriptyline to help her sleep at night because the pain kept her awake, and that she took Prednisone and Hydrocodone for pain. Although Claimant testified that she knew her doctor was not supposed to bill her directly under the Texas Workers’ Compensation system, she argued she had to pay the doctor to get treatment.

Carrier asserts that it properly denied reimbursement for the office visits because the Medical Fee Guidelines in effect at the time required the treating doctor to submit the medical treatment notes to the Carrier along with the bills, to justify the level of service provided. This did not happen. Carrier also denied the office visits, laboratory work, and the prescriptions in issue for being unrelated to the compensable injury, and consequently medically unnecessary.

Claimant was examined by Jack McCarty, D.O., the Designated Medical Examiner, on September 20, 2000. As part of his examination, Dr. McCarty reviewed an MRI taken of Claimant’s spine in February 2000, which showed A(1) negative for protrusion, (2) Mild degenerative disk disease mostly effecting L4-5, (3) No spinal stenosis.^[2] Dr. McCarty diagnosed Claimant with A[m]echanical low back syndrome and pain with no evidence of severe disk pathology.^[3] Dr.

McCarty did not find that Claimant’s compensable injury created or contributed to her current diagnosis of osteo-arthritis. Dr. McCarty found that Claimant had reach maximum medical improvement and had a whole person impairment of eight percent.^[4]

On September 12, 2001, Peter Robinson, M.D., examined Claimant at the Carrier’s request. Dr. Robinson determined that no further treatment was reasonable and necessary that related to her compensable injury. ^[5] Consequently, Carrier denied further payment for Claimant’s prescriptions, laboratory work, and office visits. Carrier contends that the prescriptions and medical treatment provided to Claimant are related to her arthritis and not her compensable injury.

Climant requested that her treating records from her current doctor, Christopher, R. Rose, M.D., be considered. These records were partially illegible, making them difficult to review. Dr. Rose checked off AAnemia (Code 285.9) in the diagnosis column on many of these records, and entered AArthritis as the diagnosis on others.^[6] While Claimant asserts she is seeing Dr. Rose for her compensable injury, the medical records from Dr. Rose do not support her. Dr. Rose’s notes indicate that he is treating Claimant for anemia and arthritis, not her compensable injury. Moreover, Dr. Rose’s records do not indicate that Claimant’s anemia and arthritis were caused by, or related to, the compensable injury.

Claimant had the burden to show that the office visits, laboratory tests, and prescriptions were related to her compensable injury. Claimant failed to do so. The record shows that she is being treated for arthritis and anemia, not the compensable injury to her lower back. Claimant failed to show that her compensable injury contributed to her current condition. Therefore, the ALJ finds that

Claimant is not entitled to reimbursement for the office visits, laboratory testing, or prescriptions because she failed to show that they were related to her compensable injury.

II. FINDINGS OF FACT

1. Claimant ____ suffered a compensable, work-related injury on ____.
2. TPCIGA for Reliance Insurance Company (Carrier) is the provider of workers’ compensation insurance covering Claimant for her compensable injury.
3. Carrier denied reimbursement for the prescriptions paid for by Claimant from February 5, 2002, to January 28, 2003, and for the office visits and laboratory tests paid for by Claimant from July 23, 2002 and April 7, 2003.
4. Carrier denied reimbursement for the prescription medications because neither Claimant nor her treating doctor submitted the proper documentation for reimbursement and because the prescriptions, office visits, and laboratory work were not related to her compensable injury and, therefore, were not medically reasonable or necessary to treat her compensable injury.
5. Claimant suffers with osteo-arthritis and anemia.
6. The office visits, laboratory tests and prescriptions in issue were provided to treat Claimant’s anemia and osteo-arthritis, not her compensable injury.
7. Claimant failed to show that the prescriptions, office visits, and laboratory work in issue were related to her compensable injury.
8. Claimant requested medical dispute resolution by the Texas Workers’ Compensation Commission’s Medical Review Division (MRD).
9. After conducting medical dispute resolution, MRD issued an order on January 28, 2004, declining to order additional reimbursement because Claimant failed to present evidence that she had submitted the medical bills to the Carrier.
10. By letter dated February 7, 2004, Claimant requested a hearing, and the case was referred to the State Office of Administrative Hearings.
11. Notice of the hearing was sent on March 19, 2004.
12. The notice contained a statement of the time, place, and nature of the hearing, and the legal authority and jurisdiction under which the hearing was to be held; a reference to the sections of the statutes and rules involved; and a short, plain statement of the matters asserted.
13. On May 20, 2004, ALJ Catherine C. Egan convened a hearing in this case. Claimant appeared telephonically and was assisted by Luz Loza, Ombudsman. Steve Tipton, attorney, appeared and represented Carrier. The hearing concluded and the record was left open for the filing of additional documents. On June 8, 2004, after the admission of the additional documentation, the record was closed.^[7]

III. CONCLUSIONS OF LAW

1. The Texas Workers’ Compensation Commission has jurisdiction over this matter puruant to the Texas Workers’ Compensation Act (the Act), specifically Tex. Labor Code Ann. § 413.031.
2. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to Tex. Labor Code Ann. § 413.031(k), and Tex. Gov’t Code Ann. ch. 2003.
3. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001, and 28 Tex. Admin. Code ch. 148.
4. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code §148.3.
5. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann.§§2001.051 and 2001.052.
6. Claimant has the burden of proof in this matter. 28 Tex. Admin. Code §148.21(h).
7. Based upon the Findings of Fact, Claimant failed to establish by a preponderance of the evidence that the prescriptions, office visits, and laboratory tests, were related to Claimant’s compensable injury.
8. Based upon the Findings of Fact and Conclusions of Law, Claimant’s request for reimbursement should be denied.

ORDER

IT IS ORDERED that TPCIGA for Reliance Insurance Company is not required to reimburse Claimant for prescriptions provided to Claimant between February 5, 2002, through January 28, 2003, or for the office visits and laboratory work provided to Claimant between July 23, 2002, and April 7, 2003.

Signed August 4, 2004.

CATHERINE C. EGAN
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS

1. Ex. 4.↑
2. Ex. 6.↑
3. Id.↑
4. Id.↑
5. Ex. 1 at 30.↑
6. Ex. 1.↑
7. On May 26, 2004, Claimant filed additional documentation and requested that they be admitted into evidence. Carrier did not object to the admission of the evidence, but requested that his comments about the evidence be included in the record. Claimant filed not objections to Carrier’s request. On June 8, 2004, the ALJ admitted Claimant’s documents as Exhibit 6 and Carrier’s comments as Exhibit 7.↑