DECISION AND ORDER

EZ RX Pharmacy (Provider) challenges the decision of the Independent Review Organization (IRO) denying reimbursement for prescription medication provided to injured worker ___ (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Republic Franklin Insurance Company (Carrier) is not liable for reimbursing Petitioner any additional amounts.

I. Background

Claimant suffered a compensable, work-related injury to her shoulder in ___. Claimant’s injury was diagnosed as a shoulder impingement. Among other things, over the following months Claimant received physical therapy, cortisone shots, and participated in a work hardening program. On November 6, 2002, Claimant underwent a required medical examination (RME) and had no impingement signs and was found to be able to return to work. Claimant was determined to be at maximum medical improvement in December 2002.

While washing her car on January 19, 2003, Claimant began suffering pain again in her shoulder. She went to a doctor and received follow-up treatment that included trigger point injections. As part of the treatment prior to and after her trigger point injections, Claimant was prescribed numerous medications: Mobic; Diazepam; Hydrocodone/APAP; and Tizanidine. Provider filled these prescriptions for Claimant in February and March 2003. Provider then billed Carrier for the prescriptions. Carrier declined reimbursement, claiming the medication was not medically necessary.

Based on Carrier’s denial, Provider sought medical dispute resolution through the Texas Workers’ Compensation Commission (Commission). The matter was referred to an IRO designated by the Commission for the review process. The IRO determined that the medications were not medically necessary treatment for Claimant’s compensable injury. Provider then requested a hearing before the State Office of Administrative Hearings (SOAH). The hearing convened and closed on January 12, 2005, with ALJ Craig R. Bennett presiding. Provider appeared through its designated representative, Nicky Otts. Carrier appeared through its attorney, Beverly Vaughn. No parties objected to notice or jurisdiction.

II. Discussion and Analysis

Carrier presents a number of arguments why the prescription medications are not medically necessary treatment for Claimant. First, Carrier argues that the car-washing injury in January 2003

was not an aggravation of the underlying compensable injury, but was separate. Carrier asserts that the resulting treatment, therefore, was not medically necessary for the initial compensable injury. Further, Carrier argues that trigger point injections were not medically necessary, but that physical therapy or other conservative treatment would have been more appropriate. Thus, Carrier contends that some of the medications prescribed in conjunction with the trigger point injections were not necessary. Finally, Carrier argues that even if the trigger point injections were medically appropriate, the prescriptions themselves were not.

At the hearing, Provider presented the testimony of Rick Taylor, M.D., who testified generally as to the efficacy and necessity of Claimant’s treatment. Further, Provider submitted a letter of medical necessity from the doctor who prescribed the medications to Claimant. In response, Carrier submitted a peer review report and the IRO decision detailing reasons why the course of treatment and, specifically, the medications were not medically necessary for Claimant.

After considering the evidence and arguments presented, the ALJ finds that Provider has not met its burden of proving that the medications were medically necessary for treatment of Claimant’s compensable injury. Although Dr. Taylor offered testimony about Claimant’s treatment, the ALJ finds his testimony generally unpersuasive on the ultimate issues presented. Dr. Taylor did not specifically treat nor examine Claimant and frequently limited his testimony to generalities about what might be an acceptable course of treatment for impingement injuries. His testimony was sparse in regard to Claimant’s specific condition and documented symptoms and the need for the treatments in issue based on that condition and those symptoms. Similarly, the letter of medical necessity by David M. Hirsch, D.O., which was submitted by Provider to support the necessity of the prescriptions, is rather conclusory and does not establish the underlying propriety of the trigger point injections themselves, to which some of the medications were related. Nor does the evidence in the record persuasively show that the treatments were necessary for a compensable injury.

Although the Carrier’s evidence is also rather conclusory, the Carrier does not have the burden of proof in this case. Ultimately, the ALJ is simply not persuaded that the preponderance of the evidence establishes that the medications in issue were medically necessary for treatment of Claimant’s compensable injury. Therefore, the ALJ declines to order reimbursement for the medications in dispute. In support of this determination, the ALJ makes the following findings of fact and conclusions of law.

III. FINDINGS OF FACT

1. ___ (Claimant) suffered a compensable, work-related injury in ___.
2. Republic Franklin Insurance Company (Carrier) is the provider of workers’ compensation insurance covering Claimant for her compensable injury.
3. Among other things, Claimant received physical therapy, cortisone shots, and underwent work hardening over the next few months.
4. Claimant was determined to be at maximum medical improvement and was released to work in December 2002.
5. While washing her car on January 19, 2003, Claimant began suffering pain again in her
6. shoulder. She went to a doctor a nd received trigger point injections. As part of the treatment immediately prior to and after her trigger point injections, Claimant was prescribed numerous medications: Mobic; Diazepam; Hydrocodone/APAP; and Tizanidine.
7. EZ RX Pharmacy (Provider) filled these prescriptions for Claimant in February and March 2003.
8. Provider then billed Carrier the sum of $430.89 for the prescriptions.
9. Carrier declined reimbursement, asserting that the prescriptions were not medically necessary treatment for Claimant’s compensable injury.
10. Based on Carrier’s denial, Provider sought medical dispute resolution through the Texas Workers’ Compensation Commission (Commission), which referred this matter to an Independent Review Organization (IRO).
11. After conducting medical dispute resolution, the IRO physician reviewer determined that the medications were not medically necessary for treatment of Claimant’s compensable injury.
12. Based on the IRO decision, MRD issued an order on June 4, 2004, declining to order reimbursement.
13. On June 14, 2004, Provider requested a hearing and the case was referred to the State Office of Administrative Hearings (SOAH).
14. On January 12, 2005, Administrative Law Judge Craig R. Bennett convened a hearing in this case. Provider appeared through its designated representative, Nicky Otts. Carrier appeared through its attorney, Beverly Vaughn. The hearing concluded and the record closed that same day. No parties objected to notice or jurisdiction.
15. Provider has failed to present persuasive evidence sufficient to show that the prescriptions in issue were medically necessary for treatment of Claimant’s compensable injury.

IV. CONCLUSIONS OF LAW

1. SOAH has jurisdiction over this proceeding, including the authority to issue a decision and order, pursuant to the Texas Workers’ Compensation Act, specifically Tex. Labor Code Ann. §413.031(k) and Tex. Gov’t Code Ann. ch. 2003.
2. The hearing was conducted pursuant to the Administrative Procedure Act, Tex. Gov’t Code Ann. ch. 2001 and 28 Tex. Admin. Code ch. 148.
3. The request for a hearing was timely made pursuant to 28 Tex. Admin. Code § 148.3.
4. Adequate and timely notice of the hearing was provided according to Tex. Gov’t Code Ann. §§ 2001.051 and 2001.052.
5. Provider has the burden of proof in this matter. 28 Tex. Admin. Code §§ 148.21(h) and 133.308(w).
6. Provider has not shown, by a preponderance of the evidence, that the medications Mobic, Diazepam, Hydrocodone/APAP, and Tizanidine were medically necessary for treatment of Claimant’s compensable injury. Tex. Labor Code Ann. §§ 408.021(a)(1-3) and 401.011(19).
7. Provider is not entitled to reimbursement for the disputed medications.

ORDER

IT IS HEREBY ORDERED THAT EZ RX Pharmacy is entitled to no additional reimbursement for the prescriptions of Mobic, Diazepam, Hydrocodone/APAP, and Tizanidine dispensed to injured worker ___ between February 27, 2003, and March 28, 2003.

Signed January 20, 2005.

CRAIG R. BENNETT
Administrative Law Judge
STATE OFFICE OF ADMINISTRATIVE HEARINGS