* Pursuant to 5 TH C IR

. R. 47.5, the Court has determined that this opinion shoul d not be

published and is not precedent except under the limit ed circumstances set forth in 5 TH C IR

. R. 47.5.4. United States Court of Appeals

Fifth Circuit



## FILED

January 4, 2005

Charles R. Fulbruge III

Clerk IN THE UNITED STATES COURT OF APPEALS

FOR THE FIFTH CIRCUIT

No. 04-50211

(Summary Calendar)

ANITA EVARO,

Plaintiff-Appellant,

versus

CONTINENTAL CASUALTY COMPANY,

Defendant - Appellee.

Appeal from the United States District Court

for the Western District of Texas

(USDC No. P-03-CV-36)

Before WIENER, BENAVIDES, and STEWART, Circuit Judges.

PER CURIAM: *

In this diversity action, Anita Evaro appeals the district court’s grant of summary judgment

for Continental Casualty Insurance based on lack of subject matter jurisdiction. For the following

reasons, we AFFIRM.

FACTUAL AND PROCEDURAL BACKGROUND

In August 1997, Anita Evaro (“Evaro”) suffered a back injury while employed as a produce1 Evaro’s treatment included back su r gery, epidural treatments, ganglionectomies,

implentation, x-rays, a trial spinal cord stimulator, and regular office visits.

2 Specifically, he suggested Evaro suffered from Munchausen Syndrome

- a facitious disorder

with physical symptoms.

2 ins pect o r for RX Staffing Corporation at its Anchor West facility. Continental Casualty Co.

(“Continental”) provided workers’ compensation insurance to RX Staffing. Evaro filed a claim for

workers’ compensation benefits for he r injury. Continental denied the claim and contested the

compensability of Evaro’s injury before the Texas Workers’ Compensation Commission (“TWCC”).

After a contested case hearing, TWCC determined that Evaro’s injury was compensable. Continental

appealed the decision to the Appeals Panel, which also ruled in Evaro’s favor. Subsequently,

Continental began payment of both income and medical benefits to Evaro in 1998. Evaro consulted

a team of physicians for her injury, among them Dr. Oei, a pain management specialist. Evaro was

eventually diagnosed with a herniated disk and under went surgery on March 16, 2000. In March

2001, Dejaune Phillips, an adjuster with Continental, requested a peer review to determine whether

the continued course of treatment Evaro was undergoing with Dr. Oei was reasonable and necessary. 1

Dr. Theodore Pearlman, a psychiatrist, conducted the peer review by looking over Evaro’s medical

records. In a report dated March 22, 2001, Dr. Pearlman concluded that Evaro’s continued treatment

by Dr. Oei and other doctors was not reasonable or medically necessary. He opined that Evaro ’s

continued problems resulted from non-physical, psychological factors which could be preventing her

improvement or contributing to the symptoms Dr. Oei and other providers were treating. 2 He

recommended that follow-up visits be terminated and Evaro weaned from pain medications.

Dr. Oei continued to see Evaro through October 2001; although Continental denied payment

for Evaro’s visit s t o Dr. Oei from May 2001 through October 2001, citing the lack of medical3

necessity for the services as indicated by Dr. Pearlman’s report. C ontinental also refused to

preaut horize a request by Dr. Oei for diagnostic tests in October 2001. D r. Oei did not contest

Continental’s refusal to pay with TWCC nor did he ask Continental to reconsider their non-payment.

Evaro contends she paid for Dr. Oei’s services herself from the end of January of 2001 until the end

of 2002; however, the district court noted there was no evidence Evaro paid for the treatments herself

nor evidence that she challenged the denial of payment to TWCC or Continental.

In August 2002, Dr. Oei performed two ganglionectomies on Evaro that Continental Casualty

had prospectively approved. Continental paid Dr. Oei for the operations but in an amount which was

reduced to meet applicable TWCC fee guidelines. D r. Oei did not challenge the reduced fee to

Continental nor did he request medical di sput e resolution with TWCC. On or about January 14,

2003, Dr. Oei notified Evaro of his decision to cease treatment of her as a patient. Evaro contends

that Dr. Oei withdrew as her physician because of Continental’s non-payment. Evaro asserts that her

condition has worsened since Dr. Oei stopped treating her. On March 27, 2003, Evaro filed suit in

Texas state court against Continental for breach of the duty of good faith and fair dealing because

Continental denied payment of workers’ compensation medical benefits without a reasonable basis.

Continental removed the case to United States District Court, Western District of Texas based on

diversity of citizenship. On January 28, 2004, the district court grant ed summary judgment for

Continental based on lack of subject-matter jurisdiction. The district court concluded that Evaro did

not exhaust her administrative remedies before TWCC prior to initiating this judicial proceeding.

Evaro filed a timely appeal.

DISCUSSION

I. Standard of Review3 The employee is specifically entitled to health care that:

(1) cures or relieves the effects naturally resulting from the compensable injury;

(2) promotes recovery; or

(3) enhances the ability of the employee to return to or retain employment.

T EX

. L AB

. C ODE § 408.021(a) (West 2004).

4 We review the grant of summary judgment de novo

, applying the same standards as the

district court. S ee Mowbray v. Cameron County, Tex.

, 274 F.3d 269, 278 (5th Cir. 2001). Summary

judgment is appropriate only when the record indicates "no genuine issue as to any material fact and

that the moving party is entitled to judgment as a matter of law." F ED

. R. C IV

. P. 56.

II. Summary Judgment

Continental ass ert s t hat the district court was correct in finding it lacked jurisdiction over

Evaro’s suit because Evaro has not exhausted her a dminist rat ive remedies with the TWCC.

Continental contends the TWCC has never ruled that Evaro is ent it led to the challenged medical

treatments, and therefore, the courts have no authority to award damages for treatment the TWCC

has not determined Evaro is entitled pursuant to Am. Motorists Ins. Co. v. Fodge

, 63 S.W.3d 801

(Tex. 2001). According to Continental, Dr. Oei should have requested medical dispute review of the

denial of payment, as was his right, so that TWCC could rule on whether payment was due.

Evaro counters that the TWCC made a final decision determining she is entitled to benefits

when it concluded her injury was compensable. “An employee who suffers a compensable injury is

entitled to all health care reasonably required by the nature of the injury as and when needed.” T E X

.

L AB

. C ODE § 408.021(a) 3

. Evaro asserts that there is at least a fact issue about whether Continental’s

denial of medical benefits was a bad faith attempt to challenge the prior compensability decision.

The power to award compensation benefits lies exclusively wit h the Texas Workers’5

Compensation Commission. B one v. Utica Nat’l Ins. Co. of Texas

, 2003 WL 21810944, at *2 (Tex.

App. Aug. 7, 2003), reh’g den ied , (Dec. 5, 2003) (quotation marks omitted); a ccord Fodge

, 63

S.W.3d at 803. TWCC has jurisdiction over disputes involving income benefits, preauthorization of

medical care, and reimbursement of medical expenses. Fodge

, 63 S.W.3d at 803 (quotation marks

omitted). The TWCC has pro mulgated rules through which an insurance carrier can review the

medical claims of health care providers. T E X

. A DMIN

. C ODE §§ 133.301-.305 (West 2004). In turn,

the rules provide for a dispute resolution process through which a health care provider or claimant

can challenge the reduced payment or non-payment by a carrier. Id. § 133.305 ; T EX

. L AB

. C ODE §

413.031(a)-(b). A party who is dissatisfied with the outcome of dispute resolution may seek relief

from the State Office of Administrative Hearings, and subsequently, from the courts. T exas

Workers' Comp. Comm'n v. Patient Advocates of Texas

, 136 S.W.3d 643, 652-53 (Tex. 2004); T EX

.

L AB

. C ODE § 413.031(k). A party must exhaust their administrative remedies and there must be a final

decision of the T WCC’s Appeals Panel before a party may seek a judicial remedy. C ervantes v.

Tyson Foods, Inc.

, 130 S.W.3d 152, 157 (Tex. App. 2003); T EX

. L AB

. C ODE § 410.251. A court has

no jurisdiction to award damages based on an insurance company’s denial of preauthorization or

failure to reimburse medical expenses if the TWCC has not determined that the claimant is entitled

to preauthorization or reimbursement. Malish v. Pac. Employers Ins. Co. , 106 S.W.3d 744, 746

(Tex. App. 2003) (quotation marks omitted).

The district court found that the only ruling TWCC ever made concerning the dispute between

Evaro and Continental was its 1998 ruling that Evaro’s injury was compensable. Evaro maintains that

the 1998 ruling by TWCC that he r injury was compensable, and thus that she is entitled to all

reasonable health benefits associated with her injury, is a final decision that satisfies the exhaustion4 322 F.3d 883 (5th Cir. 2003).

5 A party, including a health care provider, is entitled to a revi ew of a medical service

provided or for which authorization of payment is sought if a health care provider is:

(1) denied payment or paid a reduced amount for the medical service rendered;

(2) denied authorization for the payment of the service requested or performed if

authorization is required by the medical policies of the commission; or

(3) o rdered by the division to refund a payment received for a medical service

rendered.

6 requirement. Continental notes that retrospective, prospective or concurrent review of medical

treatment is distinct from comp ensability. S ee T EX

. A DMIN

. C ODE § 134.600(h)-(i). Although,

Continental cannot challenge the final decision of the TW CC co ncerning the compensability of

Eva ro ’s injury, Continental asserts it was entitled to review the reasonableness or the necessity of

Evaro’s medical treatments. I d. § 133.301(a)(9); id. § 133.304; see also T EX

. L AB

. C ODE § 413.014.

Evaro submits that her case is controlled by Gregson v. Zurich Am. Ins. Co. 4 The insurance

carrier in Gregson found the plaint iff’s injury compensable and agreed to provide coverage for back

surgery. However, the carrier refused payment for the medication prescribed to the plaintiff following

surgery; the plaint iff argued that was a breach of its duty of good faith. This Court found that the

plaint iff was not required to exhaust his administrative remedies before bringing suit. First, the Court

found that Fodge did not apply becau se t he insurance carrier already found Gregson’s injury

compensable and agreed to provide coverag e fo r his back surgery and all other reasonable and

necessary benefits incident to the treatment

- which included the post-surgery prescription. Therefore,

the issue before it was whether an employee must exhaust administrative procedures with the TWCC

when the carrier denies coverage of a medical benefit incident to the approved medical treat ment

.

The Court stated that § 413.031(a) of the Texas Labor Code 5 provides for medical dispute resolutionT EX

. L AB

. C ODE § 413.031(a)

7

of disputes arising from medical services rendered ; but, Gregson did not receive the medication so

no medical service wa s rendered. Moreover, the provision stated it provided for review where

authorization of pa yment is sought ; however, a prescription does not require preauthorization of

payment by the insurance carrier. Based on those conclusions, the Court found the medical dispute

resolution procedure did not apply to Gregson’s situ at ion, nor did any other section of the Texas

Labor or Administrative Code require an employee who s o ught a medical benefit which did not

require preauthorization to exhaust any particular remedy. Therefore, Gregson was not required to

exhaust an administrative remedy. In contrast, Dr. Oei was denied payment for a medical service that

was actually rendered, and the invasive treatments Dr. Oei provided did require pre-authorization.

T EX

. L AB

. C ODE § 413.014; T EX

. A DMIN

. C ODE § 134.600(h)-(i). Accordingly, Evaro and Dr. Oei

were entitled to seek an administrative remedy. T EX

. L AB

. C ODE § 413.031(a)-(c); Continental Cas.

Ins. Co. v. F unct ional Restoration Assocs. , 19 S.W.3d 393, 409 (Tex. 2000) (“When a workers'

compensation insurer denies payment ... the worker or the health care provider can request review

by a ‘health care provider professional review organization.’”); Bone , 2003 WL 21810944 (finding

the court lacked ju risdiction to adjudicate insurer’s refusal to pay pain management bill where

employee and physician did not exhaust th eir administrative remedies). Thus, G regson is

distinguishable.

The district court found that because Evaro did not utilize the medical dispute resolution

process, Ev aro did not exhaust her administrative remedies. Furthermore, the district court

concluded Evaro was required to exhaust her administrative remedies pursuant to Texas state law

before she filed a claim in court. We affirm essentially for the reasons stated by the district court in8

its memorandum order. Because Evaro was required to exhaust her administrative remedies, and she

did not, the district court did not have jurisdiction to hear her claim.

II. Stay versus dismissal

Evaro argues that if this Court finds the courts lack jurisdiction over her claim, the appropriate

remedy is a stay rather than dismissal. Evaro avers that because she is not a health care provider,

the statute does not provide standing for her to assert an administrative proceeding. Since TWCC

does not have the power to grant her re lief, Evaro argues TWCC’s primary jurisdiction does not

apply here and thus, a stay is more appropriate than a dismissal. For the reasons stated above, we

find Evaro’s arguments unpersuasive.

If a claim is not within a court’s jurisdict io n, and the impediment to jurisdiction cannot be

removed, then it must be dismissed. F odge

, 63 S.W.3d at 805 (quotati on marks o mitted). The

TWCC provisions state that a medical dispute review must be initiated within a year after the service

in dispute. T E X

. A DMIN

. C ODE § 133.307. Evaro’s one y ear window t o init iate review of

Continental’s non-payment in 2001 and reduced payment in 2002, or have Dr. Oei initiate review,

has passed. Since, Evaro failed to exhaust her administrative remedies, and is now time barred from

doing so, dismissal is proper.

CONCLUSION

For the foregoing reasons, the ruling of the district court is AFFIRMED.

AFFIRMED.