This appeal arises pursuant to the Texas Workers’ Compensation Act, Tex. Lab. Code Ann. § 401.001 et seq. (1989 Act). A contested case hearing (CCH) was held on February 24, 2025, in (city), Texas, with (administrative law judge) presiding as the administrative law judge (ALJ). The ALJ resolved the disputed issues by deciding that: (1) the compensable injury of (date of injury), does not extend to cervical radiculopathy, lumbar radiculopathy, lumbar radicular syndrome, lumbar intervertebral disc displacement at L4-5 and L5-S1, lumbar spinal stenosis at L4-5 and L5-S1, traumatic spondylosis at L4-5 and L5-S1, or traumatic rupture of lumbar disc L4-5 and L5-S1; (2) the first certification of maximum medical improvement (MMI) and assigned impairment rating (IR) from (Dr. C) on March 26, 2024, became final under Section 408.123 and Tex. Admin. Code § 130.12 (Rule 130.12); (3) the appellant (claimant) reached MMI on March 26, 2024; (4) the claimant’s IR is five percent; and (5) the claimant did not have disability from January 23, 2024, to the date of the CCH, resulting from an injury sustained on (date of injury). The claimant appealed, disputing the ALJ’s extent-of-injury, disability, finality, MMI, and IR determinations. The respondent (carrier) responded, urging affirmance of the disputed determinations.
DECISION
Affirmed as reformed in part, and reversed and remanded in part.
The parties stipulated that on (date of injury), the claimant sustained a compensable injury in the form of at least a cervical sprain and lumbar sprain; Dr. C, the Texas Department of Insurance (Division) selected designated doctor was appointed to determine extent of injury, MMI, IR, and disability; and the initial certification from Dr. C was received by verifiable means and not disputed timely. The claimant testified that he was injured in a motor vehicle accident.
EXTENT OF INJURY
The ALJ’s determination that the compensable injury of (date of injury), does not extend to cervical radiculopathy, lumbar radiculopathy, lumbar radicular syndrome, lumbar intervertebral disc displacement at L4-5 and L5-S1, lumbar spinal stenosis at L4-5 and L5-S1, traumatic spondylosis at L4-5 and L5-S1, or traumatic rupture of lumbar disc L4-5 and L5-S1 is supported by sufficient evidence and is affirmed.
DISABILITY
The disability issue as stated in the Benefit Review Conference Report and as agreed to by the parties at the CCH was as follows: Did the claimant have disability from January 23, 2024, to the present, resulting from an injury sustained on (date of injury)? We note that the date of injury identified in the disability issue of the ALJ’s decision was mistakenly identified as May 21, 2023. In his discussion of the evidence, conclusion of law, and decision regarding the disability issue the ALJ correctly identified the beginning date of disability in dispute as January 23, 2024. However, in Finding of Fact No. 5, the ALJ mistakenly referenced the beginning date of disability in dispute as December 7, 2023. We reform Finding of Fact No. 5 to conform to the evidence and the agreed upon beginning date of disability as follows: The compensable injury of (date of injury), was not a cause of the claimant’s inability to obtain and retain employment at wages equivalent to his pre-injury wage from January 23, 2024, through the date of the CCH. The ALJ’s determination that the claimant did not have disability from January 23, 2024, to the date of the CCH, resulting from an injury sustained on (date of injury), as reformed is supported by sufficient evidence and is affirmed.
FINALITY OF DR. C’S CERTIFICATION
Section 408.123(e) provides that, except as otherwise provided by Section 408.123, an employee’s first valid certification of MMI and first valid assignment of an IR is final if the certification or assignment is not disputed before the 91st day after the date written notification of the certification or assignment is provided to the employee and the carrier by verifiable means.
Section 408.123(f) provides in part:
(f) An employee’s first certification of [MMI] or assignment of an [IR] may be disputed after the period described by Subsection (e) if:
(1) compelling medical evidence exists of:
(A) a significant error by the certifying doctor in applying the appropriate American Medical Association guidelines or in calculating the [IR];
(B) a clearly mistaken diagnosis or a previously undiagnosed medical condition; or
(C) improper or inadequate treatment of the injury before the date of the certification or assignment that would render the certification or assignment invalid.
At the CCH the claimant argued that he met an exception to finality found in Section 408.123(f). The ALJ failed to discuss or make any findings of fact, conclusions of law, or a decision as to whether there was compelling medical evidence to establish any of the three exceptions to finality found in Section 408.123(f). Because the ALJ failed to address any of the finality exceptions, we remand this case to the ALJ to determine if there is compelling medical evidence to establish any of the three finality exceptions found in Section 408.123(f). See Appeals Panel Decision 190180, decided March 28, 2019.
MMI/IR
Because we have reversed and remanded the issue of whether Dr. C’s certification of MMI and IR on March 26, 2024, became final under Section 408.123 and Rule 130.12, we also reverse the ALJ’s determinations that the claimant reached MMI on March 26, 2024, and the claimant’s IR is five percent, and we remand the issues of MMI and IR to the ALJ for further action consistent with this decision.
SUMMARY
We affirm the ALJ’s determination that the compensable injury of (date of injury), does not extend to cervical radiculopathy, lumbar radiculopathy, lumbar radicular syndrome, lumbar intervertebral disc displacement at L4-5 and L5-S1, lumbar spinal stenosis at L4-5 and L5-S1, traumatic spondylosis at L4-5 and L5-S1, or traumatic rupture of lumbar disc L4-5 and L5-S1.
We affirm as reformed the ALJ’s determination that the claimant did not have disability from January 23, 2024, to the date of the CCH, resulting from an injury sustained on (date of injury).
We reverse the ALJ’s determination that the first certification of MMI and assigned IR from Dr. C on March 26, 2024, became final under Section 408.123 and Rule 130.12, and we remand the issue of finality of Dr. C’s certification of MMI and IR on March 26, 2024, to the ALJ for further action consistent with this decision.
We reverse the ALJ’s determination that the claimant reached MMI on March 26, 2024, and we remand the MMI issue to the ALJ for further action consistent with this decision.
We reverse the ALJ’s determination that the claimant’s IR is five percent and remand the IR issue to the ALJ for further action consistent with this decision.
REMAND INSTRUCTIONS
On remand the ALJ is to determine whether there is compelling medical evidence of any exceptions to finality found in Section 408.123(f), and then the ALJ is to determine whether Dr. C’s certification of MMI and IR on March 26, 2024, became final under Section 408.123 and Rule 130.12. Finally, the ALJ is to determine the claimant’s MMI and IR.
Pending resolution of the remand, a final decision has not been made in this case. However, since reversal and remand necessitate the issuance of a new decision and order by the ALJ, a party who wishes to appeal from such new decision must file a request for review not later than 15 days after the date on which such new decision is received from the Division, pursuant to Section 410.202 which was amended June 17, 2001, to exclude Saturdays and Sundays and holidays listed in Section 662.003 of the Texas Government Code in the computation of the 15-day appeal and response periods. See APD 060721, decided June 12, 2006.
The true corporate name of the insurance carrier is TEXAS MUTUAL INSURANCE COMPANY and the name and address of its registered agent for service of process is
JEANETTE WARD, PRESIDENT AND CEO
2200 ALDRICH STREET
AUSTIN, TEXAS 78723-3474.
Margaret L. Turner
Appeals Judge
CONCUR:
Cristina Beceiro
Appeals Judge
Carisa Space-Beam
Appeals Judge