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 July 14, 2025, with the record closing on July 22, 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 appellant (claimant) reached maximum medical improvement (MMI) on (date of injury); (2) the claimant’s impairment rating (IR) is zero percent; and (3) the claimant had disability resulting from an injury sustained on (date of injury), for the period of April 9, 2024, through the date of the CCH. The claimant appealed, disputing the ALJ’s determinations of MMI and IR. The claimant contends on appeal that the parties have agreed his compensable injury includes post- traumatic stress disorder (PTSD) and his extensive medical records and treatment history show an anticipation of further material recovery as he continues treatment beyond the MMI date, which is also the date of injury. The respondent (self-insured) responded, urging affirmance of the disputed MMI and IR determinations. The ALJ’s determination that the claimant had disability resulting from an injury sustained on (date of injury), for the period of April 9, 2024, through the date of the CCH was not appealed and has become final pursuant to Section 410.169.
DECISION
Reversed and remanded.
The parties stipulated, in part, that the claimant sustained a compensable injury that includes at least PTSD; the Texas Department of Insurance, Division of Workers’ Compensation (Division) appointed (Dr. M), D.O. as the designated doctor to address ability to return to work, MMI, and IR; and the date of statutory MMI is January 7, 2026. In evidence is a Benefit Dispute Agreement (DWC-24) dated November 22, 2021, in which the parties agreed the claimant did sustain a compensable injury on (date of injury), which includes PTSD. The claimant testified that he sustained the compensable injury in the course and scope of his work as a police officer.
Section 401.011(30)(A) defines MMI as “the earliest date after which, based on reasonable medical probability, further material recovery from or lasting improvement to an injury can no longer reasonably be anticipated.” Section 408.1225(c) provides that the report of the designated doctor has presumptive weight, and the Division shall base its determination of whether the employee has reached MMI on the report of the designated doctor unless the preponderance of the other medical evidence is to the contrary.
Section 408.125(c) provides that the report of the designated doctor shall have presumptive weight, and the Division shall base the IR on that report unless the preponderance of the other medical evidence is to the contrary, and that, if the preponderance of the medical evidence contradicts the IR contained in the report of the designated doctor chosen by the Division, the Division shall adopt the IR of one of the other doctors. 28 Tex. Admin. Code § 130.1(c)(3) (Rule 130.1(c)(3)) provides that the assignment of an IR for the current compensable injury shall be based on the injured employee’s condition as of the MMI date considering the medical record and the certifying examination.
Dr. M initially examined the claimant on May 20, 2024, and certified that the claimant reached MMI on (date of injury), the date of injury, and assessed zero percent IR. Dr. M referred the claimant for neuropsychological testing by (Dr. C), a clinical neuropsychologist. Dr. C stated in her report that the claimant did not develop a validated psychological condition such as PTSD resulting from his occupational injury first reported on (date of injury), and that from a psychological and neuropsychological standpoint, the claimant has been at MMI since (date of injury), with no correlation to an occupational injury. Dr. M certified the claimant reached MMI on (date of injury), stating without further explanation that he agreed with the assessment and conclusion of Dr. C.
On May 9, 2025, a Presiding Officer’s directive to order designated doctor exam was sent to Dr. M because several medical records were presented that Dr. M did not have when he examined the claimant in 2024. Also included were several medical records that had been generated since Dr. M’s examination in 2024. Dr. M re-examined the claimant on June 2, 2025, and again certified that the claimant reached MMI on (date of injury), the date of injury, and assessed zero percent IR. In his narrative report dated June 2, 2025, Dr. M stated, in part, that: “…on further examination of the [claimant] and supplied medical records since my last encounter, I have not changed my conclusion that the examinee does not suffer a mental health issue from his work-related accident of (date of injury). Therefore, his MMI is (date of injury).” Additionally, Dr. M stated, “I am not able, however, to include, with confidence, PTSD as a work related [sic] mental health diagnosis as the examinee, as mentioned, has rather significant elevated scores in regards to validity and reliability in his neuropsychological testing.”
In Appeals Panel Decision (APD) 043168, decided January 20, 2005, the designated doctor refused to rate the compensable thoracic injury because he did not believe it was part of the compensable injury. In that case, the Appeals Panel stated “when a designated doctor refuses to provide an IR for the compensable injury (whether the IR be zero or a significant percentage) based on the designated doctor’s opinion that the claimant does not have a compensable injury and to determine MMI based on the entire compensable injury, one of the remedies is to appoint another designated doctor.” (Citing APD 982402, decided November 23, 1998; and APD 001733, decided September 13, 2000.) The Appeals Panel held that the designated doctor is required to rate the entire compensable injury. See APD 043168, supra. The evidence establishes that Dr. M did not consider the compensable PTSD injury in determining MMI and IR. Because Dr. M did not determine MMI as defined in Section 401.011(30)(A) and he did not rate the compensable PTSD, we reverse the ALJ’s determinations that the claimant reached MMI on (date of injury), with a 0% IR.
There is no other certification of MMI/IR in evidence. Accordingly, we remand the issues of MMI and IR to the ALJ for further action consistent with this decision.
REMAND INSTRUCTIONS
A new designated doctor is to be appointed on the issues of MMI and IR in this case. The second designated doctor is to be given all the medical records, including Dr. M’s reports, and asked to assess an MMI date, and if the claimant is at MMI, an IR. The second designated doctor is to be informed that the statutory date of MMI is January 7, 2026. The second designated doctor’s report is then to be made available to the parties for comment and rebuttal evidence to the second designated doctor’s report. The ALJ is then to make a determination of MMI and IR supported by the evidence.
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 (a self-insured governmental entity) and the name and address of its registered agent for service of process is
(NAME)
CITY SECRETARY
(ADDRESS)
(CITY), TEXAS (ZIP CODE).
Margaret L. Turner
Appeals Judge
CONCUR:
Cristina Beceiro
Appeals Judge
Carisa Space-Beam
Appeals Judge