454-09-2766-m4
DECISION AND ORDER Texas Orthopedic Hospital (Petitioner) filed this case to protest a decision by a Medical Fee Dispute Resolution (MFDR) Officer of the Texas Department of Insurance, Division of Workers’ Compensation (DWC or Division) that found its request for an MFDR hearing on a 2008 fee dispute was not timely. Petitioner sought a remand […]
453-05-8921-m4
DECISION AND ORDER Insurance Company of the State of Pennsylvania (Carrier) requested a hearing on a decision by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division)[2] ordering additional reimbursement to Spring Branch Medical Center (Provider) for a hospital stay provided to Claimant, an injured worker. Provider argued […]
454-09-1883-m4
DECISION AND ORDER Hill Country Behavioral Health (Provider) requested a hearing to contest a medical fee dispute resolution order issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding medical services provided to _____ (Claimant). In its order, the Division found that Provider was entitled to reimbursement in the amount of $2,400 […]
454-09-1240-m4
DECISION AND ORDER Transcontinental Insurance Company (Carrier) requested a hearing to contest a medical fee dispute resolution order issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) regarding medical services provided _____ (Claimant). In its order, the Division found that Eric Scheffey, M.D. (Provider) was entitled to reimbursement in the amount of […]
454-09-1316-m4
DECISION AND ORDER Alta Vista Healthcare, LP (Alta Vista), requested a hearing to contest a decision by the Texas Department of Insurance, Division of Workers’ Compensation (Division), Medical Review Division (MRD) that denied Alta Vista reimbursement for all services involving the claimant’s right shoulder. MRD based its decision on a separate contested case proceeding before […]
454-08-3351-m4
DECISION AND ORDER Mario Kapusta, M.D. (Dr. Kapusta or Provider), requested a hearing to contest a decision by the Texas Department of Insurance, Workers Compensation Division (Division), Medical Fee Dispute Resolution Section (MFDR), which determined that Texas Mutual Insurance Company (TMI or Carrier) had properly denied Dr. Kapusta reimbursement for assisting in a spinal surgery. […]
454-08-3847-m5
DECISION AND ORDER Safety National Casualty Corporation (Carrier) appealed from an adverse Medical Dispute Resolution decision issued by the Texas Department of Insurance, Division of Workers’ Compensation (Division) ordering it to reimburse Dallas Multidisciplinary Clinic/Dallas Integrated Healthcare (Provider) for physical therapy services rendered between January 9, 2006, and March 15, 2006, for Claimant ____. A […]
454-08-3848-m5
DECISION AND ORDER From June 26, 2007, through August 29, 2007, Petitioner, Texas Health, L.L.C., a CARF-accredited facility,[1] provided work hardening services to a workers’ compensation claimant. Respondent, Dallas National Insurance Company, determined that the treatment was not medically necessary. The amount in dispute is $6,228.80 for 11 visits in a four-week period and related […]
454-08-4471-m5
DECISION AND ORDER I. INTRODUCTION Gabriel Gutierrez (Petitioner and Provider) appealed the decision of the Medical Dispute Resolution Division of the Texas Department of Insurance, Division of Workers’ Compensation (the Division) regarding services provided by Petitioner to a workers’ compensation claimant, ___ (Claimant) from March 14, 2006, through April 28, 2006. The Medical Review Division […]
454-08-3756-m4
DECISION AND ORDER Eric Vanderwerff, D.C., (Provider) seeks reversal of an order denying payment for $2,028 of chiropractic services for Claimant ___.The Administrative Law Judge (ALJ) finds that Provider properly billed for medically necessary services. American Home Assurance Company (Carrier) is ordered to reimburse Provider. I.DISCUSSION Claimant suffered a compensable back injury, a lumbar sprain/strain, […]