454-13-0881-m4
DECISION AND ORDER ____ challenges the denial of reimbursement by Dallas Area Rapid Transit (DART) for homecare she provided. DART denied reimbursement based on its conclusion, among other reasons, that ____ was, at the time of the disputed services, neither a licensed certified health care practitioner nor a non-licensed individual who provides or renders healthcare […]
454-13-2726-m4
DECISION AND ORDER Shannon Medical Center (Provider) seeks reimbursement for outpatient surgical services provided to a worker’s compensation claimant. Employers Insurance Company of Wausau (Carrier) denied reimbursement because the surgery was not preauthorized and was not provided pursuant to an emergency. Based on the lack of preauthorization, the Administrative Law Judge (ALJ) concludes that Provider […]
454-13-0853-m4
DECISION AND ORDER Liberty Insurance Corporation (Carrier) challenges the order of reimbursement to Baylor Orthopedic and Spine Hospital (Provider) for outpatient surgical services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that Carrier met its burden of proof that the amount of reimbursement ordered was incorrect. Nevertheless, Carrier owes Provider $80.68 […]
454-13-0855-m4
DECISION AND ORDER Public WC Program (Carrier) challenges calculations contained in a Medical Fee Dispute Resolution decision (MDR Decision) by the Texas Department of Insurance (TDI), Division of Workers’ Compensation (Division). The MDR Decision calculations show that Carrier should pay additional reimbursement to Northwest Texas Hospital (Provider) for outpatient facility services provided to an injured […]
454-11-7994-m4-etal
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by American Casualty Company of Reading, PA (American Casualty) for two hospital outpatient procedures (HOP) performed at Vista’s facility. On November 29, 2004,[2] and January 17, 2005,[3] the injured worker underwent a lumbar transforaminal epidural steroid injection (ESI), billed under CPT […]
454-11-1907-m4-etal
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by Zurich American Insurance Company (Zurich) for hospital outpatient procedures performed at Vista’s facility for the same injured worker on three occasions. The services were provided on March 11, 2004;[1] April 29, 2004;[2] and June 17, 2004.[3] The March 11, 2004 […]
454-11-4905-m4-etal
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by Zurich American Insurance Company (Zurich) for hospital outpatient procedures performed at Vista’s facility for the same injured worker on three occasions. The services were provided on February 27, 2003;[1] July 22, 2003;[2] and March 11, 2003.[3] The February 27, 2003 […]
454-11-5439-m4-etal
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by Zurich American Insurance Company (Zurich) for three hospital outpatient procedures (HOP) performed at Vista’s facility on three separate occasions for the same injured worker. The services were provided on May 15, 2003,[1] October 22, 2003,[2] and February 5, 2004.[3] The […]
454-11-6169-m4-etal
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by Zurich American Insurance Company (Zurich) for four hospital outpatient procedures (HOP) performed at Vista’s facility on four separate occasions for the same injured worker. The services were provided on March 12, 2004,[1] November 24, 2003,[2] March 5, 2004,[3] and October […]
454-11-7518-m4
DECISION AND ORDER Vista Medical Center Hospital (Vista) challenges the denial of additional reimbursement by Zurich American Insurance Company (Zurich) for outpatient services, specifically a lumbar epidural steroid injection (ESI), CPT Code 62311, provided to an injured worker on January 12, 2004. The Administrative Law Judges (ALJs) find that Vista did not present evidence proving […]