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At a Glance:
Title:
10066
Date:
November 10, 2009
Status:
Concurrent Medical Necessity

10066

November 10, 2009

DECISION AND ORDER

This case is decided pursuant to Chapter 410 of the Texas Workers’ Compensation Act and Rules of the Division of Workers’ Compensation adopted thereunder.

ISSUES

A contested case hearing was held on November 10, 2009, to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the IRO that the Claimant is not entitled to an L4-L5 epidural steroid injection with fluoroscopy, epidurogram with anesthesia to include treatment codes #62311, #77003, #72274, and #01991 for the compensable injury of _______________?

PARTIES PRESENT

Claimant/Petitioner appeared and was assisted by ombudsman NW. Carrier/Respondent appeared by telephone and was represented by RJ, attorney.

AGREEMENT

The parties reached an agreement. The agreement resolves only those issues to be decided at this hearing. The agreement does not resolve all issues with regard to this claim and is not a settlement.

In this decision, this Agreement section includes findings of fact and the Decision section constitutes the conclusions of law.

The Hearing Officer found:

A.Respondent/Carrier delivered to Petitioner/Claimant a single document stating the true corporate name of Carrier, and the name and street address of Carrier’s registered agent, which document was admitted into evidence as Hearing Officer’s Exhibit Number 2.

The parties agreed as follows:

  1. The Texas Department of Insurance, Division of Workers’ Compensation, has jurisdiction to hear this case.
  2. Venue is proper in the (City) Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
  3. On _______________, Claimant was the employee of (Employer), and sustained a compensable injury.
  4. The preponderance of the evidence is contrary to the decision of the IRO with respect to the L4-L5 epidural steroid injection with fluoroscopy and epidurogram and Claimant is entitled to L4-L5 epidural steroid injection with fluoroscopy and epidurogram to include treatment codes #62311, #77003, and #72274.
  5. The preponderance of the evidence is not contrary to the decision of the IRO with respect to treatment code #01991 monitored anesthesia care (MAC), and Claimant is not entitled to treatment code #01991 (MAC).

DECISION

Claimant is entitled to L4-L5 epidural steroid injection with fluoroscopy and epidurogram to include treatment codes #62311, #77003, and #72274 for the compensable injury of _______________. Claimant is not entitled to treatment code #01991 (MAC) for the compensable injury of _______________.

ORDER

Respondent/Carrier is liable for the benefits as set forth in this Decision and Order. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

The true corporate name of the insurance carrier is WAUSAU UNDERWRITERS INSURANCE COMPANY, and the name and address of its registered agent for service of process is:

CORPORATION SERVICES COMPANY

701 BRAZOS STREET, SUITE 1050

AUSTIN, TEXAS 78701

Signed this 10th day of November, 2009

Cheryl Dean
Hearing Officer

End of Document
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