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.

ISSUE

A medical contested case prehearing was held on December 20, 2012 to decide the following disputed issue:

Is the preponderance of the evidence contrary to the decision of the Independent Review Organization (IRO) that Claimant is not entitled to revision of left shoulder arthroscopy SAD and distal clavicle with CPT Codes 29826, 29824, 29823, and 29999?

PARTIES PRESENT

Prior to the date of the prehearing, Provider/Petitioner Dr. B filed a request to withdraw his dispute in this case. Claimant failed to appear for the prehearing and did not respond to the Division’s 10-day letter. Carrier/Respondent appeared, by telephone, and was represented by JL, attorney.

BACKGROUND INFORMATION

Although properly notified, the Claimant failed to appear for the medical contested case prehearing scheduled for 11:30 a.m. on December 20, 2012. By virtue of Claimant’s failure to appear, evidence was presented at that proceeding. A letter advising that the prehearing had convened and that the record would be held open for ten days to afford Claimant the opportunity to respond and request that the prehearing be rescheduled to permit her to present evidence on the disputed issue was mailed to Claimant on December 28, 2012. Claimant failed to respond to the Division’s 10-day letter and, on January 24, 2013, the record was closed.

Having failed to appear and offer evidence in support of the necessity of the requested procedure, Claimant failed to prove that the preponderance of the evidence is contrary to the determination of the IRO that she is entitled to revision of left shoulder arthroscopy SAD and distal clavicle with CPT Codes 29826, 29824, 29823, and 29999 for the compensable injury of (Date of Injury).

Even though all the evidence presented was not discussed, it was considered. The Findings of Fact and Conclusions of Law are based on all of the evidence presented.

FINDINGS OF FACT

1. Carrier stipulated to the following facts:
   1. Venue is proper in the (City)Field Office of the Texas Department of Insurance, Division of Workers’ Compensation.
   2. On (Date of Injury), Claimant was the employee of (Employer), Employer, and sustained a compensable injury.
   3. On (Date of Injury), Employer provided workers’ compensation insurance coverage through Insurance Company of the State of Pennsylvania.
   4. The Independent Review Organization (IRO) determined that the health care at issue was not reasonably required for the compensable injury of (Date of Injury).
2. The Division sent a single document stating the true corporate name of Carrier and the name and street address of Carrier’s registered agent for service with the 10-day letter to Claimant at her address of record. That document was admitted into evidence as Hearing Officer Exhibit Number 3.
3. No evidence was received to show that revision of left shoulder arthroscopy SAD and distal clavicle with CPT Codes 29826, 29824, 29823, and 29999 is health care reasonably required for the compensable injury of (Date of Injury).
4. Claimant failed to appear for the December 20, 2012 medical contested case prehearing and did not respond to the Division’s letter offering her the opportunity to have the prehearing rescheduled.
5. Claimant did not have good cause for her failure to appear for the medical contested case prehearing of December 20, 2012.

CONCLUSIONS OF LAW

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.
3. The preponderance of the evidence is not contrary to the decision of the IRO that revision of left shoulder arthroscopy SAD and distal clavicle with CPT Codes 29826, 29824, 29823, and 29999 is not health care reasonably required for the compensable injury of (Date of Injury).

DECISION

Claimant is not entitled to revision of left shoulder arthroscopy SAD and distal clavicle with CPT Codes 29826, 29824, 29823, and 29999 for the compensable injury of (Date of Injury).

ORDER

Carrier is not liable for the benefits at issue in this hearing. Claimant remains entitled to medical benefits for the compensable injury in accordance with §408.021.

The true corporate name of the insurance carrier is INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA and the name and address of its registered agent for service of process is:

CORPORATION SERVICE COMPANY

211 EAST 7th STREET, SUITE 620

AUSTIN, TEXAS 78701

Signed this 24^th day of January, 2013.

Jennifer Hopens
Hearing Officer