453-02-0935-m4
DECISION AND ORDER I. Background and Procedural History The Clinic for Special Surgery (the Clinic or Petitioner) is an ambulatory surgical center (ASC). Patient ____ was treated at the Clinic with an epidural steroid injection. The Clinic submitted a bill for $2,840.48 to Hartford Fire Insurance (Hartford) for services rendered to___ Hartford paid the Clinic […]
453-06-0037-m4
DECISION AND ORDER Vista Hospital of Dallas (Vista) requested a hearing to contest a decision by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division), denying additional reimbursement to Vista for surgery and a hospital stay provided to Claimant, an injured worker.[1] American Home Assurance Company (Carrier) had […]
453-99-2019-m4-etal
DECISION AND ORDER Paul J. Harph (Provider) appealed the findings and decisions of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in the above causes. The findings and decisions denied reimbursement for surgical procedures performed by Dr. Harph. The issues presented relate to the applicability of modifiers -65 and -22, under the Commission’s […]
454-12-1946-m4
DECISION AND ORDER ____ (Claimant) challenges the denial of reimbursement by ______ (______) for services provided to an injured worker. The Administrative Law Judge (ALJ) concludes that Claimant did not timely file a request for medical fee dispute resolution. Consequently, Claimant is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no disputed […]
454-13-2363-m4
DECISION AND ORDER Parker City Pharmacy (Provider) seeks reimbursement of $3,269.55 from Continental Casualty Insurance Company (Carrier) for prescription medications it dispensed to an injured worker (Claimant) on December 27, 2004, and January 24, 2005. The Administrative Law Judge (ALJ) finds the Provider is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are […]
454-15-1876-m4-np
DECISION AND ORDER Zurich American Insurance Co. (Carrier) appeals the approval of full reimbursement to Texas Health Fort Worth (Provider) for services provided to an injured worker because the Provider released the injured worker to a rehabilitation facility rather than home. The Administrative Law Judge (ALJ) concludes that under the Inpatient Hospital Fee Guideline (Guideline), […]
454-12-1961-m4
DECISION AND ORDER I. INTRODUCTION Various hospitals (Providers) requested hearings on decisions by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division)[1] denying additional reimbursement to Providers under the Stop-Loss Exception for a hospital stay provided to an injured worker. Providers argued that reimbursement for the admission should […]
454-18-5138-m4-np
DECISION AND ORDER This case involves a dispute regarding payment for medical services provided by Healthcare Provider (HCP)covered by the worker’s compensation insurance system. The Texas Department of Insurance’s Division of Worker’s Compensation (Division) conducted a medical fee dispute resolution (MFDR) and declined to order Carrier to reimburse HCP amount of $276.03. The Administrative Law […]
454-18-2743-m4-np
DECISION AND ORDER Carrier challenges a decision of the Texas Department of Insurance, Division of Worker’s Compensation (Division) that awarded Healthcare Provider (HCP) reimbursement for a combination of several drugs compounded into a topical cream. Carrier appeared at the hearing and presented evidence in support of its position that, by compounding multiple ingredients into a […]
454-18-3323-m4-np-etal
DECISION AND ORDER Carrier challenges a decision of the Texas Department of Insurance, Division of Workers’ Compensation (Division) that awarded Healthcare Provider (HCP) a $1,688.74 reimbursement for a compound topical cream prepared by HCP. Carrier argued that because the compound cream was not a drug approved by the Food and Drug Administration (FDA), it required […]