453-05-1196-m2
DECISION AND ORDER Texas Mutual Insurance Company (Petitioner) requested a hearing before the State Office of Administrative Hearings following a Decision of the Texas Workers’ Compensation Commission (Commission) acting through Speciality IRO, an Independent Review Organization (IRO). The Commission’s Order granted a preauthorization request for work conditioning for ___ (Claimant). This decision grants the relief […]
453-05-0117-m2
DECISION AND ORDER Hartford Casualty Insurance Company (Petitioner) requested a hearing before the State Office of Administrative Hearings (SOAH) following a decision of the Texas Workers’ Compensation Commission (Commission) acting through Maximus, an Independent Review Organization (IRO). The Commission’s Order granted a preauthorization request for a pain management program for ___ (Claimant). This decision grants […]
453-05-1197-m2
DECISION AND ORDER I. INTRODUCTION Truck Insurance Exchange (“Petitioner”) challenged a decision by an Independent Review Organization (“IRO”), issued on behalf of the Texas Workers’ Compensation Commission (“Commission”) in a preauthorization dispute. The IRO found that Petitioner improperly denied preauthorization for a chronic pain management program (“CPMP”), intended to provide therapy for a claimant suffering […]
453-05-1540-m2
DECISION AND ORDER I. INTRODUCTION ___ (Claimant) submitted a request to VF Corporation, his workers’ compensation insurance carrier (Carrier), to preauthorize epidural steroid injection (ESI) treatment for the chronic cervical neck pain he has experienced for several years. The Carrier denied the request and ___ requested medical dispute resolution. An independent review organization (IRO), acting […]
453-04-3680-m2
DECISION AND ORDER St. Paul Mercury Insurance Company (Carrier) denied ___’s (Petitioner) request to preauthorize a radiofrequency thermocoagulation stellate ganglion block procedure recommended by Petitioner’s pain management physician, C. Michel Oliva, M.D. An Independent Review Organization (IRO) agreed with Carrier’s denial and Petitioner has appealed to the State Office of Administrative Hearings (SOAH). At issue […]
453-05-0119-m2
DECISION AND ORDER This is a dispute over a request for preauthorization for a permanent in-home hydrotherapy spa for workers’ compensation claimant ___ (the Claimant). The Administrative Law Judge (ALJ) concludes the request should be denied. I. HISTORY The Claimant suffered a lower back injury on ___. He underwent lumbar fusion surgery, but it was […]
453-04-5999-m2
DECISION AND ORDER I. INTRODUCTION ___ (Claimant) has appealed a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (TWCC). The decision concerned the denial by North River Insurance Company of NE (Carrier) denial of a request by Paul Ellis, M.D., (Provider) request for pre-authorization of medical services for […]
453-04-7612-m2
DECISION AND ORDER ___. (Claimant) challenges the decision by an Independent Review Organization (IRO) denying her request to preauthorize outpatient surgical services for bilateral facet injections. Texas Mutual Insurance Company (Carrier) denied the request as medically unnecessary and the IRO upheld that decision. The Administrative Law Judge (ALJ) agrees with the IRO and concludes preauthorization […]
453-05-0965-m2
DECISION AND ORDER Kenneth Berliner, M.D. (Provider) challenged the decision of University of Texas System (Carrier) denying preauthorization for arthroscopic knee surgery for Claimant. In this decision, the Administrative Law Judge (ALJ) finds that Provider did not meet its burden of showing that the surgery is reasonable and necessary medical care and should be preauthorized. […]
453-05-0118-m2
DECISION AND ORDER ___ (Claimant) challenges the decision by an Independent Review Organization (IRO) denying her request for a Medial Branch Block (MBB). Texas Mutual Insurance Company (Carrier) denied the request as medically unnecessary, and the IRO upheld that decision. The Administrative Law Judge (ALJ) agrees with the IRO and concludes preauthorization for the MBB […]