453-04-7286-m2
DECISION AND ORDER I. DISCUSSION ___(Claimant),[1] an injured worker, requested a hearing to contest an Independent Review Organization (IRO) decision that an epidural steroid injection (ESI) prescribed by his doctor should not be preauthorized because it is medically unnecessary. The Administrative Law Judge (ALJ) concludes the ESI is medically necessary and should be provided. A […]
453-04-6341-m2
DECISION AND ORDER American Home Assurance Company (Carrier) is challenging the decision of the Texas Workers’ Compensation Commission’s (Commission=s) designee, an independent review organization (IRO), to grant preauthorization for ___(Claimant) to receive thirty sessions of a Chronic pain management program at the request of Jasmin Erlichman, M.D. (Provider). The Administrative Law Judge (ALJ) agrees with […]
453-04-7147-m2
DECISION AND ORDER The issue in this case is whether a repeat magnetic resonance imaging (MRI) of the Claimant’s lumbar spine should be preauthorized. American Home Assurance Company (Petitioner) appeals the decision of the Texas Workers’ Compensation Commission’s (Commission) designee, an independent review organization (IRO), which granted preauthorization for the repeat MRI. This decision finds […]
453-04-5887-m2
DECISION AND ORDER I. DISCUSSION Travelers Indemnity Company (Petitioner) appealed the Findings and Decision of the Texas Workers Compensation Commission (Commission) acting through Envoy Medical Systems, L.P., an Independent Review Organization (IRO). The IRO disagreed with the Petitioner’s decision to deny preauthorization of the proposed purchase of an RS-4i. The RS-4i is a medical device […]
453-04-6425-m2
DECISION AND ORDER Claimant _____, through her doctor, sought pre-authorization for a cervical discogram with CT scan. American Home Insurance Company (Carrier) determined that the procedure was unnecessary and denied the request for pre-authorization. A reviewer with an Independent Review Organization (IRO) agreed with Carrier. The Administrative Law Judge concludes that the requested procedure is […]
453-04-7285-m2
DECISION AND ORDER I. DISCUSSION American Home Assurance Company (Petitioner) filed a request for a hearing following issuance of the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through Texas Medical Foundation, an Independent Review Organization (IRO). The IRO disagreed with the Petitioner’s decision to deny preauthorization of the proposed MRI of […]
453-04-5977-m2
DECISION AND ORDER After an Independent Review Organization (IRO) denied preauthorization for a chronic pain management program, Behavioral Healthcare Associates (Petitioner) appealed. This decision finds that Petitioner did not prove that the chronic pain management (CPM) program is medically necessary healthcare for Claimant. I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There were no contested issues of […]
453-04-6352-m2
DECISION AND ORDER Texas Mutual Insurance Company (TMI or Carrier) has appealed the decision by an Independent Review Organization (IRO) to grant preauthorization for Claimant ___ to receive 40 sessions of chronic pain management services. TMI disputes the IRO’s conclusion that these services are medically necessary. This decision agrees with TMI and finds that the […]
453-04-6592-m2
DECISION AND ORDER This case is an appeal by Marvin L. Faulkner, D.O., (“Petitioner”) from action by the Medical Review Division (“MRD”) of the Texas Workers’ Compensation Commission (“Commission”) in a preauthorization dispute. The MRD found that Petitioner’s request for preauthorization of medical services should be dismissed on the basis of Petitioner’s failure to comply […]
453-04-5888-m2
DECISION AND ORDER After an Independent Review Organization (IRO) granted preauthorization for an elbow ulnar nerve revision/release, American Home Assurance Company (Carrier) appealed. This decision finds that the Carrier failed to sustain its burden of proving that the requested procedure is not medically necessary and preauthorizes the treatment. I. PROCEDURAL HISTORY AND NOTICE On June […]