453-04-0009-m2
DECISION AND ORDER _______ (Claimant) challenges the decision of an Independent Review Organization (IRO) denying her request to preauthorize one visit consisting of eight electromyographic (EMG) guided Botox injections. The Insurance Company of the State of Pennsylvania (Carrier) had denied the claim as medically unnecessary, and the IRO upheld that decision. This decision finds that […]
453-04-1201-m2
DECISION AND ORDER _______ (Petitioner) is appealing the decision of Maximus, an independent review organization (IRO) certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (Commission) Medical Review Division tracking number M2-04-0008-01 denying preauthorization for eight Botox trigger point injections to the lumbar region.[1] The IRO determined from the medical documentation submitted […]
453-04-1814-m2
DECISION AND ORDER ___ (Claimant) disputes the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission, TWCC) affirming the denial by Indiana Lumbermens Mutual Insurance Company (Carrier) of pre-authorization for a lumbar myelogram and CT scan. The Administrative Law Judge (ALJ) finds that pre-authorization should be ordered because the […]
453-03-4355-m2
DECISION AND ORDER RS Medical challenges the decision of the University of Texas System (UTS) denying preauthorization for an RS-4i interferential and muscle stimulator (RS-4i) for an injured worker, Claimant ___. Finding that RS Medical did not meet its burden of showing that the requested equipment is reasonable and necessary medical care and should be […]
453-04-1155-m2
DECISION AND ORDER ___ (Claimant) challenged the decision of Security Insurance of Hartford (Carrier), denying preauthorization for a lumbar discogram. The Administrative Law Judge (ALJ) finds that Claimant met his burden of showing that the requested procedure is reasonable and necessary medical care and should be preauthorized. Therefore, the ALJ orders Carrier to authorize the […]
453-03-2378-m2
DECISION AND ORDER I. DISCUSSION Ace Insurance Company of Texas (Petitioner) requested a hearing following an adverse determination by the Texas Workers’ Compensation Commission (Commission) acting through the Ziroc, an Independent Review Organization (IRO), approving the preauthorization request of John Sazy, M.D., to perform a lumbar discogram with CT scan on ___ (Claimant).[1] The ALJ […]
453-04-0978-m2
DECISION AND ORDER ___ (Petitioner) requested a hearing following an adverse determination by the Texas Workers’ Compensation Commission (Commission), Medical Review Division (MRD) denying the preauthorization request of Petitioner to undergo a right knee arthroscopic chondroplasty. The basis of the denial was that the MRD determined that there was no evidence the Petitioner sought or […]
453-04-2776-m2
DECISION AND ORDER East Texas Chiropractic (Provider), challenged the decision of ACE USA/ESIS (Carrier) denying preauthorization for a lumbar discogram for ___ (Claimant). In this decision, the Administrative Law Judge (ALJ) finds that Provider met its burden of showing that the requested procedure is reasonable and necessary medical care and should have been preauthorized. Therefore, […]
453-05-2073-m2
DECISION AND ORDER Claimant ___ sustained a compensable injury to her back on ___, when she fell off a ladder, causing pain from her head to her spine and radiating down both legs. After an Independent Review Organization granted preauthorization for a chronic pain management program for Claimant, Texas Mutual Insurance Company appealed and filed […]
453-04-2214-m2
DECISION AND ORDER Advantage Healthcare Systems (Provider) challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission) denying preauthorization of a six-week chronic pain management course to treat for ___ (Claimant) in connection with her shoulder and wrist injury. The MRD concluded that chronic pain management was not medically […]