453-04-1357-m2
DECISION AND ORDER ___ (Petitioner) is the Claimant and Petitioner in this case. He is appealing an Independent Review Organization’s (IRO) determination that United States Fire Insurance Company (Carrier) correctly denied his preauthorization request for additional diagnostic testing ordered by his orthopedic surgeon in preparation for a spinal fusion surgery. The Administrative Law Judge (ALJ) […]
453-04-2221-m2
DECISION AND ORDER Travelers Indemnity Company (Carrier) appealed the decision by an Independent Review Organization (IRO) to grant Ihsan F. Shanti, M.D. (Provider) preauthorization to provide a spinal cord stimulator trial. TIC disputes the IRO’s conclusion that these services are medically necessary. This decision finds that the requested procedure is medically reasonable and necessary and […]
453-04-2252-m2
DECISION AND ORDER Ihsan Shanti, M.D., appealed an independent review organization (IRO) determination that a chronic pain management program he requested was medically unnecessary to treat an injured worker (the Claimant). Service Lloyds Insurance Company (Service Lloyds) had denied the claim. This decision concludes that the Claimant’s condition satisfied the requirements for a chronic pain […]
453-04-2704-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 Employers General Insurance Company (Carrier) of pre-authorization for bilateral L1-S1 lumbar facet nerve joint blocks.The Administrative Law Judge (ALJ) finds that pre-authorization should be ordered because the requested […]
453-04-0075-m2
DECISION AND ORDER RS Medical (Provider) challenged the decision of Continental Casualty Company (Carrier) denying preauthorization for an inferential muscle stimulator, model RS4I (RS4I), for an injured worker, (Claimant). In this decision, the Administrative Law Judge (ALJ) finds that Provider did not meet its burden of showing that the requested equipment is reasonable and necessary […]
453-04-2764-m2
DECISION AND ORDER ___ (Claimant), an injured worker, appealed an independent review organization (IRO) determination that his request for preauthorization of a magnetic resonance imaging (MRI) with contrast was medically unnecessary. Old Republic Insurance Company (Old Republic) had denied the claim. This decision concludes that the MRI is medically necessary because it would help resolve […]
453-05-2033-m2
DECISION AND ORDER After an Independent Review Organization (IRO) granted preauthorization for a chronic pain management (CPM) program, Hartford Insurance Company (Hartford) appealed. This decision finds that Hartford proved that the CPM program is not medically necessary healthcare for the Claimant ___ I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There were no contested issues of jurisdiction […]
453-04-0390-m2
DECISION AND ORDER American Home Assurance Company, (AHAC), petitioner, seeks an order from the State Office of Administrative Hearings (SOAH) to reverse the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC)ordering preauthoriation for certain medical services. Following a hearing and consideration of the evidence, the Administrative Law Judge (ALJ) […]
453-04-1212-m2
DECISION AND ORDER After an Independent Review Organization (IRO) granted preauthorization for ten biofeedback and counseling sessions, the City of San Antonio (Carrier) appealed. The Administrative Law Judge (ALJ) concludes Carrier failed to meet its burden of proving the treatment program was not medically necessary and preauthorizes the treatment. I. DISCUSSION Background On March 13, […]
453-04-2220-m2
DECISION AND ORDER Texas Mutual Insurance Company, (TMIC), petitioner, seeks an order from the State Office of Administrative Hearings (SOAH) to reverse the decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC) on the issue of whether there should have been preauthorized for a chronic pain management program. Following a […]