453-04-1538-m2
DECISION AND ORDER Healthview (Provider), on behalf of Markesha Beal (Claimant), challenged the decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission upholding Pacific Indemnity Company’s (Carrier) denial of preauthorization for a 20-day course of work hardening. Both Carrier and the MRD concluded that work hardening was not medically necessary to […]
453-04-2253-m2
DECISION AND ORDER I. DISCUSSION John Sazy, M.D., (Petitioner) requested a hearing following an adverse determination by the Texas Workers’ Compensation Commission (Commission) acting through the Texas Medical Foundation, an Independent Review Organization (IRO), denying the preauthorization request of Petitioner to perform a lumbar myelogram and post-myelogram CT scan on T.R.B. (Claimant).[1] This decision grants […]
453-04-1953-m2
DECISION AND ORDER American Home Assurance Co., (Carrier) appealed the decision of an Independent Review Organization (IRO) authorizing 20 sessions of work hardening for Claimant J. M. The work hardening was to be performed at the facilities of Omni Physical Therapy (Provider). The Administrative Law Judge (ALJ) finds that Carrier met its burden of showing […]
453-04-2296-m2
DECISION AND ORDER Ace USA/ESIS (Carrier) appealed the decision of the Independent Review Organization (IRO) approving the preauthorization request of injured worker M.T. (Claimant) for total knee replacement surgery. After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that Carrier has shown by preponderance of the evidence that the requested total knee replacement […]
453-04-0816-m2
DECISION AND ORDER C. C. (Claimant) challenged the decision of K-Mart Corporation (Carrier), denying preauthorization for a lumbar discogram with CT scan. In this decision, the Administrative Law Judge (ALJ) finds that Claimant did not meet its burden of showing that the requested procedure is reasonable and necessary medical care and should be preauthorized. Therefore, […]
453-04-2254-m2
DECISION AND ORDER Service Lloyds Insurance Company (Carrier) appealed the decision of the Independent Review Organization (IRO) approving the preauthorization request of HealthPartners Group, Inc. (Provider) for 30 sessions of chronic pain management for M.T., an injured worker. After considering the evidence presented, the Administrative Law Judge (ALJ) concludes that Carrier has shown by preponderance […]
453-03-3765-m2
DECISION AND ORDER Neuromuscular Institute of Texas, P.A., (Provider) appealed the decision of Ziroc, an independent review organization certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (TWCC) Medical Review Division tracking number ___, denying preauthorization of ten biofeedback sessions for a workers’ compensation claimant (Claimant). American Home Assurance Company (Carrier) denied […]
453-04-1211-m2
DECISION AND ORDER American Home Assurance Company (AHAC or Carrier) appealed the decision by an Independent Review Organization (IRO) to grant preauthorization for Claimant to receive an EMG of the upper extremities. AHAC disputes the IRO’s conclusion that these services are medically necessary. This decision agrees with the IRO and finds that the requested procedure […]
453-03-4230-m2
DECISION AND ORDER I. DISCUSSION RS Medical (Petitioner) appealed the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through MAXIMUS, an Independent Review Organization (IRO), denying the preauthorization request of Petitioner for the purchase an interferential and muscle stimulator for indefinite use by ___ (Claimant).[1] This decision grants the relief sought by […]
453-03-4356-m2
DECISION AND ORDER I. DISCUSSION RS Medical (Petitioner) appealed the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through MAXIMUS, an Independent Review Organization (IRO), denying the preauthorization request of Petitioner for the purchase an interferential and muscle stimulator for indefinite use by ___ (Claimant).[1] This decision denies the relief sought by […]