453-05-9316-m2
DECISION AND ORDER ___ (Claimant), through his doctor, sought pre-authorization for a thoracic discogram with CT scan. The East Texas Educational Insurance Association (Carrier) determined that the procedure was unnecessary and denied the request for pre-authorization. A reviewer with an Independent Review Organization (IRO) agreed with the Carrier, and as a result, Claimant is now […]
453-05-3057-m2
DECISION AND ORDER Mr. ___ (Petitioner), an injured claimant, has challenged the decision of an Independent Review Organization (IRO) acting on behalf of the Texas Workers’ Compensation Commission (Commission)[1] in a dispute regarding preauthorization for a left knee arthroscopy with meniscectomy (medial or lateral).[2] The IRO found that the proposed procedure was not medically necessary […]
453-05-7316-m2
DECISION AND ORDER Kenneth G. Berliner, M.D. (Provider), challenged the decision of Ace USA/ESIS (Carrier), denying preauthorization for a lumbar discogram with CT scan. In this decision, the Administrative Law Judge (ALJ) finds that Provider did not meet his burden of showing that the requested procedure is reasonable and necessary medical care and should be […]
453-05-9434-m2
DECISION AND ORDER I. INTRODUCTION ___ (Claimant) challenges a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD),[1] regarding Claimant’s request for preauthorization for eight additional sessions of chronic pain management. The IRO found that Carrier’s denial of Claimant’s request should be upheld. The […]
453-05-6734-m2
DECISION AND ORDER __ the Claimant, sought preauthorization for a cervical spine discogram. Liberty Mutual Fire Insurance (Carrier) denied the request for preauthorization, and an Independent Review Organization (IRO) determined the requested treatment was not medically necessary. The Administrative Law Judge (ALJ) agrees with the IRO and concludes that preauthorization for a discogram should be […]
453-05-7677-m2
DECISION AND ORDER Zurich American Insurance Company (Carrier) requested a hearing on a decision by an Independent Review Organization (IRO) granting preauthorization to Syzygy Associates, L.P. (Provider) for six sessions each of individual psychotherapy and biofeedback for injured worker __ (Claimant). This decision concludes that Carrier has shown that the psychological therapy sessionswere not medically […]
453-05-9318-m2
DECISION AND ORDER Claimant __ sustained a compensable injury to her back on___. An Independent Review Organization, acting on behalf of the Texas Workers’ Compensation Commission (Commission), denied preauthorization for a chronic pain management program for Claimant. Tommy Overman, Ed.D, is challenging that decision. This decision finds that the request for chronic pain management program […]
453-05-7330-m2
DECISION AND ORDER __(Claimant) requested a hearing on the decision of the Independent Review Organization (IRO)[1] denying preauthorization for bilateral lumbar facet medial nerve block injections. After considering the evidence and arguments presented, the Administrative Law Judge (ALJ) concludes that Claimant has shown by a preponderance of the evidence that the requested treatment is medically […]
453-05-9869-m2
DECISION AND ORDER American Home Assurance Company (Carrier) requested a hearing on the decision of the Independent Review Organization (IRO)[1] granting preauthorization for 20 sessions of work hardening to be provided by South Texas Healthcare Center (Provider) to ___(Claimant). After considering the evidence and arguments presented, the Administrative Law Judge (ALJ) concludes that Carrier has […]
453-05-7320-m2
DECISION AND ORDER Continental Casualty Co. (Carrier) challenges the decision of an Independent Review Organization (IRO) granting preauthorization of a cervical CT scan at C1-T1 and a lumbar CT scan at L1-S1for workers= compensation insurance claimant, __(Claimant). The IRO found that the requested procedures were medically necessary. This decision finds that, based on the evidence […]