453-03-2696-m2
DECISION AND ORDER Brian Randall, D.C. (Provider) appealed the decision of the Texas Workers’ Compensation Commission’s (Commission) designee, an independent review organization (IRO), which denied Provider’s preauthorization request to perform a revision right total knee arthroplasty with a placement filter prior to the knee replacement for a workers’ compensation claimant (Claimant).[1] _________ (Carrier) denied preauthorization […]
453-03-1936-m2
DECISION AND ORDER This case involves the appeal by an injured worker (Claimant) from the decision of an Independent Review Organization (IRO) that affirmed the denial by St. Paul Fire & Marine Insurance Company (Carrier) of preauthorization for bilateral brachial plexus decompression.[1] The decision reverses the IRO, finding the Claimant met the burden of proving […]
453-03-1527-m2
DECISION AND ORDER _________ (Claimant) has appealed the decision of an Independent Review Organization (IRO)[1] denying authorization for knee replacement surgery for him. In this decision, the Administrative Law Judge (ALJ) finds that knee replacement surgery is reasonable and necessary medical care for Claimant. Therefore, the Insurance Company of the State of Pennsylvania (Carrier) is […]
453-03-2031-m2
DECISION AND ORDER I. DISCUSSION George Frey, M.D. (Petitioner) appealed the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through MAXIMUS, an Independent Review Organization (IRO). The Commission’s Order denied Petitioner’s preauthorization request for a lumbar discogram with CT scan for his patient, ___ (Patient). The Commission determined that the thoracic and […]
453-03-1813-m2
DECISION AND ORDER Petitioner,_____,[1] appealed an Independent Review Organization (IRO) reviewer’s decision denying preauthorization for a power wheelchair. The IRO reviewer found, and the Carrier, Argonaut Southwest Insurance Company, argued that there was insufficient documentation of neurological loss to prove the wheelchair is medically necessary. Finding medically necessity, this decision grants the preauthorization request. I. […]
453-03-2694-m2
DECISION AND ORDER ___ (Petitioner) appealed the Independent Review Organization’s (IRO=s) decision denying her preauthorization for a total left knee replacement. This decision finds the requested preauthorization should be granted. I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There were no contested issues of jurisdiction or notice. Therefore, those matters are addressed in the findings of fact […]
453-03-2032-m2
DECISION AND ORDER This case involves the appeal by Behavioral Healthcare Associates (Petitioner) from the decision of an Independent Review Organization (IRO) that denied a request for preauthorization for four hours of psychological evaluation and testing. The decision disagrees with the IRO, finding the tests will produce objective data that will better enable the treating […]
453-03-2033-m2
DECISION AND ORDER ____ (Claimant), challenged the decision of the National Union Fire Insurance Company of Pittsburgh, PA (Carrier), denying preauthorization for epidural steroid injections (injections). In this decision, the Administrative Law Judge (ALJ) finds that Claimant met her burden of showing that the requested procedures are medically necessary and should have been preauthorized. Therefore, […]
453-03-1634-m2
DECISION AND ORDER ___ (Claimant), challenged the decision of the State Office of Risk Management (Carrier) denying preauthorization for a left knee arthroscopy with debridement, possible patellofemoral realignment, and possible mosaic-plasty. In this decision, the Administrative Law Judge (ALJ) finds that Claimant met her burden of showing that the requested procedures are medically necessary and […]
453-03-2380-m2
DECISION AND ORDER STAT 2000 challenges the decision of the Independent Review Organization (IRO) denying preauthorization for the purchase of a neuromuscular stimulator for injured worker ____ (Claimant).[1] After considering the evidence and arguments, the undersigned Administrative Law Judge (ALJ)[2] finds that STAT 2000 has shown, by a preponderance of the evidence, that the requested […]