453-05-7485-m5
DECISION AND ORDER I. INTRODUCTION Texas Mutual Insurance Company (Carrier) disputes a decision of the former Texas Workers’ Compensation Commission (TWCC), Medical Review Division (MRD) regarding medical services for___ (Claimant). MRD agreed with WOL+MED/Edward Wolski (Provider) and ordered Carrier to pay Provider an additional $225.65 for current procedural terminology (CPT) code 64999, interferential current therapy […]
453-05-2886-m5
DECISION AND ORDER I. INTRODUCTION San Antonio Accident Injury Care (Provider) and Texas Mutual Insurance Company (Carrier) each dispute portions of a decision by the former Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) regarding medical services that the Provider furnished to ___(Claimant). An independent review organization (IRO) agreed with the Carrier that services […]
453-05-6381-m5
DECISION AND ORDER I. SUMMARY Orthopaedic Institute Pharmacy, the Provider, appealed the decision of Maximus, an independent review organization (IRO), in Texas Workers’ Compensation Commission (TWCC)[1] Medical Review Division (MRD) tracking number M5-05-1771-01, denying reimbursement for prescription medication provided to the Claimant. This decision orders that Continental Casualty Company, the Carrier, is not required to […]
453-05-8918-m5
DECISION AND ORDER I. SUMMARY Texas Mutual Insurance Company (Carrier) and Southeast Health Services (Provider) appealed the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC)[1], which ruled on fee issues, and adopted the decision of Texas Medical Foundation, an independent review organization. This decision orders that the Carrier is […]
453-05-4267-m5
DECISION AND ORDER Liberty Mutual Fire Insurance Company (Carrier) challenges the decision of the Independent Review Organization (IRO)[1] granting reimbursement for physical therapy, office visits, and related treatment provided to injured worker ___(Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Carrier has shown that the services […]
453-05-9073-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier ) appealed the decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD)[1] to adopt the decision of its designee, an Independent Review Organization (IRO), which granted reimbursement for services provided a workers’ compensation claimant (Claimant) by the Pain and Recovery Clinic of North Houston[2] […]
453-05-1993-m5
DECISION AND ORDER Petitioner, East Texas Chiropractic (Provider), challenged the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission[1] (TWCC) denying reimbursement from American Casualty Company of Reading, PA (Carrier) for medical services provided to an injured worker (Claimant). Provider disputes the conclusion of the Independent Review Organization (IRO) […]
453-05-3060-m5
DECISION AND ORDER American Safety Casualty Insurance (Carrier) and healthcare provider Eric A. VanderWerff, D.C., appealed the findings and decision of the Texas Workers’ Compensation Commission’s (Commission’s)[1] designee, an independent review organization (IRO) and the Commission’s Medical Review Division (MRD). This decision finds partially in favor of the Carrier and partially in favor of Dr. […]
453-05-0125-m5
DECISION AND ORDER Highpoint Pharmacy (Petitioner) appealed the findings and decision of the Texas Department of Insurance, Division of Worker’s Compensation’s (Department’s) designee, an independent review organization (IRO), which found that prescriptions that Petitioner provided a workers’ compensation claimant (Claimant) were not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by the […]
453-05-3059-m5
DECISION AND ORDER The provider, Suhail Al‑Sahli, sought reimbursement for approximately one month of work hardening provided to claimant___ in the spring of 2004. Citing a lack of medical necessity, the carrier, ACE Insurance Company (ACE), declined to pay for the disputed services. An Independent Review Organization (IRO) determined that the disputed services were unnecessary. […]