453-05-4325-m5
DECISION AND ORDER Highpoint Pharmacy (Petitioner) seeks reimbursement of $2,286.75 for prescriptions provided to two workers’ compensation claimants. The Texas Workers’ Compensation Commission (Commission),[1] acting through an independent review organization (IRO), denied reimbursement for the medications provided to each claimant on the basis that they were not medically necessary. This decision also denies the requested […]
453-05-5859-m5
DECISION AND ORDER I. DISCUSSION Gabriel Gutierrez, D.C. (Petitioner) requested a hearing following an April 5, 2005 Decision of the Texas Workers’ Compensation Commission (Commission),[1] which upheld a decision of Medical Review of Texas, an Independent Review Organization (IRO), and denied reimbursement for a diagnostic interview and work hardening program provided by Petitioner to injured […]
453-05-5445-m5
DECISION AND ORDER Petitioner, William W. Summers, D.C. (Provider), challenged the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission[1] (TWCC) denying reimbursement from Highlands Insurance Corporation (Carrier) for medical services provided to an injured worker (Claimant). Provider disputes the conclusion of the Independent Review Organization (IRO) that these […]
453-05-6596-m5
DECISION AND ORDER I. FINDINGS OF FACT On____, the Claimant and Respondent,___, suffered an injury to her neck that was a compensable injury under the Texas Workers’ Compensation Act (“the Act”), TEX. LABOR CODE ANN. ch. 401 et seq. As part of her treatment for persistent pain associated with the injury, Respondent received a prescription […]
453-05-4248-m5
DECISION AND ORDER An Independent Review Organization (IRO) determined that various chiropractic services rendered by Health and Medical Practice (Provider) to Claimant for her compensable injury were medically necessary. The Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission)[1] ordered the University of Texas System (Carrier) to reimburse Provider $6,279.57 for the disputed […]
453-05-5313-m5
DECISION AND ORDER I. INTRODUCTION This case presents a challenge by Trace Alexander, D.C. (Provider) to a decision of an independent review organization (IRO) on behalf of the Texas Department of Insurance, Division of Worker’s Compensation, in a dispute regarding medical necessity for chiropractic treatment. The IRO found that the insurer, Texas Mutual Insurance Company […]
453-05-2095-m5
DECISION AND ORDER I. Introduction Continental Casualty Company (Carrier) challenges a decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD),[1] regarding medical services that Pain & Recovery Clinic of North Houston (Provider or Pain & Recovery Clinic) provided ___(Claimant) from October 20, 2003, through December 19, 2003. An independent review organization (IRO) […]
453-05-4410-m5
DECISION AND ORDER Fidelity & Guaranty Insurance Company (Carrier) and Integra Specialty Group (Integra) both requested a hearing to contest a determination by the Texas Workers’ Compensation Commission (Commission) Medical Review Division (MRD)[1] that the Carrier should pay for some, but not all, of the services Integra provided to an injured worker from November 4, […]
453-05-4513-m5
DECISION AND ORDER I. DISCUSSION Texas Mutual Insurance Company (Petitioner) requested a hearing to contest the January 28, 2005, Findings and Decision of the Texas Workers’ Compensation Commission (Commission).[1] The Commission relied upon an October 27, 2004 decision of the Medical Review Institute of America, an Independent Review Organization (IRO), and ordered reimbursement for services […]
453-05-2079-m5
DECISION AND ORDER I. DISCUSSION On October 30, 2004, Texas Mutual Insurance Company (TMIC) requested a hearing in this docket. TMIC had received on October 8, 2004, the Findings and Decision of the Medical Review Division of the Texas Workers’ Compensation Commission (Commission). The Commission’s Findings and Decision relied upon a June 29, 2004, decision […]