453-05-4268-m5
DECISION AND ORDER The State Office of Risk Management (SORM) challenges the decision of the Independent Review Organization (IRO) recommending reimbursement for chiropractic services from December 16, 2003 through January 16, 2004 (Disputed Services) provided by Robynn M. Poortvliet, D.C. to an injured worker (Claimant). After considering the evidence and arguments of the parties, the […]
453-05-4411-m5
DECISION AND ORDER Claimant__. (Claimant) has challenged a decision by an Independent Review Organization (IRO) upholding a decision by Sentry Insurance (Carrier) denying her reimbursement, on the basis of medical necessity, for out-of-pocket expenses she incurred for prescription medications purchased between October 22, 2003, and August 25, 2004 (the disputed medications). The Administrative Law Judge […]
453-05-4456-m5
DECISION AND ORDER I. DISCUSSION Texas Mutual Insurance Company (TMIC) timely requested a hearing to contest the January 20, 2005 Findings and Decision of the Texas Workers’ Compensation Commission (Commission). The Commission relied upon a November 16, 2004 decision of Specialty Independent Review Organization, Inc., an Independent Review Organization (IRO). The Commission granted reimbursement for […]
453-05-4470-m5
DECISION AND ORDER I. SUMMARY Texas Mutual Insurance Company (Carrier) appealed the decision of Speciality Independent Review Organization, Inc., an independent review organization (IRO), in Texas Workers’ Compensation Commission (TWCC)[1] Medical Review Division (MRD) tracking number M5-04-4006-01, granting partial reimbursement for medical services provided to the Claimant. This decision orders that the Carrier is required […]
453-05-0877-m5
DECISION AND ORDER Galaxy Health Care Centers, P.A. (Galaxy), a health care provider, requested a hearing on a decision of the Texas Workers’ Compensation Commission’s (the Commission’s) Medical Review Division and an Independent Review Organization (IRO). That decision denied reimbursement for services provided from August 6, 2003, through September 26, 2003, and from October 24, […]
453-05-0969-m5
DECISION AND ORDER American Home Assurance Company (AHAC) challenges the decision of the Texas Workers’ Compensation Commission (Commission),[1] acting through an independent review organization (IRO), in a dispute regarding the medical necessity of physical medicine treatments provided to Claimant__. The Administrative Law Judge (ALJ) finds in favor of AHAC. I. PROCEDURAL HISTORY, NOTICE, AND JURISDICTION […]
453-05-4086-m5
DECISION AND ORDER Cotton D. Merritt, D.C., (“Petitioner”) challenged the decision of an independent review organization (“IRO”) on behalf of the Texas Workers’ Compensation Commission (“Commission”)[1] in a dispute regarding the medical necessity of chiropractic therapy. The IRO found that the insurer, Texas Mutual Insurance Company (“Respondent”), properly denied reimbursement for some of the physical […]
453-05-4890-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenged the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC)[1] that it pay Jack T. Barnett, D.C. (Provider) for chiropractic treatment and related services provided to an injured worker (Claimant). Carrier disputes the conclusion of the Independent Review Organization […]
453-05-4146-m5
DECISION AND ORDER Cotton D. Merritt, D.C., (Petitioner) has challenged the decision of an Independent Review Organization (IRO) upholding a decision by Old Republic Insurance Company (Respondent) denying Petitioner reimbursement, on the basis of medical necessity, for certain electrodiagnostic testing performed on Claimant __(the disputed tests).[1] The Administrative Law Judge (ALJ) finds that Petitioner met […]
453-05-4486-m5
DECISION AND ORDER San Antonio Accident/Injury Care (Provider) has challenged a decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission)[1] in a dispute regarding the medical necessity of chiropractic services provided to an injured claimant between April 19 and July 2, 2004. The MRD’s decision was based on the findings […]