453-05-3725-m5
DECISION AND ORDER Kenneth Berliner, M.D., (Petitioner) 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 upheld Texas A&M System’s (Respondent) denial of reimbursement for services provided a workers’ compensation claimant (Claimant). Respondent claimed that the services […]
453-05-2059-m5
DECISION AND ORDER This is a dispute over reimbursement for medical services performed for a repetitive stress injury to Claimant’s right shoulder. The amount in controversy is $1,026.00. The Administrative Law Judge (ALJ) concludes the services were medically necessary and orders reimbursement. I. FACTUAL AND PROCEDURAL HISTORY Claimant reported a work-related injury to her right […]
453-05-4467-m5
DECISION AND ORDER Liberty Mutual Insurance Company (“Petitioner”) challenged, in part, 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 Petitioner wrongly denied reimbursement for physical therapy and related services that Kris Wilson, […]
453-05-4904-m5
DECISION AND ORDER EMCASCO Insurance Company (EMCASCO) requested a hearing to contest an independent review organization (IRO) determination, issued on behalf of the Texas Workers’ Compensation Commission (Commission),[1] that certain services provided to an injured worker (Claimant) by San Antonio Pain Relief Center (Center) from February 23, 2004, through April 19, 2004, were medically necessary […]
453-05-3407-m5
DECISION AND ORDER This case concerns the proper level of reimbursement for the rental and subsequent purchase of an RS4i neuromuscular stimulator, a piece of durable medical equipment (DME). The Administrative Law Judge (ALJ) concludes reimbursement should be at the amounts billed by the Respondent, RS Medical. I. FACTUAL AND PROCEDURAL HISTORY Workers’ compensation claimant […]
453-05-4512-m5
DECISION AND ORDER The Neuromuscular Institute of Texas (NIT) appealed an Independent Review Organization’s (IRO’s) determination upholding a decision by Liberty Mutual Insurance Company (Carrier) denying NIT reimbursement, on the basis of medical necessity, for certain physical medicine treatments provided to Claimant __ (Claimant). The Administrative Law Judge (ALJ) finds that NIT failed to meet […]
453-05-0944-m5
DECISION AND ORDER San Antonio Accident Injury Care (Provider) challenges an Independent Review Organization (IRO) decision concluding that chiropractic services provided to an injured worker (Claimant) were not medically necessary. Based on the evidence presented at hearing, the Administrative Law Judge (ALJ) concludes the disputed services were not medically. Consequently, Provider is not entitled to […]
453-04-4686-m5
DECISION AND ORDER I. STATEMENT OF CASE Texas Mutual Insurance Company (Carrier) disputes three decisions of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission[1] in disputes regarding medical necessity for therapeutic exercises, procedures, gait training, and unusual travel fees provided by Work Ready Rehab (Provider) to __ (Claimant). The IRO […]
453-05-3207-m5
DECISION AND ORDER I. STATEMENT OF CASE Texas Mutual Insurance Company (Carrier) disputes three decisions of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission[1] in disputes regarding medical necessity for therapeutic exercises, procedures, gait training, and unusual travel fees provided by Work Ready Rehab (Provider) to __(Claimant). The IRO in […]
453-05-4066-m5
DECISION AND ORDER I. INTRODUCTION This case presents a challenge by Waco Ortho Rehab (Provider) to portions of a decision by the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (Commission)[1] based in part on a determination by an independent review organization (IRO) regarding the medical necessity for specified chiropractic treatments. The IRO […]