453-05-1639-m5
DECISION AND ORDER The issue involved is whether Insurance Company of the State of Pennsylvania (Carrier) correctly denied payment of $1,045 billed by Laurence Neil Smith, D.C. (Provider) for chiropractic treatments provided to an injured worker (Claimant) between February 3 and March 3, 2003. Carrier challenged the medical necessity of the treatment, but Provider contended […]
453-05-3771-m5
DECISION AND ORDER Highpoint Pharmacy (Provider) appealed the findings and decision of the Texas Workers’ Compensation Commission’s designee,[1] an independent review organization (IRO), which found that prescriptions that Provider provided a workers’ compensation claimant (Claimant) were not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by the Protective Insurance Company (Carrier). This […]
453-05-2838-m5
DECISION AND ORDER The provider, SCD Back and Joint Clinic (SCD) sought reimbursement for six months of various medical and therapeutic services provided to claimant ___in ___ for a back injury. Citing a lack of medical necessity, the carrier, Texas A&M University (A&M), declined to pay for the disputed services. An Independent Review Organization (IRO) […]
453-05-2774-m5
DECISION AND ORDER Buena Vista Workskills (Provider) challenges the decision of an Independent Review Organization (IRO) upholding the decision of Liberty Mutual Insurance Company (Carrier) denying reimbursement for a work hardening program provided to an injured worker. Because Provider failed to prove the program was medically necessary, reimbursement should be denied. Administrative Law Judge (ALJ) […]
453-05-2807-m5
DECISION AND ORDER I. Introduction Both Liberty Mutul Fire Insurance Company (Carrier) and Capitol Work Rehab & Therapy (Work Rehab or Provider)[1] challenged a decision of the Texas Workers= Compensation Commission’s (TWCC or Commission) Medical Review Division (MRD)[2] regarding certain medical services that Work Rehab provided ___(Claimant). MRD, relying on a determination of an independent […]
453-05-2762-m5
DECISION AND ORDER This case is an appeal by Rehab 2112 (Provider) from a decision of an independent review organization (IRO) on behalf of the Texas Workers= Compensation Commission[1] in a dispute regarding medical necessity for work hardening treatments and a functional capacity evaluation (FCE). The IRO found that the Fidelity & Guaranty Insurance Company […]
453-05-2835-m5
DECISION AND ORDER I. SUMMARY Liberty 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 M5-05-0084-01, granting partial reimbursement for medical services provided to the Claimant. This decision orders that the Carrier is required […]
453-05-3772-m5
DECISION AND ORDER I. SUMMARY Texas Mutual Insurance Company (Carrier) appealed the decision of Medical Review of Texas, an independent review organization (IRO), in Texas Workers= Compensation Commission (TWCC)[1] Medical Review Division (MRD) tracking number M5-04-3880-01, granting reimbursement for medical services provided to the Claimant. This decision orders that the Carrier is required to reimburse […]
453-05-0939-m5
DECISION AND ORDER Gabriel Gutierrez, D.C. (Petitioner) appealed the decision of the Texas Workers’ Compensation Commission (TWCC),[1] designee, an Independent Review Organization (IRO), which denied his request for reimbursement for a work hardening program (WHP) provided from May 28, 2003, through July 9, 2003, as not medically necessary. The Administrative Law Judge (ALJ) concludes that […]
453-05-3726-m5
DECISION AND ORDER I. DISCUSSION Medpro Clinics (Petitioner) requested a hearing to contest the January 5, 2005 Findings and Decision of the Texas Workers’ Compensation Commission (Commission). The Commission relied upon a December 23, 2004 decision of Speciality Independent Review Organization, Inc., an Independent Review Organization (IRO), and denied reimbursement for services provided by Petitioner […]