453-04-8918-m5
DECISION AND ORDER This case is a dispute over whether Southwestern Bell Telephone Company (Respondent) should reimburse Highpoint Pharmacy (Petitioner) for the cost of filling prescriptions for two ointments. The medical necessity of the ointments is the only issue to be resolved. The Administrative Law Judge (ALJ) concludes that Provider did not meet its burden […]
453-05-2760-m5
DECISION AND ORDER I. INTRODUCTION American Casualty Company (Carrier) disputes the decision of the Texas Workers’ Compensation Commission (TWCC or Commission)/Medical Review Division (MRD)[1] directing Carrier to pay Real Health Care (Provider) for certain claims originally denied because Carrier found that the treatments were unrelated to the compensable injury (denial code “R”). The disputed services […]
453-04-7620-m5
DECISION AND ORDER Texas Mutual Insurance Company (TMI) appeals a decision by the Texas Workers’ Compensation Commission’s (TWCC)[1] Medical Review Division (MRD) regarding the medical necessity for a portion of work-hardening services provided to a workers’ compensation claimant (Claimant) during April 2003 by Edward Wolski, M.D. TMI denied payment for the services, and MRD referred […]
453-05-2972-m5
DECISION AND ORDER I. DISCUSSION Cody B. Doyle, D.C., (Petitioner) requested a hearing to contest the November 4, 2004 Findings and Decision of the Texas Workers’ Compensation Commission (Commission). The Commission relied upon an October 5, 2004 decision of Medical Review Institute of America, an Independent Review Organization (IRO), and denied reimbursement for services provided […]
453-05-3660-m5
DECISION AND ORDER REHAB 2112 (Provider) appealed the decision of the Texas Workers’ Compensation Commission’s (Commission’s)[1] Medical Review Division (MRD), which found, based on a review by an independent review organization (IRO), that some of the work hardening services provided by Rehab 2112 to Claimant, ___, were not medically necessary. The Administrative Law Judge (ALJ) […]
453-05-3065-m5
DECISION AND ORDER Petitioner, Waco Ortho Rehab (Provider), appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission[1] (TWCC) denying reimbursement from Liberty Insurance Corporation (Carrier) for medical services provided to an injured worker (Claimant). Provider disputes the conclusion of the Independent Review Organization (IRO) that these services […]
453-05-3383-m5
DECISION AND ORDER Liberty Mutual Fire Insurance (Carrier) challenges a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission[1] in a dispute regarding medical necessity for office visits and chiropractic treatment given by Jimmy Todd Ruland, D.C. (Provider). The IRO found that Carrier improperly denied reimbursement for the conservative […]
453-05-2932-m5
DECISION AND ORDER Southeast Health Services, Inc. (Southeast) 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 it provided to an injured worker (Claimant) from September 12, 2003, through February 13, 2004, were not medically necessary; and a Commission medical […]
453-05-3361-m5
DECISION AND ORDER I. DISCUSSION Cotton D. Merritt, D.C. (Provider) disputes a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (TWCC)/Medical Review Division (MRD) regarding Texas Mutual Insurance Company’s (Carrier’s) denial of payment for various services provided Claimant from April 30, 2003, through July 18, 2003, including office […]
453-05-3363-m5
DECISION AND ORDER James Tanner, D.C. (Provider) challenges an Independent Review Organization (IRO) decision concluding that chiropractic services he provided to an injured worker (Claimant) were not medically necessary. Based on the evidence presented at hearing, the Administrative Law Judge (ALJ) also concludes the disputed services were not shown to be medically necessary for the […]