453-05-3086-m5
DECISION AND ORDER I. INTRODUCTION West Belt Medical, PLLC (Provider) seeks reimbursement for certain medical services that it furnished to _____ (Claimant). The Travelers Companies (Carrier) denied reimbursement for those services by claiming that they were not medically necessary. An independent review organization (IRO) partially agreed with the Carrier and found that some of those […]
453-05-4163-m5
DECISION AND ORDER Petitioner, Texas Mutual Insurance Company (Carrier), requested a hearing following the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC), acting through Texas Medical Foundation, an Independent Review Organization (IRO), ordering reimbursement to New Help Clinics, P.A. (Provider) for medical services provided to ___ (Claimant) […]
453-05-2758-m5
DECISION AND ORDER First Rio Valley Medical, P.A. (First Rio) appeals a decision by the Texas Workers= Compensation Commission’s (TWCC) Medical Review Division (MRD) regarding the medical necessity and documentation of services provided to a workers= compensation claimant (Claimant) during November and December 2003 for an injury that occurred on ___. The University of Texas […]
453-05-3288-m5
DECISION AND ORDER Jairo Puentes, M.D., contested an independent review organization (IRO) decision, issued on behalf of the Texas Workers= Compensation Commission (Commission), concluding that a magnetic resonance imaging (MRI) performed on an injured worker (Claimant) was medically unnecessary. Texas Mutual Insurance Company (Texas Mutual) had denied payment for the MRI. The Administrative Law Judge […]
453-05-4167-m5
DECISION AND ORDER Patrick Davis, D. C. (Provider), challenged the decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (TWCC or Commission) denying reimbursement to him for a variety of rehabilitation services provided to ___ (Claimant) between October 27, 2003 and January 30, 2004 (treatment period). This is a mixed medical […]
453-04-3713-m5
DECISION AND ORDER Liberty Mutual Insurance Company (Carrier) requested a hearing on a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (Commission) in a dispute regarding medical necessity for chiropractic services, including office visits and testing. The IRO found that Carrier improperly denied reimbursement for physical therapy given […]
453-04-3736-m5
DECISION AND ORDER I. DISCUSSION In SOAH Docket No. 453-04-3736.M5, Hartford Underwriters Insurance Company (HUIC) requested a hearing following a January 30, 2004 Findings and Decision of the Texas Workers’ Compensation Commission (Commission). The Commission’s January 30, 2004 Findings and Decision (January Decision), relied upon a January 27, 2004 decision of Maximus, an Independent Review […]
453-04-1175-m5
DECISION AND ORDER ___ (Claimant) challenges the decision by an Independent Review Organization (IRO) denying his request to receive reimbursement for membership in the Corpus Christi Athletic Club. Liberty Mutual Fire Insurance Company (Carrier) denied the request as medically unnecessary and the IRO upheld that decision. The Administrative Law Judge (ALJ) agrees with the IRO […]
453-05-2035-m5
DECISION AND ORDER Mega Rehab Center (Petitioner) has challenged the decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (Commission) in a dispute regarding the medical necessity of chiropractic treatment and related services. The IRO found that the insurer, American Casualty Company (Respondent), properly denied reimbursement for services that […]
453-04-7321-m5
DECISION AND ORDER The worker’s compensation claimant (Claimant) in this case sustained a compensable injury to her left upper extremity on ___. At issue are approximately three months of therapeutic services mostly aquatic therapy and land-based therapeutic exercises provided in 2002 by the petitioner, Truman Davidson, D.C. The carrier, Texas Mutual Insurance Company (TMIC), citing […]