453-05-1117-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenges and Independent Review Organization (IRO) decision concluding chiropractic services provided by Cotton Merritt, D.C. (Provider) to an injured worker were medically necessary. The Administrative Law Judge (ALJ) concludes the disputed services were not medically necessary for the treatment of Claimant’s injury. Consequently, Provider is not entitled […]
453-05-1132-m5
DECISION AND ORDER I. INTRODUCTION Carl M. Naehritz III, D.C. (Provider) appealed the Texas Workers’ Compensation Commission’s Medical Review Division’s (MRD’s) decision issued on August 19, 2004. MRD generally accepted the Independent Review Organization’s recommendation but calculated the amount to be reimbursed as $384 for eight office visits. MRD denied reimbursement for other disputed services […]
453-05-0524-m5
DECISION AND ORDER This case is a dispute over whether American Home Assurance Company (Carrier) should reimburse VONO (Provider) for prescription medications Carisoprodol (SOMA) and Temazepam (Restoril). The medical necessity of the medications is the only issue to be resolved. The Administrative Law Judge (ALJ) concludes that Provider did not meet its burden of proving […]
453-05-2975-m5
DECISION AND ORDER Liberty Mutual Fire Insurance Company (the ACarrier) appeals the decision of the Independent Review Organization (IRO) requiring reimbursement of $2,917 for therapeutic exercises, office visits, manual traction, kinetic activities, and aquatic therapy/exercises provided to a workers compensation claimant from March 17, 2003 through June 11, 2003. The Administrative Law Judge (ALJ) concludes […]
453-05-3188-m5
DECISION AND ORDER Neuromuscular Institute of Texas B P.A. (Neuromuscular Institute) contested an independent review organization (IRO) decision, issued on behalf of the Texas Workers’ Compensation Commission (Commission), concluding that certain physical therapy sessions, post-injection therapy, a March 2004 office visit, and a pre-authorized work conditioning session were medically unnecessary. At the hearing, Wausau Underwriters […]
453-04-0988-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) in which Liberty Mutual Fire Insurance (Carrier) denied payment for various services provided Claimant including four units (15 minutes per unit) of one-on-one physical […]
453-05-0622-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) that it pay Angela Upchurch, D.C. (Provider) for chiropractic treatment and related services provided to an injured worker (Claimant). Carrier disputes the IRO’s conclusion that these services were medically […]
453-05-0210-m5
DECISION AND ORDER This proceeding concerns appeals from two decisions by Independent Review Organizations (IROs) that were joined for hearing at the State Office of Administrative Hearings (SOAH). At issue in both cases is the medical necessity of two prescription medications, Mobisyl cream and Naproxen, that Petitioner, Claimant ___, purchased. Respondent, Ace Insurance Company of […]
453-05-0522-m5
DECISION AND ORDER This proceeding concerns appeals from two decisions by Independent Review Organizations (IROs) that were joined for hearing at the State Office of Administrative Hearings (SOAH). At issue in both cases is the medical necessity of two prescription medications, Mobisyl cream and Naproxen, that Petitioner, Claimant ___, purchased. Respondent, Ace Insurance Company of […]
453-05-3083-m5
DECISION AND ORDER ___, a workers= compensation claimant, seeks reimbursement of $510 for co-payments associated with her purchase of seven medications (Tizanidine, Effexor, Arthrotec, Duragesic, Bextra, Neurontin, and Carisoprodol) during the period from February 14, 2003, through December 3, 2003. The Texas Workers= Compensation Commission (Commission), acting through an independent review organization (IRO), denied reimbursement […]