453-04-6622-m5
DECISION AND ORDER This is a dispute over reimbursement for services performed for an injury suffered by Claimant while in the course and scope of her employment. The Administrative Law Judge (ALJ) concludes that the therapeutic services should be reimbursed, as Texas Mutual Insurance Company, (Carrier and Petitioner) failed to state rationales on its EOBs […]
453-05-0947-m5
DECISION AND ORDER VONO (Petitioner) challenged the findings and decision of the Texas Workers’ Compensation Commission’s designee, an independent review organization (IRO), which found the prescription medications that Petitioner provided a workers’ compensation claimant (Claimant) from May 23, 2003, through July 25, 2003, were not medically necessary. The IRO’s decision upheld a denial of reimbursement […]
453-05-3061-m5
DECISION AND ORDER Rehab 2112 appealed the decision of the Texas Workers= Compensation Commission’s (Commission=s) Medical Review Division (MRD), which found, based on a review by an independent review organization (IRO), that work hardening services provided to Claimant ___ were not medically necessary. The MRD decision denied reimbursement, except for work hardening services provided on […]
453-05-1199-m5
DECISION AND ORDER I. INTRODUCTION Johann Van Beest, D.C. (Provider) disputes a decision of an independent review organization (IRO) on behalf of the Texas Workers= Compensation Commission (TWCC) regarding medical services for __(Claimant). The IRO could not find that the disputed services were reasonably medically necessary due to the Claimant’s compensable injury, and based on […]
453-05-0621-m5
DECISION AND ORDER This is a dispute over reimbursement for 17 sessions of work hardening services. The Administrative Law Judge (ALJ) concludes the work hardening program was not medically necessary for the Claimant and therefore denies reimbursement. I. DISCUSSION The Claimant is a 31-year-old male who allegedly twisted his lower back and contused his left […]
453-05-0938-m5
DECISION AND ORDER I. SUMMARY Eric A. Vanderwerff, D.C., (Provider) appealed the decision of Texas Medical Foundation, an independent review organization certified by the Texas Department of Insurance, in Texas Workers= Compensation Commission (TWCC) Medical Review Division tracking number M5-04-3208-01, denying reimbursement for medical services provided to the Claimant. This decision orders that Indemnity Insurance […]
453-05-3038-m5
DECISION AND ORDER Cotton D. Merritt, D.C., (Provider) challenges an independent review organization (IRO) decision denying reimbursement from Continental Insurance Company (Carrier) for therapeutic exercises, range-of-motion measurements, and office visits provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes the disputed services were not shown to be medically necessary for the treatment […]
453-04-7666-m5
DECISION AND ORDER Rehab 2112 seeks review of a decision of the Texas Workers’ Compensation Commission’s (Commission’s) Medical Review Division (MRD), which was based on a review by an independent review organization (IRO). The decision denied reimbursement for certain work hardening services provided to Claimant ___ The Administrative Law Judge (ALJ) finds that half of […]
453-04-7153-m5
DECISION AND ORDER Highpoint Pharmacy (Petitioner) appealed the findings and decision of the Texas Workers’ Compensation Commission’s designee, an independent review organization (IRO), which found that carisoprodol prescriptions that Petitioner provided a workers’ compensation claimant (Claimant) were not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by the Liberty Mutual Insurance Company […]
453-05-3037-m5
DECISION AND ORDER Cotton D. Merritt, D.C., (Provider) has challenged a 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 services provided to an injured claimant. The IRO concluded that some, but not all, of the services were medically […]