453-04-2259-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenges an Independent Review Organization (IRO) decision granting reimbursement to Health & Medical Practice Associates (Provider) for physical therapy services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes the disputed services were not medically necessary. Consequently, reimbursement is denied. I. Jurisdiction and Notice […]
453-03-4642-m5
DECISION AND ORDER First Rio Valley Medical, P. A. (Provider), challenged the decision of the Medical Review Division of the Texas Workers’ Compensation Commission (MRD/Commission) denying reimbursement to it for sessions of physical medicine that Provider administered to ___ (Claimant) from October 10, 2001, through June 14, 2002, and for the review of a medical […]
453-04-6624-m5
DECISION AND ORDER The provider in this case, Mega Rehab (Petitioner) billed $741.82 for a surgical tray – a set of supplies – used in administering a cervical epidural steroidal injection on June 13, 2003. The carrier, Liberty Mutual Insurance Corporation (Respondent), paid $100.00 for the tray. There is no applicable maximum allowable reimbursement (MAR), […]
453-04-4289-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) appealed the decision of an Independent Review Organization (IRO) upholding the reimbursement for therapeutic exercises and other procedures administered to Claimant between August 27, 2002, and October 30, 2002. In this decision, the Administrative Law Judge (ALJ) finds that Carrier met its burden of showing that the […]
453-04-5235-m5
DECISION AND ORDER I. DISCUSSION Texas Mutual Insurance Company (Petitioner) requested a hearing to contest the Findings and Decision of an independent review organization (IRO), assigned by the Texas Workers Compensation Commission (Commission), allowing Excel Therapy Associates (Respondent) reimbursement for joint mobilization from May 8, 2003, through June 12, 2003, and therapeutic exercises from April […]
453-04-5795-m5-etal
DECISION AND ORDER This is a dispute over reimbursement for therapeutic and work hardening services performed for an injury suffered by Claimant while in the course and scope of his employment. The Administrative Law Judge (ALJ) concludes some of the therapeutic services should be reimbursed, but no work hardening is entitled to reimbursement. I. FACTUAL […]
453-04-0017-m5
DECISION AND ORDER This is a dispute over reimbursement for a lumbar magnetic resonance imaging test (MRI). The Administrative Law Judge (ALJ) orders reimbursement. I. HISTORY OF THE CASE The workers’ compensation claimant, ___ (the Claimant) injured her lower back and left leg on ___, when she stepped into a drainage hole and fell during […]
453-04-4593-m5
DECISION AND ORDER This case is an appeal by Chad Blackwell, D.C. (Petitioner or Provider), from 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 treatment. The IRO found that the insurer, The University of Texas System (Respondent or […]
453-04-7044-m5
DECISION AND ORDER This is a consolidated matter regarding treatment rendered to Claimant ___ between July 8, 2003, and March 24, 2004. Trinity Universal Insurance Company (Carrier) appealed the decision of an Independent Review Organization (IRO) that found most of the treatment consisting of physical therapy, office visits, and work hardening rendered by Central Dallas […]
453-04-7095-m5
DECISION AND ORDER This is a dispute over reimbursement of $3,456.00 for work hardening services performed by Respondent Ergonomic Rehabilitation of Houston (Ergo Rehab). The Administrative Law Judge (ALJ) orders reimbursement. I. HISTORY OF THE CASE The workers’ compensation claimant, ___ (the Claimant), sustained an injury to her left wrist on ___. She underwent surgical […]