453-05-9868-m5
DECISION AND ORDER I. INTRODUCTION Albertson’s, Inc. (Petitioner/Carrier) disputes the decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission.[1] The IRO found that work hardening services provided by Rehab 2112 (Respondent/Provider) to ___(Claimant) from June 27 through August 9, 2003, were not medically necessary. However, although Carrier denied reimbursement […]
453-05-9682-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 his employment. The Administrative Law Judge (ALJ) concludes that the therapeutic services should be reimbursed, as Lumbermen’s Underwriting Alliance (Carrier and Petitioner) failed to state denial codes or rationales on […]
453-05-7479-m5
DECISION AND ORDER Petitioner Cornerstone Clinic, Inc. (Provider) disagrees with the decision of an independent review organization (IRO) issued on behalf of the Texas Workers’ Compensation Commission (Commission)/Medical Review Division (MRD)[1] finding that the medical services provided Claimant from June 14, 2004, to December 17, 2004, were not medically necessary. The amount in dispute is […]
453-05-4087-m5
DECISION AND ORDER Marsha Miller, D.C. (Provider) appealed the decision of the Independent Review Organization (IRO) on behalf of the Texas Workers’ Compensation Commission (TWCC) denying reimbursement for services provided to an injured worker (Claimant). The IRO did not find that the disputed services were medically necessary due to Claimant’s compensable injury, and based on […]
453-05-4252-m5
DECISION AND ORDER I. STATEMENT OF CASE Laurence N. Smith, D.C., (Respondent/Provider) disputes the decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission[1] regarding medical necessity for physical medicine procedures provided to __(Claimant). Texas Mutual Insurance Company (Respondent/Carrier) denied these services. The IRO found that only two office visits, […]
453-05-9362-m5
DECISION AND ORDER The provider, Nacogdoches Rehabilitation Group, sought reimbursement for approximately one month of services provided to claimant ___in the summer of 2004. The carrier, Deep East Texas Self-Insurance Fund, declined to pay for the disputed services on the basis that the services were not medically necessary. An Independent Review Organization (IRO) determined that […]
453-05-9331-m5
DECISION AND ORDER In this case, Petitioner Alief Independent School District (AISD) seeks relief from an order of the Texas Workers’ Compensation Commission’s[1] Medical Review Division, requiring it to reimburse Respondent Horizon Health (Horizon) 5148.65 for medical services. The Administrative Law Judge (ALJ) concludes AISD should pay Horizon Health the full amount in dispute. I. […]
453-05-9363-m5
DECISION AND ORDER Claimant ___disputes a decision of an independent review organization on behalf of the Medical Review Division of the Texas Workers’ Compensation Commission[1] that the medications that Claimant purchased were not medically necessary. This decision finds that Claimant is due reimbursement for Vicodin purchased on August 2, 2004, but not for the purchase […]
453-05-4327-m5
DECISION AND ORDER Liberty Mutual Insurance Company, as the insurance carrier for Southwestern Bell Telephone Company (Carrier), challenges the decision of the Independent Review Organization (IRO)[1] granting reimbursement for physical therapy, office visits, and related treatment provided to injured worker __ (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge […]
453-05-6540-m5
DECISION AND ORDER Neuromuscular Institute of Texas (Provider) challenges the decision of the Independent Review Organization (IRO)[1] denying reimbursement for physical therapy, office visits, and related treatment provided to injured worker __ (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Provider has not shown that the […]