453-04-4197-m5
DECISION AND ORDER Liberty Mutual Insurance Company (Carrier) requested a hearing on a decision by the Medical Review Division (MRD) of the Texas Workers= Compensation Commission ordering reimbursement of $489 to Network of Physicians Management (Provider) for services provided to Claimant. The Carrier urged in this proceeding that Explanation of Benefits (EOB) forms pertaining to […]
453-04-3686-m5
DECISION AND ORDER I. SUMMARY Galaxy Health Care Centers (Provider) appealed the decision of Envoy Medical Systems, LLC, an independent review organization (IRO) certified by the Texas Department of Insurance, in Texas Workers= Compensation Commission (TWCC) Medical Review Division (MRD) tracking number M5-03-1681-01, denying reimbursement for medical services provided to the Claimant. Additionally, the Provider […]
453-04-3450-m5
DECISION AND ORDER Medway Health, Inc. (Medway), requested a hearing to contest a decision by an Independent Review Organization (IRO) that denied reimbursement of $10,240.00 for four weeks of work-hardening services provided to Claimant ___during March and April 2002. Medway contends the services were medically reasonable and necessary. Medway also disputes a decision by the […]
453-04-3596-m5
DECISION AND ORDER The issue involved is whether Texas Mutual Insurance Company (Carrier) correctly denied payment of $9,493 billed by Chiropractic Health Center of Grand Prairie (Provider) for treatment and services provided an injured worker (Claimant). Carrier challenged the medical necessity of the treatment, but Provider contended the services were necessary. The Administrative Law Judge […]
453-04-6582-m5
DECISION AND ORDER I. DISCUSSION First Rio Valley Medical, PA (First Rio) requested a hearing to contest an Independent Review Organization (IRO) decision that aquatic therapy, electrical stimulation, ultrasound, and an office visit provided to an injured worker (Claimant) were medically unnecessary. First Rio argued that the services were necessary because it needed to try […]
453-04-0847-m5
DECISION AND ORDER I. SUMMARY Liberty Mutual Fire Insurance Company (Carrier) asserts that the disputed services, including office visits, massage therapy, spinal manipulation, trigger point therapy, and interferential current, performed from May 31, 2002, through January 22, 2003 (approximately $3,128.00) were not medically necessary. The Independent Review Organization (IRO) found that the disputed services were […]
453-04-4455-m5
DECISION AND ORDER Insurance Company of the State of Pennsylvania (Carrier) requested a hearing on a decision by the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (Commission) ordering additional reimbursement to Texas Ortho Hospital (Provider) for a hospital stay provided to Claimant, an injured worker. The decision ordered Carrier to reimburse Provider […]
453-04-1278-m5
DECISION AND ORDER Main Rehab and Diagnostic (Main Rehab) seeks reimbursement of $1,644.00 for treatments and office visits provided a workers’ compensation claimant. The Administrative Law Judge (ALJ) orders reimbursement of the disputed amount, plus interest. I. HISTORY AND ISSUES The workers’ compensation claimant, ___(the Claimant), fractured her wrist when she slipped and fell on […]
453-04-2707-m5
DECISION AND ORDER Texas Mutual Insurance Company, (Petitioner) requested a hearing following a December 19, 2003, Decision of the Texas Workers’ Compensation Commission (Commission). The Commission, relying upon a December 9, 2003, decision of Ziroc, an Independent Review Organization (IRO), ordered reimbursement for two units per day of therapeutic exercises[1] provided by Central Dallas Rehab […]
453-04-2851-m5
DECISION AND ORDER Stephen Dudas, D.C., (Petitioner) appealed the decision of the Texas Workers= Compensation Commission’s Medical Review Division (MRD), which found that a nerve conduction velocity (NCV) test billed by Dr. Dudas to the University of Texas System (Respondent) was not reimbursable. MRD noted that the interpretation listed Roger S. Blaire, M.D., as the […]