453-04-1160-m5
DECISION AND ORDER Main Rehab and Diagnostic (Petitioner) appealed the decisions of the Texas Workers’ Compensation Commission’s (Commission) designee, an independent review organization (IRO), in MR Docket Nos. M5-03-3103-01 and M5-04-0315-01, which denied reimbursement for a work hardening (WH) program and associated functional capacity evaluations (FCEs) and office visits Petitioner provided to a workers’ compensation […]
453-04-3029-m5
DECISION AND ORDER This case is a dispute over whether reimbursement is appropriate for post-surgical therapy rendered to Claimant by Curtis Adams, D.C. (Provider), between September 11, 2002, and January 28, 2003. Provider sought reimbursement from Liberty Mutual Fire Insurance Company (Carrier) for the treatment rendered to Claimant, which Carrier denied as not medically necessary. […]
453-04-1960-m5
DECISION AND ORDER Liberty Mutual Insurance Company (Carrier) appealed a decision by Maximus, an independent review organization certified by the Texas Department of Insurance, in Texas Workers= Compensation Commission (TWCC) Medical Review Division file number M5-03-1377-01 ordering reimbursement to a provider in the amount of $5,689 for treatment and services for an injured worker (Claimant). […]
453-04-2028-m5
DECISION AND ORDER Central Dallas Rehab (Provider) challenges an Independent Review Organization (IRO) decision denying it reimbursement for chiropractic services provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes that the services provided were not appropriate for Claimant’s injury. Consequently, reimbursement is denied. I. Statement of the Case Administrative Law Judge (ALJ) […]
453-03-3690-m5
DECISION AND ORDER Texas Mutual Insurance Company (Texas Mutual) appealed an independent review organization (IRO) decision that therapeutic exercises and offices visits provided to an injured worker (Claimant) by Arthur Cornett, D.C., from February 25, 2002, through April 12, 2002, were medically necessary. As appellant, Texas Mutual had the burden of proof.[1] The Administrative Law […]
453-04-1958-m5
DECISION AND ORDER This case is an appeal by the Texas Injury Clinic (APetitioner) from a decision of an independent review organization (AIRO) on behalf of the Texas Workers= Compensation Commission (ACommission) in a dispute regarding medical necessity for chiropractic treatment. The IRO found that the insurer, Liberty Mutual Insurance Company (ARespondent), properly denied reimbursement […]
453-04-2302-m5
DECISION AND ORDER Town East Rehabilitation, (Provider) appealed the decision of an Independent Review Organization (IRO) upholding the denial of office visits, therapeutic activities, and exercises administered to ___ (Claimant) from February 3, 2003, through June 23, 2003. In this decision, the Administrative Law Judge (ALJ) finds that Provider failed to meet its burden of […]
453-04-0144-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission awarding reimbursement to Central Dallas Rehab (Provider) for sessions of physical medicine and other treatments that Provider administered to ___(Claimant) from March 21, 2002, through May 28, 2002. The MRD ordered reimbursement […]
453-03-4396-m5
DECISION AND ORDER American Casualty Company of Reading, PA. (Carrier) denied payment for services provided to a worker with cervical, thoracic, and lumbar injuries. Carrier asserted that many of the services provided were not reasonable or medically necessary. Jonathan D. Skeries., D.C., (Provider) requested medical dispute resolution. An independent review organization (IRO) concluded the services […]
453-04-1214-m5
DECISION AND ORDER I.DISCUSSION In this case, Carlos Gonzalez, D.C., the Petitioner, seeks reimbursement for chiropractic treatments and office visits provided a workers’ compensation claimant (Claimant) from August 21, 2002 through January 30, 2003. The Administrative Law Judge (ALJ) finds the Petitioner should be reimbursed for the first six weeks of the services and office […]