453-04-1646-m5
DECISION AND ORDER Thomas S. Solby, D.C. (Provider) appealed the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission) declining to order reimbursement of $1,000 for hot/cold pack treatments (CPT Code 97010), mechanical traction (CPT Code 97012), electric stimulation (CPT Code 97014), and office visits with manipulation (CPT Code […]
453-03-3859-m5
DECISION AND ORDER This is a dispute over reimbursement for chiropractic services and diagnostic tests performed for an injury suffered by Claimant while lifting heavy equipment. The Administrative Law Judge (ALJ) concludes the services were not medically necessary and denies reimbursement. I. FACTUAL AND PROCEDURAL HISTORY Claimant reported a work-related injury to his low back […]
453-04-1162-m5
DECISION AND ORDER Petitioner, Liberty Mutual Fire Insurance Company (Carrier), appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) ordering reimbursement to Kelly Alana, D.C., (Dr. Alana/Provider) for medical services provided to _____, Claimant. Carrier disputes the IRO’s conclusion that these services are medically necessary. The […]
453-03-3875-m5
DECISION AND ORDER St. Joseph Regional Health Center (Petitioner) appealed the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through Ziroc, an Independent Review Organization (IRO), finding physical therapy treatments were not medically necessary for the treatment of injured worker ___ (Claimant). After considering the evidence and arguments of the parties, the […]
453-04-0674-m5
DECISION AND ORDER This is a dispute over reimbursement for chiropractic services performed for a repetitive stress injury to Claimant’s right wrist. The Administrative Law Judge (ALJ) concludes the services were not medically necessary and denies reimbursement. I. FACTUAL AND PROCEDURAL HISTORY Claimant reported a work-related injury to her right wrist on ________. She was […]
453-04-1167-m5
DECISION AND ORDER This case is an appeal by the Joseph F. Wilson, D.C. (“Petitioner”), 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, Texas Mutual Insurance Company (“Respondent”), properly denied […]
453-04-0016-m5
DECISION AND ORDER This case involves the appeal by Medical Associates (Petitioner) from the decision of an Independent Review Organization (IRO) that found various passive treatments and therapies given the injured worker, _______ (Claimant), prior to his arthroscopic knee surgery were not medically necessary. The services had a MAR value of $2,883. The decision agrees […]
453-04-2687-m5
DECISION AND ORDER I. SUMMARY John C. Torres, D.C., (Provider) appealed the decision of Independent Review Incorporated, an independent review organization certified by the Texas Department of Insurance, in Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) tracking number M5-04-0125-01, denying reimbursement for medical services provided to the Claimant. This decision orders that Employers […]
453-04-0146-m5
DECISION AND ORDER Claimant _______ injured his back on _______, while lifting a heavy object. Dana Santelli, D.C., provided various services to _______ from April 5, 2002, through February 14, 2003, including office visits with manipulations, massage, and myofascial release. Citing a lack of medical necessity, Texas Mutual Insurance Company (TMIC) denied reimbursement for these […]
453-03-3876-m5
DECISION AND ORDER This is a dispute over reimbursement for occupational therapy services performed for a repetitive stress disorder to Claimant’s left arm and neck. The Administrative Law Judge (ALJ) concludes the services were not medically necessary and denies reimbursement. I. FACTUAL AND PROCEDURAL HISTORY Claimant reported a work-related repetitive stress injury to her left […]