453-04-2781-m5
DECISION AND ORDER This case is an appeal by the Dana J. Santelli, 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, Pacific Employers Insurance Company (“Respondent”), properly denied […]
453-03-2988-m5
DECISION AND ORDER The Neuromuscular Institute of Texas, P.A. (Institute) is appealing the decision of the Texas Workers’ Compensation Commission’s (Commission’s) designee, an independent review organization (IRO), which upheld the denial of reimbursement by the Insurance Company of the State of Pennsylvania (Carrier) based on lack of medical necessity for treatment provided to Claimant ___ […]
453-03-3424-m5
DECISION AND ORDER Liberty Mutual Insurance Company (Petitioner) challenges an Independent Review Organization (IRO) decision granting reimbursement to Kelly Alana, D.C. (Respondent), for passive and active physical therapy related services provided to an injured worker from August 2001 to February 2002. The Administrative Law Judge (ALJ) concludes that because the services provided were not appropriate […]
453-04-1321-m5
DECISION AND ORDER This case is an appeal by the Neuromuscular Institute of Texas, PA (“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, ACE/ESIS, Inc. (“Respondent”), properly denied reimbursement […]
453-04-2029-m5
DECISION AND ORDER I. PROCEDURAL HISTORY El Paso Physical Therapy (Provider) seeks reimbursement from American Home Assurance Company (Carrier) for $2,732.00 in medical services associated with physical therapy services that Provider administered to worker’s compensation claimant ___ from April 15 to June 8, 2003. An Independent Review Organization (IRO) denied reimbursement for these expenses. Provider […]
453-03-4084-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenged the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission ordering reimbursement to Central Dallas Rehab (Provider) for sessions of physical medicine and also office visits with treatments that Provider administered to _____ (Claimant) from August 21, 2002, through November 11, 2002.[1] […]
453-04-1982-m5
DECISION AND ORDER This case is an appeal by Irving Imaging (“petitioner”) from a decision of an independent review organization (“IRO”) on behalf of the Texas Workers’ Compensation Commission (“commission”) in a dispute regarding the medical necessity for magnetic resonance imaging (“MRI”). The IRO found that the insurer, Texas Mutual Insurance Co. (“respondent”), properly denied […]
453-03-2742-m5
DECISION AND ORDER Central Dallas Rehab (Central) appealed independent review organization (IRO) decisions that work hardening program and physical therapy programs provided to an injured worker (Claimant) were medically unnecessary. Transcontinental Insurance Company (Transcontinental) had denied the claim. This decision concludes that Central failed to carry its burden of proving that the services were medically […]
453-03-4447-m5
DECISION AND ORDER This case is a dispute over whether reimbursement is appropriate for treatment rendered to _____ (Claimant) by Suhail S. Al-Sahli, D.C. (Provider), between June 28, 2002, and January 3, 2003. Provider sought reimbursement from University of Texas System (Carrier) in the amount of $8,269.00 for treatment rendered to Claimant, which Carrier denied. […]
453-04-0995-m5
DECISION AND ORDER The issue involved is whether Texas Mutual Insurance Company (Carrier) correctly denied payment for physical therapy billed by Azalea Orthopedic & Sports (Provider), using Current Procedural Technology (CPT) Code 97110. Carrier interprets CPT Code 97110 as requiring exclusive one-on-one patient contact. Provider contends that the Texas Workers’ Compensation Commission (the Commission) rules […]