453-03-4250-m5
DECISION AND ORDER Main Rehab and Diagnostic (Petitioner) sought reimbursement from American Casualty Company of Reading, Pa. (Carrier) for physical therapy and office visits from July 1, 2002, through October 7, 2002, provided to ___ (Claimant). Carrier contended that the services were not medically reasonable or necessary. An Independent Review Organization (IRO) agreed with Carrier […]
453-04-0662-m5
DECISION AND ORDER First Wellness Center appealed an independent review organization (IRO) determination denying its claim against the City of Houston (City) for care it provided to treat an injury suffered by a City employee.[1] The City provided workers’ compensation coverage for its workers through a self-insurance program. First Wellness did not appear at the […]
453-04-0821-m5
DECISION AND ORDER Humpal Physical Therapy (Petitioner) appealed the findings and decision of the Texas Workers= Compensation Commission’s designee, an independent review organization (IRO), which found that physical therapy Petitioner provided a workers= compensation claimant (Claimant) was not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by Facility Insurance Company (Respondent). This […]
453-04-0823-m5
DECISION AND ORDER I. INTRODUCTION Sheriff Ilo, D.C. (Provider) disagrees with a Texas Workers’ Compensation Commission (TWCC) Medical Review Division (MRD) decision, based on an independent review organization (IRO) review, concerning medical services for R.O. (Claimant). The IRO and MRD agreed with American Protection Insurance, Co. (Carrier) that certain services that the Provider furnished the […]
453-03-2744-m5
DECISION AND ORDER I. SUMMARY OxyMed, Inc. (Petitioner) sought reimbursement for certain durable medical equipment (DME) it provided to Claimant who suffered a work-related injury. Royal Indemnity Company (the Carrier) denied payment stating the equipment was not medically necessary and had not been preauthorized. Petitioner sought review of the Carrier’s denial. Pursuant to Petitioner’s request […]
453-04-0678-m5
DECISION AND ORDER I. STATEMENT OF CASE East Texas Chiropractic (ETC) challenges the decision of the State Office of Risk Management (SORM) to deny reimbursement for a lumbar MRI provided to an injured worker (Claimant) sixteen days after her injury. A hearing at the State Office of Administrative Hearings convened and closed December 2, 2003, […]
453-03-3355-m5
DECISION AND ORDER ___ (Petitioner) appealed the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through Maximus, an Independent Review Organization (IRO), denying Petitioner reimbursement for certain chiropractic services. This decision grants part of the relief sought by Petitioner. I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There were no contested issues regarding notice […]
453-04-0626-m5
DECISION AND ORDER Liberty Mutual Fire Insurance Company (Carrier) has appealed the decision of the Independent Review Organization (IRO) granting reimbursement for physical therapy treatments provided to injured worker M.S. (Claimant). After considering the evidence and arguments of the parties, the Administrative Law Judge (ALJ) concludes that Carrier has failed to show by a preponderance […]
453-03-4252-m5
DECISION AND ORDER ___ (Claimant) appealed the decision of an Independent Review Organization (IRO) upholding the denial of reimbursement for certain procedures performed and prescription drugs purchased from November 1, 2002, through January 24, 2003. In this decision, the Administrative Law Judge (ALJ) finds that Claimant should be partially reimbursed for two medical procedures and […]
453-03-0931-m5
DECISION AND ORDER I. INTRODUCTION Mockingbird Workskills (Petitioner or Provider) seeks reimbursement from Legion Insurance Company (Carrier) for $3,008.00 in disputed medical services associated with seven dates of service for a work hardening program provided to workers’ compensation claimant ___ (Claimant), between April 24, 2001, and May 18, 2001. Carrier denied payment on the basis […]