453-05-4508-m5
DECISION AND ORDER American Casualty Insurance Company of Reading, Pennsylvania, Carrier, and Waco Ortho Rehab, Provider, both requested hearings to contest Independent Review Organization (IRO) and Texas Workers’ Compensation Commission (Commission) medical review division (MRD) decisions concerning Carrier’s denial of payment for some of the services provided to an injured worker, Claimant, from ___, through […]
453-05-5249-m5
DECISION AND ORDER Eric A VanderWerff, D.C. (Dr. VanderWerff) appeals a decision by the Texas Workers’ Compensation Commission’s (TWCC)[1] Medical Review Division (MRD) that denied reimbursement for chiropractic services provided to a workers’ compensation claimant (Claimant) between March 15 and July 21, 2004. Wausau Underwriters Insurance Company (Carrier) denied reimbursement based on lack of medical […]
453-05-3360-m5
DECISION AND ORDER Carl M. Naehritz III, D.C. (Provider) contested the decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (the Commission)[1] ordering partial reimbursement for treatment provided to Claimant, leaving $3,725.07[2] in dispute for diagnostic radiology, neurology and neuromuscular procedures, physical medicine and rehabilitation, special services and reports, office and […]
453-05-7744-m5
DECISION AND ORDER Pain and Recovery Clinic (Provider) appealed the decision of an Independent Review Organization (IRO) upholding the denial of reimbursement for physical therapy services administered to claimant ___(Claimant) from April 1, 2004 to June 11, 2004. In this decision the Administrative Law Judge (ALJ) finds that Provider failed to meet its burden of […]
453-05-6799-m5
DECISION AND ORDER I. INTRODUCTION This case presents a challenge by Clem C. Martin, D.C. (Provider) to a decision of an independent review organization (IRO) on behalf of the Texas Department of Insurance, Division of Workers’Compensation[1], in a dispute regarding medical necessity for chiropractic treatment. The IRO found that the insurer, Lumbermen’s Mutual Insurance Company […]
453-05-7321-m5
DECISION AND ORDER Texas Mutual Insurance Company, Petitioner, requested a hearing to contest an Independent Review Organization (IRO) decision that certain services provided by Abilene Healthcare and Injury Clinic, Respondent, to an injured worker, Claimant, were medically necessary and to contest a decision by the Texas Workers’ Compensation Commission Medical Review Division, MRD,[1] that certain […]
453-05-3675-m5
DECISION AND ORDER Petitioner Neuromuscular Institute of Texas (Provider) disagrees with the decision of an independent review organization (IRO) issued on behalf of the Texas Workers’ Compensation Commission (TWCC)/Medical Review Division (MRD) finding that the medical services provided Claimant by Provider between May 13 and July 31, 2003, were not medically necessary.[1] Liberty Mutual Fire […]
453-05-4823-m5
DECISION AND ORDER Highpoint Pharmacy (Provider) challenges the findings and decision of the Texas Workers’ Compensation Commission’s[1] designee, an independent review organization (IRO), which found that prescriptions that Provider provided a workers’ compensation claimant (Claimant) were not medically necessary healthcare. The IRO’s decision upheld a denial of reimbursement by the State Office of Risk Management […]
453-05-9160-m5
DECISION AND ORDER Crowne Chiropractic Clinic, Petitioner, requested a hearing to contest an Independent Review Organization (IRO) decision that certain services it provided to an injured worker, Claimant, were not medically necessary. The Respondent, American Home Assurance Company, had denied the claim on that basis.[1] This decision concludes that Petitioner should not recover because it […]
453-05-1230-m5
DECISION AND ORDER This is a dispute over reimbursement for services performed for an injury suffered by Claimant while in the course and scope of his employment. The Administrative Law Judge (ALJ) concludes that the work hardening services should be not be reimbursed, since the services provided by Respondent, Syzygy Associates, L.P., were not medically […]