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Medical Fees
March 25, 2020
ORDER GRANTING PLEA IN JURISDICTION The Texas Workers’ Compensation Commission filed a Plea in Jurisdiction seeking Summary Dispositions in the above cases. The cases were consolidated into one hearing with five other cases involving the same parties and similar facts, but the Plea in Jurisdiction involves only the two cases numbered above. The entire group of seven cases was referred to mediation but no settlement was reached and the hearing on the plea and the...

Retrospective Medical Necessity
March 22, 2020
DECISION AND ORDER Injured worker________[1] (Claimant) has appealed a decision of the Medical Review Division (MRD) of the Texas Workers= Compensation Commission (the Commission) denying reimbursement of $323.00 she paid for immunotherapy and intradermal skin tests provided to her from June 15, 2001, through September 7, 2001, by her treating physician. The MRD=s denial of payment was based on its review of a decision made by an independent review organization (IRO) physician who found the...

Medical Fees
March 13, 2020
DECISION AND ORDER I. Background and Procedural History The Clinic for Special Surgery (the Clinic or Petitioner) is an ambulatory surgical center (ASC). Patient ____ was treated at the Clinic with an epidural steroid injection. The Clinic submitted a bill for $2,840.48 to Hartford Fire Insurance (Hartford) for services rendered to___ Hartford paid the Clinic $2,236.00. The Clinic requested dispute resolution. The Medical Review Division (MRD) of the Texas Worker’s Compensation Commission (Commission) declined to...

Medical Fees
March 8, 2020
DECISION AND ORDER Zurich American Insurance Co. (Carrier) appeals the approval of full reimbursement to Texas Health Fort Worth (Provider) for services provided to an injured worker because the Provider released the injured worker to a rehabilitation facility rather than home. The Administrative Law Judge (ALJ) concludes that under the Inpatient Hospital Fee Guideline (Guideline), the Provider was not entitled to additional reimbursement and is entitled to only $30,914.83. I.I. JURISDICTION, NOTICE, AND PROCEDURAL HISTORY...

Medical Fees
March 8, 2020
DECISION AND ORDER Parker City Pharmacy (Provider) seeks reimbursement of $3,269.55 from Continental Casualty Insurance Company (Carrier) for prescription medications it dispensed to an injured worker (Claimant) on December 27, 2004, and January 24, 2005. The Administrative Law Judge (ALJ) finds the Provider is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no issues of notice or jurisdiction. Therefore, these matters are addressed in the Findings of Fact and Conclusions of Law...

Medical Fees
March 8, 2020
DECISION AND ORDER ____ (Claimant) challenges the denial of reimbursement by ______ (______) for services provided to an injured worker. The Administrative Law Judge (ALJ) concludes that Claimant did not timely file a request for medical fee dispute resolution. Consequently, Claimant is not entitled to reimbursement. I.JURISDICTION, NOTICE, AND PROCEDURAL HISTORY There are no disputed issues of notice or jurisdiction. Therefore, those matters are set out in the Findings of Fact and Conclusions of Law...

Medical Fees
March 8, 2020
DECISION AND ORDER Paul J. Harph (Provider) appealed the findings and decisions of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) in the above causes. The findings and decisions denied reimbursement for surgical procedures performed by Dr. Harph. The issues presented relate to the applicability of modifiers -65 and -22, under the Commission’s medical fee guidelines, to the surgical procedure used. In this decision, the Administrative Law Judge (ALJ) find that Provider is...

Medical Fees
March 8, 2020
DECISION AND ORDER Vista Hospital of Dallas (Vista) requested a hearing to contest a decision by the Medical Review Division (MRD) of the Texas Department of Insurance, Division of Workers’ Compensation (Division), denying additional reimbursement to Vista for surgery and a hospital stay provided to Claimant, an injured worker.[1] American Home Assurance Company (Carrier) had paid Vista $24,190.60. Vista sought an additional $88,643.11. Carrier denied payment based on its assertions that Vista inappropriately calculated its...

Retrospective Medical Necessity
March 8, 2020
DECISION AND ORDER I. DISCUSSION Ernie V. Fields, D.C. (Petitioner) requested a hearing to contest the Findings and Decision of the Texas Workers’Compensation Commission (Commission) denying Petitioner reimbursement from South Plains School Worker’s Compensation Program (Respondent) for work conditioning. Petitioner also disputed the decision of the independent review organization (IRO), Envoy Medical Systems, L.P., that the physical performance tests[1] performed April 20, 2004, and June 24, 2004, were not medically necessary The Administrative Law Judge...

Pre-Authorization
March 7, 2020
DECISION AND ORDER This is an appeal from a decision by an Independent Review Organization (IRO) affirming Pacific Employers Insurance Company’s (Carrier) denial of preauthorization for a discogram with post CT scan as not medically necessary. The decision affirms the IRO because the Petitioner failed to appear at hearing, and the evidence supports the finding that the procedure is not medically necessary. I. PROCEDURAL HISTORY, NOTICE & JURISDICTION There are no contested issues of notice...

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