• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Print this page
You are here: Home . wc . idr . apdmedical


Back to Previous Page

Appeals Panel Decision Manual - Medical Benefits Issues

Acronym List

Medical Benefits Issues

Compliance with choice of doctor requirements. (M01)
Reimbursement for medical travel expenses. (M02)
Timely dispute of treating doctor. (M03)

Other medical benefits issues. (M00)

Compliance With Choice Of Doctor Requirements (M01)

Initial Choice Of Treating Doctor. An IW is entitled to an initial choice of treating doctor from the list of Division-approved doctors. Section 408.022(a); Section 126.9(a). The first doctor providing health care to an IW will be considered the IW's initial choice of treating doctor. Section 126.9(c). Section 408.022(e) and Section 126.9(c) list instances that do not constitute an initial choice of treating doctor. Section 408.022(f), provides that "This section does not apply to requirements regarding the selection of a doctor under a workers' compensation health care network established under Chapter 1305, Insurance Code, except as provided by that chapter."

Insufficient Evidence Of Initial Selection. The IW went to her HMO primary care physician (Dr. F); however, Dr. F did not treat the IW but rather referred her to her prior workers' compensation physician (Dr. B) to treat her current workers' compensation injury. Dr. B provided no treatment to the IW because prior to her appointment Dr. B noticed he had acted as the designated doctor in one of the IW's previous workers' compensation claims. The employer's risk management office referred the IW to Dr. M, who became the IW's treating doctor. The HO determined among other things that the IC was discharged from liability for payment to the IW's treating doctor prior to August 28, 1998, due to her failure to comply with Section 126.9. The AP reversed and rendered, stating that the facts were insufficient to support the implied finding that it was necessary for the IW to seek approval to change her treating doctor, as Dr. M was her initial selection. The AP found insufficient evidence to establish that Dr. F rendered health care as defined in Section 401.011(19), and therefore determined Dr. F was not her initial treating doctor. APD 990121.

Sufficient Evidence Of Initial Selection. Dr. P provided the IW with emergency care by performing surgery to reattach that portion of the IW's finger that had been amputated in the compensable injury. Dr. P only provided the IW with follow-up care after his surgery. Thereafter, the IW began treating with Dr. M. The hearing officer determined that Dr. P was not the IW's initial choice of treating doctor and that the IW began treating with Dr. M, the IW's initial choice of a treating doctor. The AP held that the evidence sufficiently supported the HO's determination that the claimant's initial choice of treating doctor for workers' compensation purposes was Dr. M. APD 031638.

IW's Change Of Treating Doctor. An IW who is dissatisfied with his or her initial choice of treating doctor may notify the Division in writing, or by telephone when medical necessity exists for immediate change, and request from the Division authorization to select an alternate treating doctor. Section 408.022(b); APD 950663. Section 408.022(b) and Section 126.9(d) detail what an IW must do to request a change of treating doctor. Upon receipt of the IW's request, the Division issues an order within 10 days either approving or denying the request. Section 126.9(f). Section 408.022(c) and Section 126.9(e) list some of the criteria the Division uses to make its determination. With good cause, an IW or IC may dispute the Division's order within 10 days after receiving the order and request a BRC. After a BRC, an unresolved dispute may proceed to a CCH and then to an appeal to the AP. Section 126.9(g).

The AP has recently addressed the standard to be used in reviewing a change of treating doctors in APD 022245 and APD 020022. In APD 022245, the issue was framed as whether the IW was "entitled to change treating doctors". The AP cited to APD 020022, and held that the issue is broader than whether the particular Division employee who approved the change abused his or her discretion. Evidence may be presented and considered in addition to what was stated on the Employee's Request to Change Treating Doctors (DWC-53). The hearing officer must evaluate whether a change should be allowed in accordance with the standards set forth in Section 408.022 and Rule 126.9.

IW Entitled To Change Treating Doctor. The HO determined that the IW was entitled to a change of treating doctor because the treating doctor refused to continue the IW's medical care due to the IC's refusal to pay the medical bills. The AP affirmed the HO's determination. APD 012317.

IW Not Entitled To Change Treating Doctor. The IW requested a change of treating doctor on the basis that she was not satisfied with her current doctor's treatment. The HO determined the IW was not entitled to a change of treating doctor because the medical evidence presented was insufficient to establish that the initial treating doctor's treatment was inappropriate or that a conflict existed between the IW and the initial treating doctor to the extent that the doctor/patient relationship was jeopardized or impaired or that the IW was entitled to a change of treating doctor based on any other criteria in Section 408.022 or Section 126.9. The AP affirmed the HO's determination. APD 001422.

IW's Failure To Comply With Change Of Doctor Requirements. Rule 126.9(h) provides that the Division may, after holding a benefit CCH, relieve the carrier of liability for health care furnished by a doctor or health care provider at the doctor's direction if: (1) the doctor chosen by the employee is not on the (Division-approved doctor) list at the time the medical treatments or services are rendered; or (2) the employee failed to comply with Division rules regarding a change of treating doctor. IC is relieved of liability for the cost of health care under Section 408.024.

IC Not Relieved Of Liability For Health Care Benefits. The IW sustained a crush fracture and laceration to his hand while working for the employer. The IW reported the injury to the employer's secretary, and asked her which doctor he should see. The secretary recommended a doctor that was close to the employer's premises because the IW was bleeding profusely and because she believed the injury was an emergency requiring immediate medical attention. The IW went to the recommended physician. The IW later returned for a follow-up visit, but because he had to wait four hours to see the doctor, the IW went to a second doctor. The second doctor recommended a hand surgeon to the IW. The IW did not submit an Employee's Request to Change Treating Doctor (DWC-53) for the second doctor he consulted, but did submit a DWC-53 for the hand surgeon he consulted. The HO determined that the IC was relieved of liability for health care provided by the second doctor pursuant to Section 126.9(h)(2) because the IW failed to comply with the rules regarding a change of treating doctor when he changed to the second doctor. The AP reversed, finding that the employer's recommended doctor provided emergency care and as such did not constitute an initial choice under Section 126.9(c)(3). The AP found that the second doctor was the IW's initial choice of treating doctor, and that the IW properly complied with the requirements to change treating doctor. The AP therefore found that the IC was not relieved of liability under Section 126.9(h)(2). APD 020867.

Reimbursement For Medical Travel Expenses (M02)

An IW may request reimbursement from an IC for travel expenses incurred for medical treatment for the IW's compensable injury when:

  1. medical treatment for the compensable injury is not reasonably available within 30 miles from where the IW lives; and
  2. the distance traveled to secure medical treatment is greater than 30 miles one-way. Section 134.110(a).

The IW must submit a Request for Travel Reimbursement (DWC Form-48) to the IC within one year of the date the expenses were incurred. Section 134.110(b). The request must include documentation or evidence (such as itemized receipts) of the amount of the expense. Section 134.110(c). Reimbursement is based on the travel rate for state employees on the date of travel. Section 134.110(d). See Section 134.110(d) for the methods used in measuring travel mileage. When an IW's travel expenses reasonably include food and lodging, the IC reimburses actual expenses not to exceed the current rate for state employees on the date the expense is incurred. Section 134.110(d). Reimbursement for travel expenses, including food and lodging, is only available to the IW. APD 060440-s (please note that although this APD was decided under prior Section 134.6, concerning dates of travel prior to May 2, 2006, which is the effective date of Section 134.110, the new section on travel reimbursement also does not provide for reimbursement of travel expenses for anyone other than the IW).

Timely Dispute Of Treating Doctor (M03)

With good cause, an IW or an IC may dispute the order regarding a change to an alternate treating doctor within 10 days after receiving the order. The dispute will be handled through the dispute resolution process described in Chapters 140 - 143 of the Division's rules. Section 126.9(g).

Although filing a DWC-45 to request a BRC is the preferred way to dispute a Division order regarding a change of treating doctors, that is not the only way such a dispute may be made. The AP has held that an IC disputing a change of treating doctor in a TWCC-21 (now PLN-11) filed within the 10-day period to timely contest the approval or denial of a request to change treating doctors is an adequate dispute. APD 000620.

Party Did Not Waive Right To Dispute Division Order Regarding Change In Treating Doctor. The IC filed a TWCC-21 (now PLN-11) disputing the change of treating doctors on March 27, 2001, and filed a TWCC-45 (now DWC-45) that only disputed entitlement to TIBs on April 2, 2001. The HO determined that the IC did not waive the right to dispute the change of treating doctors pursuant to Section 126.9(g). As the IC filed its dispute within 10 days after receiving the order approving the IW's request to change treating doctors, the AP affirmed the HO's determination. APD 011513.

Party Waived Right To Dispute Division Order Regarding Change In Treating Doctor. The order approving the IW's change in treating doctors was placed in the IC representative's box on September 5, 2002. The IC did not dispute the order until September 20, 2002, more than 10 days after the IC received the order. The HO determined that the IC waived its right to dispute the order. The AP affirmed the HO's determination. APD 030567.



For more information, contact:

Contact Information and Other Helpful Links