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Advisory 96-07

PREAUTHORIZATION OF HOSPITALIZATION FOR SPINAL SURGERY

According to Commission Rule 133.206, if the insurance carrier is liable for the costs of spinal surgery related to a compensable injury, then liability will include the services of the surgeons and ancillary providers during the hospitalization and the hospital services. As a result, hospitalization for spinal surgery for which the insurance carrier is liable under Rule 133.206 does not require preauthorization pursuant to Rule 134.600. The carrier is liable only for the reasonable and necessary costs associated with the hospitalization (including the length of stay) and the medical services and procedures that are the basis for the hospitalization. Carriers are encouraged to audit spinal surgery bills to ensure that only reasonable and necessary costs are billed and reimbursed.

The Commission may issue a Notice of Violation (NOV) against any carrier for violating section 415.002(19) of the Texas Labor Code for unreasonably disputing the necessity of health care should the carrier deny payment for hospitalization for spinal surgery because it was not preauthorized.

Signed April 26, 1996

Todd K. Brown, Executive Director



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