Disputes about medical treatment - medical necessity

Español

After your work injury, you may need medical treatment. The insurance carrier pays for your medical treatment that is necessary and related to your work injury. Sometimes there are disputes about whether certain medical treatments or services are needed (medical necessity).

Medical necessity disputes

If the insurance carrier will not approve the medical treatment your doctor thinks you need, you or your healthcare provider can ask for a review of the denial. An independent review organization (IRO) will review the insurance carrier’s denial and make a decision about whether the treatment is needed (medical necessity).

What if you don’t agree with the IRO’s decision?

If a party does not agree with the IRO decision, they can appeal it.

To appeal an IRO decision:

• Ask for a medical hearing no later than the 20th day after the date the IRO decision was sent.
• Follow the directions on the DWC Form-049, Request to Schedule a Medical Contested Case Hearing (MCCH).
• Send a copy of the request to the DWC Chief Clerk of Proceedings by:
  • Mail:
    Texas Department of Insurance, Division of Workers’ Compensation
    Hearings, Mail Code HRG
    PO Box 12050
    Austin, TX 78711-2050, or
  • Fax: 512-804-4011
• Send a copy of the request to the other parties.

Learn more about medical hearings in 28 Texas Administrative Code (TAC) Section 133.308(s).

What happens after a medical hearing is requested?

DWC will send a letter with the date of the hearing and an explanation of the parties' rights and responsibilities.

At the hearing, the ALJ listens to the evidence about whether the medical treatment is necessary (medical necessity). Witnesses answer questions under oath, and each party explains their side of the case. After the hearing, the ALJ reviews the evidence and makes a decision about the medical necessity of the treatment.

What if you don’t agree with the medical hearing decision?

If a party disagrees with the medical necessity decision, they can ask for judicial review of the decision.

To learn more about seeking judicial review of a medical necessity decision, see Texas Labor Code Section 413.0311(d) and 28 TAC Section 133.308(s)(1)(F).

Learn more about:

• Fast facts about medical dispute resolution (MDR) by an IRO.
• Rules about how to get medical treatment approved before you receive it (preauthorization).
• Rules about medical necessity disputes.
• Official Disability Guidelines.
• Information about asking for a review by an IRO.
• Medical Contested Case Hearing Decision Manual – Medical Necessity.
• Acronyms used in medical contested case hearings.
• Sending information.
• How to attend a hearing.