Mail to: - Texas Department of Insurance

• 732 – “Accurate coding is essential for reimbursement. Services are not reimbursable as billed. CPT and/modifier billed
incorrectly.
3. These services was denied by the Respondent, after reconsideration with denial reasons:
• W4 – “No additional reimbursement allowed after review of appeal/reconsideration.”
• 891 – “The insurance company is reducing or denying payment after reconsidering a bill.”
4. The Requestor submitted relevant documentation to substantiate the level of anesthesia service billed. Per Rule 134.600 (c)
(1) (B) carrier is liable for all reasonable and necessary medical costs relating to the health care: preauthorization of
any health care listed in subsection (p) of this section that was approved prior to providing the health care.
Therefore the carrier is liable for all reasonable and necessary medical costs relating to this procedure.
5. The Requestor was given preauthorization for a LT Sacroiliac injection and LT Sciatic nerve/piriformis injection, according
to the preauthorization letter dated April 02, 2007 and Case Number: 1906118.
6. Per Commissioner’s Bulletin #B-0028-07, if a specified health care treatment or service is preauthorized,
treatment/service and related ancillary charges for services provided within a the preauthorized service is not subject to
retrospective review of the medical necessity of the treatment service.
90 minutes ÷ 15 = 6 units
CPT code 00630-QZ =8 units + 6 units = 14 units
$16.51(2007conversion factor) x 125%= $20.64
$20.64 x 14 units =$288.96 (MAR)
7. Therefore, according to rule 134.202(c) (1) reimbursement of $288.96 is recommended.
8. A referral has been made to Legal and Enforcement.
PART VI: GENERAL PAYMENT POLICIES/REFERENCES
Texas Labor Code Section 413.011(a-d), Section 413.031 and Section 413.0311
28 Texas Administrative Code Section 134.1, Section 134.202, 134.600
Texas Government Code, Chapter 2001, Subchapter G
Commissioner’s Bulletin #B-0028-07
PART VII: DIVISION DECISION
Based upon the documentation submitted by the parties and in accordance with the provisions of Texas Labor Code Section 413.031,
the Division has determined that the Requestor is entitled to reimbursement. The Division hereby ORDERS the Carrier to remit to the
Requestor the amount of $288.96 plus applicable accrued interest per Division Rule 134.130, due within 30 days of receipt of this
Order.
ORDER :
01/11/08
Authorized Signature Medical Fee Dispute Resolution Officer Date
PART VIII: YOUR RIGHT TO REQUEST JUDICIAL REVIEW
Either party to this medical fee dispute has a right to request an appeal. A request for hearing must be in writing and it must be
received by the DWC Chief Clerk of Proceedings within 20 (twenty) days of your receipt of this decision. A request for hearing
should be sent to: Chief Clerk of Proceedings, Texas Department of Insurance, Division of Workers Compensation, P.O. Box
17787, Austin, Texas, 78744. Please include a copy of the Medical Fee Dispute Resolution Findings and Decision together with
other required information specified in Division Rule 148.3(c).
Under Texas Labor Code Section 413.0311, your appeal will be handled by a Division hearing under Title 28 Texas Administrative
Code Chapter 142 Rules if the total amount sought does not exceed $2,000. If the total amount sought exceeds $2,000, a hearing
will be conducted by the State Office of Administrative Hearings under Texas Labor Code Section 413.031.
Si prefiere hablar con una persona en español acerca de ésta correspondencia, favor de llamar a 512-804-4812.
MR-04 (09/12/07) MFDR Tracking #: M4-08-1601-01 Page 2 of 2