Disputes about medical treatment

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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).

Need help?

Call DWC Customer Service at 800-252-7031, Monday through Friday, 8 a.m. to 5 p.m., Central time;
The Office of Injured Employee Counsel (OIEC) is a state agency that offers injured employees free help with workers’ compensation claims. If you do not have an attorney and want help from an ombudsman, contact OIEC at 866-393-6432, ext. 44186;
If you want an attorney and need help finding one, contact the State Bar of Texas at 800-252-9690.

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 §133.308(s).

What happens after a medical hearing is requested?

DWC will schedule a prehearing conference.

At the prehearing conference, an administrative law judge (ALJ) will explain the parties’ rights, the procedures, and help:

determine if the appeal was filed on time (timely);
talk about the issue(s) to be decided;
talk about information and facts about the claim;
work to reach an agreement;
set deadlines for parties to share information (discovery); and
set a date for the medical hearing.

After the prehearing conference, DWC will schedule a medical hearing.

At the medical 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 §413.0311(d) and 28 TAC §133.308(s)(1)(F).

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