Judicial Review of Medical Necessity Disputes

Judicial Review of Medical Necessity Disputes

In 2003, the Texas legislature amended Texas Labor Code §413.031 allowing the Division to promulgate rules creating an alternative dispute resolution for medical disputes.  As a result, TWCC (now known as Texas Department of Insurance, Department of Workers’ Compensation) adopted Rule 133.309 allowing injured workers or medical providers to request low cost dispute resolution for medical necessity by requesting a case review doctor for one hundred dollars.  The case review doctor conducts a peer review and issues an opinion.  The opinion is deemed final and unappealable. 

Plaintiffs filed suit seeking declaratory judgment, challenging the validity of Rule 133.309, but the district court granted summary judgment in favor of the DWC.  The Third Court of Appeals reversed and rendered in Texas Department of Insurance, Division of Workers’ Compensation v. Insurance Council of Texas, 2008 Tex. App. LEXIS 2024 (2008). The appellate court felt that legislative intent and the plain meaning of the statute "allow for judicial review of medical necessity disputes."  Recent changes to medical dispute resolution made case review doctors obsolete and, therefore, it is thought the DWC will not appeal this decision to the Supreme Court.