1. (a) The commission may authorize a required medical examination for any reason set forth in the Texas Workers' Compensation Act (the Act), Texas Labor Code, §408.004 whether the request for the examination is made by the carrier or a division of the commission. The request shall be made in the form and manner prescribed by the Commission.
2. (b) The commission shall not require an injured employee to submit to a medical examination at the insurance carrier's request until the insurance carrier has made an attempt to obtain the agreement of the injured employee for the examination. The insurance carrier shall notify the commission in the form and manner prescribed by the commission about any agreement or non-agreement of the injured employee regarding the requested examinations. If an agreement is secured for an additional required medical examination within a 180-day period pursuant to subsections (d) and (e) of this section, the written notification must also include an explanation of why good cause exists for the additional required medical examination.
3. (c) An insurance carrier's request for a medical examination order shall be delivered to the commission office managing the claim, and be sent by certified mail to the injured employee, or the employee's representative on the same day. A carrier is entitled to only one required medical examination, as allowed by the Act, §408.004 every 180 days, except as permitted in subsection (d) and (e) of this section.

4. (d) For dates of injury on or after September 1, 1997, the commission may approve additional required medical examinations at the insurance carrier's request before the expiration of 180 days in the event that a medical opinion is needed to determine if:

   1. (1) there has been a change in the injured employee's condition;
   2. (2) there is a need to change the injured employee's diagnosis;
   3. (3) the treatment should be extended to another body part or system, or if the extent of injury has changed;
   4. (4) the compensable injury is a producing cause of additional problems or conditions;
   5. (5) disability exists, because of newly discovered information;
   6. (6) proposed surgery, other than spinal surgery, is necessary to treat the compensable injury; or
   7. (7) the injured employee has reached maximum medical improvement and to determine the impairment rating when the examination relates to a body part or system that is outside the expertise of the insurance carrier's required medical examination doctor selected under subsection (c) of this section.
5. (e) Except for the reason listed in subsection (d)(7) of this section, any request by an insurance carrier for an additional required medical examination shall be submitted only after the insurance carrier has previously had an examination under subsection (c) of this section. Unless good cause exists, a request for an additional required medical examination under subsection (d) of this section will not be approved during a 180-day period for the same reason or rationale.
6. (f) The injured employee shall not be required to submit to more than three required medical examinations at the request of the insurance carrier under this section within any 180 consecutive day period.
7. (g) The commission shall monitor all insurance carrier requests for medical examinations that are requested before the expiration of the 180-day period under subsections (d) and (e) of this section through statistical analysis, audits, or other appropriate means.

8. (h) An unreasonable request for an additional medical examination under subsections (d), (e) and (f) of this section includes:

   1. (1) a request for an additional examination for a reason which does not comply with this section;
   2. (2) a request for a different doctor without sufficient grounds;
   3. (3) a request which would result in a violation of subsection (f) of this section; and
   4. (4) a request which provides false, incomplete, or misleading information.
9. (i) An insurance carrier who unreasonably requests an additional required medical examination as defined in subsection (h) of this section, commits a Class B administrative violation. An insurance carrier who demonstrates a pattern of unreasonably requesting additional required medical examinations commits a Class A administrative violation.

Source Note:The provisions of this §126.5 adopted to be effective January 30, 1991, 16 TexReg 313; amended to be effective January 1, 1998, 22 TexReg 11693.