1. (a) The commission may authorize a required medical examination (RME) for any reason set forth in the Texas Workers'Compensation Act (the Act), Texas Labor Code, §408.004, §408.0041, or §408.151 at the request of the insurance carrier (carrier),or the commission. The request shall be made in the form and manner prescribed by the commission. A carrier is not entitled to take action with respect to benefits based on, and the commission shall not consider, a report of an RME doctor that was not approved or obtained in accordance with this section.

2. (b) carriers are entitled to RMEs by a doctor of their choice in accordance with this subsection as follows:

   1. (1) Pursuant to Texas Labor Code §408.004, once every 180 days, to resolve any questions about the appropriateness of the health care received by the injured employee (employee), or similar issues. The carrier's first RME may be requested at any time after the date of injury. A subsequent examination may be requested once every 180 days after the first examination and must be performed by the same doctor unless otherwise approved by the commission. For dates of injury on or after September 1, 1997, the commission may approve no more than three RMEs at the carrier's request before the expiration of 180 days in the event that a medical opinion is needed to determine if:

      1. (A) there has been a change in the employee's condition;
      2. (B) there is a need to change the employee's diagnosis;
      3. (C) the treatment should be extended to another body part or system, or if the extent of injury has changed;
      4. (D) the compensable injury is a producing cause of additional problems or conditions;
      5. (E) disability exists, because of newly discovered information; or
      6. (F) a proposed surgery is necessary to treat the compensable injury.
   2. (2) Pursuant to Texas Labor Code §408.0041, for the purpose of evaluating a designated doctor's determination on maximum medical improvement (MMI) and/or permanent whole body impairment rating. A carrier is entitled to an examination under this subsection only upon receipt of a Report of Medical Evaluation from a Designated Doctor under §130.6 of this title (relating to Designated Doctor Examinations for Maximum Medical Improvement and/or Impairment Rating).

   3. (3) Pursuant to Texas Labor Code §408.151, to determine if the employee's medical condition is a direct result of the impairment resulting from a compensable injury. For the purposes of this subsection, the carrier may not require an employee to submit to an RME more than once per year if:

      1. (A) an employee is receiving supplemental income benefits on or after the second anniversary of the date of the employee's initial entitlement to supplemental income benefits, and
      2. (B) in the preceding year, the employee's medical condition resulting from the compensable injury had not improved sufficiently to allow the employee to return to work during that year.
3. (c) On or after September 1, 2003, the doctor selected to perform an RME must be on the commission's approved doctors list and, if the purpose of the examination is to evaluate MMI and/or permanent impairment, be authorized to assign impairment ratings under §130.1(a) of this title (relating to Certification of Maximum Medical Improvement and Evaluation of Permanent Impairment).

4. (d) Except for an examination under subsection (b)(2) of this section, the commission shall not require an employee to submit to a medical examination at the carrier's request until the carrier has made an attempt to obtain the agreement of the employee for the examination as required by subsection (g). The carrier shall notify the commission in the form and manner prescribed by the commission of any agreement or non-agreement by the employee regarding the requested examination. An examination of an employee by a doctor selected by the carrier shall be requested as follows:

   1. (1) Prior to requesting an RME from the commission, the carrier shall send a copy of the request to the employee and the employee's representative (if any) in the manner prescribed by subsection (g) of this section in an attempt to obtain the employee's agreement to the examination.
   2. (2) The carrier shall give the employee ten days to agree to the examination. The ten-day period begins from the date the carrier sends the request to the employee and the employee's representative (if any). Though the employee has ten days to respond to the request, the carrier is not prohibited from contacting the employee by telephone to discuss the request with the employee and obtain the employee's response.
   3. (3) The carrier shall send the request to the commission after either obtaining the employee's answer to the request or when the employee fails to respond after the ten-day period.
5. (e) The commission shall monitor all carrier requests for medical examinations that are requested before the expiration of the 180-day period subsection (b)(1) of this section through statistical analysis, audits, or other appropriate means.

6. (f) An unreasonable request for an additional medical examination under subsection (b) 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 (b) of this section; and
   4. (4) a request which provides false, incomplete, or misleading information.
7. (g) The carrier shall send a copy of the request for a medical examination order required by subsection (d) of this section to the employee and the employee's representative (if any) by facsimile or electronic transmission if carrier has been provided with a facsimile number or email address for the recipient, otherwise, the carrier shall send the request by other verifiable means.
8. (h) The carrier shall maintain copies of the request for a medical examination order and shall also maintain verifiable proof of successful transmission of the information. For these purposes, verifiable proof includes, but is not limited to, a facsimile confirmation sheet, certified mail return receipt, delivery confirmation from the postal or delivery service, or a copy of the electronic transmission.

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; amended to be effective December 26, 1999, 24 TexReg 11399; amended to be effective January 2, 2002, 26 TexReg 10899.