1. (a) The insurance carrier is liable for the reasonable and necessary medical costs relating to the health care treatments and services listed in subsection (h) of this section, required to treat a compensable injury, when any of the following situations occur:

   1. (1) there is a documented life-threatening degree of a medical emergency necessitating one of the treatments or services listed in subsection (h) of this section;
   2. (2) the treating doctor, his/her designated representative, or injured employee has received pre-authorization from the carrier prior to the health care treatments or services; or
   3. (3) when ordered by the commission.
2. (b) Second opinions for spinal surgery are addressed in Chapter 133, Subchapter C of this title (relating to Second Opinions for Spinal Surgery).
3. (c) The insurance carrier shall designate an accessible direct telephone number, and may also designate a facsimile number for use by the treating doctor or the injured employee to request pre-authorization during normal business hours. The direct number shall be answered or the facsimile responded to, by the carrier's agent who is delegated to approve or deny requests for pre-authorization, within the time limits established in subsection (e) of this section.
4. (d) Prior to the date of the proposed treatment or service, the treating doctor, or his/her designated representative, shall notify the insurance carrier's delegated agent by telephone or transmission of a facsimile of the recommended treatment or service listed in subsection (h) of this section. Notification shall include the medical information to substantiate the need for the treatment or service recommended. If requested to do so by the carrier, the treating doctor shall also notify the insurance carrier of the location and estimated date of the recommended treatment or service, and the name of the health care provider performing the treatment or service, if other than the treating doctor.
5. (e) Within three working days of the treating doctor's request for pre-authorization, the insurance carrier's delegated agent shall notify the treating doctor by telephone or transmission of a facsimile of the insurance carrier's decision to grant or deny pre-authorization. When the insurance carrier denies or approves pre-authorization, the insurance carrier shall send written approval, or, if denying pre-authorization, documentation identifying the reasons for denial. Notification shall be sent to the injured employee, injured employee's representative if known, and the treating doctor, or the treating doctor's designated representative, within 24 hours after notification of denial or approval.
6. (f) The insurance carrier must maintain accurate records to reflect information regarding the pre-authorization request and approval/denial process.
7. (g) If a dispute arises over the denial of pre-authorization by the insurance carrier, the doctor or the injured employee may proceed to a medical dispute resolution as described in the Act, §8.26, and §133.305 of this title (relating to Request for Medical Dispute Resolution).

8. (h) The health care treatments and services requiring pre-authorization are:

   1. (1) all nonemergency hospitalizations, ambulatory surgical center care, and transfers between facilities;
   2. (2) psychiatric or psychological therapy or testing except as a part of work hardening;
   3. (3) all external and implantable bone growth stimulators;
   4. (4) all chemonucleolysis, facet, or trigger point injections;
   5. (5) all nonemergency myelograms, discograms, or surface electromyograms;
   6. (6) unless otherwise specified, repeat individual diagnostic study, with a fee established in the current Medical Fee Guideline of greater than $350 or DOP (documentation of procedure) (Diagnostic study is defined as any test used to help establish or exclude the presence of disease/injury in symptomatic persons; the test can help determine a diagnosis, screen for specific diseases/injury, guide the management of an established disease/injury and help formulate a prognosis.);
   7. (7) video fluoroscopy;
   8. (8) radiation therapy or chemotherapy;
   9. (9) biofeedback except as a part of work hardening;
   10. (10) physical therapy or occupational therapy beyond eight weeks of treatment;
   11. (11) work hardening, in excess of six weeks (limited to a one-time two-week extension);
   12. (12) work conditioning, in excess of four weeks (limited to a one-time two-week extension);
   13. (13) all durable medical equipment in excess of $500 per item and all TENS units;
   14. (14) nursing home, convalescent, residential, and all home health care services and treatments;
   15. (15) pain clinics, chemical dependency clinics, or weight loss clinics; and
   16. (16) all nonemergency dental services, including reconstructive dental care or dental appliances.

Source Note:The provisions of this §134.600 adopted to be effective December 23, 1991, 16 TexReg 7099; amended to be effective April 1, 1997, 22 TexReg 1317.