Texas Administrative Code › Title 28 - INSURANCE › Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION › Chapter 126 - GENERAL PROVISIONS APPLICABLE TO ALL BENEFITS › Section 126.11 - Extension of the Date of Maximum Medical Improvement for Spinal Surgery

Current through Reg. 49, No. 28; July 12, 2024
(a) The commission may approve an extension
				of the date of maximum medical improvement, subject to subsection (f) of this
				section, if the injured employee has had spinal surgery or has been approved
				for spinal surgery in accordance with §
									134.600
				of this title (relating to Preauthorization, Concurrent Review, and Voluntary
				Certification of Health Care), 12 weeks or less before the expiration of 104
				weeks from the date income benefits began to accrue. Only one extension of the
				date of maximum medical improvement pursuant to this section may be granted.
				Approval for spinal surgery is either the notification from the insurance
				carrier (carrier) that the spinal surgery has been preauthorized or a decision
				from the appeal process finding the insurance carrier liable for the reasonable
				costs of spinal surgery. Any extension of the date of maximum medical
				improvement ordered by the commission must be to a specific and certain
				date.
(b) Upon application by
				either the injured employee or the insurance carrier, the commission may by
				order extend the date of maximum medical improvement past the period of 104
				weeks from the date income benefits began to accrue as described in the Texas
				Labor Code, §
									401.011(30)(B).
				The request shall be made in the form and manner prescribed by the commission.
				The commission shall issue an order approving or denying the request for an
				extension of the date of maximum medical improvement within ten days of the
				date the request is received by the commission.
(c) Prior to submission to the commission of
				a request for an extension of the date of maximum medical improvement, the
				requestor shall request from the treating doctor or surgeon the information
				listed in subsection (f) of this section. The request shall also be sent to the
				injured employee, the injured employee's representative, and the insurance
				carrier by first class mail on the same day it is submitted to the treating
				doctor or surgeon. The treating doctor or surgeon shall provide to the injured
				employee, the injured employee's representative, and the insurance carrier the
				information requested in subsection (f) of this section within ten days of the
				date the request is received. If the requesting party has not received the
				information from the treating doctor or surgeon within 15 days, the request may
				be submitted to the commission without this information.
(d) After the actions in subsection (c) have
				been completed, a request for an extension of the date of maximum medical
				improvement shall be filed at the commission field office managing the claim by
				personal delivery or first class mail. A request is deemed filed upon receipt
				at the appropriate field office. In addition, the request shall be sent to the
				injured employee, the injured employee's representative, and the insurance
				carrier on the same date it is sent to the commission. If the information from
				the treating doctor or surgeon is absent when the request is received,
				commission staff may invoke the provisions of §
									102.9
				of this title (relating to Submission of Information Requested by the
				Commission) to secure any necessary information.
(e) A request for an extension of the date of
				maximum medical improvement shall be filed no earlier than 12 weeks before the
				expiration of 104 weeks after the date income benefits began to accrue. The
				commission shall deny any request for an extension of the date of maximum
				medical improvement that is received by the commission prior to 12 weeks before
				the expiration of 104 weeks after the date income benefits began to accrue or
				is received on or after the expiration of 110 weeks from the date income
				benefits began to accrue.
(f) In
				making the determination to approve or deny a request for an extension of the
				date of maximum medical improvement, the commission shall consider:
(1) typical recovery times for the specific
				spinal surgery procedure;
(2)
				projected date and information regarding when the condition may be medically
				stable as provided by the treating doctor or the surgeon;
(3) case specific information regarding any
				extenuating circumstances that may have resulted in variances from conservative
				treatment protocols and time frames that may impact recovery times as provided
				by the treating doctor or the surgeon;
(4) information from any source regarding
				intentional or non-intentional delays in securing the surgery or medical
				treatment for the compensable injury;
(5) any pending, unresolved disputes
				regarding the date of maximum medical improvement; and
(6) any pertinent information provided by the
				insurance carrier, injured employee, and/or the injured employee's
				representative regarding the extension being requested under this
				section.