Current through Reg. 49, No. 38; September 20, 2024
(a) Initiating an
examination. At the request of the insurance carrier, an injured employee, the
injured employee's representative, or on its own motion, the division may order
a medical examination by a designated doctor to resolve questions about:
(1) the impairment caused by the injured
employee's compensable injury;
(2)
the attainment of maximum medical improvement (MMI);
(3) the extent of the injured employee's
compensable injury;
(4) whether the
injured employee's disability is a direct result of the work-related
injury;
(5) the ability of the
injured employee to return to work; or
(6) issues similar to those described by
paragraphs (1) - (5) of this subsection.
(b) Requirements for a request. To request a
designated doctor examination, a requester must:
(1) provide a specific reason for the
examination;
(2) report the injured
employee's current diagnosis or diagnoses and body part or body parts affected
by the injury;
(3) provide general
information about the identity of the requester, injured employee, treating
doctor, and insurance carrier;
(4)
identify the workers' compensation health care network certified under
Insurance Code Chapter 1305 through which the injured employee is receiving
treatment, if applicable;
(5)
identify whether the claim involves medical benefits provided through a
political subdivision under Labor Code §
504.053(b)(2)
and the name of the health plan, if applicable;
(6) submit the request on the form prescribed
by the division under this section. A copy of the prescribed form is:
(A) on the division's website at
www.tdi.texas.gov/wc; or
(B) at the division's headquarters in Austin,
Texas or any division field office location;
(7) submit the request to the division and a
copy of the request to each party listed in subsection (a) of this section who
did not request the designated doctor examination;
(8) provide all information listed in
subparagraphs (A) - (G) of this paragraph that applies to the type of
examination the requester seeks:
(A) if the
requester seeks an examination on the attainment of MMI, include the statutory
date of MMI, if any;
(B) if the
requester seeks an examination on the impairment rating of the injured
employee, include the date of MMI that has been determined to be valid by a
final decision of the division or a court or by agreement of the parties, if
any;
(C) if the requester seeks an
examination on the extent of the compensable injury, include a description of
the accident or incident that caused the claimed injury and a list of all
injuries in question;
(D) if the
requester seeks an examination on whether the injured employee's disability is
a direct result of the work-related injury, include the beginning and ending
dates for the claimed periods of disability and state if the injured employee
is either not working or is earning less than pre-injury wages as defined by
Labor Code §
401.011(16);
(E) if the requester seeks an examination on
the injured employee's ability to return to work in any capacity and the
activities the injured employee can perform, include the beginning and ending
dates for the periods to be addressed. If no dates are included, the designated
doctor must examine the injured employee's work status as of the date of the
examination;
(F) if the requester
seeks an examination to determine whether an injured employee entitled to
supplemental income benefits may return to work in any capacity for the
identified period, include the beginning and ending dates for the qualifying
periods to be addressed and whether this period involves the ninth quarter or a
subsequent quarter of supplemental income benefits;
(G) if the requester seeks an examination on
topics under subsection (a)(6) of this section, specify the issue in sufficient
detail for the designated doctor to identify and answer the questions; and
(9) provide a signature
to attest that every reasonable effort has been made to ensure the accuracy and
completeness of the information in the request.
(c) Scheduling an examination within 60 days.
The division will not schedule a designated doctor examination within 60 days
of the most recent designated doctor examination absent a showing of good
cause.
(1) Good cause requires the requester
to show that the requested examination is reasonably necessary to resolve the
submitted questions and that it will affect entitlement to benefits.
(2) If the requester already asked for an
examination on the claim, they must also show that the submitted questions
could not reasonably have been included in the previous examination.
(d) Denial of a request. The
division will determine whether good cause exists on a case-by-case basis. The
division will deny a request for a designated doctor examination and provide a
written explanation for the denial to the requester if:
(1) the request does not comply with any of
the requirements of subsection (b) or (c) of this section;
(2) the request would require the division to
schedule an examination that violates Labor Code §§
408.0041,
408.123, or
408.151;
(3) there is an unresolved dispute about
compensability reported under §
124.2 of this title (relating to
Insurance Carrier Reporting and Notification Requirements); or
(4) the request lacks any legal or factual
basis that would reasonably merit approval.
(e) Examination ordered during a dispute.
During a dispute on the compensability of a claim as a whole, if a division
administrative law judge or benefit review officer determines that an expert
medical opinion would be necessary to resolve a dispute about whether the
claimed injury resulted from the claimed incident, the administrative law judge
or benefit review officer may order the injured employee to attend a designated
doctor examination to address that issue.
(f) Disputes about designated doctor
requests. The dispute resolution processes in Chapters 140-144 and 147 of this
title (relating to dispute resolution processes, proceedings, and procedures)
govern disputes about designated doctor requests.
(1) The insurance carrier, an injured
employee, or the injured employee's representative may dispute the division's
approval or denial of a designated doctor examination request.
(2) Until the division has either approved or
denied the request, a party may not dispute the designated doctor examination
request itself or the accuracy of any information on the request.
(3) To dispute an approved or denied request
for a designated doctor examination, a party may seek an expedited contested
case hearing under §
140.3 of this title (relating to
Expedited Proceedings). The party must file the request within three working
days of receiving the order under §
127.5(b) of this
title (relating to Scheduling Designated Doctor Appointments).
(4) If the division receives and approves a
timely request for expedited proceedings to dispute a designated doctor
examination, the division will stay the disputed examination pending the
outcome of the expedited contested case hearing.
