| (a) This section does not apply if statutory maximum medical
improvement (MMI) has been reached. Statutory MMI is the later of:
(1) the end of the 104th week after the date that temporary
income benefits (TIBs) began to accrue; or
(2) the date to which MMI was extended by the commission through
operation of Texas Labor Code §408.104.
(b) If there has not been a certification in accordance with §130.1
of this title (relating to Certification of Maximum Medical Improvement and
Evaluation of Permanent Impairment) that an injured employee has reached MMI,
an insurance carrier (carrier) may follow the procedure outlined in this section
to resolve whether an employee has reached MMI. The carrier shall presume,
only for purposes of invoking this procedure, that an employee has reached
MMI, if:
(1) it appears that the employee has failed to attend two or
more consecutively scheduled health care appointments and the number of days
between the two examinations is greater than 60 except for laminectomy, spinal
fusion or diskectomy in which case the number of days between the two examinations
is greater than 90;
(2) the treating doctor has examined the employee at least
twice for the same compensable injury after the date on which TIBs began to
accrue, and the doctor's medical reports as filed with the insurance carrier
for all examinations and reports conducted after the first of the two examinations,
indicate a lack of medical improvement in the employees condition since the
date of the first of the two examinations;
(3) the employee was previously found not to be at MMI by a
designated doctor but the employee has reached the date the designated doctor
estimated that the employee would reach MMI; or
(4) the employee is four weeks past the point that the claim
has become a Work Release Outlier Claim as defined by commission rule.
(c) A carrier permitted by subsection (b) of this section to
invoke this procedure may request the treating doctor to provide a report
on the employee's medical status as it relates to MMI. Note - nothing in this
section prohibits the carrier from contacting the treating doctor about whether
the employee has reached MMI.
(d) The treating doctor shall evaluate the employee's condition
within 14 days of receiving the request from the carrier under subsection
(c) of this section. The evaluation shall be conducted in accordance with §130.1
of this title and the report filed within seven working days of the date of
the examination. If the treating doctor determines that the employee has permanent
impairment but is not authorized to certify MMI or assign an impairment rating,
the doctor shall refer the employee to a doctor who is so authorized and this
doctor shall comply with the requirements of this section, §130.1 and §130.3
of this title (relating to Certification of Maximum Medical Improvement and
Evaluation of Permanent Impairment and Certification of Maximum Medical Improvement
by Doctor Other Than Treating Doctor).
(e) If the treating doctor fails to respond as required by
this rule, or if the treating doctor certifies that the employee has not reached
MMI, the carrier may request a designated doctor under §130.5 (relating
to Entitlement and Procedure for Requesting Designated Doctor Examinations
Related to Maximum Medical Improvement and Impairment Rating).
|
