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NOTICE OF INDEPENDENT REVIEW DECISION July 30, 2004 IRO Case # M5-04-3281, amended 8 3 04 Texas Worker's Compensation Commission: Envoy Medical Systems, LP Envoy ; has been certified as an independent review organization IRO ; and has been authorized to perform independent reviews of medical necessity for the Texas Worker's Compensation Commission TWCC ; . Texas HB. 2600, Rule133.308 effective January 1, 2002, allows a claimant or provider who has received an adverse medical necessity determination from a carrier's internal process, to request an independent review by an IRO. In accordance with the requirement that TWCC assign cases to certified IROs, TWCC assigned this case to Envoy for an independent review. Envoy has performed an independent review of the proposed care to determine if the adverse determination was appropriate. For that purpose, Envoy received relevant medical records, any documents obtained from parties in making the adverse determination, and any other documents and or written information submitted in support of the appeal. The case was reviewed by a physician who is Board Certified in Neurological Surgery, and who has met the requirements for TWCC Approved Doctor List or has been approved as an exception to the Approved Doctor List. He or she has signed a certification statement attesting that no known conflicts of interest exist between him or her and any of the treating physicians or providers, or any of the physicians or providers who reviewed the case for a determination prior to referral to Envoy for independent review. In addition, the certification statement further attests that the review was performed without bias for or against the carrier, medical provider, or any other party to this case. The determination of the Envoy reviewer who reviewed this case, based on the medical records provided, is as follows: 2.
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