A Texas Workers’ Compensation Update from Downs & Stanford, P.C.
The Texas Workers’ Compensation landscape is constantly evolving. Each month, our experienced attorneys provide focused updates that matter most helping you manage risk, control costs, and approach claims with confidence.
Inducted into the College of Workers’ Compensation Lawyers
Congratulations to Stuart Colburn on a Distinguished Honor
We are proud to recognize Stuart Colburn on his induction into the College of Workers’ Compensation Lawyers—a prestigious honor reserved for attorneys who have demonstrated excellence, professionalism, and a commitment to advancing the practice of workers’ compensation law. This distinction reflects not only a remarkable career, but also a lasting impact on the Texas workers’ compensation community.
Well deserved!
We are excited to bring back our monthly Lunch & Learn program designed to help you stay current on key industry topics while earning continuing education (CE) credit. Each session delivers practical insights you can apply immediately, and you will walk away with CE credit for your participation.
The first 25 adjusters to sign up will be in the course. Once you have registered, you will receive confirmation for the Webinar. The Zoom link will be emailed the Monday before each Webinar. Please note that if you have taken the course before in the last two years, you will not be eligible for credit again per 28 Texas Administrative Code Section 19.1010(7)(c).
Join us on May 8, 2026, from 12:00 P.M. to 1:00 P.M. to discuss: Legal Defenses with John V. Fundis and D. Rynn Freiling.
This month’s update highlights major findings from the Texas Workers’ Compensation Research and Evaluation Group (WCREG), the latest fatality data, and upcoming DWC events that may be of interest to system participants.
📊 AMA Guides Study: 4th vs. 6th Edition
WCREG completed a comparison of impairment ratings under the 4th and 6th Editions of the AMA Guides, with notable system-wide implications.
Key findings (373-case sample):
- 59% of cases received lower impairment ratings under the 6th Edition
- 30% received higher ratings
- 11% remained unchanged
Overall impact:
- Average impairment rating decreased from 5.4% → 3.8%
- Approximately a 30% overall reduction
High-severity claims (≥6% under 4th Edition):
- 86% resulted in lower ratings under the 6th Edition
Financial impact estimate:
- If applied to 2022 claims, projected savings could reach ~$185,000 per week, driven by lower impairment ratings on higher-value claims
Takeaway: Transitioning to the 6th Edition could significantly reduce impairment ratings and long-term indemnity costs, though implementation will take time.
⚠️ 2024 Texas Workers’ Compensation Fatality Census
The Division of Workers’ Compensation reported 557 fatality claims in 2024, reflecting a modest decline from the prior year.
Leading causes of fatalities:
- Transportation incidents: 43%
- Violent acts: 75 fatalities (13%)
Workforce demographics:
- 92% male workers
- 28% age 55 and older
Ethnicity distribution:
- 45% Hispanic/Latino workers
- 39% White (non-Hispanic) workers
Takeaway: Transportation-related incidents remain the leading cause of workplace fatalities in Texas, with older and male workers disproportionately affected.
📅 Upcoming Event: DWC Annual Conference
Dates: September 1–2, 2026
Location: Embassy Suites, San Marcos
Theme: “Navigating the Path: From Basics to Mastery”
CE Credits: Up to 8 hours available for adjusters (TDI-approved)
Thank you for staying informed with DWC Happenings. We will continue to provide updates on developments impacting the Texas workers’ compensation system.
Author: R. Christopher Esson
Here are the highlights, the lowlights, and the “well, that’s interesting” moments from recent Texas Workers’ Compensation Decisions.
APD 260449, 2026 TX Wrk. Comp. LEXIS 10
DECISION:
At the CCH, the ALJ granted the IW’s request to keep the record open for two weeks for a pending neuropsychological report. The ALJ also indicated the self-insured would have time to submit a peer review or further analysis and arguments. Instead, ALJ closed the record 4 days after the CCH and issued a decision. The AP reversed noting the records was closed before the ALJ’s own stated timelines to the parties had lapsed. The case was remanded to allow for the inclusion of the medical report and time for the self-insured to respond.
WHAT THIS MEANS FOR YOU:
The AP will, at the very least, allow the parties the amount of time the ALJ’s stated on the record to submit evidence.
APD 260120, 2026 TX Wrk. Comp. LEXIS 9
DECISION:
The DD issued two DWC-69s, both finding a 0% IR but choosing different MMI dates. The ALJ found the injury did not extend to an assortment of conditions. But the ALJ chose the DWC-69 from the DD with the later MMI date that rated and considered the conditions found not compensable. The AP reversed finding the earlier MMI date and the same 0% IR based on the conditions the ALJ found compensable.
WHAT THIS MEANS FOR YOU:
Confirm the ALJ chose the correct MMI/IR certification that “marries up” with the extent of injury determinations.
APD 260449
DECISION:
The IW alleged multiple extent of the injury conditions that she alleged occurred on the day of the injury (right shoulder) and some follow-on conditions (left shoulder) she injured when she fell at the hospital following surgery for the compensable injury. DWC denied requests for a DD for extent for the left shoulder follow-on conditions based on the mistaken belief a DD had already addressed these extent conditions (but the DD addressed the right shoulder). At the CCH, the IW requested a POD. The self-insured was unopposed. The ALJ indicated she would rule after she heard the evidence. The ALJ never announced a ruling on the motion for a POD. The ALJ closed the record without issuing a POD. The AP found the ALJ abused her discretion. The AP writes, “As the DWC-32s were denied based on a mistaken belief that the designated doctor had already addressed the disputed conditions, we find the ALJ abused her discretion in failing to issue the requested POD.”
WHAT THIS MEANS FOR YOU:
When possible, ask the ALJs to rule on all motions and objections before leaving the CCH.
APD 260374
DECISION:
The IW submitted a SIBs application for a quarter under the “old” rules that were into effect prior to 12/24/25. The ALJ erroneously believed the IW submitted four applications in week 3 of the qualifying period when five was required. In fact, the DWC-52 indicates the IW made 6 job work searches. The AP remanded (not rendered) for the ALJ to consider all the evidence.
WHAT THIS MEANS FOR YOU:
Must read those SIBs applications carefully.
Sharman v. Am. Zurich, S.W.3d , 2026 Tex. App. LEXIS 2746 (Tex. App.—Dallas Mar. 25, 2026, no pet. h.)
DECISION:
The IW alleged she fell at work. The IC denied she fell relying in part on video evidence at work on the day of the injury that she was walking fine before and after the alleged injury and statements from co-workers that she did not report an injury. DWC determined she did not sustain a compensable injury, and she sought judicial review pro se. On the day of trial, she decided not to testify. The trial judge granted the IC’s motion for directed verdict, and the appeals court affirmed since the IW “failed to put on any evidence, supported by expert or lay testimony, of a compensable injury.”
WHAT THIS MEANS FOR YOU:
Video evidence can be persuasive.
Author: Stuart Colburn
⚖️ Compliance & Investigations: PLN-11 Requirements
Compliance & Investigations (C&I) within the Division of Workers’ Compensation has emphasized that carriers must provide case-specific, factual information when filing a PLN-11.
In a recent matter, a carrier filed a PLN-11 stating it was “unable to determine whether the injury resulted in disability and that the investigation would continue.” Relying on that PLN-11, the carrier did not initiate income benefits on day 15 after receiving notice of the claim.
A complaint was filed, and C&I issued a consent order finding that the carrier failed to timely initiate income benefits. In that consent order, C&I noted the “PLN-11 was deficient because [the carrier] did not provide any fact-specific explanation for a dispute.”
C&I deemed the PLN-11 insufficient, and the carrier’s suspension of benefits based on the PLN-11 was invalid. C&I also reiterated that the PLN-11 instructions require a full and complete statement explaining the reasons for the action taken.
C&I stated that a generic statements with no further description of the factual basis for the actions taken are not sufficient. In those instances the PLN-11 would be considered invalid and would not allow a carrier to suspend benefits.
Insufficient examples include generic statements such as:
- “No medical evidence to support disability”
- “Not part of compensable injury”
- “Liability in question”
- “Under investigation”
- “Eligibility questions”
The carrier in this case was fined for failing to timely initiate income benefits.
Takeaway: Ensure all disputes—whether on a PLN-11 or PLN-1— contain some factual description related to the claim for why the benefits will be impacted in whole or part.
Author: John V. Fundis
THE IMPACT OF PRE-AUTHORIZED MEDICAL CARE ON MAXIMUM MEDICAL IMPROVEMENT
A practical look at how pre-authorized medical care influences MMI determinations in Texas workers’ compensation claims.
I. INTRODUCTION
In a case I had early last year against a capable Claimant’s attorney, I was faced with the issue of pre-authorized medical care and how it might impact the Designated Doctor’s certification of maximum medical improvement (“MMI”). It should be noted that the three cases that I cite in this article deal with either affirming or overturning a Designated Doctor’s certification of MMI and impairment rating. However, the same arguments can be used to either support or overturn a treating doctor/treating doctor referral/Post-DD RME’s certification. Naturally, the big difference would be the fact that these other certifications would not have the benefit of the presumptive weight given to a Designated Doctor’s opinions.
In my case, I had anticipated that Claimant’s counsel would use the pre-authorized PRIDE Program to overturn the Designated Doctor’s certification. To counter this argument, I pointed out that the Designated Doctor’s report in our case was not only extremely thorough and well-reasoned, but that the Designated Doctor was fully aware of the Claimant’s referral to and participation in the PRIDE Program. In fact, the Designated Doctor mentions the PRIDE Program in his report.
Furthermore, I admitted in my closing argument that APD 0715799 does state that a Designated Doctor’s certification can be rejected if the medical records post-MMI establish significant and steady improvement (emphasis added). Claimant’s counsel came back with a few citations stating that the “significant and steady improvement” standard was “no longer the law” and cited several Appeals Panel Decisions to support his position. To say the least, I was taken aback by this position and wrote down these Appeals Panel numbers so that I could research them later.
Following this Contested Case Hearing (“CCH”), I read an article from another highly respected Claimant’s firm that also addressed the issue regarding the impact of pre-authorized medical care on MMI. One of the main points of this article was that pre-authorized medical care affects MMI more than any other variable. I agree with this statement, and I am seeing Claimants’ counsel use pre-authorized medical care frequently to overturn certifications they do not agree with.
II. LEGAL AUTHORITY
Rule 134.600 (p) and (q) cover the issue of pre-authorization. Of particular interest are the Rule’s provisions regarding work hardening, work conditioning, and physical and occupational therapy services. It is these types of services that are often used to defeat certifications of MMI.
In APD 110670, the Appeals Panel determined that the Designated Doctor’s opinion on MMI was against the great weight and preponderance of the evidence so as to be clearly wrong and manifestly unjust. The primary basis for this opinion was the fact that there were in evidence three Carrier pre-authorizations covering postoperative physical therapy and chronic pain management. Id. Furthermore, there was a letter from one of the Claimant’s treating physicians noting that her patient had been referred to the Designated Doctor prematurely because her patient had not had enough postoperative care. Id.
Despite this evidence, the Designated Doctor placed the Claimant at MMI and provided an impairment rating. Id. The Administrative Law Judge in this claim adopted the Designated Doctor’s certification in their Decision and Order, and the Claimant filed a Request for Review. Id. In their decision, the Appeals Panel noted that it was important to note that all the pre-authorizations for postoperative physical therapy and chronic pain management were post-MMI. Id. Furthermore, this Appeals Panel noted that there was clear evidence in the medical records that this Claimant had made significant and substantial improvement following the postoperative physical therapy and chronic pain management. Id. The Designated Doctor was given the opportunity to review this evidence by way of a Letter of Clarification. Id. However, the Designated Doctor did not change his or her mind. Id.
In reviewing a “great weight” challenge, the Appeals Panel correctly noted that they must examine the entire record to determine if: (1) there is only “slight” evidence to support the findings; (2) the finding is so against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust; or (3) the great weight and preponderance of the evidence supports its non-existence. See Cain v. Bain, 709 S.W. 175 (Tex. 1986).
This Appeals Panel noted in APD 110670 that there was no assertion that the physical therapy and chronic pain management following the date of MMI were due to anything other than a compensable injury. Furthermore, they noted that the medical records in evidence from both the chronic pain management program and the physical therapist reasonably anticipated further material recovery or lasting improvement to the Claimant’s injury, and that they anticipated this recovery and improvement after the date of the Designated Doctor’s assessment of MMI. Id. They go on to point out that the same medical records note that substantial improvement was well documented. Id. For those reasons, the Appeals Panel reversed the Hearing Officer’s determination. Id. For a similar analysis and result, see Appeals Panel No. 111639.
Finally, there is the Appeals Panel Decision No. 122627. I recommend Carriers keep this Appeals Panel Decision in mind going forward. In this claim, the Administrative Law Judge did not adopt the Designated Doctor’s certification, and the Self-Insured filed a Request for Review requesting that the Designated Doctor’s certification be adopted. Id. The Appeals Panel in this claim reversed and rendered. Id.
In this claim, the Designated Doctor determined that the Claimant reached MMI on July 9, 2012, with a 0% impairment rating. Id. His rationale for the MMI date was the fact that the Claimant was released to full duty and that it appeared that the Claimant’s condition had become static. Id. Of critical importance in this decision was the fact that the Designated Doctor was clearly aware that the Claimant had been prescribed and completed eight weeks of physical therapy after his date of MMI. Id. (Emphasis added) In fact, the Designated Doctor had reviewed those physical therapy notes prior to reaching his decision on MMI. Id.
Nonetheless, the Administrative Law Judge in this claim used the fact that the Claimant had undergone physical therapy after the date of MMI as a reason not to adopt the Designated Doctor’s certification. Id. In response to this ruling, the Appeals Panel observed that a finding of MMI does not mean that there will not be a need for some future medical treatment, and the need for such additional treatment does not mean that MMI was not reached at the time it was certified. APD 991932. Given this evidence, this Appeals Panel reversed the Administrative Law Judge’s determination regarding MMI and rendered a new decision that the Claimant reached MMI per the Designated Doctor.
III. THINGS TO CONSIDER GOING FORWARD
I realize this is a lot to process, so I thought I would boil all this down to a few simple observations that you can use going forward to assess certifications of MMI when you have the issue of pre-authorized medical care being used to dispute the certification you want adopted.
💡 Key Considerations
1. First, make sure that the physical therapy and/or chronic pain management program and/or medical care in issue address the compensable injury or injuries at issue.
2. Second, determine whether medical records supporting the medical treatment the subject of the pre-authorized medical care state that the treating doctors and/or physical therapists reasonably anticipated further material recovery or lasting improvement to the Claimant’s compensable injury, and that those opinions are based upon a reasonable medical probability. Further, these opinions must anticipate such recovery or improvement after the date of MMI in dispute.
3. Third, remember that the Appeals Panel Decisions has stated that the participation in a work hardening program or continuing medical treatment alone is not inconsistent with the concept of MMI.
4. Finally, read the Designated Doctor’s report (or any certifying doctor’s report) carefully. Is it a good report? Has the Designated Doctor, treating doctor, treating doctor referral, or Post-DD RME done a capable and thorough job of explaining why he or she believes the Claimant is at MMI? Next, are they aware of the fact that the Claimant has been recommended for additional physical therapy, work hardening, or pain management? If so, have they reviewed those records and taken them into consideration in their assessment of MMI? If they have, that will go a long way in buttressing their opinions on MMI.
IV. CONCLUSION
As I said at the beginning, I think that Carriers will see Claimants, especially those represented by counsel, increasingly argue that pre-authorized medical care post-MMI defeats any certification of MMI. While preauthorized medical may present a challenge, it is not a certain death knell for the certification that the Carrier may want to adopt.
You may recall that I started off this article by referring to a case on this issue that I had in early 2025. Because the Designated Doctor in my claim knew the Claimant had been referred to the PRIDE Program, had done a very thorough report, and the fact that there was no evidence of significant or steady improvement after the date of MMI, the Carrier prevailed.
Author: Christopher M. Losey
Our Attorneys at Downs & Stanford, P.C. remain focused on helping you manage risk, control costs, and navigate claims with confidence.
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