The nurse reviewer in the following case study observed a pair of patterns in the medical records for a Motor Vehicle Accident (MVA) that helped to serve as mitigate points in favor for the insurance adjuster. This article will cover the key details of the case and the patterns noticed by the nurse review and will discuss pre-date of loss (DOL) history of the patient, multiple large gaps in the medical records, inconsistent pain complaints, and objective clinical findings from the fact pattern. The takeaways from the case may be of interest to casualty adjusters and defense attorneys.
Facts of the case:
The MOI in the police report was the same as reported by the claimant. Moreover:
Following the incident and a three-week time lapse, the patient presented to a chiropractor with reports of a loss of consciousness and inability to walk.
The initial evaluation by the chiropractor noted subjective complaints of back pain, left shoulder pain, and bilateral knee pain secondary to MVA. The claimant was ambulatory at the scene, immobilized, and transported to the ER. The initial exam at the ED was positive for mild left shoulder tenderness, bilateral paraspinal tenderness, and left knee contusion without swelling or bruising.
There were multiple time lapses during the treatment timeline. Lapses in care can impede progress and healing, as well as suggest a less serious set of symptoms. A lumbar spine MRI was performed, and the claimant received bilateral sacroiliac facet joint injections for pain management. She continued treatment with pain management and made a demand of $250,000.
No pre-DOL medicals were submitted for review. This is a significant “red flag” in several respects because:
As a matter of standard practice, facet injections are performed for diagnostic and therapeutic purposes with no more than two levels injected at time. If the patient experiences a 50% or more decrease in pain, the facet joint is confirmed as the cause of pain. However, conservative treatment is recommended before undergoing facet injections. In this case, a complete course of conservative care is questionable given the treatment lapses.
The medical records in this case did not document improvement in symptoms to support injections, and the claimant's attorney informed the insurance adjuster that she was still treating. Pain management and injections were not recommended as related due to the extended gaps in treatment that were inconsistent with soft tissue healing.
The claimant began treatment after a three-week gap, allowing for intervening events to occur. While chiropractic treatment in absence of spinal manipulation is appropriate for soft tissue injuries to reduce pain and inflammation, according to MDGuidelines, frequency is up to 12 visits within six weeks of care.
The claimant did not exhibit any documented improvement throughout treatment. She reported that her pain produced severe symptoms that inhibited her activities of daily living. New reports of loss of consciousness (LOC) at time of the loss and inability to ambulate at the time of the loss were not consistent with prior documented facts of the loss.
Additional concerns:
The claimant was referred for neurosurgical consult five months prior to being seen and noted multiple long gaps in chiropractic treatment, which is inconsistent with reports of severe pain. Severe pain is typically incapacitating and normally requires medical intervention with narcotics to function. The gaps in treatment did not support failed therapy.
Continued reports of severe pain with gaps in treatment were inconsistent. The differences between acute versus chronic radiological findings were critical to the defense. The MRI reported did not note any acute findings to support trauma related pathology. For acute pathologies the MRI signal is high intensity, while non-acute findings exhibit a low intensity signal.
Based on the impact and initial evaluation in the ER, the claimant suffered soft tissue cervical, thoracic, and lumbar injury with a left knee contusion. While the claimant attended 29 chiropractic visits over seven months, there were multiple large gaps in treatment that were inconsistent with normal injury resolution; for example, the claimant had a delay of five months after the referral to pain management.
Furthermore:
Two main concerns emerged, namely:
Nurse reviewers and consultants are able to assist adjusters and attorneys with bodily injury claims through detailed chronology and case analysis as seen in this brief case summary.
We would like to thank Kari Williamson for providing insight and expertise that greatly assisted this research.
Kari Williamson leads J.S. Held’s Medical Bill Review & Nurse Consulting services. Kari is frequently invited to speak and publish as a leader in the legal nurse consultant field on emerging medical-legal and insurance claims issues, such as data mining, bill audits, medical reviews, internal or external medical assistance, claims education, and new ways to measure and improve outcomes. She writes for a variety of national and regional insurance and legal publications and often speaks to law firms, insurance groups, and other industry organizations.
Kari can be reached at [email protected] or +1 615 398 5229.
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