To Populate or not to Populate

Keith More

On January 6, 2022, my client Mr. Gomez filed a CT claim. He was a max earner so there is or was no motivation for him to file a claim other than he was truly hurt. The case was accepted and he began to receive treatment for his low back. Eventually, a right L5 hemilaminectomy and microdiscectomy were recommended and authorized.  The surgery went forward on March 15, 2022. Unfortunately, the surgery did not go well and Mr. Gomez woke to a drop foot    and developed numbness in both legs. He was then diagnosed with an injury to his lumbar, sacral and pelvic sympathetic nerves. A right foot orthosis brace was authorized for the drop foot, however, the injections into the low back to  alleviate the pain were denied.

Here's where the story gets interesting. The surgeon appealed the denial for the injections, and low and behold the ICW UR, certified the treatment. Side note – make sure the doctors are accessible to you, so you can ask them or write to them to appeal noncertifications. Often times, this will work.  Nonetheless, the surgeon referred Mr. Gomez to a pain management doctor in the same practice and within the MPN. The pain management doctor evaluated him and agreed he required continued care and medications.  Mr. Gomez was then diagnosed with CRPS and experienced issues with his legs going numb. The pain management doctor, in his first report, noted the foot drop and the numbness but somehow in his report indicated that a neurological evaluation was done where all of the measurements were completed and Mr. Gomez had, "gait normal''.  See below at the bottom.

 

The same report goes on to indicate that:

The pain management doctor then goes on to do RFA's for Aquatic therapy, leg braces, a shower bench, and a shower hose. Simple right? Nope, the UR jumped on the ‘gait normal' and denied all of the requests. The basis for the denial, you guessed it, is if his gait is normal, then there is no need for any of this treatment. Even with the recognition of the failed back surgery, the drop foot, numbness in both lower extremities, and the CRPS, the UR hung their hat on the gait normal.

So as every good Applicant's attorney would do, I called the doctor and asked how his gait could be normal. What do you mean, the doctor exclaimed! So I responded, "your report says ‘gait normal' and if you look at all of your reports, that same paragraph is just reprinted over and over."  With that, he admitted that this was just a pre-populated part of the report and that he would rectify the issue with a supplemental report. He did issue a supplemental report by adding an addendum to the bottom of his last report.  Will this be enough to overturn the UR? I hope so, as I have spent hours trying to get Mr. Gomez this treatment. The defense attorney was very receptive, and I provided her with all of the information, so we will see how that goes.

To the extent that in your practice, you come across a populated portion of a medical report, READ IT  and call the doctor out on it immediately. This could save you hours of time and help your clients get the treatment they need.

 If you want more information and/or want to see documentation regarding this story, please email me at kmore@bentleymore.com or visit my website Bentley and More, LLP