Paralyzed by the System but Never Crippled
by Keith More

 

My client on April 19, 2019, fell through a skylight while at work for telecommunication giant Ericsson, Inc. The fall resulted in him being paralyzedfrom the waist down at age 22. At 22 years old, this vibrant young man found himself unable to stand, unable to walk, unable to urinate on his own and unable to live a normal life as he once knew. We knew we had both a Work Comp case and a Third Party PI case. We also knew there was a ton of employer negligence. Nonetheless, the building owner had a limited multimillion dollar insurance policy and through the Civil Action we were able to obtain the policy limits. Additionally, another defendant in the Civil Action paid another 8 figures due to some masterful litigation by two of my partners Greg Bentley & Clare Lucich. The lien from the Work Comp case was waived and saved my client an additional 2.5 million dollars. 

Keith More

But, that is not what this article is about. This article is about the incredible UR system we have in place that is denying paralyzed 22 year olds medical treatment. Following 3 years of rehabilitation including several months in Chicago at the Shirley Ryan Ability Lab this now 25 year old young man, can stand with the assistance of AFO braces for minutes at a time. On July 19, 2022, an RFA was received by Constitution State Services and according to the UR, the recommendation letter was completed by Genex for Constitution State Services. Hmm, I thought utilization review was to be done by doctors. Well, because the AFO braces were not fitting properly and needed adjusting, the PTP did an RFA for "bilateral AFO evaluation".

Shockingly, the UR recommendation prepared by GENEX indicates that there is inadequate clinical data suggestive of pathology to support the need for AFO evaluation. Say what???? The pathology is a documented fact that my client is paralyzed. How is that for supportive documentation both objective and subjective. Dr. Lisa Pitino a DO licensed in CA noncertified the evaluation. Upon performing a google search, Dr. Pitino has an office at 2212 E 4th St. in Santa Ana. Dr. Pitino appears to have a reputable office working with St. Joseph Heritage Group.

The PTP also asked for two hours of home health aide, a gardener and a pool cleaner. With all of his rehabilitation and will to stand, this prideful young man with a lifetime ahead of him only needs two hours a day in help. Some paraplegics require 24/7 help, while others may require 8 hours per day, yet two hours is denied. I ask the doctor, how would you like him to mow his lawn, or pull weeds. How shall he clean the pool ? The case law in CA is clear, these are compensable items.

The more amazing thing about the UR noncertification is the fact that the PTP requested a modified vehicle. A modified vehicle that a 25 year old could use to regain some sense of independence. He was authorized to undergo a driver's evaluation and sure enough he passed no problem. Specifications were provided as to what he needs as a paraplegic to drive, and of course Dr. Pitino non-certified the request saying, "there was inadequate clinical data suggestive of pathology to support the need for a modified vehicle. As such, the request for a modified vehicle that includes left column-mounted push/pull hand control, a left drop-down signal extension, and a right spinner knob at 2 o'clock." She even notes the actual specs for the car.

What do you mean "inadequate clinical data"? I cannot make this up, this is copied right out of her UR noncertification.

History of Condition: This case involves a now 25-year-old male with a history of an occupational claim from 04/19/2019. The mechanism of injury was detailed as fall. The current diagnosis was documented as traumatic spinal cord injury secondary to fall with LI incomplete spinal cord injury, and paraplegia secondary to spinal cord injury. The comorbid condition was noted as sexual dysfunction and neurogenic bladder retention.

To this end, I have now written a letter to Dr. Pitino asking her if these are really her professional medical opinions or are these the opinions of GENEX. Even UR doctors have to read these recommendations by someone else when dealing with catastrophically injured human beings. We will not allow anyone to cripple us into these outrageous denials. The sad thing is that even with us doing an IMR that outlines all of the above, MAXIMUS will most likely uphold these non-certs. Point being, never give up.

Click here if you want to see documentation regarding this story, please contact Keith More.