This motor vehicle accident case illustrates the importance of complete medical and occupational records.  It also shows how a thorough and detailed review and analysis was of value to the client.

The event and injury

The claimant was the restrained front seat passenger involved in a low-velocity impact MVA.  The claimant presented for treatment the day after the loss with symptoms of only shoulder tenderness that expanded over time with physical therapy, pain management and excessive diagnostics.  A formal demand was not submitted.

Mechanism of Injury (MOI)

The nurse reviewer noted that the MOI in the police report differed from what was reported by the claimant in the ER, who reported the vehicle was struck so hard it lifted off the ground.  The two MOI versions were radically different

The reported MOI is inconsistent with a front passenger left shoulder trauma.  According to the records, neither was the claimant tossed about the interior nor were there reports that the shoulder was moved in an abnormal way.  Shoulder injuries have a typical/common mechanism signature.  A low speed MVA is not one of them.

Finally, the areas of impact on the vehicle and the claimant’s body did not correspond to the subjective complaints, as there would not be any expected interior impact to the left shoulder (as a front seat  passenger) from the MVA.


MVA-related claims are driven by complex data and analysis.  In their review and analysis, nurse reviewers are careful to look at Mechanism of Injury and other key data points

Comparison of Pre and Post Date of Loss Records

The nurse reviewer reported that no pre-DOL records were submitted.  Despite the lack of pre-DOL records, the claimant’s occupation as a nursing assistant puts her at added risk for injury and potential for prior injury. 

Inconsistencies and Take-aways

There were seven sets of inconsistencies in the records flagged by the nurse reviewer in this case:

  • The MOI did not align with subjective complaints and objective exam findings.  The claimant was the restrained front seat passenger in low-velocity impact.  Left shoulder trauma/pain would not appear to have a related Mechanism of Injury in this case.
  • Subjective complaints were reported too late in the timeline to clearly correlate with the MOI and were disjointed as they relate to initially non-reported body impact points secondary to the MVA.  Once the claimant sought treatment with pain management four days post-DOL, she claimed new onset of neck pain, mid back pain, low back pain, right knee and left elbow pain — all inconsistent with the initial exam and physics of a low velocity impact.
  • The claimant’s symptoms on the DOL suggested a possible cause other than the MVA and/or complaints not supported by objective data points. The claimant only had tenderness without objective loss of motion or strength.  In other words, the clinical exam on the date of loss did not align with an acute injury or really a chronic one.
  • The radiological findings reviewed did not support acute or chronic pathology.  For example, x-rays performed in the ER on the day after the loss suggested minor soft tissue injury only.  MRI studies did not correlate with physical exams, noting normal neurological and orthopedic testing.
  • A lumbar MRI noted degenerative facet enlargement and stenosis consistent with age; a knee MRI noted an old medial collateral ligament injury supporting pre-existing pain; and, a left elbow MRI noted effusion that would appear consistent with her occupation that requires repetitive lifting, as no left elbow injury was reported on the DOL. Of interest, a shoulder MRI was never completed.
  • No pre-existing medical issues were reported that would affect post-DOL medical issues/radiological findings.
  • Initiation with a pain management practice FOUR days post DOL is irregular and was considered a red flag.  The claimant did not meet criteria for chronic pain management supervision.

Conclusions

Only the initial ER evaluation the day after the loss was recommended, as the claimant’s reported severe pain and ongoing subjective complaints were inconsistent with the MVA and medical necessity for pain management treatment.

KARI