Here’s another case where Mechanism of Injury (MOI) and a prior, degenerative condition figure into mitigating a high-exposure claim.

The claimant was a 48-year-old female injured in a retail store.  Based on the limited incident report, she was struck after grabbing a metal framing stud, when the bundles fell and struck her on the head, back, shoulders, arms, and neck.  The claimant was not transported by EMS, and no first aid was rendered in the store.

ER records were not submitted to determine injuries at the time of the loss.  After a two and a half month gap in treatment, the claimant appeared to have attended chiropractic treatment without submitted records.  MRI’s of the cervical spine, lumbar spine, bilateral knees, and left shoulder were performed, and the claimant received cervical and lumbar spine injections without relief.

According to the claimant’s medical records, she received surgical recommendations for left knee arthroscopic meniscus repair, cervical spine fusion and lumbar discograms.  In addition, the nurse reviewer found extensive diagnostics, including pain management injections, surgical recommendations for the left knee, neck fusion and discograms.

A demand was made for $2 million.

Mechanism of Injury (MOI)

The incident report indicated that the claimant was struck by a galvanized metal stud that would weigh approximately two pounds.  The claimant later reported she was transported to the ER, which would not appear factual from the incident report.

The lack of medical necessity for transport from the scene suggested a low-acuity injury, as severe injuries normally require EMS transport.  The incident report indicated the claimant was struck by the 2×10 galvanized metal stud.  Being struck by a falling stud would appear to have a mechanism to produce contusions.  There would not appear to be an MOI to produce knee, cervical spine, or lumbar spine injury.  Head contusion and shoulder contusion would appear possible and expected to be self-limiting.

The MOI did not appear to be present consistent with the claimant’s complaints, and it was judged that continued reported severe pain was inconsistent with function. Future cervical spine surgery would not appear related to the loss. MRI’s did not indicate any surgical pathology, and EMG study noted only mild irritation which would not appear to support surgery.  Medical necessity for discograms estimated future cost did not appear to be present.  Discograms can produce pain in discs that do not require surgery, and if surgery has been decided there would be no medical indication to perform.  In addition, this would appear unrelated to the loss at this time.


Here’s another case study where missing records figured into mitigating a claim.

Comparison of pre and post Date of Loss (DOL)

No pre-DOL medicals were submitted for review and analysis.  It’s important to note that pre-DOL medical records should be reviewed in order to establish a baseline of the claimant’s medical condition(s).

Inconsistencies

The claimant’s presentation of the facts of loss and her subjective complaints appeared to conflict with the incident report; namely…

  • The claimant was not transported according to the incident report, and there was no indication that the claimant was pinned under the studs.
  • She later reported she was transported and pinned, which is inconsistent and not supported by ER records, as such records were missing.
  • There was a large gap in treatment.
  • Excessive diagnoses did not appear to correlate with ER diagnosis of contusion
  • Missing records with gap in treatment.  Suspect chiropractic treatment that was not submitted.  Missing records of the clinical exam on the date of loss spoke to the acuteness and or chronicity of subjective complaints.
  • Radiological findings did NOT support acute or chronic pathology; instead, appear to be pre-existing degenerative knee and spinal findings.

Conclusion

Based on the incident report, it would appear that the claimant suffered self-limiting contusions.  The ER bill appeared to document the injury as a right shoulder contusion.  The claimant had a two and one half-month gap in treatment prior to obtaining advanced imaging.  Records to support medical necessity were not submitted, and gaps in treatment allowed for intervening events.

The claimant reported severe pain symptoms inconsistent with gaps in treatment and lack of narcotic use, and the MOI for bilateral knee complaints would not appear to be present.  Diagnostic studies indicated degenerative findings.

In addition, the relationship of the cervical and lumbar spine complaints would appear to be questionable based on the incident report, and medical necessity for injections and surgical recommendations would not appear to be present.

Briefly stated…

  • None of the treatments would be recommended as related.  Complete ER records are needed prior to determining if the ER visit was related to the reported incident.  All missing records would be needed to determine if any additional treatments were related.
  • Claiming need for surgery that would not appear to be present based on gap in treatment, ER diagnosis codes, and incident report

My takeaways…

  • This is another example of a teachable case where MOI and data relating to degenerative pathology will make or break a claim.
  • Reported MOI details are extremely important in aligning and analyzing alleged medical injuries
  • Gaps in care are typically a RED flag and often supports resolution of a medical condition.
  • A growing list of subjective complaints after an immediate period of time is suspect.  Typically, most acute/traumatic injuries are readily diagnosable.   This is particularly true if new body area/impact points are reported several weeks after the fact.

KARI