In this case, a low-velocity Motor Vehicle Accident resulted in injury claims that were not clinically consistent with objective findings.  The data points suggested other motives for treatment or possible drug seeking behavior.  These data points were:

  • The Mechanism of Injury produced by a low velocity impact from a trailer backing into a traverse is atypical for severe lumbar radicular pain and right knee injury (no knee strike)
  • Degenerative MRI findings consistent with chronic changes rather than acute ones
  • Lack of objective findings to clinically correlate with MRI to support subjective symptoms

In addition, the claimant’s prolonged severe pain complaints were disproportionate with objective clinical examinations, suggesting other motives for treatment or possible drug seeking behavior.

The event and injury

The claimant was in a low-velocity MVA when a trailer backed into a traverse vehicle.  Initial subjective complaints included severe radicular lumbar spine pain and right knee injury absent any knee strike or contusion.

The claimant’s treatment consisted of excessive diagnostic studies, prolonged physical therapy and pain management treatment.  The claimant’s attorney demand was not submitted for review.  In addition, there was no report of injury at the scene and the reviewer noted that the claimant waited three hours before driving to seek treatment. 

Mechanism of Injury (MOI)

The nurse reviewer found the MOI in the police report was the same as what was reported by the claimant.  In addition, the nurse noted that claimant reported the backing incident to all providers, correlating the initial MOI with the physician and EMS records.

However, when assessing whether the claimant’s subjective complaints aligned with the MOI, the review concluded that severe lumbar radicular pain and right knee injury was not consistent with a low velocity impact from a trailer backing into a traverse. Moreover, the reviewer’s analysis found that a low velocity impact would not appear to have the force to produce lumbar or knee injury.


MVA claims often carry red flags with them.  Couple that with exploding substance abuse, and you have a potentially costly exposure.

Comparison of Pre and Post Date of Loss Records

No preDOL records or diagnostics were submitted for review and comparison. However, given the noted degenerative changes on the post DOL diagnostics, it is possible the claimant had undergone prior treatment for some of post DOL complaints.

Inconsistencies

The nurse reviewer found that the MOI did not align with subjective complaints and objective exam findings.  Severe radicular lumbar pain is atypical with no report of injury at the scene or ability to drive three hours prior to seeking treatment.

In assessing whether subjective complaints were reported too late in the timeline to correlate with the MOI, the nurse reviewer found that the MRI noted degenerative changes consistent with age along with normal neurological exam on the date of the loss.  A much later MRI of the right knee noted minimal effusion (thought to be associated with degenerative pathology), and an exam on the DOL noted no injury to the right knee. Extreme pain (10/10) in the setting of low velocity impact and without objective data is a red flag and can draw into question the motives of the claimant.  Despite ongoing complaints and post DOL diagnostics, no acute pathology was identified and the neurological and orthopedic examinations remained normal/negative. In this case, the MRI findings supported pre-existing degenerative pathology.  In addition to pre-existing degenerative disc disease, the claimant’s delay in onset of right knee pain suggests an intervening event.

Conclusions

The big teachable moment in this case is to be sure to align subjective complaints and objective findings.  The nurse reviewer discovered several incongruent data points, including a Mechanism of Injury inconsistent with severe lumbar radicular pain and right knee injury and a degenerative MRI consistent with chronic changes rather than acute ones.  Moreover, the reviewer noted that severe radicular lumbar pain is not consistent with no report of injury at the scene or ability to drive three hours prior to seeking treatment. 

In short, the nurse noted a lack of objective findings to clinically correlate with MRI to support subjective symptoms.