In this MVA-related case study, MKC red-flagged some big inconsistencies that helped to mitigate a $2.85 million demand. It underscores the importance of Mechanism of Injury (MOI) and of sounding the alarm when key records are missing! See if you can spot anything else that ought to figure into the claim.
The injury accident
A 58-year-old male with long-standing, pre-existing degenerative disease of cervical and lumbar spine, was in a low-speed collision as a restrained driver. The man was able to drive his vehicle from the scene, and his vehicle had mild damage.
The claimant presented to the emergency department hours later, complaining of neck, low back, and left shoulder pain. He was treated and released from the ED with a soft tissue injury diagnoses.
The claimant treated his injury with orthopedics and chiropractic care and he had multiple imaging studies. He eventually underwent a left rotator cuff repair and then an ACDF (anterior cervical discectomy and fusion).
The patient’s lawyer alleged that the claimant sustained an acute cervical injury and rotator cuff tear as a result of the accident. Later in the timeline, he had subjective complaints of a head injury. A demand for $2.85 million was made.
MKC’s review and analysis
Regarding Mechanism of Injury, the claimant’s description of the accident in the ED was consistent with the police report, inasmuch as the accident involved a low-speed, rear-end collision with claimant as an injured driver. We note that the claimant later expanded his description of the MOI to state he hit his shoulder on the steering wheel; hit his head on the headrest; that he was taken by ambulance to the ED; and that his car was totaled — none of which were supported by documentation.
The claimant’s initial presentation was consistent with soft tissue neck strain. He did not present like an individual with a significant internal shoulder injury (i.e., his initial ED exam noted normal function), serious head injury/concussion or an acute cervical spine injury.
When we compared pre-Date of Loss and post-Date of Loss records, here’s what we found:
- Pre-DOL records outline a multiple-year history of neck and low back pain.
- Pre-DOL cervical and lumbar MRIs were significant for multi-level degenerative pathology.
- Post-DOL cervical and lumbar MRIs were significant for degenerative pathology at the same levels with noted progression of the disease.
While there were numerous pre-DOL records, they ended with a date of service nine years prior to the DOL. Given the prior history of neck and back pain, the lack of records is concerning.
Some patterns emerged for us after looking at the claimant’s presentation and the medical records. These included several inconsistencies:
- First, the MOI aligned with his subjective soft tissue complaints in the ED. However, the allegations of a left rotator cuff tear, head trauma and acute cervical disc injury are inconsistent with the medical data points. As we’ve noted, the mechanics of the MVA and initial exams do not support internal derangement of the left shoulder. Additionally, a significant lumbar and/or head injury was not supported by data points.
- In addition, there were several gaps in treatment after the claimant’s ED visit that were not consistent with the acute injuries that he was alleging. The claimant reported new subjective complaints consistent with a traumatic brain injury (TBI) 14 months post DOL. The medical timeline, in conjunction with the MVA information would not support a TBI.
- The claimant’s occupation was that of a left-hand dominant construction worker/painter who also liked to restore old cars. His work and recreational history placed him at risk for repetitive motion pathologies as well as multi-joint degeneration. Pre and post DOL spinal MRIs noted the same degenerative pathology at the same levels.
Finally, the left shoulder MRI revealed degenerative changes in the joint. And, pre and post DOL subjective complaints were similar, and exam findings were consistent.
After nurse review and analysis, MKC recommended only the initial ED visit and the four chiropractic visits. Based on the nurse review and analysis, recommended services included only the initial ED visit, the four chiropractic visits and the initial physician visit. The anterior cervical discectomy and fusion surgery were not recommended based on the submitted records. These exceptions to the claim helped to significantly mitigate the overall exposure of a $2.85 million demand.
A big-red-flag take-away
It is very important to understand the importance of the pre-DOL records. In this case, there were pre-DOL records going back to 11 years prior to the accident in question. However, records for the nine years prior to the DOL were not included.
Considering the claimant’s longstanding history of cervical and lumbar disc disease, these records are critical to understanding his baseline status prior to the DOL. The lack of records may be a deliberate attempt to suppress information that would support a recent treatment history for his degenerative pathology.