This nurse review of the medical records revealed data points which raised concerns with this Motor Vehicle Accident-related claim. Despite his injury claim, the claimant delayed treatment — raising the possibility of an intervening injury – and the initial exam was coded to indicate a pre-existing condition. Plus, the claimant’s professional activities raised concerns about the claim.
The event and injury
The claimant – a man – was a restrained passenger in a vehicle which was side swiped by a truck at low speed. When the claimant first sought medical care three days post Date of Loss, he reported cervical, thoracic, lumbar pain and right shoulder pain.
He had surgery on his lumbar spine one year after the Date of Loss.
Mechanism of Injury (MOI)
The MOI was a side swipe impact at low speed on the driver’s side. The location of the claimant in the vehicle is unknown as there were several passengers reportedly in the vehicle. The MOI does not support subjective complaints.
Comparison of Pre and Post Date of Loss Records
No pre Date of Loss records were submitted for review.
The claimant delayed seeking medical care for three days after the date of loss. Anytime there is a delay in treatment it provides an opportunity for intervening injuries.
The chiropractor who treated the claimant on a specific 2017 date and post DOL billed the appointment as a new visit, but according to the records, the claimant appears to have been an established patient. Failure of the claimant and the physician to disclose that the claimant was an established patient – and possibly treating for the same complaints pre Date of Loss as he attempted to link to the Date of Loss – is concerning.
According to the initial chiropractic assessment three days postdate of loss, the physician documented several data points which raised concern about the claim with the nurse reviewer.
- First, it was noted that the claimant had treated with other providers prior to the time he initiated care on a 2017 date, but no other physician records were submitted for review.
- Second, he reported he was 0% improved since he initiated care, which confirms he was an established patient with this physician.
- Next, pain in the cervical, thoracic and lumbar spine was reportedly the “same with no improvement as compared to the last visit” again which confirms he had symptoms prior to the date.
- And finally, he was instructed to continue the previous plan of care.
The documentation supports that the claimant was most likely an established patient at the time he was seen on initially post MVA in 2017. It appeared that he was treating pre Date of Loss. The nurse saw a big red flag when she noted that the chiropractor tried to link the claimant’s complaints to the Date of Loss, since it appears the claimant was an established patient prior to the Date of Loss.
On 01/03/2018, the claimant’s clinical exam changed. He was referred for a lumbar MRI on 01/08/2018. Under clinical history on the MRI report was written “low back pain while bending to pick child, injury 11/25/2017.” Note that the claimant does not relate his pain to the MVA, but to lifting his child.
Imaging of the lumbar spine confirmed degenerative disc disease with facet arthrosis at L5-S1. Radiological findings were not acute.
In addition, no consideration was given that his job employed as a house painter caused or contributed to his pain complaints.
The Legal Nurse Consultant review established that the claimant was not a new patient with the chiropractor in late November 2017, raising concerns that the claimant was possibly trying to link prior pain to the DOL which he was already treating for. This is a reminder that pre-DOL baseline is critical,
The review also put a spotlight on the importance of coding. The nurse found the chiropractor billed the claimant for a new patient appointment, when he was an established patient. The claimant self-reported that he developed pain after lifting his child. He did not report the onset of low back pain to the MVA, raising the possibility of an intervening event.
The nurse review determined that the claimant was a house painter and continued to work. However, no consideration was given if his work activities were the etiology of his subjective complaints.