In this personal injury case, omitted pre-Date of Loss records specifically imaging reports caused the nurse reviewer to wonder if the claimant’s injuries were the same as before the accident or had progressed. The same is true of omitted post-DOL pain management records, which raised unresolved questions about the claimant’s care prior to the accident by the same doctor.
The event and injury
The claimant was a 55-year-old female who was struck by a taxi cab while standing in the street. She had gotten out of her vehicle to guide her husband out of a parking space when a cab that had been stopped began to move forward when the light turned green. The taxi driver did not see the claimant due to the sun being in his eyes.
There was no demand letter related to the claim. The claimant appears to be alleging that she exacerbated pre-existing degenerative disease in her low back for which she had had three prior surgeries.
Mechanism of Injury (MOI)
The police report for this case described the incident as a low-speed, low-impact pedestrian versus auto accident. It was not clear by this report if the cab hit the claimant on her right side or if she fell to her right side after being hit. In later reports of the MOI, the claimant stated she fell to the right and rolled under the cab.
Her complaints of right-sided flank pain, right hip pain, and right knee pain are consistent with the MOI.
Comparison of Pre and Post Date of Loss Records
The pre-DOL records reveal that the claimant had 3 prior lumbar surgeries including a laminectomy and 2 fusions. In addition, the claimant was treating with a pain management specialist up to the DOL and had received several sacroiliac injections for ongoing sacral neuritis and sacroiliitis. It appears she continued to treat with the same pain management physician post DOL.
However, the post-DOL records were not submitted for review. Furthermore, pre-DOL diagnostics and records related to her back surgeries were not submitted for comparison review.
The nurse reviewer flagged several concerns after her examination and analysis of the records in this case:
- While a mild lumbar soft tissue injury was possible the records did not identify acute significant injury.
- The claimant had an extensive pre-DOL history of low back pain. The claimant self reported the same complaints post-DOL.
- Despite her subjective complaints, her neurological exams were normal.
Finally, not all pre-DOL records were submitted. Comparison review of post-DOL imaging to pre-DOL imaging could not be done due to a lack of those records.
The claimant’s post-DOL complaints and exam findings were consistent with her pre-DOL history. This should mitigate the overall exposure. Nevertheless, selective omission of records is a red flag. While pre-DOL records were submitted, there were numerous records that were not. Specifically…
- Pre-DOL imaging reports would be helpful to determine if findings are the same or have progressed.
- Post-DOL pain management records were omitted and should be obtained to see if they align with the care provided by the same doctor prior to the accident.
Pre-existing 3 level fusion made the case a high-dollar exposure. However, understanding that a fusion carries increased, ongoing degenerative pathology in and of itself is important. Fortunately the event did not result in fractures or damage to the fused lumbar levels. There is no indication of new or worsening neurological findings, as the medical records supported soft tissue injuries.