A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL

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1 CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z v. INS. CO. CLAIMS NO.: MOTOR CLUB OF AMERICA INS. CO DRP NAME: Margaret Knuetter (Respondent) NATURE OF DISPUTE: Medical necessity AWARD OF DISPUTE RESOLUTION PROFESSIONAL I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP), designated by the American Arbitration Association under the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New Jersey Automobile Insurance Cost Reduction Act as governed by N.J.S.A. 39:6A-5, et. seq., and, I have been duly sworn and have considered such proofs and allegations as were submitted by the Parties. The Award is DETERMINED as follows: Injured Person(s) hereinafter referred to as: EV and IR. 1. ORAL HEARING held on 11/17/ ALL PARTIES APPEARED at the oral hearing(s). NO ONE appeared telephonically. 3. Claims in the Demand for Arbitration were AMENDED and permitted by the DRP at the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made by the parties regarding the issues to be determined (Stipulations, if any, set forth below). For EV: the bills for Paramus Surgery Center, Amrish Patel and Thomas Ragukonis are withdrawn. 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: This is a claim for payment of bills incurred by EV and IR as a result of an auto accident of 9/19/00. Claimant submitted the following: For EV: HCFA from Gleason Chiropractic Center, DOS 4/1/02 through 10/30/02 Report of Charles Gleason, DC, dated 10/19/02. Dr. Gleason states that EV was involved in an auto accident on 10/19/00. Positive findings included positive compression,

2 CASE NO. 18 Z bilateral shoulder depressor, Dejerens traid and Valsalva, Kemps bilateral, SLR bilateral, hypoesthicia left C2, C5, T2, T7, T12, DTR +1 of biceps brachioradialis on left, achilles reflexes on left, decreased ROM in all planes of cervical and lumbar spine. MRI of lumbar spine revealed herniations at L3-4, L4-5, L5-S1. MRI of cervical spine revealed herniations at C2-3 and C6-7 with spondylitic ridging at C3-4 and C5-6. MRI of the right knee revealed tear of the posterior horn of medial meniscus. Upon review of her subjective findings, chiropractic treatment consisted of manipulations to the vertebral column, hydrocollator and electrical muscle stimulation, kinetic activities and 3D active trac table to decompress the cervical and lumbar disc. Letter from to Dr. Gleason, dated 7/22/02 advising that benefits are terminated effective 4/13/01 Notification from Dr. Gleason of commencement of treatment, faxed 5/9/02 requesting pre-certification. SOAP notes of Dr. Gleason for all dates of service with physical examinations dated 4/1/02 through 10/25/02 Prescription from Thomas Ragukonis, MD for treatment with Dr. Gleason 3xweek for 4 weeks, dated 4/10/02 Follow up evaluation of Dr. Ragukonis, dated 6/27/02. Dr. Ragukonis has dismissed EV from his care and she will be continuing to see Dr. Gleason, Dr. Massoud and Dr. Ruoff. Operative report of Dr. Ragukonis, dated 10/23/02 for provocative discography, L3-4, L4-5 and L5-S1, manometric study at same levels and fluoroscopy. Operative report of Dr. Ragukonis, dated 3/13/02 for bilateral psoas myograms, bilateral psoas compartment blocks, caudal epidural steroid injection, caudal epidural serapin injection and fluoroscopy. Report of Dr. Gleason, dated 8/15/03. Dr. Gleason states that EV began chiropractic treatment with Dr. Andrew Hogan after the accident with limited improvement. She also underwent physical therapy with limited success. Dr. Hogan referred her for MRI studies. Upon discharge, her complaints continued and she presented to Dr.Ragukonis on Feb. 6, He performed a series of three caudal epidural steroid injections. Due to the severity of her ongoing pain syndrome, she presented to his office on 4/1/02. He examined her and the results are above. His diagnosis was cerviial sprain/ strain, HNP at C2-3, C6-7, L3-4, L4-5 and L5-S1. At the time of the last examination, she was still complaining of significant neck, midback, low back, shoulder and left knee pain. She is unable to tolerate much standing, sitting, walking and lifting. Initial evaluation of Dr. Ragukonis, dated 2/6/02 For IR: HCFA from Dr. Gleason, DOS 4/1/02 through 10/702 HCFA from Dr. Ragukonis, DOS 3/13/02 through4/10/02 HCFA from Richard Siegfried, MD, for DOS 4/10/02 Bill from Medical Park Imaging, for DOS 5/15/02, and 5/19/02 Fax from QRS Managed Care to Dr. Gleason advising him that as of 6/21/01, IR was at MMI for chiropractic care and no further treatment will be allowed. Letter from MCA to Dr. Gleason advising that due to IME of Dr. Lawrence Keller no fault benefits were terminated on 7/22/01 Report of Dr. Gleason, dated 10/19/02. Dr. Gleason states that IR was involved in an auto accident on 10/19/00. Positive findings included: positive compression, bilateral shoulder

3 CASE NO. 18 Z depresser, positive Dejerens traid and Valsalval, Kemps test positive on bilateral, positive SLR bilateral, hyposthicia left C2, C5 T7, T12 bilateral, DTR decreased +1 of biceps brachioradialis positive on the left side, achilles reflexes positive on left, decreased ROM in all plains in cervical and lumbar spine. MRI of 10/27/00 of the thoracic spine had revealed spondylosis deformans. MRI of the lumbar spine revealed HNP at L5-S1, MRI of cervical spine revealed bulging of the annulus fibrosis at C5-6. Chiropractic treatment consisted of specific manipulative adjustments to the vertebral column, application of hydrocollator and electrical muscle stimulation, kinetic activities and 3D active trac table which decompresses the cervical and lumbar disc. Fax to QRS from Dr. Gleason to advise of commencement of treatment, dated 5/9/02 with attachments SOAP notes from Dr. Gleason for all dates of service Operative report of Dr. Ragukonis, DOS 4/10/02 for bilateral psoas compartment blocks, bilateral psoas myograms, caudal epidural steroid injection, caudal epidural Serapin injection, caudal epidurogram and fluoroscopy. Operative reports of Dr. Ragukonis, DOS 3/13/02 3/27/02 for caudal epidural steroid injection, caudal epidrual Serapin injection, caudal epidurogram and fluoroscopy. EOB from MCA showing payment of bill to Dr. Ragukonis after adjustments Letter to Dr. Ragukonis from QRS advising of modification of treatment to trigger point injections HCFA from Richard Siegfried, MD for DOS 4/10/02 Bill from Medical Park Imaging for DOS 5/1/01 through 5/5/01 HCFA from Paramus Surgery Center for DOS 3/13/02 through 4/10/02 Follow up evaluation of Dr. Ragukonis, dated 4/25/02. Dr. Ragukonis stes that IR is status post three invasive pain management procedures to her lower back. She states that she is 70% improved but is dissatisfied with this. She will continue physical therapy with Dr. Gleason. Regarding her cervicalgia, she is 60% improved under Dr. Gleason and was encouraged to get one cervical epidural steroid injection which she is reluctant to do. Initial evaluation of Dr. Ragukonis, dated 2/20/02. Dr. Ragukonis states that IR had been treating with Dr. Hogan for chiropractic care which had limited success. He examined her and his impression was myofascial pain syndrome, bilateral psoas muscle spasm, herniated disc at L5-S1, disc dessication of the lumbar spine, cervicalgia, left upper extremity radiculopathy, herniated disc of cervical spine and dessication of the cervical vertebral bodies. His plan was to continue care with Dr. Hogan, to engage in lumbar epidural steroid injection with examination before the injection to evaluate the need for psoas compartment blocks or trigger point injections. Report of Dr. Gleason, dated 8/15/03. Dr. Gleason states that IR had been treating with Dr. Hogan with limited success. She first presented at this office on 4/1/02 with complaints of sharp stabbing neck pain radiating into the left arm with numbness and tingling in both hands, constant mid back pain, and constant low back pain radiating into the left leg, daily headaches. He examined her and his impression was cervical sprain/ strain, disc herniations at C5-6 and L5-S1 Respondent submitted the following: For EV:

4 CASE NO. 18 Z Peer review of Jeffrey Schlesinger, DC dated2/13/01. Dr. Schelesinger reviewed records submitted to him and determined that the treatment by Dr. Hogan from 9/20/02 through 1/29/01 was medically necessary as was a referral to Dr. Noor. Letter to Dr. Ragukonis denying treatment plan. Report of Lawrence Keller, DC, dated 3/289/01. Dr. Keller examined EV on that date and reviewed records submitted. He determined that she has not responded appreciably to chiropractic care despite a consistent treatment regimen. She has attained maximum therapeutic benefit from chiropractic. Letter to EV from MCA advising of termination of chiropractic benefits effective 4/13/01 Denial letters fro Chiropractic Center, and Main Medical Imaging Report of E. Megariotis, MD dated 3/25/02 re orthopedic evaluation. Dr. Megariotis determined that EV needed surgery to her right knee. Follow up report of Dr. Megariotis, dated 7/2/02. He determined at that time that she had not reached maximal attainable medical benefits. She required additional physiotherapy and rehabilitation of her neck, both legs shoulders and low back, but of an active nature rather than passive chiropractic manipulation which he believed may be aggravating her severe facet arthrosis and contractures and worsening the pain she is experiencing. He questioned the need for the additional chiropractic treatment by Dr. Gleason. Report of Felix Roque, MD, dated4/11/02. Dr. Roque examined EV on that date and his impression was that she had resolved cervical, lumbar sprain and lumbar radicular pain. Her main symptoms are due to underlying osteo arthritis disease worsened by the accident. He recommended one additional month of physical therapy and an orthopedic evaluation of her right knee. From a pain management perspective, he found that she had reached maximum medical benefits. Letter from respondent to Gleason Chiropractic Center denying payment. Letter to EV from Preserver Group advising of denial of pain management benefits. For IR: Report of Lawrence Keller, DC, dated 4/9/01. Dr. Keller examined IR on that date and reviewed records for respondent. He found that she has responded favorably to chiropractic care and is capable of performing her normal daily routine. Her subjective complaints were substantiated by objective findings warranting continuation of her chiropractic are of one visit per week for six to eight weeks prior to re-evaluation. Follow-up report of Dr. Keller, dated 6/27/01. Dr. Keller re-examined IR and found that her clinical status is essentially unchanged since her last exam and that she had reached maximum therapeutic benefit. Letter from respondent to IR informing her of termination of chiropractic benefits effective 7/22/01 Letter from QRS to Dr. Andrew Hogan, dated 10/12/01 informing him of termination. Letter from QRS to Dr. Ragukonis informing him of non-certification pending IME. Request from QRS for that IME Report of Todd Koppel, MD dated 4/2/02. Dr. Koppel examined IR on that date for respondent. He determined that she had not reached maximum medical improvement and recommended trigger point injections. He agreed with the two lumbar epipdural steroid injections performed by Dr. Ragukonis but did not find any further injections appropriate or medically necessary given the patient's poor response thus far.

5 CASE NO. 18 Z Respondent has also advised that the benefits afforded EV have exceeded $200,000 and that there may be additional bills of which they are currently unaware. I have reviewed the submissions of the parties. I find that claimant EV has sustained the burden of proving that there was a need for additional chiropractic care, but I find that respondent has presented a strong position regarding the lack of medical necessity for that care. For that reason, I am awarding 50% of the demand for Dr. Gleason which will be subject to reduction for fee schedule. That award is also made subject to availablity of any remaining coverage under the policy. I further find that for the two epidural injections of 3/13/02 and 3/27/02, respondent has not paid a total of $2400. Since it is conceded that these injections were medically necessary, I am awarding that amount. I am denying the demand for the injection of 4/10/02 as well as the bill for the anesthesiologist for that date. I can find no reference to the diagnostic studies performed by Medical Park Imaging in the submissions and I am therefore denying those as well. As to the bill of Dr. Gleason, I find that while there was a need for additional treatment, there should have been a reduction in the number of visits and increase in the periods between such visits. I am awarding 60% of the demand for Dr. Gleason, subject to reduction for fee schedule. Interest has not been calculated and is deemed waived. Attorney fees and costs are awarded. 5. MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to For EV - Gleason Chiropractic Center For IR - Gleason Chiropraactic Center Thomas Ragukonis, MD Richard Sigfried,MD Medical Park Imaging $14, $7, Claimant & attorney $13, $7, " " $7, $2, " " $1, $0.00 $ $0.00 Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. Award to Gleason Chiropractic Center subject to reduction for fee schedule. Also subject to availabilty of benefits to EV 6. INCOME CONTINUATION BENEFITS: Not In Issue

6 CASE NO. 18 Z ESSENTIAL SERVICES BENEFITS: Not In Issue 8. DEATH BENEFITS: Not In Issue 9. FUNERAL EXPENSE BENEFITS: Not In Issue 10. I find that the CLAIMANT did prevail, and I award the following COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A. 39:6A-5h. (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $325 filing fee (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1800. (C) INTEREST is as follows: waived per the Claimant.. This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. 12/19/03 Date Margaret Knuetter, Esq.