Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, CLCP, MSCC, LNCC
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- Kristian Gilbert
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1 FIG Services, Inc. P.O. Box 1161 Hendersonville, NC (828) Ph (828) Fx FIGservices.com March 12, 2014 Susan J. Sadow, P.C. Attorney Susan Sadow 400 Galleria Parkway, Suite 1500 Atlanta, GA Phone: 770/ Fax: 770/ Re: Danielle Opher (DOB: 01/13/80) Dear Mrs. Sadow, Thank you for the opportunity to assist with Ms. Danielle Opher. It is understood you are requesting that I review the provided medical records regarding injuries sustained on 09/21/2012 and project Ms. Opher's future medical care with associated costs. In the essence of time, details of Ms. Opher's medical diagnosis/ treatment/rehabilitation/recovery and subsequent symptoms/residual disability are deferred to the medical records. As requested, this letter will serve to identify future care and associated costs for Ms. Opher's future medical care. These costs are based on usual/customary & reasonable charges (70%ile) within Ms. Opher's geographical location. Future medical care and associated costs include the following diagnosis - status post left epicondylitis, status post left lateral epicondyl release with partial ostectomy & extensor mechanism repair (04/12/13), left upper extremity Reflex Sympathetic Dystrophy (RSD), right lower extremity RSD, and severe depression. Past medical treatment has included surgery, left upper extremity stellate ganglion blocks, lumbar sympathetic nerve blocks, medications, physical therapy, and assistance with activities of daily living. Ms. Opher continues with symptoms/pain limiting her functioning and interfering with her return to work and activities of daily living. Thank you for the opportunity to assist with Ms. Opher's case. Best regards, Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, CLCP, MSCC, LNCC Nurse Life Care Planner
2 FIG Services, Inc. P.O. Box 1161 Hendersonville, NC (828) Ph (828) Fx FIGservices.com Visits, Dr. Fowler/Pain Management Monthly x 2 years, then every 3 months x 2 years, then every 6 months $ $16, Georgia WC Fee Schedule (GWCFS) Visits, Dr. Payne/Orthopedist (left upper extremity) Visits, Dr. Titelman/Orthopedist (right shoulder) Visits, Ms. Klopstock/Counselor Every 3 months x 2 years, then every 6 months x 2 years, then yearly Every 3 months x 2 years, then every 6 months x 2 years, then yearly Weekly x 6 months, then 2x/month for 6 months $ $7, GWCFS $ $7, GWCFS $ $7, Alejandra Klopstock Psychological evaluation (SCS trial) Once $ $ GWCFS Stellate ganglion blocks series in 2 years (3 injections per series) G8907 G $ $9, GWCFS
3 Lumbar sympathetic blocks series in 2 years (3 injections per series) G8907 G $ $9, GWCFS Ketamine infusion trial Allow $ $1, GWCFS Spinal cord stimulator trial Once $7, $7, GWCFS Spinal cord stimulator implant Once $35, $35, GWCFS Spinal cord stimulator revision Allow $35, $105, GWCFS Spinal cord stimulator annual programming Yearly $ $4, GWCFS PT evaluation Allow $ $ GWCFS PT sessions sessions per year x 2 years $ $3, GWCFS Page 3 of 6
4 OT/PT evaluation Allow 2 evals $ $ GWCFS OT/PT sessions Allow 12 sessions per eval $ $2, GWCFS OT home evaluation Once $ $ GWCFS X-rays, left elbow Allow $ $ GWCFS MRI, left elbow Allow $1, $2, GWCFS X-rays, right shoulder Allow $ $ GWCFS MRI, right shoulder Allow $1, $2, GWCFS Comprehensive metabolic profile (CMP) ** Yearly $ $1, GWCFS Page 4 of 6
5 Therapeutic drug assay Yearly $ $2, GWCFS Cymbalta 60mg/day (#30) (generic) Monthly $ $117, CVS Hydrocodone 10/325mg 4x/day (#120) (generic) Monthly $ $42, Kroger Nortriptyline 50mg evening (#30) (generic) Monthly $ $12, CVS Ondanestron 4mg 3x/day (#90) (generic) Monthly $ $125, Kroger Zonisamide 100mg 4x/day (#120) Monthly $ $102, Publix Oxcarbazepine 150mg 2x/day (#60) Monthly $ $45, Kroger Hydromorphone 2mg 6x/day (#180) Monthly $ $39, Kroger Specialized compound cream 3-4/x day (360 grams/month) Monthly x 2 years $2, $70, Page 5 of 6 Westchase Compounding Pharmacy
6 TENS unit (Flex-It, 4 leads) Every 5 years $ $5, Lgmedsupply.com TENS unit supplies Every 3 months $ $8, Lgmedsupply.com Mileage Allow for miles RT $ $2, IRS.org TOTAL $800, DOB 01/13/80 (age 34, 46.0 LE) Page 6 of 6
WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT
FIG Services, Inc. P.O. Box 1161 Hendersonville, NC 28793 828.698.9486 Ph 828.698.9327 Fx FIGservices.com WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT CLAIMANT: Mr. James Lee Richards CARRIER: Ohio
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