LIABILITY MEDICARE SET-ASIDE ARRANGEMENT

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Annabel Russell
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FIG Services, Inc. P.O. Box 1161 Hendersonville, NC 28793 828.698.9486 Ph 828.698.9327 Fx FIGservices.

1 FIG Services, Inc. P.O. Box 1161 Hendersonville, NC Ph Fx FIGservices.com LIABILITY MEDICARE SET-ASIDE ARRANGEMENT CLIENT: John Smith SOCIAL SECURITY NUMBER: XXX-XX-1234 DATE OF INJURY: 10/16/2010 GENDER: Male DATE OF BIRTH: 07/13/1959 CURRENT AGE: RATED AGE: n/a LIFE EXPECTANCY (RATED LE): 27.1 years chronological age; rounded to 27 years JURISDICTION: Ohio MSA CALCULATION METHOD: UCR MSA ALLOCATOR: Shelene Giles REPORT DATE: 06/04/14 55 (life expectancy calculated from 55 - since less than 6 weeks to birth date) CURRENT ICD-9 DIAGNOSES CODES: 805.0, 805.2, 553.9, x2, x2, 820.0, x3 Medicare-Covered Proposed Amount (Medical Expenses) $ 82, Medicare-Covered Proposed Amount (Medications) $ 16, Total Medicare-Covered Services $ 100, Annuity Information Seed Amount $7, Annual Payment Amount $3, The total Liability Medicare Set-Aside (LMSA) recommended allocation is $100, (rounded to nearest dollar amount), inclusive of both future medical cost and future prescription treatment. Should an annuity be utilized to fund the LMSA account, a seed amount of $7, (to include the first two (2) years medical/prescription cost) would be recommended with the remaining funds of $92, to be divided over the remaining life expectancy. The remaining annual payments (life expectancy - 1) would be in the amount of $3, It is anticipated that an LMSA will assist in the claim settlement for future injury-related medical care by adequately addressing the interests of Medicare in accordance with the Medicare Secondary Payer Act (42 U.S.C. 1395y(b)(2)). This LMSA was developed by applying information found in the medical records, miscellaneous documentation, correspondence, and experience of this MSA Allocator. The LMSA calculation of future injury-related expenses is based on the research and the opinion of the author of this plan. If more information becomes available at a later date, an additional report will be considered to update the LMSA upon request. Additional information may or may not change the LMSA amount. The recommended Page 1 of 11

2 allocation may be recalculated and/or reduced upon receipt of additional medical information. Should there be a significant change in medical treatment, additional medical records should be provided and the LMSA should be reviewed/revised as needed. Significant changes in the medical condition and/or new medical information not available at the time of this LMSA writing that would change the future medical cost allocation, before CMS approval, requires CMS notification and submission of a revised LMSA Arrangement reflecting these changes. All figures used to calculate the LMSA allocation may be based on one or all of the following sources: Physicians Fee Reference 2014, Medical Disability Advisor, PowerTrak, or MedData, national/local vendors, and CDC Life Expectancy Table. Recommendations are based on treatment rendered within the last three (3) years along with projected treatments according to the individual s diagnoses. These costs are rounded to the nearest dollar. Present day (2014) costs were utilized and no provisions have been made for future inflation. This LMSA may be subject to approval by the Centers for Medicare & Medicaid Services ( CMS ) if the settlement meets CMS workload threshold criteria. Good faith efforts have been made to adequately consider Medicare s future interest. Per the CMS Policy ID 3976, certain classifications of medication are not covered under Medicare Part D Prescription Drug Program. These medications included, but not limited to, over-the-counter medications. If applicable, these drugs are identified separately and are not included in this LMSA. Part D prescription drugs in this MSA proposal have been allocated based on the following information received from the CMS review contractor and the CMS Central Office: Part D prescription drugs are allocated monthly for life expectancy or at the current prescribed frequency and/or dosage unless there is documentation showing the actual frequency and/or dosage is less or will be lessened over time. Tapering of Part D prescription drugs will be considered only if there is clear documentation from the treating physician that utilization is currently being tapered. If the medical records indicate that a brand name drug is being prescribed, the brand name drug must be priced unless there is documentation to support the usage of the generic form of the drug. If records note that a generic form of the drug can be prescribed but the brand name drug is being dispensed, the brand name drug must be priced. Drug utilization cannot be reduced for future definitive procedures such as a spinal cord stimulator, intrathecal pump implantation surgery, etc. If these are current interventions and have not resulted in a reduction of drug utilization, future drug utilization cannot be reduced unless the physician specifically indicates that the procedure will result in decreased Part D drug utilization. Introduction Mr. Smith was referred by Mr. Defense Attorney for the development of a LMSA to assess future medical costs related to the injury incurred on October 16, This report provides the recommended LMSA allocation and other preliminary information to consider for the settlement purposes. Medical Records Reviewed Primary Care MD 08/20/13 & 12/17/13 Specialist MD 11/06/13 & 11/20/13 Diagnostic studies 11/08/13 Lab Work 11/27/13 Page 2 of 11

3 Relevant UNRELATED Past History Chronic obstructive pulmonary disease (COPD) Degenerative disc disease S/P right tibia fracture S/P right shoulder injury Hypertension controlled with medications Description of Injury/Medical Case History On 10/16/10, Per medical records, Mr. Smith was involved in a motor vehicle accident (unhelmeted operator of motorcycle, automobile pulled in front of him, tried to stop, collided with automobile, and thrown airborne into a ditch) resulting in multiple trauma. He did loss consciousness. He spent approximately one month in the hospital. Diagnosis included fracture dislocation of the left elbow, fractures of both lower extremities, fractures in the thoracic and cervical spinal regions, facial abrasions, and nasal injury. Surgeries included left elbow lateral collateral ligament repair, extensor tendon repair, hematoma evacuation, left femur intramedullary nailing, closed treatment of left great toe fracture, right legal application of multiplane external fixator, closed treatment of right proximal femur/femoral head fracture, closed treatment of right acetabular fracture, closed treatment of right third metatarsal fracture, closed treatment of left fibular fracture; open reduction internal fixation of right tibia, closed treatment of right fibular shaft fracture, removal of external fixator right leg, and removal of superficial pin right leg (10/29/10). Mr. Smith was eventually discharged home non-weight bearing of the right lower extremity and partial weight bearing of the left lower extremity. Discharge instructions included extensive home health physical therapy and assistance with activities of daily living provided by his sister. Subsequently, Mr. Smith also underwent additional surgery C2-T1 laminectomy with decompression of spinal cord, C3-T1 posterior spinal fusion, C3-T1 posterior spinal instrumentation, open treatment at C6-C7, and T1 fractures, placement of local autograft and allograft for fusion, and application/removal of cranial tongs (03/03/11)by Dr. Specialist. (Details of Mr. Smith' medical care/treatment/ complications/outcomes are deferred to the medical records.) On 10/15/13, Mr. Smith was re-evaluated by Dr. Primary Care with continued symptoms/pain, restricted range of motion, antalgic gait with use of cane. Dr. Tiger recommended various diagnostic studies and lab work. On 11/06/13, Dr. Primary Care noted "S/P multi trauma with multiple fractures in legs and back injuries w/o spine surgery..." An EMG/NCV study of the lower extremities revealed abnormalities, including right greater than left lower extremity nerve injuries effecting peroneal and tibial nerves. On 11/20/13, Dr. Primary Care noted "S/P multi-trauma with neck and multiple arm fractures pain numbness and tingling and weakness in the arms..." An EMG/NCV study of the upper extremities revealed abnormalities, including mild right carpal tunnel syndrome, mild bilateral ulnar neuropathies with slowing from the above to below elbow segments, lack of recruitment fairly globally in the left arm consistent with history of cervical reconstruction and multi-trauma; and global weakness without extensive on-going denervation seen in the left arm. Page 3 of 11

4 According to Dr. Specialist report dated 12/17/2013, medical records indicated the following diagnoses: - Left elbow extensor tendon and lateral collateral ligament disruptions with left elbow fracture dislocation with hypertrophic bony fragments along the lateral and ventral aspect of the distal humerus and medial inferior humeral condyle with retained metallic anchors - Left ulnar neuropathy at elbow - Left acromioclavicular and glenohumeral joint space compromise with spurring and degenerative changes - Left comminuted femur fracture with mild degenerative changes of the left hip joint with joint space compromise, and remodeled femoral shaft fracture, and metallic internal fixation - Left knee degenerative changes with mild medial tibiofemoral joint space compromise - Left proximal fibular fracture with posttraumatic changes of the proximal fibular metaphysis - Left ankle medial malleolar posttraumatic changes with spurring of the superior aspect of the calcaneus - Left great toe fracture with left foot degenerative changes with spurring of the proximal navicular tarsal, and degenerative changes of the first DIP joint with join space compromise and spurring and degenerative changes of the visualized DIP joints of the left foot - Right shoulder dislocation with postsurgical and degenerative changes with right acromioclavicular joint space compromise spurring and degenerative changes - Right ulnar neuropathy at elbow - Right carpal tunnel syndrome - Bilateral lower extremity, right greater than left, nerve injuries affecting the peroneal and tibial nerves, most consistent with preganglionic injury affecting the tibial nerves best localized at L5-S1, with likely both axial and peripheral nerve injuries, with likely bilateral peripheral injury to the perineal nerves - Right femoral head fracture with right leg length shortening - Right hip dislocation - Right hip, moderate degenerative changes with possible intra-articular loose body and spurring of the right greater trochanter, with femoral acetabular joint space compromise - Myositis ossifcans of the medial muscularture of the right hip - Right posterior acetabular wall fracture - Right knee degenerative and posttraumatic changes, with medial tibiofemoral and patellofemoral joint space compromise with patellar spurring - Right tibia-fibular fractures with posttraumatic changes - Right ankle posttraumatic changes with implanted hardware - Right third metatarsal fracture - Right foot, degenerative disease of the first PIP and MTP joints and most of the visualized DIP joints - Lumbar multilevel degenerative disc disease with disc bulges L2-3 through L5-S1 - T7 vertebral compression fracture with thoracic degenerative joint disease with osteophyte formation at T6-7, T11-12, and T12-L1, with intact pedicle screws at T1 - Right diaphragmatic hematoma-resolved - Rib fracture left #1 - Spinous process fractures with inferior displacement, C5, C6, C7, T1 with prevertebral hematoma C2-C3-C4; and vertebral body avulsion fractures C3, C4, C5, and C6, with cervical spondylosis and disc space narrowing at C5-6, status post laminectomy C3-7, with bilateral pedicle screws and posterior fixation rods C3-7, with degenerative changes with spurring at C3-4 and C5-6- C2-C3 central disc herniation with myelopathy and canal stenosis; C3-C4 right disc herniation with myelopathy and canal stenosis; C4-5 left central disc protrusion/herniation with myelopathy and canal stenosis; left C4 foraminal stenosis; bilateral C5 foraminal stenosis, C5-C6 right central disc protrusion with myelopathy and canal stenosis with bilateral foraminal stenosis; C6, C7, left central and pre-foraminal disc protrusion with myelopathy, canal stenosis, and bilateral foraminal stenosis; C7-T1 hypertrophic changes Page 4 of 11

5 contributing to left foraminal stenosis, with electrodiagnostic documentation of cervical abnormalities affecting the left upper extremity - Cervical spinal stenosis C2-C7 with cervical myelopathy and incomplete cord injury - Cervical spinal cord contusion C3-4 - Traumatic brain injury with left subdural hematoma with residual memory difficulties - Respiratory failure requiring endotracheal intubation and mechanical ventilation, with multiple bilateral calcified pulmonary nodules - Anemia due to acute blood loss - resolved - Malnutrition - Abrasions right upper eyelid, bridge of nose, and right forehead - Osteopenia - Chronic multiple site pain - Paranasal sinus disease Dr. Specialist's report dated 12/17/13 indicated the following diagnostic studies/lab work: - 11/27/13 pulmonary function testing with diffusion studies & pre-and postbronchodilator studies essentially normal - Blood laboratory studies showed normal liver enzymes, normal CBC (including hemoglobin, hematocrit, and cell indices; slight elevated total protein, mildly increased creatinine, mild decreased to mild filtration rate), and mildly elevated blood glucose - 11/08/13 lumbar CT scan showed atherosclerotic calcification of abdominal aorta without evidence for aneurysm - 11/08/13 chest CT scan showed multiple bilateral calcified pulmonary nodules and normal diaphragms - 11/08/13 brain MRI negative - Primary care physician recommended for follow-up with blood glucose, creatinine, glomerular filtration rate, pulmonary nodules, and aortic arteriosclerotic vascular disease. Since Mr. Smith is a smoker, it is recommended he follow-up with his primary care physician for periodic abdominal ultrasound evaluations of abdominal aorta, screen for possible development of aneurysmal disease in the future, and discuss the multiple bilateral calcified pulmonary nodules. Dr. Specialist also noted "...This gentlemen has multiple site implanted orthopedic hardware and will require lifelong follow-up treatment, likely will require multiple additional surgeries, will require lifelong medication treatment, likely will require episodic treatment with physical therapy and manipulative treatment, and likely will require periodic injection therapy. He may benefit from hand/upper extremity specialist consulting regarding his bilateral ulnar neuropathies at the elbow and right carpal tunnel syndrome..." Current Medications Flexeril 10mg 3x/day Gabapentin 600mg 3x/day Norco 7.5/325mg as needed (average 2-3 times weekly) Over-the-counter Naproxen (as needed) Current Medical Treatment In a letter dated 06/10/14, Dr. Primary Care noted he continues to see Mr. Smith on an ongoing basis (every 3 months) for prescription medication refills. His physician specialties are seen on an as needed basis. None of Mr. Smith' treating physicians have recommended surgery in the future and Mr. Smith has no plans for future surgical intervention at this time. Also, Mr. Smith' family/friends assist with his activities of daily living (transportation, errands/shopping, cooking, cleaning) which averages two hours/day at times. Page 5 of 11

6 Symptoms/Functional Assessment According to Dr. Specialist's reports, Mr. Smith reported the following symptoms and limitations: Continued numbness/tingling in both upper extremities (left worse than right) Persistent numbness and tingling in both lower extremities (right worse than left)' Upper and lower extremity weakness Altered sensation on left side of chest/abdomen Difficulty with vision (wears glasses), memory, and balance Episodes of falling backwards - but does not lose consciousness Bilateral maxillary sinus area pain (right worse than left) with pain, pressure & feeling of partial nasal obstruction on the right Persistent left shoulder pain with restricted and painful motion and stiffness Left elbow pain laterally and with movement Restricted motion of left elbow with incomplete extension of left elbow Continuous neck pain and stiffness with restricted and painful neck motion with numbness, tingling, and weakness in both upper extremities down to fingertips & frequent spasms Upper/mid thoracic axial spinal pain with restricted motion Left sided chest wall pain, worse with deep breathing Chronic morning cough productive of clear sputum Bilateral hip and proximal femur region pain with stiffness with restricted and painful hip range of motion bilaterally with numbness, tingling, and weakness in both lower extremities (right worse than left) Knee discomfort (right worse than left) with popping and cracking Knee pain with stiffness and restricted and painful motion Bony deformity of right mid-tibia with pain in region of deformity Numbness and tingling of both feet Restricted range of motion of great toes bilaterally Pain 4-5 out of 10 Pain less with medications and hot shower Pain worse with activity or static position Does not do inside chores, outside chores, or exercise Sister assists with socks, shoes and trousers Significant difficulty going downstairs, or walking on incline/decline, or uneven surfaces Vision is "off" Mental fog/memory affected Medical Supplies None Durable Medical Equipment Grab bars in shower have been recommended Cane Page 6 of 11

7 Projected Future Treatment Periodic provider follow-up to include orthopedic care for the upper extremity and lower extremities injuries/conservative & surgical interventions, neurosurgeon for spinal injuries/ conservative & surgical interventions, physical medicine and rehabilitation specialist for pain management and rehabilitation, and primary care for long term medication management. Periodic physical therapy evaluation to determine rehabilitation need and to develop and implement a physical therapy program formal or home exercise program to improve functional status, pain relief, and independence. Periodic diagnostic studies (upper extremities, lower extremities, and spine) to include x-rays, MRI/CT scans, EMG/NCV studies to assess for stability/degeneration/secondary diagnoses. Periodic lab work to assess kidney and liver function secondary to chronic medication use. Medications for pain/symptom management. Durable medical equipment (cane) for assistance with mobility. Life Expectancy Per review, the National Vital Statistics Report, Vol. 62, No. 7, January 6, 2014, Table 1, yields an average life expectancy of a fifty-five (55) year old to be 27.1 additional years. Therefore, we used a life expectancy of twenty-seven (27) years to determine the frequency and cost of Mr. Smith' medical needs. Please note that if the rated ages were obtained by appropriate vendors and provided in accordance with CMS guidance, it may alter life expectancy and future cost projections as depicted in this LMSA allocation. Please advise if you wish to have FIG Services generate rated ages to apply to this LMSA Allocation, or please provide updated rated ages to us if you have those in your file. Thank you for the opportunity to assist you with Mr. Smith' case. Best regards, Shelene Giles, MS, BSN, BA, RN, CRC, CNLCP, CLCP, MSCC, LNCC MSA Allocator Page 7 of 11

8 FIG Services, Inc. P.O. Box 1161 Hendersonville, NC Ph Fx FIGservices.com MEDICARE COVERED RECOMMENDATIONS RECOMMENDATION CODE FREQUENCY UNIT COST ANNUAL YEARS LIFETIME TOTAL Primary Care Physician Every 3 months $ $21, Specialty consults (orthopedic surgeon, neurosurgeon, pain management) Allow 10 over LE $ $2, Physical Therapy Evaluation Allow 4 evaluations $ $ Physical Therapy Allow 12 per eval $ $9, Occupational Therapy Evaluation Allow 4 evaluations $ $ Physical Therapy Upper extremity x-rays (left elbow/shoulder & right shoulder) Allow 12 per eval $ $9, x2, Allow 10 over LE $ $3, Upper extremity MRI (left elbow/shoulder & right shoulder) Allow 1 over LE $2, $2, Upper extremity EMG/NCV studies (left & right) Lower extremity x-rays (left femur/ fibula & right hip/femur/tibia/ fibula/ ankle) x2, x2, Allow 3 over LE $1, $4, x2, x2, 73510, Allow 10 over LE $ $5, Page 8 of 11

9 RECOMMENDATION CODE FREQUENCY UNIT COST ANNUAL YEARS LIFETIME TOTAL Lower extremity MRI (left femur/fibula & right hip/femur/ tibia/fibula/ankle) Allow 3 over LE $2, $6, Lower extremity EMG/NCV studies (left & right) x2, x2, Allow 3 over LE $1, $0.00 Cervical spine x-ray Allow 10 over LE $ $1, Cervical spine CT Allow 3 over LE $1, $5, Thoracic spine x-ray Allow 10 over LE $ $1, Thoracic spine CT Allow 3 over LE $1, $5, Comprehensive metabolic panel & venipuncture Yearly $ $2, Cane Every 5 years $ $ TOTAL $82, Page 9 of 11

10 MEDICARE COVERED MEDICATIONS PRICING RESOURCE COST PER UNIT UNITS PER MONTH RX PER YEAR YEARS LIFETIME TOTAL MEDICATION NDC Norco 7.5/325mg as needed (average 2-3x weekly) ** RedBook $ $8, Gabapentin 600mg 3x/day** (costed 300mg x2) RedBook $ $6, Flexeril 10mg 3x/day** RedBook $ $2, ** Generic TOTAL $16, Page 10 of 11

11 NON-MEDICARE COVERED RECOMMENDATIONS RECOMMENDATION CODE FREQUENCY UNIT COST ANNUAL YEARS LIFETIME TOTAL Grab bars x4 Every 5 years $ $ OTC Naproxen Every 6 months $ $ TOTAL $ Page 11 of 11

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