Sergio G. Carro, Esq.

Transcription

1 CASE NO.

2 CASE NO. 18 Z The case, which is a consolidated matter, presents the following claims: Pain Center: $53, Saddle Brook Surgicenter: $12, Gregory Surgical: $29, Gregory Anesthesia: $10, Dr. Hermann: $ Thus, the total demand stands at $105, The Pain Center claim is broken down as follows: On 3/1/02, lumbar facet joint epidural injection and injections into major joints and fluoroscopies were administered and billed at $2, The same services were performed on 3/8/02. On 3/15/02, the same services were again administered with the addition of trigger point injections. This date was billed at $3, On 7/19/02, the same services were administered with some variation in the number of injections. The total billed for this date was $3, On 10/5/02, again the same services were performed and again with slight variation in the number of injections. This date was billed at $2, Dates of service 10/12/02, 10/19/02, 11/2/02, and 11/23/02 all involved the same injection therapy and were each billed at $3, For 6/19/03, Claimant seeks reimbursement for a trigger point injection amount of $ Biofeedback was administered on 2/22/02, 2/27/02 and 2/28/02 and billed at a total of $ And, lastly, physical therapy from 2/22/02 through 6/19/03 is included in this claim for a total of $22,561.35, of which only $4, is actually outstanding. Gregory Surgical's claim is for surgical center fees associated with the above mentioned injections on the following dates of service: 10/5/02; 10/12/02; 10/19/02; 11/2/02; 11/23/02; and 12/7/02.

3 CASE NO. 18 Z Gregory Anesthesia's claim is, obviously, for anesthesia services performed at Gregory Surgical on the same dates of service included in Gregory Surgical's claim. Saddle Brook Surgicenter's claim is for surgical center servics associated with the aforementioned injection therapy on the following dates of service: 7/19/02; 7/26/02; and 8/2/02. Dr. Hermann's claim is for an office visit on 7/26/02, associated with the injection therapy of that same date. As to the three dates of biofeedback, I note that this treatment predates the cut-off date by several months and is not denied by any of the reports or medical opinions put forward by the Respondent. Accordingly, I award Pain Center the sum of $ for the trhree dates noted above. As to the injection therapy, Respondent denied the bills based on medical necessity. In this regard, Respondent relies on the report of Dr. Philip Rubinfeld dated 11/2/03 who opined that the treatment rendered by Pain Management after termination of pain management benefits was not medically necessary. Respondent also submits a second report by Dr. Rubinfeld dated 1/24/01 which was prepared regarding a different patient. The basis for the submission of this report is to establish a standard of care relative to injection therapy of the nature administered in this case. For this limited application, the report has relevancy in the within proceding. Respondent also submits an award of DRP Alterman who found Dr. Rubinfeld's analysis to be the standard of care in this situation. Essentially, Dr. Rubinfeld states that the standard of care for treatment of facet joint syndrome is to perform one or two facet joint blocks to determine if the facet joint is the source of pain. If the facet joint is determined to be the primary source of pain (i.e., the facet joint block provides temporary pain relief by >50%), then a more permanent procedure such as radiofrequency rhizotomy of the medial branch is indicated to provide long-term relief. I note that Dr. Qureshi of Pain Center does not challenge or contradict Dr. Rubinfeld's opinion as to the standard of care outlined above. I also note that Claimant Saddle Brook offers no contrary opinion. Therefore, I find that the proofs in this case substantiate the standard of care as outlined by Dr. Rubinfeld. Accordingly, I award two lumbar injection treatment dates. The first two dates on injection therapy were 3/1/02 and 3/8/02, both performed at Saddle Brook. I note that Saddle Brook and the attending anesthesiologist were paid by Respondent for these dates. Pain Center's bill remains outstanding and I therefore award $5, representing the fees charged for these two dates by Pain Center. The balance of the injection therapy is denied.

4 CASE NO. 18 Z For the same reason, the entirety of the Gregory Surgical and Gregory Anesthesia bills are denied as the treatment at this point in time was beyond the standard of care established in this case. Therefore, Claimant's fail to establish the medical necessity of these treatments. As to Dr. Hermann's bill for 7/26/02, I note that this office visit predates Respondent's cut-off and I see no reason to deny the bill. The office visit, although coinciding with an injection date, served a different purpose unrelated to the injections. Accordingly, I award Dr. Hermann $ The final treatment to be considered is the physical therapy mentioned above. Respondent paid for physical therapy through the cut-off date of 10/21/02. Thereafter the treatment was denied on the basis of an examination and report performed by Isaiah Florence, MD, dated 9/18/02. Dr. Florence found an essentially normal examination and opined that the patient had reached maximum medical improvement in the area of pain management. Accordingly, no further physical therapy was recommended. The treatment records provided by Pain Center fail to reveal any significant change in complaints or symptomology from treatment date to treatment date. In fact, with the exception of one date of service, the patient always indicates a pain rating of 8, 9 or 10 regardless of the treatment. Clearly, she was deriving no benefit from the physical therapy since she continuously reported her pain as being the worst possible pain. I fail to see how the same treatment, month after month, can be considered medically necessary if no benefit is being derived by the patient. Accordingly, I deny the claim for physical therapy bills. 5. MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to Pain Center $53, $5, Pain Center Gregory Surgical $29, $0.00 N/A Gregory Anesthesia $10, $0.00 N/A Saddle Brook $12, $0.00 N/A Dr. Hermann $ $ Dr. Hermann Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. 6. INCOME CONTINUATION BENEFITS: Not In Issue

5 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): $ to Claimant Dr. Hermann and $ to Claimant Pain Center. (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1, to the attorney for Dr. Hermann; and $2, for the attorney for Pain Center. (C) INTEREST is as follows: Awarded in the amount of $ to Pain Center. $9.17 to Dr. Hermann and This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. January 21, 2004 Date Sergio G. Carro, Esq.