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.: NJ MANUFACTURERS DRP NAME: Margaret Knuetter (Respondent) NATURE OF DISPUTE: Pre- Certification, 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: HL. 1. ORAL HEARING held on 3/17/ ALL PARTIES APPEARED at the oral hearing(s). Respondent 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). The bills total $ FINDINGS OF FACTS AND CONCLUSIONS OF LAW: This is a claim for payment of bills incurred by HL as a result of an auto accident of 8/17/02. Claimant submitted the following: Assignment NJ Insurance ID card Bill from Chee Gap Kim, MD, for DOS 8/28/02 to 2/7/03 Initial evaluation of Chee Gap Kim, MD, dated 8/28/02. Dr. Kim state that HL is a 51 year old woman who presented with a chief complaint of neck pain. She had been

2 CASE NO. 18 Z involved in an auto accident on 8/17/02, was sent to St. Mary Hospital, where she was treated and released. Her neck pain was heavy, pressing, pins and needles in nature and radiated down to the right hand accompanied by tingling numbness and weakness. She had low back pain that radiated down to both legs accompanied by tingling numbness and weakness. She had headaches. He examined her and his impression was cervical radiculopathy, lumobsacral radiculopathy, r/o herniated intervertebral disc and traumatic headache. She was placed on a physical therapy program, home exercise program, therapeutic heats and electrical stimulation. She needs MRI to evaluate the probable cervical and lumbosacral disc herniations. She will also need EMG/ NCV studies if radicular symptoms persist. Office notes for 9/11/02 to 2/7/03 EMG/NCV report dated 10/10/02 with findings of bilateral C5, C6 and L5 radiculopathy Report of Michael Amoroso, MD, of Progressive Open MRI, dated 9/26/02 re MRI of cervical and lumbar spine with findings of central and left posterior disc herniation at C4-5 and C506, resulting in thecal sac compression and pressure effect on the cervical cord; annular bulges at L4-5 and L5-S1, central posterior disc herniation at L4-5 resulting in pressure along the ventral aspect of the thecal sac and central posterior disc herniation at L5-S1 resulting in partial obliteration of the anterior epidural fat without thecal sac compression. Termination letter from respondent to HL effective 1/9/03 for neurological treatment Fax from NJM to Dr. Kim, dated 1/28/03 denying further PT as benefits were terminated on that date. Fax from Dr. Kim requesting therapy, dated 1/27/03 with attachments Fax from NJM dated 1/6/03 denying TPI as per Neuro IME Fax from NJM authorizing 12 visits for PT from 1/10/03 to 2/7/03 in response to fax from Dr. Kim. Fax denying TPD, dated 12/20/02 as per IME in response to pre-cert request Pre-cert request and response, positive, dated 12/9/02, 11/15/02 Appeal letter from Dr. Kim, dated 11/5/02 requesting review of denial of TPI as patient has developed large trigger points on bilateral trapezii, and needs the TPI to relieve the severe pain and break the trigger points. Pre-cert request and denial for trigger point injections, dated 10/31/02 Authorization of 12 visits for PT, from 10/14/02 to 11/12/02 in response to request from Dr. Kim for pre-cert Denial of EMG/ NCV upper and lower. Rationale - according to Care Path 2 and 6, where a diagnosis of radiculopathy is apparent, the electrodiagnostic testing is not recommended. Appeal letter from Dr. Kim to respondent requesting review of denial of EMG/ NCV testing as the patient has been suffering from severe pain, tingling, numbness and weakness on both arms and legs and showed severely limited range of motion, muscle spasm on physical exam. MRI studies showed large, multiple herniated disks. Shee needs EMG/ NCV to evaluate the probable cervical and lumbosacral radiculopathy. The tests help to promulgate further rehabilitation program and to prognosticate. It is also necessary to determine whether she neds other forms of therapy such as laminectomy and epidural injections.

3 CASE NO. 18 Z Denial faxes from NJM for EMG/ NCV dated 1010/02, 10/7/02, 10/3/02 in response to request from Dr. Kim dated 10/3/02 Letter from Dr. Kim, dated 1/8/04. Dr. Kim explains his rationale for the EMG/NCV testing. He states that it is very important in managing a patient to have precise diagnosis. The tests help to predict how long reasonably the conservative therapy should be continued, when the patient is going to feel better, whether he has to refer him for surgical treatment or other forms of interventional therapy. They were also necessary to differentiate from other diseases that cause paresthesia and weakness such as carpal tunnel syndrome, peripheral neuropathy, or other neurological diseases. HNP is only one cause of many etiological factors. The date on the NCV studies vary significantly by many factors, such as age, temperature, height, metabolic diseases and other factors. Letter of Dr. Kim in response to reports of Dr. Carmickle (below). Dr. Kim comments on the fact that Dr. Carmickle initially had limited information for review when the studies were denied. After she was given the entire chart, she questioned the credibility of the test because there was only one graph of the EMG findings. In Dr. Kim's opinion, the review has either limited hands-on knowledge of how the EMG tests were performed or completely disregards the discomfort of the patients who undergo the tests. He states his report is very well organized and all the pertinent information is on the report. He questions the need for the NCV graph as the table gives all the necessary information. He is criticial of the denial based on the fact that he only gave general discussion of the use of electrodiagnostic studies, and not specific for this patient. He stes that he gave detailed description as to why the tests were necessary. Respondent submitted the following: Letter from NJM to HL denying further neurological treatment effective 1/9/03 based on IME of 12/12/02 Report of Lynne Carmickle, MD, dated 12/20/02. Dr. Carmickle states that she examined HL on 12/12/02 with complaints of headaches, neck pain and some low back pain. Orthopedic testing is normal as is neurological - motor, sensory, teep tendon reflexes and Romberg's. She reviewed the MRI study and the EMG/ NCV studies which she finds are not compatible with the stated injury. She then questions the credibility of the studies. The only actual EMG date is example from the right lumbar paraspinals, and no date for other muscles tested is inclujded. She concluded that the patient had no objective findings or subjective complaints consistent with radiculopathy and the MRI do not demonstrate any evidence of nerve root impingement. She found no need for the studies. She also saw no need for further treatment including trigger point injections, epidurals, or facet-joint injections. Fax from respondent to Dr. Kim, dated 1/28/02 advising of termination, 10/3/02 denying testing of EMG/NCV, 10/7/02 denying testing, 10/10/02 denying testing, 11/4/02 denying TPI pending neuro IME,, 12/20/02 denying TPI per IME, 1/6/03 denying TPI per peer review Peer review report of J Remigio, MD, dated 10/4/02. Dr. Remigio staes that he has reviewed medical reports of Dr. Kim dated 8/28/02, 9/11/02 and 10/3/02 and MRI studies. Based on the patient's history, physical exam and neurological exam findings, radiculopathy has been established. As per care path 2 and 6 where radiculopathy is apparent, the testing is not recommended. Also the testing will not change or alter the patient's treatment.

4 CASE NO. 18 Z Peer review of Dr. Remigio, dated 10/10/02 in response to appeal from Dr. Kim. Dr. Remigio repeats his conclusion that once the diagnosis of radiculopathy is established, Care Paths 2 and 6 state testing is not warranted. Peer review report of Dr. Remigio, dated 1/3/03 denying TPI after report of Dr. Carmickle. EOB's from NJM for 10/15/02 to 2/7/03 Rollow up report of Dr. Carmickle, dated 1/12/04. Dr. Carmickle reviewed records and confirmed her conclusion that there was no need for the electrodiagnostic testing and insufficient documentation to support it. Follow up report of Dr. Carmickle, dated 2/21/04 after review of additional records. Dr. Carmickle again confirms her findings and notes that Dr. Kim has not actually indicated how the testing would have specifically directed the course of this patient's care and that there are discrepancies in the data that he has not addressed in his letter of 1/8/04 There are several issues involved in this claim. The first is the non-payment for physical therapy session of 11/12/ 02 for which claimant billed $90. Claimant had pre-certified treatment for 4 weeks at 3 times a week. Respondent states that this particular visit was the 13 th visit during that period and that payment was therefore denied. I find that the proper remedy was to reduce the payment by 50% for failure to precertify as long as the therapy was medically necessary. For that portion of the demand, I will allow $45. The next issue is the medical necessity of the electrodiagnostic testing. I find it disturbing that respondent's two examiners reach different assessments of the exams of Dr. Kim. Dr. Carmickle states that in reviewing the record there is no objective or subjective signs of radiculopathy and that therefore the tests are unnecessary. Dr. Remigio, on the other hand finds that since the radiculopathy was apparent, the testing was redundant. I find that the working diagnosis of Dr. Kim, coupled with the complaints of numbness, tingling, spasm and results of the MRI exams warranted the testing. I further find that Dr. Kim clearly elucidates why the testing is needed in terms of evaluating further courses of treatment. This is especially true since HL had several herniated discs in the cervical and lumbar spine. I will allow for the testing as medically necessary. The final issue is the medical necessity of the TPI from 11/7/02 to 2/7/03. I find that Dr. Kim has sustained the burden of proving that those injections were medically necessary. After denial by respondent, he appealed the decision giving clear indications that there were areas in the trapezii bilaterally that had large trigger points that were not improving. That portion of the demand is allowed. The award is subject to reduction for deductible, copayment and fee schedule as applicable. Interest has not been calculated and is deemed waived. Attorney fees and costs are awarded. 5. MEDICAL EXPENSE BENEFITS: Awarded

5 CASE NO. 18 Z Provider Amount Claimed Amount Awarded Payable to Chee Gap Kim, MD $2, $2, Claimant & attorney Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. Award subject to reduction for deductible, copayment and fee schedule as applicable. 6. INCOME CONTINUATION BENEFITS: Not In Issue 7. 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): $285 filing fee (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1100. (C) INTEREST is as follows: waived per the Claimant.. This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. 4/6/04 Date Margaret Knuetter, Esq.

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

CASE NO. 18 Z 600 08247 03 2 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 600 08247 03 v.