The URL can be used to link to this page

Home My WebLink About94-04992 " ,Ii " , , , , " " , " 'I .., ill c 2 i\ V) '\ " " A,~ " '.l I , I, " ,I ,I I, ,(') ~ ~ '::t' ( " I I, ! ,~ I , I r- 'd J " , , I, J .\ ..... ~ .1 ~ '" " -- ":I" - . ~ ~ ~ ,. ~ J. .... ., .. ,,' 0 ~ ""= , ,. .)- " - .,J, ., 110 ~, "j'. . "" ' , " " I' f N ,'., <lJ ~ J1 ~ ~~ ~ ~~ ~ ;~ 8 . ~~ ~8 ~~ ~~ ~ . is ~ U) I .. '" . 0-1 ~ . . :::: 'r! :E a. :> ~ i . ~~ ~~ ~tl r.. ~ ~ ~ &i e; .. ij 'tl ~ 2! ~ ~ ,., ... . ~ ..J:z .... <;'-0 '""< ~ < l= l.lJ Vl~~IJJZ oo<~< llJ'711..J,""> ljc::"'t-<Il..J QJ::..J8~:t>- Oo1d~~!:2~ ~QJ:::z~:tz . llJ Q 0 I- IJJ QJ:: ~ ill I: <Il c.. ~O~<~~ ~ ..J '" ... <Il o l.l."- ....- ..J < ..J l.l. ~ U , . . ,., ... ~ .. N .. N:;!~~ ... N '" ~ ~ . 'If oz~... ",~ci>- ~~~~ ~~~~ ,~ ' , 0",0:; <IlIJJ<IlO "'0"'''' ~O~< ~'" ~U ---~ , . : .,\""l~,_ 6. Continuing to suffer episodic neck pain as a direct result of the accident, Plaintiff returned to Dr. Kretzlng on August 31, 1993 and on September 30, 1993, and resumed treatment and therapy which continued until February 3, 1994. 7. Dr. Kretzlng referred Plaintiff to Dr. Daniel Hely, of Carlisle, Pennsylvania, an orthopedlo specialist for evaluation and treatment. 8. At the time of the accident, Plaintiff was Insured by a policy of Defendant. Defendant assigned Claim No. 38-6537.289 to her case. 9. Pursuant to the Motor Vehicle Financial Responsibility Act (MVFRA) 75 Pa. C.S.A. S1701 et seq., Defendant Insurance company submitted Plaintiff's claim to the Consolidated Rehabilitation Company (CRC), a certified Peer Review Organization, fQr an evaluation of whether the treatment received by Plaintiff was reasonabla and necessary. 10. CRC Initially determined that none of the treatment and therapy provided to Plaintiff alter March 10, 1993 was reasonable and necessary. A copy of the determination Is attached hereto as Exhibit 'A'. 11. Pursuant to 75 Pa. C.S.A. 51797 (b)(2) , Plaintiff's physician, Dr. Harold Krltzlng, requested reconsideration of the Peer Review Organization's Initial determination. A copy of Dr. Kretzlng's raquest for reconsideration Is attached hereto as Exhibit 'B'. 12. Upon reconsideration, CRC initially determined that all the treatment and therapy provided to Plaintiff until November 9, 1993 was reasonable and necessary. A copy of the reconsideration Is attached hereto as Exhibit 'C'. 2 ~ Consolidated Rehabilitation Company " A comprehenlive Pur Flevlew Or.lnlullon certified by Ihe Commonwealth of Pennlylvama CONF1DENTlAL REPORT Mar-ch 9, 1994 Ma. Becky pastor, AN Medic::.al IlApruentative Conaolidated Rehabilitation Co, HARRISBURO ttAR 16 1894 RECEtVED 1\.: Mary ShaMon Claim '36 6537 2B9 D/A: 11/11/92 Dear Ms. Pastor, At the r~est of CRC, I reviewed certain llIlIdical recorda for medical eare render~ to the claimant, Mary ~on tor purpoHS of a peer review analysil. The recorda lIhich I reviewvd included the follO'oling r llecord8 from the offi~s of. Alexander Sprir~ Rehabilitation dat~ 11/23/92-1/22/93 and 9/30/93-1/13/941 records from the lelvedere Me4ical Center of 11/l3/92~2/7/94: x-ray reports of 8/31/93 and MRI ac:an of 9/17/93: bil1inci fra:n the offi~ of Dr. Filip: recor:da ficitl the office of Dr. Hac&1uao: Ell. recorda and ArB. a.INICAL IIIS1'tRY '1'he elaimAnt, Mar;y 5haMon, initially came under the care of Dr. Kretzing at the Belvedere Medical Center on 11/13/92 with II chief coqllaint of neck pain. Her history revealed that she had been involved in ,a MVA on 11/11/92. In that accident she wu the 4river of a car that wu struck. in the rear. She wu 42 y.ars old at the time of the accident .mJ 41d 110 to an !R on the following clay becaWMl of epistaxia. A.'l x-ray liU taken 1Ih1ch revealed a fracture of the maxillBrf spine. In addition to this injury, she also was treat~ for a cervical sp1:ain. Th'~ \ treatmentJ incl1..'Cled outpati.nt theJ::'apy at the AlexanCeC' Spring Rehab Center. Or. KJ::'Bt2inq oJ::'d.recl the thenpy and also followed her on a regular basis dur- inq the eourse of her tJ::'eatment. The records indicat. that she trHted at this centeJ::' thrcuqh 1/22/9:J. The treat::nent was d111ccntinueC for .~rox::'llII.t:elY eight: mcn~ ar~ then J::'es~ on 9/30/93. This trea~~r.t has continued threugh 1/:3/94. The clai~t also had x-rays taken of the ce~/ic::a1 spine which revealed ~e 9\Jbele ceqenentive changes. An Ml\I scan of t~e cervical s;line was obtained on 9/17/93 whico... sl".cwec! lnL'lirnal spc:ndylitic changes at C4-5 en ~.,e J::'i;ht. So evicence o~ ~~ h.~iated disc mataJ::'lal Wa3 noted. ~~e race res ~~~icat. ~~at in Dec~~r et 1992, she uncer.ent a sept~pl.1ty ~~e ~~@ e~a~tic ~.pe31 de!:ecticn ~::h a nasa: ~~~ne ~:act~re ar.d na~a: sepeal fr~ctura. ~.is ~as ecncuctad OV Ct'. ~acalU5c at: Carlisle ~ospit:al. Plc.:lsc ;t';r'I~ r, . .: :611'\ S ~ro.d 51 PO 8.. '~I? l..InSdJlc. :,,, 19..w6.JI:" ':151',q" !J!O 2 ,''; ; l~' N7 ., ~q :: :036 ,'o1~~I~ "'..ue J.(lddOn HCllhu :-':.w ;.".y 0103l 16(9) ~047..s II" :;"X '~Oq\ ~47.~~4~ = 11 ~~ 8&bcOcI&lSI.d, S.m,'1 ~;usou,!h. ~^ 1'2.17 ,'1:1366...'900 c.\x ~l~' !t,..:'~1 HARRISBURG MAR t 6 1994 ReI Mdry Sh4MOn Claim ,3e 6537 289 Page 2 RECEiveD The office re<:orda fran Dr. Kretling indicated that'. the claimant continued to have neck pain throUih Septerrt.ler of 1993 at which point an MRI scan wu obtained. As indicated the HIlI sean was WNL. Physical ,xlllIination alae r.vealed no n.uro- logical deficits and normal RQ\ of the cervical spine. 'l'he note. fran FetmJary 1993 indicated that she had a diegnoais of . cervical Dtrain which wu reaolving. She did not have any appointlne1lta with Dr. !(r.tling tran 2/9/93 until 8/31/93 when she ",ported that .he w.a having IIIlre nec:lc pain. By 8/31/93 she indi- cated that her pain had persisted and that certain physical act1vit1es allljJl:ilva- ted h.r pain. Th. Pl' treat:llllnte vere also rell\llllld at the Alexander Spring Rehab center in Novlll'blr of 1993 and these treatments cont:inlJld into February of 1994. The u_bnenta c:onailted primarily of exerci... to ill'proYe 101 and deer.... lIIllIc1e ton. in the cervical parupinal llIIIoSCle. Illd upper tnpuiWl 1llUSC1es. other trubnant.8 inc1u&1d lIIOist Mat, elec. stilm11ation aM therapeutic .....19.. The reeor&l a1.eo indicate that: 1IIhen the claimant', neck pain reoc:c:urred in Auguat of 1993, Dr. lCret:,zing did nor&lr PI' ulliIb'oent, vith a cUagnosia of c:hronie neck peine 'l'he.. trHtmenta continu~ frCllll 9/30/93 t:hru early Febr:uart of 1994. ~ ItBVIPJf bu.a+~ Bued on a revi..., uf the records, it ia my opinion that the claillllnt did I.lWltain 80ft tiuue/cervical .train injuria which c:culd be direetly attributed to th. HVA of 11/11/92. Therefore, the claimant: did ~eHr:ve a ccurse of regular physician 8valuationa and outpatient P'1' treatments for a period of approxi- Il'Ately 3 to 4 months follO\ling the MVA. 'l'he treatment frOlll the Alexander Sp.r1n; Rehab center ane! Belvedere Medic:a1 Center wcule! have been clinically appropriate through 3/10/93. Treatment beycnd that date, in tfti opinion, vould have repre- sented excessive C'&re. '1'he cla.l.mit.nt's injuries litre clearly of the actt t~ variety and ahollld have ruolvec! within 3 to 4 montha follO\ling the MVA. It 11 tlIY opinion that the tteat:llllnt fran the Belvedere Medical Center and the Alexander Sprin9 Rehab Center fran 5eptueer of 1993 through February of 1994 IIculd not be ccneid.rlC! reasonable or nec.....ry. If I can be of any furth.r assistanc. to you ....ith respeet to this file, p1...J. ~cntaet ~ at your convenience. I , 5incerely yeurs, 'J'i'---. (, ~~, 1M 71 ~ ,f;! Marc A. ~ia~~cc, Me ~ ?hysic~ ~edicin. and Rehabilitation i :::.:;nllC! in rr.ysicial'.' s acur.ce to avoid delay. ), ~RC) Consolidated Rehabilitation Company CONFIDENTIAL REPORT ,\ cOn1pr~h~nsiv~ Peer R~vi~w Organllullon c~rtll1ed by lh~ Cllmmonweullh of Pennsyl\'unla April 30, 1994 Becky Pastor, R.N. P.O. Box 1719 2616 North Broad street Lansdale, PA 19446-0827 RB: DATB OF ACCIDENT: CLAIM NO.: MARY SHANNON 11/11/92 38-6537-289 Dear Ms. Pastor: At your request, a reconsideration of the original peer review performed by Mark A. Maiatico, M.D., was performed concerning the physical therapy care rendered to the above-named claimant at Alexander Spring Rehabilitation, Inc. The fOllowing documentation was available for my review: 1. Application for Benefits dated 12/4/92. 2. Emergency room records from Carlisle Hospital dated 11/12/92. 3. Invoice from Thomas S. Filip, D.M.D., P.C., dated 11/12/92. 4. Office notes. operative report and invoices from Russell A. Macaloso, M.D. 5. Physician records from Harold G. Kretzing, M.D., dated 11/13/92 through 2/9/93 and 8/31/93 through 2/7/94. 6. Radiology results of the cervical spine dated 8/31/93. 7. MRI results of the cervical spine dated 9/17/93. 8. Treatment records from Alexander Spring Rehabilitation, Inc. dated 11/23/92 through 1/22/93 and 9/30/93 through 2/3/94., , Also invoices datad 11/30/93 through 1/24/94. 9. Original peer review performed by Mark A. Maiatico, M.D., dated 3/9/94. 10. Letter requesting reconsideration dated 3/29/94. HISTORY: Ms. Shannon is a 46-year-old female at the time of the alleged motor vehicle accident on 11/11/92. She received emergency room care at Carlisle Hospital secondary to a fractured maxilla. She sought further medical attention of Dr. Kretzing secondary to continued neck pain. She was referred eor treatment to Alexander Spring Rehabilitation on 11/23/92 and treated through 1/:~/93. She )'.:...~~ .~":I'1 '. continued.. . ~,'lll'l" Jrll.1lJ it I I \ I,,~ .., 'I :0 1" \1;Jpl~ \ \ .:nll~ rtJl.hhlll Hl:I~nh .,0,:..... \:n.:'i'I,'W:'; : 1:1~ J.10Clllo:k JlvlJ, )lll(l.!.,j I)'tl.,rltlr'~ rt. i) \ (:.:- ..il', :.11": I \ . ',!.,Ul . .~_ ,.ai- :"'1 '-I J' 11 ~ '. I .:.: I\fl.....),j, ,,'j, ," F \ \ .,1'1 ',". RE: Mary Shannon Becky Pastor, R.N. April 30, 1994 Page Two returned to Dr. Kretzing on 8/H/93 secondary to episodic neck pain. Cervical spine x-rays and an MRI were performed. Physical therapy waB reinstituted on 9jJO/93 and treatment was continued through 2/3/94. COURSE OF TREATMENT: An initial physical therapy evaluation was performed on 11/23/92 stating objective deficits and implementing care consisting of moist t.eat, electrical stimulation, soft tissue massage, myofascial release and a home exercise program. Reasonable goals and plan of care were set forth. Therapeutic exercise was initiated on 1/7/93. However, there is no documentation indicating what type of exercise was implemented. Hoist h8at was discontinued on 1/13/93. On 1/18/93 exercise had increased to two hours in duration. On 1/22/93 the patient had no subjective complaints of pain, all goals were met and the patient's treatment was discontinued. Upon re-referral on 9/30/93, the patient had Bubjective complaints of neck pain beginning approximately one month prior secondary to maintained cervical spine extension while dancing. SUbjectively she rated her pain at a level of 8/10 and pain was increased with many activities of daily living. Objectively range of motion was as follows: Flexion of the cervical spine equal to 450, extension 160, left side bending 240, right side bending 260, left rotation 560 and right rotation 720. Diffuse tenderness was noted, as was hypertonus. Treatment was initiated consisting of moist heat, soft tissue massage with myofascial release, manual cervical traction, suboccipital release and therapeutic exercise. Treatment note on 10/5/93 indicates decreased side glide of the C4-5 motion segment and OA restriction, left greater than right. Therapeutic exercise waB initiated on 10/8/93. This therapeutic exercise and kinetic activity was progressed throughout the duration of treatment. There is reference to an exercise sheet in the treatment records.' However, this is not available for my review. On 10/26/93, cervical spine range of motion was documented as follows: Flexion equal to 460, extension 42", left side bending and right side bending 250, left rotation and right rotation 550. SUbjectively pain was noted to equal 1/10 on this date, with an average pain level equal to 4/10. . On 11/2/93 a relative decrease in c8rvical spine flexion and extension was documented with other ranges being the same. On 11/9/93 minimal to no segmental restriction was noted and cervical side bending had increased to approximately 350 with rotation left equal to 680 and right 640. On 11/11/93, cervical spine range of motion was noted to be within functional limits. Hcwever, on 11/19/93, flexion was noted to be decreased approximately 50~. On this date ultrasound was added for the left , continued. . . REI Mary Shannon Becky Pastor, R.N. April 30, 1994 Page Three upper trap. On 11/30/93 active range of motion was noted to be within normal limits. On an unspecified date after 11/30/93, left side bending was decreased 50'. However, other motions were within functional limits. On 1/11/94, cervical spine range of motion was noted to be full and overhead activities were well tolerated. On '/24/94 neck pain had increased, possibly secondary to shoveling and cervical spine range of motion was noted to be decreased to 50'. Treatment had continued consisting of soft tissue massage, manual cervical traction, moist heat and a modified exercise program. On 2/3/94 it was documented that pain levels varied from 3-7/10. At this time the patient was discharged to a home exercise program. ANALYSIS AND CONCLUSIONS: The followil.g professional opinions are stated within a reasonable degree of medical certainty and based upon the documentation available for my review. It is my opinion that the original course of physical therapy from 11/23/92 through 1/22/93 is both reasonable and necessary. It is also my opinj on that the ini tilll evaluation dated 9/30/93 documents significant objective deficits and the initiation of treatment was reasonable and necessary. It is my opinion, however, that treatment rendered beyond 11/9/93 would be considered unreasonable and unnecessary. Based upon the documentation, it is apparent that a relative plateau had been reached by this date. Documentation beyond this date indicates fluctuating symptoms and objective detici ts . It is my opinion that the patient should have been discontinued to either a fitness or a home exercise program. In summary, it is my opinion that treatment rendered at Alexander spring Rehabilitation, Inc. would be considered reasonable and' appropriate through 11/9/93. . It I can be cf any further assistance to you with regards to this report. please do not hesitate to contact me. Thank you. Sincerely, . ~ ',' I \.... (' )r_l...("........'....- - p r ;yr, , 7.. ~.':i( , - ,j.J .j I 11'} William c. McCafferty, P.T. WCM: PT8 ~ Consolidated Rehabilitation Company ~~.'Ji"lj'lllllthm ~,'rI!OIJt"jt... _" u_.___"__ ".__._. ..._____.____.___ .-.. _.._--~..- --- -----.-------.- . M~dknl Cu,~ MlInug~f1l~nl . Peer Rc\'l~w Orgllnilllllllll . Hu,pilul R~ill\hur,ell1el1l Sen I~es . Ind~pelld~nll\.l~dkul Exum . Voeullunul R~huhillluliun :\Ikhad A, :\lllrnlllc. :\1. Ed Dire~tllr May 14, 1994 Becky Pastor, R.N. Consolidated Rehabilitation company 2616 North Broad street P. o. Box 1719 Lansdale, PA 19446-0827 RII DATD OW ACCIDINTI CLAIM HO. I NARY 8JlAHHOH 11/11/92 38-1537-289 Dear Ms. Pastor: The following is an addendum to the initial reconsideration report dated 4/30/94. New documentation available for my review includes: 1. Telephone conversation with Christopher 1<. FiSher, P.T., dated 5/10/94. 2. Letter from Christopher 1<. Fisher, P.T., requesting reconsideration dated 4/27/94. 3. Letter from Harold G. I<retzing, M.D., requesting reconsideration dated 3/29/94. 4. Exercise flow sheet and home exercise program. Letter requesting reconsideration indioates that the initial peer review was based solely on the time treatment was rendered following injury. Mr. Fisher indicates that treatment reviewed was not reviewed based upon objective deficits and functional limitations. He indicates that on 11/16/93, overhead exercise was initiated in order to prepare patient for overhead work duties. This resulted in severe stiffness and palpable spasm. This form of treatment was not reintroduced until mid to late 12/93 and was progressed with appropriate toleration. He indicates that the goal of treatment was to return to performance of work duties without incurring pain and spasm. He indicates that troatment was focused on this goal and that discharge summary indicates a significant change in pain level, cervical range of motion and strength. continued. . . Ilk.I'l1.: 1~':1'1' " j,,\ "'1 :!)lfl.\I.lp!.! \\I'I1lIL' ILl<l,j,'1l Ik'.:11I, :is.(, Il.lt'I.:L'l.:K ['hll i'lll<.' .II :11,1,', ilrot,,,J')l "I,' ", -,UI, , ," ',,"" ','r ," '.',' ,"II,I'llf'll. I \ ," ~.1 ',' , .' "1'1':'1.1 REI Mary Shannon Becky Pastor, R.N. May 14, 1994 Page TWO As stated in my initial review dated 4/30/94, it was my opinion that the initiation of treatment on 9/30/93 was both reasonable and necessary. It was my opinion that a reasonable plan of care was instituted and relevant goals were formulated. It was my opinion that, given the relative plateau reached in therapy as of 11/9/93, that treatment rendered beyond this date would be considered unreasonable and unnecessary. It was my opinion that the dOClumentation indicates nuotuating symptoms and objeotive deficits beyond this date. However, in light of the new documentation, i.e. the exercise flow sheet, it is apparent that treatment beyond this date was focused on functional gains. It appears that the primary functional goal beyond this point wall reasonable tolerance of overhead activity without increase in pain. Objective documentation on 1/11/94 indicates that cervical spine range of motion was full. There is no indication of subjective pain rating. Full therapeutic exercise program was continued, including crate lifting and Physioball exercises. Objeotive documentation on 2/1/94 indicates that nexion of the cervical spine was full, however, there was a 50% limitation in left and right side bending, as well as extension. Documentation on 2/3/94 then indicates that extension was within normal limits, with left side bending equal to 340 and right side bending 420. This discharge note indicates that the range of motion varies week to week. In light of the new documentation, it is my opinion that treatment rendered beyond 11/9/93 was, in fact, reasonable and necessary up until 1/11/94. It is my opinion that this represents a reasonable time frame to achieve the aforementioned functional goals. It is apparent, basec:i upon the objective documentation, that cervical spine range of motion was, in fact, fluctuating on both a daily and weekly basis. Additionally, complaints of pain varied on a daily to weekly basis as well. In summary, it is my opinion that treatment rendered beyond 1/11/94 would, in fact. be considered unreasonable and unnecessary. If you have any questions regarding this report, please do not hesitate to contact me. Thank you. Sincerely, , " "/""'.-/ r; 'II (; A"" .,' . \. _.- /,.' c ""oJ'~ ( /' It )1.-1. . / . William C. McCafferty, P.T. WCM:PT8 ~RC) Consolidated Rehabilitation Company ~~(/jd6j/jt<lljvn SpWd/tsts . M~dkul Cuse Munugem~m . P~er Review Orgunizull,)O . Ho,~pilul R~lmburscf1t~nt SerVice, . Independent Medical E~am . Vocutlonal Rehubllltutlon Michtld A, ,'I.lorrorlc. 1\1, Ed Dln:ctor PROVIDER: RECONS IDERATT.ON "/Jt~ d,t~~ aJ (, !,-?; 7.J..J' 1 @~J6f'A~~J ;eJdLL~ ClailllF.lnt: Claimll Date Request for Reconsideration Received:~-~-~~ (Additional information included) Date Request for Reconsideration Received: (Without any additional documentation) Acknowledgement mailed from CRC: 'JI-J'-"Y- Date Provider response received stating that no further info would be forthcoming/records received: t' " .J a. .. - 6. (l.L.c.n. ~ /l'.~ "-tf-' 5"/,).j9 Ii Reconsideration Determination: Reconsideration Determination Complete Date: ~ Initial Determination Upheld Initial Determination Modified Initial Determination Reversed EX~~;~Ff:;:~~7~~~2~;~~ -~ ~~~ "1LA::~.~t. ~<.k~. ~T~"'?~ / , Medical Representative Pica)!.: R~pl~ r,l :1'11" -..; 13rn(lu)1 .,,' "'1 '-1,'1 '_. ~ ,'I~l BJb<o<k 51vll, 'iull..:"l 1'llhl"Uf\lll. !J, I ~~.17 1 ' ~ \ . 1'1' ... <q,l lIt' !).., '-:'1'1 -. ':OJI.') .\1iJphr ,-\\'l!nul: HiJlJLlon Hlttllhl" \,"~',l,l :l.:r~~'1 '1:-i1J.l ,C .,11'.1,11..' 1\, '1.1'&1\..;''1:- ," ," ',. ".... ~ Consolidated Rehabilitation Company 'S~li.,61Iil'lti~1l Spi,.",ti,/j ---'~-------"---._-----'--- ._,~.__.- ------.---------------. .... .---,-.-. . M~\Jicul Cus~ M.lIlug~rn~nl . P~~r R~vi~w Organlzmiull . Unspital R~ilnhllrS~fIl~nl S~rs' IC~S . Il1u~p~nu~nl M~uicl1l E~uln . Vllcullonul R~huhilllUlion Michucl ,.\, :"s1'lrrll/lC. 1\01, Ed Director May 14, 1994 Becky Pastor, R.N. consolidated Rehabilitation Company 2616 North Broad street P. O. Box 1719 Lansdale, PA 19446-0827 RBI DATB or ACCIDBHTI CLAIM NO. I DRY 811ANKON 11/11/12 :se-U37-an Dear Ms. Pastor: The following is an addendum to the initial reconslderation report dated 4/30/94. New documentation available for my review includes: 1. Telephone conversation with Christopher K. Fisher, P.T., dated 5/10/94. 2. Letter from Christopher K. Fisher, P. T. , requesting reconsideration dated 4/27/94. 3. Letter from Harold G. Kretzing, M.D., requesting reconsideration dated 3/29/94. 4. Exercise flow sheet and home exercise program. Letter requesting reconsideration indicates that the initial peer review was based solely on the time treatment was rendered following injury. Mr. Fisher indicates that treatment reviewed was not reviewed based upon objective deficits and functional limitations. He indicates that on 11/16/93, overhead exercise was initiated in order to prepare patient for overhead work duties. This resulted in severe stiffness and palpable spasm. This form of treatment was not reintroduced until mid to late 12/93 and was progressed with appropriate toleration. He indicates that the goal of treatment was to return to performance of work duties without incurring pain and spasm. He indicates that treatment was focused on this goal and that discharge summary indicates a significant change in pain level, cervical range of motion and strength. continued. . . rh~;hl! :~~~'l\ ;'d :'111) '; flrll,hJ ')1 'I.) "1,,\ . -! OJ ..1',1.." '\ 'I.J..tl., 1:- ))1" \1.lpll! \\l..'nUI! IlaJJI)n Ikll!nr\ ,OJ I 'I ~s BabcJ)ck Blvd, ,'illll~ "I J"Il~hllrl.!h, ?\ 1:1:.\"," Ll':' '"".-1(11.1 'k'.\ !o.:r',":'.' 'I:-:l/I~ " . ~ ".J.:' REI Mary Shannon Becky Pastor, R.N. May 14, 1994 Page Two As stated in my initial review dated 4/30/94, it was my opinion that the initiation ot treatment on 9/30/93 was both reasonable and necessary. It was my opinion that a reasonable plan of care was instituted and relevant goals were tormulated. It was my opinion that, given the relative plateau reached in therapy as ot 11/9/93, that treatment rendered beyond this date would be considered unreasonable and unnacessary. It was my opinion that the documentation indicates nuctuating symptoms and objective deticits beyond this date. Howev0r, in light ot the new documentation, i.e. the exercise tlow sheet, it is apparent that treatment beyond this date was tocused on tunctional gains. It appears that the primary functional goal beyond this point was reasonable tolerance ot overhead activity without increase in pain. Objective documentation on 1/11/94 indicates that cervical spine range ot motion was full. There is no indication ot subjective pain rating. Full therapeutic exercise program was continued, including crate lifting and Physioball exercises. Objective documentation on 2/1/94 indicates that nexion of the cervical spine was tull, however, there was a 50' limitation in left and right side bending, as well as extension. Documentation on 2/3/94 then indicates that extension was within normal limits, with left side bending equal to 340 and right side bending 420. This discharge note indicates that the range of motion varies week to week. In light of the new documentation, it is my opinion that treatment rendered beyond 1119/93 was, in tact, reasonable and necessary up until 1111/94. It is my opinion that this represents a reasonable time frame to achieve the aforementioned functional goals. It is apparent, based upon the objective documentation, that cervical spine range ot motion was, in tact, fluctuating on both a daily and weekly basis. Additionally, complaints of pain varied on a daily to weekly basis as well. In summary, it is my opinion that treatment rendered beyond 1/11/94 would, in fact, be considered unreasonable and unnecessary. If you have any questions regarding this report, please do not hesitate to contact me. Thank you. Sincerely, . , ~~' n ~ ," ",' " l,' --1_ /.\//(. Ct;."..... L li'tf..~ ~I.. ~ . /. William c. McCafferty, P.T. WCM:PT8 e; ,. r. .r . - ..' 'r.': , " , .:. . , fT., , L '} 'l"..1 fb ...,., ,,'I NEW MATTER 1. The claims of Plaintiff ar.e limited by the terms of the MVFRL, 75 Pa. C.S.A. 11701 ~ ~. as amended by Act 6, April 15, 1990 ("Act 6"). ~. The bills in dispute were incurred after the effective date of Act 6. 3. state Farm has paid $6,672.78 to various health care providers on behalf of Mary L. Shannon. 4. Thereafter, based upon the totality of the circumstances including a lack of objective evidence of injury, state Farm sought professional assistance in assessing the reasonableness, necessity and relatedness of the injuries. 5. Therefore, state Farm submitted Plaintiff's matter to a Commonwoalth approved Peer Review Organization established for the purpose evaluating treatment and health care services provided to an injured person. state Farm is required by the terms of MVFRL to contract with such Commonwealth approved peer review organizations for the purpose of assessing the reasonableness, necessity and relatedness of treatment. 6. A Commonwealth approved peer review organization has opined that the medical expenses at issue were neither reasonable nor necessary under the terms of the policy under Pennsylvania Law. On the basis of the peer reviews dated 3/09/94 and 4/30/94 state Farm has denied payment. - 2 - 7. Plaintiff has not and cannot sustain damages as a result of a diminished payment or non-payment of automobile accident related bills. ~ 75 Pa. Cons. stat. 11797(a). since Plaintiff cannot sustain such damage, the lack standing to sue state Farm. 8. This Honorable Court lacks jurisdiction to entertain this matter as state Farm performed a peer review in accordance with the Pennsylv~nia Motor Vehicle Financial Responsibility Law. Accordingly, Plaintiff's claims are barred by the terms of 11797(b)(4) as Plaintiff has not exhausted her administrative remedies by requesting and paying for a reconsideration by the peer review organization. 9. The amounts in dispute in this case represent charges for excessive treatment which was neither reasonable nor neceseary within the meaning of the insurance policy in question and/or the motor vehicle financial responsibility law. 10. The charges at issue in this case and for which insurance coverage is claimed from state Farm are unreasonable and unnecessary in the context of the accident in question. The nature and extent of injuries. damages and other losses alleged by Plaintiffs are denied. 11. Plaintiff's claims for insurance benefits are barred by lack of consideration. - 3 ~ I ' I' , I I") , " 0:,..,111011\_,.., MARY L. SHANNON, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 84. 4882 CIVIL TERM Plaintiff v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, JURY TRIAL DEMANDED Defendant NOW comes Mary L. Shannon, by and through her attonreys, FLOWER, MORGENTHAL, FLOWER & LINDSAY, and replies to New Matter as follows: 1. Admitted. 2. Admitted. 3. After reasonable Investigation, Plaintiff Is without Information sufficient to form a belief as to the truth of the statement In Paragraph 3. 4. After reasonable Investigation, Plaintiff Is without Information sufficient to form a belief as to the truth of the statement in Paragraph 4. 5. Admitted. 6. Admitted. 7. Denied that Plaintiff has not and cannot sustain damages as a result of a diminished payment or non-payment of automobile accident related bills. Denied that Plaintiff does not have standing to sue State Farm, 8. Denied that this Court lacks Jurisdiction to entertain this matter. Plaintiff exhausted her administrative remedies by requesting a reconsideration by the peer review organization. Cllw,II\c)I\_,... ... 9. Denied that the charges at Issue In this case are unreasonable or unnecessary In the context of the accident In question, the nature and extent of the Injuries and the damages and other losses alleged by Plaintiff. 10. Denied that the charges at Issue In this case are unreasonable and unnecessary. 11. Denied that Plaintiff's claim for Insurance benefits are barred by lack of consideration. By way of further answer, Plaintiff gave valuable consideration for her Insurance coverage. 12. Paragraph 12 Is a conclusion of law to which no response Is required. 13. Denied. Plaintiff 113 entitled to recover attorney's fees because Defendant's withholding of medical benefits was not made In good faith and for reasonable cause. 14. Paragraph 14 Is a conclusion of law to which no response Is required. 15. Denied that Plaintiff's claims are barred by the statute of limitations. 16. Denied that Plaintiff has .10t pled any claims In respect to herself. WHEREFORE, Plaintiff prays this Honorable Court to enter Judgment In Its favor and against the Defendant with costs of suit and attorneys' fees. FLOWER, MORGENTHAL, FLOWER & LINDSAY Attorneya for Plaintiff By: 2 ,1 JUt ~ Il 5l PH '95 , !\ " , I, 'If ; ',j t ll~f r,U/J"FI, I'i'.',~';' I" " I',I(), ""r 1'1 1ft, ' r. f" ' r " 'I ;,,1. 'A'" ~ , , I I I' I I.- r ~ :',-J ~ ~ :r.: , 'S... n. r;; I" ~ ~ ('-I, ~ .~ ,.-, ... . .,. ~~ ~~ .. :t.-~ ........ ., " ',' "I , 'I i I ~ I .: ,