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The Rogak Report: 31 Jul 2008 ** No Fault - Physical Therapy **

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  • insurancelawyer
    PHYSICAL THERAPY CLAIM DEFEATED BY IME; FEE SCHEDULE EXPLAINED Sports PT of NY PC v. New York Central Mutual Fire Ins. Co., AAA Case No. 412008016586, AAA
    Message 1 of 1 , Jul 31, 2008
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      Sports PT of NY PC v. New York Central Mutual Fire Ins. Co., AAA Case No. 412008016586, AAA Assessment No. 17 991 11221 08 (

      Burt Feilich, Arbitrator)

      Edited by Lawrence N. Rogak

      This case, defended by the office of Lawrence N. Rogak LLC,  involved a claim in the amount of $508.03 and concerns the issue of physical therapy services rendered by the applicant on behalf of the claimant for the diagnosis and treatment of injuries sustained in an accident that occurred on August 21st, 2004.

      New York  Central contended that the services rendered were not medically necessary on the basis of an IME report.

      The applicant was a self-employed physical therapist located in Syracuse, New York.  "Consequently," ruled the Arbitrator, "I believe that the fee schedule maximum daily allowable billing limit for all physical therapy modalities employed by applicant is a total of $47.28. That number is based on a conversion factor in Region 1 for a self-employed physical therapist of 5.91, multiplied by 8, which is the maximum number of hours of therapy allowed per day by the fee schedule. The comparative maximum rate for a self-employed physical therapist in the NYC/LI Region 4 would be $61.60, which is based on a conversion factor of 7.70 times 8 hours per day."

      "Additionally, a review of the bills submitted by applicant indicates that a duplicate bill was submitted for services rendered on November 21st, 2005. Consequently, by my calculation, the proper amount in dispute should be a total of $378.24 consisting of 8 days of therapy at the maximum daily rate of $47.28."

      "Applicant submits the initial therapy evaluation report dated November 15th, 2005. It indicates that the patient was a 22-year old female who was a driver injured in a motor vehicle accident on August 21st, 2004. She came under the care of orthopedist, Dr. Todd Grime, who ordered an initial course of physical therapy."

      "Thereafter, on November 15th, 2005, on the basis of an order from Dr. Grime on November 8th, 2005, claimant went to applicant's facility for chief complaints of pain in the left shoulder and left upper extremity. The note states that the referring diagnosis was left shoulder pain and rotator cuff impingement. No other details were submitted showing the care claimant received between late summer 2004 and late 2005."

      "The physical examination on November 15th, 2005 revealed the following: pain, tenderness and restriction of motion of the left shoulder with a number of positive orthopedic tests. There was weakness of the left hand grip. The recommendation was for a course of physical therapy for the shoulder using multiple modalities."

      "On January 26th, 2006, a progress note indicated that claimant said her pain had not improved since her last visit on December 12th, 2005. Consequently, claimant was discharged as a patient."

      "Applicant has submitted orders from Dr. Grime for physical therapy dated November 8th and December 8th, 2005."

      "Applicant has also submitted its daily physical therapy treatment records. In defense of the claim, respondent submits the IME report of orthopedist, Dr. John Ring, dated February 8th, 2005. This report indicates that claimant stopped receiving physical therapy on December 30th, 2004, where she had been going 3 times per week since the time of the accident. Dr. Ring reviewed a report from Dr. Grime, dated January 13th, 2005 whereby it was indicated that claimant's left shoulder complaints had resolved. That report from Dr. Grime was not submitted into evidence. Claimant also told him that she lost only 3 weeks from work as a toll collector following the accident. Claimant's present complaints at the time of the IME were pain in his neck and left shoulder and she no longer had any numbness in the shoulder and left arm. Dr. Ring's physical examination was entirely within normal limits with no abnormalities of orthopedic and peripheral neurological function in any areas of the body. In his opinion, claimant had sustained sprains and strains of the cervical spine and left shoulder that had resolved. He thought there was no disability and that claimant had no further need for orthopedic care or physical therapy for any injuries sustained in the accident of August 21st, 2004."

      "As a result of Dr. Ring's examination, respondent denied all further orthopedic and physical therapy services as of February 25th, 2005."

      "After having evaluated all of the medical evidence, I find that respondent's IME report was sufficient to meet the burden of proof that this additional physical therapy rendered in the period from November 15th to December 8th, 2005 was not medically necessary for this patient. In particular, nearly 10 months before the period of treatment claimed in this case, Dr. Ring found no evidence of any continuing effects from the accident of August 21st, 2004, and there was some documentation from the treating orthopedic surgeon that as of January 2005 no further treatment was needed for the injuries sustained in the accident. Applicant did not submit a more recent re-evaluation from Dr. Grime, the prescribing physician."

      "Thus, I sustain the denials of claim issued by respondent as no further physical therapy services were necessary after the effective date of the denial of claim based on the IME examination."

      "Therefore, my award is in favor of respondent, and the claim is denied in its entirety."

      Comment: Aside from the win, which was nice, the Arbitrator's explanation of the application of the fee schedule is very useful.

      Larry Rogak

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