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The Rogak Report: 31 Jul 2009 ** No Fault - Medical Necessity **

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  • insurancelawyer
    WHEN CLAIMANT HAS ACTUALLY HAD SURGERY, IME DOCTOR S FINDING OF NO INJURY IS SIMPLY NOT CREDIBLE In the Matter of the Arbitration between: Philip Rafiy MD,
    Message 1 of 4 , Jul 31, 2009
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      WHEN CLAIMANT HAS ACTUALLY HAD SURGERY, IME DOCTOR'S FINDING OF NO INJURY IS SIMPLY "NOT CREDIBLE"

      In the Matter of the Arbitration between: Philip Rafiy MD, Long Island Spine & Ortho and Global Liberty Ins. Co. of N.Y., AAA Case No. 412009013747, AAA Assessment No. 17 991 08897 09, Insurer's Claim File No. 07246101 (Glen A. Cacchioli, arbitrator)

      Edited by Lawrence N. Rogak

      In this no-fault arbitration, the issue was the medical necessity of x-rays, office visits and spinal surgery.  On March 5, 2007, Assignor was involved in a motor vehicle accident. Following the accident Assignor was treated by various health care providers. On June 27, 2007, Assignor appeared for an Independent Medical Examination (IME). The IME, performed by Dr. Lewin, failed to reveal any evidence of continuing injury.

      On March 17, 2008, due to continuing pain in the neck Assignor came under the care and treatment of Applicant, at which time an examination was performed. Impression included cervical radiculopathy. Physical therapy was recommended. An MRI of the cervical spine performed on April 22, 2008, revealed disc herniation at C6-C7 with impingement. On June 2, 2008 and November 20, 2008, Assignor was seen for follow up evaluations. There was no improvement in Assignor's condition. Treatment plan was altered to include cervical steroids and physical therapy with cervical traction. Subsequent examination on January 14,  2009, revealed no improvement in Assignors condition despite physical therapy and medication. Surgery was recommended.

      On January 27, 2009, cervical spine fusion was performed. On February 11, 2009, Assignor was re-evaluated following the surgery and x-rays were taken of the cervical spine.

      Applicant billed Respondent for an office visit that took place on March 17, 2008, and x-rays which were performed the same day, an office visit on May 12, 2008, surgery on January 27, 2009, and x-rays on February 11, 2009. Respondent denied the bills based on the IME report of Dr.Lewin dated June 27, 2008. Applicant now seeks reimbursement for all services provided to Assignor.

      "In reviewing all the evidence I find that Respondent has failed to establish lack of medical necessity," held the Arbitrator. "I find the IME report of Dr. Lewin not credible. It strains belief that his examination failed to reveal any evidence of significant cervical injury. Therefore, I choose to rely on the Applicant-physician's opinion over the IME doctor on the issue of medical necessity."

      "Assignor sustained an injury to the cervical spine, herniated disc with impingement, which was confirmed by MRI. Assignor underwent months of conservative care without improvement in her condition before surgery was contemplated. When it was apparent that conservative care was not working it was the opinion of the treating physician that surgery was medically necessary. I find nothing in the medical reports/records that would lead me to conclude that the surgery was not medically necessary."

      "In light of the above, I must concur with the opinion of the treating physician that Assignor's condition required surgery and Respondent's IME was insufficient to establish lack of medical necessity. Accordingly, Applicant's claim is granted in it's entirety.  Attorney fees are to be calculated by adding the amount of the award ($12,376.89) plus interest."

      Comment:  When an insurance company like this one denies first party benefits to people who are obviously injured, and injured badly enough to require surgery, it gives a black eye to the entire insurance industry.

      Larry Rogak

    • ray_wahl2000
      Well hey Larry - if claimant s symptoms were so severe, why did it take his treating physician(s) 13 months to send him or her for an MRI anyway? And what
      Message 2 of 4 , Jul 31, 2009
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        Well hey Larry - if claimant's symptoms were so severe, why did it take his treating physician(s) 13 months to send him or her for an MRI anyway? And what about the IME? In one line it says the IME was done in June 07, then later it says June 08. Were there 2 IMEs done, coincidentally one year to the day apart, or was there only one in 07 or only one in 08 or what? Makes a difference. If the (only) IME was done in June 07, there would have apparently been no "objective" evidence available to Dr. Lewin at that time. N'est pas?

        [Larry Rogak responds: I have no more information than what is contained in the arbitration award. It is hard to say whether the two IME dates are a typo or a coincidence. But when a claimant needs spinal fusion, and has it, they obviously had a problem. Arbitrators seldom use strong language like "not credible" if they simply feel that an IME or peer report fails to overcome the presumption of medical necessity. This particular insurance carrier has been rebuked by courts and arbitrators a number of times with unusually strong language indicating a lack of credibility. You can draw your own conclusions from that. -- LNR]












        --- In TheRogakReport@yahoogroups.com, "insurancelawyer" <insurancelawyer@...> wrote:
        >
        > WHEN CLAIMANT HAS ACTUALLY HAD SURGERY, IME DOCTOR'S FINDING OF NO
        > INJURY IS SIMPLY "NOT CREDIBLE"
        >
        >
        >
        > In the Matter of the Arbitration between: Philip Rafiy MD, Long Island
        > Spine & Ortho and Global Liberty Ins. Co. of N.Y., AAA Case No.
        > 412009013747, AAA Assessment No. 17 991 08897 09, Insurer's Claim
        > File No. 07246101 (Glen A. Cacchioli, arbitrator)
        >
        > Edited by Lawrence N. Rogak
        >
        > In this no-fault arbitration, the issue was the medical necessity of
        > x-rays, office visits and spinal surgery. On March 5, 2007, Assignor
        > was involved in a motor vehicle accident. Following the accident
        > Assignor was treated by various health care providers. On June 27, 2007,
        > Assignor appeared for an Independent Medical Examination (IME). The IME,
        > performed by Dr. Lewin, failed to reveal any evidence of continuing
        > injury.
        >
        > On March 17, 2008, due to continuing pain in the neck Assignor came
        > under the care and treatment of Applicant, at which time an examination
        > was performed. Impression included cervical radiculopathy. Physical
        > therapy was recommended. An MRI of the cervical spine performed on April
        > 22, 2008, revealed disc herniation at C6-C7 with impingement. On June 2,
        > 2008 and November 20, 2008, Assignor was seen for follow up evaluations.
        > There was no improvement in Assignor's condition. Treatment plan was
        > altered to include cervical steroids and physical therapy with cervical
        > traction. Subsequent examination on January 14, 2009, revealed no
        > improvement in Assignors condition despite physical therapy and
        > medication. Surgery was recommended.
        >
        > On January 27, 2009, cervical spine fusion was performed. On February
        > 11, 2009, Assignor was re-evaluated following the surgery and x-rays
        > were taken of the cervical spine.
        >
        > Applicant billed Respondent for an office visit that took place on March
        > 17, 2008, and x-rays which were performed the same day, an office visit
        > on May 12, 2008, surgery on January 27, 2009, and x-rays on February 11,
        > 2009. Respondent denied the bills based on the IME report of Dr.Lewin
        > dated June 27, 2008. Applicant now seeks reimbursement for all services
        > provided to Assignor.
        >
        > "In reviewing all the evidence I find that Respondent has failed to
        > establish lack of medical necessity," held the Arbitrator. "I find the
        > IME report of Dr. Lewin not credible. It strains belief that his
        > examination failed to reveal any evidence of significant cervical
        > injury. Therefore, I choose to rely on the Applicant-physician's
        > opinion over the IME doctor on the issue of medical necessity."
        >
        > "Assignor sustained an injury to the cervical spine, herniated disc with
        > impingement, which was confirmed by MRI. Assignor underwent months of
        > conservative care without improvement in her condition before surgery
        > was contemplated. When it was apparent that conservative care was not
        > working it was the opinion of the treating physician that surgery was
        > medically necessary. I find nothing in the medical reports/records that
        > would lead me to conclude that the surgery was not medically necessary."
        >
        > "In light of the above, I must concur with the opinion of the treating
        > physician that Assignor's condition required surgery and
        > Respondent's IME was insufficient to establish lack of medical
        > necessity. Accordingly, Applicant's claim is granted in it's
        > entirety. Attorney fees are to be calculated by adding the amount of
        > the award ($12,376.89) plus interest."
        >
        > Comment: When an insurance company like this one denies first party
        > benefits to people who are obviously injured, and injured badly enough
        > to require surgery, it gives a black eye to the entire insurance
        > industry.
        >
        > Larry Rogak
        >
      • David M. Barshay
        Does anyone other than me know why you despise Global? David M. Barshay, Esq. Baker, Sanders, Barshay, Grossman, Fass, Muhlstock, and Neuwirth, LLC 150
        Message 3 of 4 , Jul 31, 2009
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          Does anyone other than me know why you despise Global?

          David M. Barshay, Esq.
          Baker, Sanders, Barshay, Grossman, Fass, Muhlstock, and Neuwirth, LLC
          150 Herricks Road
          Mineola, New York 11501
          516.741.4799


          [Larry Rogak responds: I don't know what you know about my feelings, Dave, but I simply report these decisions and make objective commentary on them. I'm simply a journalist and commentator when it comes to these case reports. -- LNR]



          On Jul 31, 2009, at 7:20 PM, "ray_wahl2000" <jxhurley@...<mailto:jxhurley@...>> wrote:



          Well hey Larry - if claimant's symptoms were so severe, why did it take his treating physician(s) 13 months to send him or her for an MRI anyway? And what about the IME? In one line it says the IME was done in June 07, then later it says June 08. Were there 2 IMEs done, coincidentally one year to the day apart, or was there only one in 07 or only one in 08 or what? Makes a difference. If the (only) IME was done in June 07, there would have apparently been no "objective" evidence available to Dr. Lewin at that time. N'est pas?

          [Larry Rogak responds: I have no more information than what is contained in the arbitration award. It is hard to say whether the two IME dates are a typo or a coincidence. But when a claimant needs spinal fusion, and has it, they obviously had a problem. Arbitrators seldom use strong language like "not credible" if they simply feel that an IME or peer report fails to overcome the presumption of medical necessity. This particular insurance carrier has been rebuked by courts and arbitrators a number of times with unusually strong language indicating a lack of credibility. You can draw your own conclusions from that. -- LNR]

          --- In TheRogakReport@yahoogroups.com<mailto:TheRogakReport%40yahoogroups.com>, "insurancelawyer" <insurancelawyer@...> wrote:
          >
          > WHEN CLAIMANT HAS ACTUALLY HAD SURGERY, IME DOCTOR'S FINDING OF NO
          > INJURY IS SIMPLY "NOT CREDIBLE"
          >
          >
          >
          > In the Matter of the Arbitration between: Philip Rafiy MD, Long Island
          > Spine & Ortho and Global Liberty Ins. Co. of N.Y., AAA Case No.
          > 412009013747, AAA Assessment No. 17 991 08897 09, Insurer's Claim
          > File No. 07246101 (Glen A. Cacchioli, arbitrator)
          >
          > Edited by Lawrence N. Rogak
          >
          > In this no-fault arbitration, the issue was the medical necessity of
          > x-rays, office visits and spinal surgery. On March 5, 2007, Assignor
          > was involved in a motor vehicle accident. Following the accident
          > Assignor was treated by various health care providers. On June 27, 2007,
          > Assignor appeared for an Independent Medical Examination (IME). The IME,
          > performed by Dr. Lewin, failed to reveal any evidence of continuing
          > injury.
          >
          > On March 17, 2008, due to continuing pain in the neck Assignor came
          > under the care and treatment of Applicant, at which time an examination
          > was performed. Impression included cervical radiculopathy. Physical
          > therapy was recommended. An MRI of the cervical spine performed on April
          > 22, 2008, revealed disc herniation at C6-C7 with impingement. On June 2,
          > 2008 and November 20, 2008, Assignor was seen for follow up evaluations.
          > There was no improvement in Assignor's condition. Treatment plan was
          > altered to include cervical steroids and physical therapy with cervical
          > traction. Subsequent examination on January 14, 2009, revealed no
          > improvement in Assignors condition despite physical therapy and
          > medication. Surgery was recommended.
          >
          > On January 27, 2009, cervical spine fusion was performed. On February
          > 11, 2009, Assignor was re-evaluated following the surgery and x-rays
          > were taken of the cervical spine.
          >
          > Applicant billed Respondent for an office visit that took place on March
          > 17, 2008, and x-rays which were performed the same day, an office visit
          > on May 12, 2008, surgery on January 27, 2009, and x-rays on February 11,
          > 2009. Respondent denied the bills based on the IME report of Dr.Lewin
          > dated June 27, 2008. Applicant now seeks reimbursement for all services
          > provided to Assignor.
          >
          > "In reviewing all the evidence I find that Respondent has failed to
          > establish lack of medical necessity," held the Arbitrator. "I find the
          > IME report of Dr. Lewin not credible. It strains belief that his
          > examination failed to reveal any evidence of significant cervical
          > injury. Therefore, I choose to rely on the Applicant-physician's
          > opinion over the IME doctor on the issue of medical necessity."
          >
          > "Assignor sustained an injury to the cervical spine, herniated disc with
          > impingement, which was confirmed by MRI. Assignor underwent months of
          > conservative care without improvement in her condition before surgery
          > was contemplated. When it was apparent that conservative care was not
          > working it was the opinion of the treating physician that surgery was
          > medically necessary. I find nothing in the medical reports/records that
          > would lead me to conclude that the surgery was not medically necessary."
          >
          > "In light of the above, I must concur with the opinion of the treating
          > physician that Assignor's condition required surgery and
          > Respondent's IME was insufficient to establish lack of medical
          > necessity. Accordingly, Applicant's claim is granted in it's
          > entirety. Attorney fees are to be calculated by adding the amount of
          > the award ($12,376.89) plus interest."
          >
          > Comment: When an insurance company like this one denies first party
          > benefits to people who are obviously injured, and injured badly enough
          > to require surgery, it gives a black eye to the entire insurance
          > industry.
          >
          > Larry Rogak
          >
        • Rick
          How would the insurer know that the medical examinations which took place 9 months post IME were valid or part of the same billing treatment patterns we all
          Message 4 of 4 , Aug 5, 2009
          • 0 Attachment
            How would the insurer know that the medical examinations which took place 9 months post IME were "valid" or part of the same billing treatment patterns we all experience. It's not as if the IME found no injuries after the surgery - obviously claimant dr did not find any injury around the time of the IME; if anything I believe the insurer acted credibility relying on an IME; the IME dr should be the one to take the hit if anyone should. I am not sure the arbitrator was fair here to either the insurer or the IME dr


            --- In TheRogakReport@yahoogroups.com, "insurancelawyer" <insurancelawyer@...> wrote:
            >
            > WHEN CLAIMANT HAS ACTUALLY HAD SURGERY, IME DOCTOR'S FINDING OF NO
            > INJURY IS SIMPLY "NOT CREDIBLE"
            >
            >
            >
            > In the Matter of the Arbitration between: Philip Rafiy MD, Long Island
            > Spine & Ortho and Global Liberty Ins. Co. of N.Y., AAA Case No.
            > 412009013747, AAA Assessment No. 17 991 08897 09, Insurer's Claim
            > File No. 07246101 (Glen A. Cacchioli, arbitrator)
            >
            > Edited by Lawrence N. Rogak
            >
            > In this no-fault arbitration, the issue was the medical necessity of
            > x-rays, office visits and spinal surgery. On March 5, 2007, Assignor
            > was involved in a motor vehicle accident. Following the accident
            > Assignor was treated by various health care providers. On June 27, 2007,
            > Assignor appeared for an Independent Medical Examination (IME). The IME,
            > performed by Dr. Lewin, failed to reveal any evidence of continuing
            > injury.
            >
            > On March 17, 2008, due to continuing pain in the neck Assignor came
            > under the care and treatment of Applicant, at which time an examination
            > was performed. Impression included cervical radiculopathy. Physical
            > therapy was recommended. An MRI of the cervical spine performed on April
            > 22, 2008, revealed disc herniation at C6-C7 with impingement. On June 2,
            > 2008 and November 20, 2008, Assignor was seen for follow up evaluations.
            > There was no improvement in Assignor's condition. Treatment plan was
            > altered to include cervical steroids and physical therapy with cervical
            > traction. Subsequent examination on January 14, 2009, revealed no
            > improvement in Assignors condition despite physical therapy and
            > medication. Surgery was recommended.
            >
            > On January 27, 2009, cervical spine fusion was performed. On February
            > 11, 2009, Assignor was re-evaluated following the surgery and x-rays
            > were taken of the cervical spine.
            >
            > Applicant billed Respondent for an office visit that took place on March
            > 17, 2008, and x-rays which were performed the same day, an office visit
            > on May 12, 2008, surgery on January 27, 2009, and x-rays on February 11,
            > 2009. Respondent denied the bills based on the IME report of Dr.Lewin
            > dated June 27, 2008. Applicant now seeks reimbursement for all services
            > provided to Assignor.
            >
            > "In reviewing all the evidence I find that Respondent has failed to
            > establish lack of medical necessity," held the Arbitrator. "I find the
            > IME report of Dr. Lewin not credible. It strains belief that his
            > examination failed to reveal any evidence of significant cervical
            > injury. Therefore, I choose to rely on the Applicant-physician's
            > opinion over the IME doctor on the issue of medical necessity."
            >
            > "Assignor sustained an injury to the cervical spine, herniated disc with
            > impingement, which was confirmed by MRI. Assignor underwent months of
            > conservative care without improvement in her condition before surgery
            > was contemplated. When it was apparent that conservative care was not
            > working it was the opinion of the treating physician that surgery was
            > medically necessary. I find nothing in the medical reports/records that
            > would lead me to conclude that the surgery was not medically necessary."
            >
            > "In light of the above, I must concur with the opinion of the treating
            > physician that Assignor's condition required surgery and
            > Respondent's IME was insufficient to establish lack of medical
            > necessity. Accordingly, Applicant's claim is granted in it's
            > entirety. Attorney fees are to be calculated by adding the amount of
            > the award ($12,376.89) plus interest."
            >
            > Comment: When an insurance company like this one denies first party
            > benefits to people who are obviously injured, and injured badly enough
            > to require surgery, it gives a black eye to the entire insurance
            > industry.
            >
            > Larry Rogak
            >
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