My Persistence Saved the Insurance Carrier $125,000 and Generated More Cases*
by Joan C. Burton, RN, BSN, ONC, COHN, CLNC
My most memorable case taught me the importance of requesting additional information before reaching a conclusion. A self-employed woman filed a workers’ compensation claim indicating she injured her neck, left shoulder and upper arm when moving a file cabinet in her home office. As a Certified Legal Nurse Consultant, I learned more about how the injuries occurred, saved the insurance company money and saved the woman from unnecessary surgery.
As a Certified Legal Nurse Consultant, I learned more about how the injuries occurred, saved the insurance company money and saved the woman from unnecessary surgery.
After the alleged injury the claimant’s family physician referred her to an orthopedic surgeon. The orthopedic surgeon’s examination was entirely within normal limits with normal strength noted. However, because she continued to complain of pain in her neck and left upper arm with “a little numbness in her left index finger,” an MRI of her neck was ordered only three days after the injury. The MRI, performed the following day, showed evidence of C5-6 disc degeneration with broad-based central/left paracentral C5-6 disc protrusion. C6-7 disc degeneration and narrowing was also noted. A small focal intraforaminal disc protrusion was seen on the left contributing to left C6-7 foraminal stenosis.
When the Symptoms Didn’t Make Sense, I Challenged the Cause of the Injury
The patient was referred to a spine surgeon, who reviewed her MRI and examined her the next day, approximately one week after the injury. This exam showed reflexes in the left triceps decreased to nil. Surgery was discussed. The claimant wished to try conservative treatment first. She was scheduled to undergo a C7 nerve root block and begin physical therapy with cervical traction. She was started on a Prednisone taper. Following the injection, she reported 50% improvement in her symptoms. An EMG was recommended. This showed mild left median neuropathy (carpal tunnel syndrome) of the wrist and mild left ulnar neuropathy. No evidence of an isolated brachial plexopathy or cervical radiculopathy was noted. The surgeon was confused about the negative radiculopathy and the fact that her symptoms had changed somewhat. A thoracic MRI was completely negative other than for disc degeneration.
At the next office visit, the patient reported improvement with physical therapy. The surgeon recommended an anti-inflammatory and continuation of therapy. She was seen two months later for foot and heel pain not related to the work injury. No neck or upper extremity symptoms were mentioned. The physical therapy notes documented bilateralupper extremity complaints.
After another month (six months after the injury and approximately five months after the first injection) she saw the spine surgeon for continued complaints of pain in her neck and rather vague symptoms in the left arm and hand. A repeat C6-7 injection was recommended.
One month later she presented to the spine surgeon. At this time an anterior cervical discectomy and fusion were recommended due to her pain, weakness and decreased sensation in a C7 distribution. Before authorizing such surgery, the insurance company sent the file to me for review.
My Detective Work Uncovered a Whole New Scenario for the Claimant’s Complaint
After reviewing the medical records and the nature of the injury, I requested a photo of the file cabinet. I was imagining a large four-drawer cabinet, heavy and awkward to move. But the photograph showed not a typical file cabinet, but a small cart on wheels with slots for hanging folders. I was very concerned about whether this lightweight cart could have caused a disc herniation. Clearly, that was unlikely. However, the surgeon insisted that it could have happened, especially in light of the fact that she had no previous problems with her neck whatsoever.
I then began to question any previous symptomatology. At the claimant’s first office visit to the spine surgeon, she was asked to complete a patient history questionnaire. When asked if she had any previous problems of this nature, she circled “No.” Since her MRI showed evidence of pre-existing degenerative changes, I felt that she probably did have such problems in the past. I therefore requested the records from her family physician for five years prior to the injury.
These office notes did not reveal any problems with her neck or upper extremities. However, I noticed test results on cerebrospinal fluid for protein, glucose and bacteria. This is the typical lab specimen received following a myelogram procedure. The family physician’s office insisted they had no records of any such study. They did not even know why her CSF was being tested.
Finally, I noticed that the ordering physician for the lab study was a local neurologist. His office was contacted to obtain medical records. To my surprise, we received voluminous records regarding the claimant’s complaints of neck and left upper extremity pain, including a CT/myelogram performed three years earlier for the same symptoms she was complaining of at this time. Apparently, the laboratory had the name of the claimant’s family physician on file and sent the results to him as a courtesy. The family physician knew nothing about the claimant’s neck pain and visit to the neurologist. The claimant had flat out denied any previous problems with her neck or upper extremities.
I also questioned why the spine surgeon continued to recommend the cervical spine surgery when the EMG was negative for radiculopathy. The EMG did show evidence of carpal tunnel problems.
In my report, I indicated that the claimant’s weakness, pain, numbness and tingling of the left upper extremity could be carpal tunnel symptoms. Her cervical MRI only showed a small disc protrusion at C6-7, but clearly showed evidence of pre-existing degenerative changes, foraminal stenosis and endplate signal changes.
I suggested that a carpal tunnel release might be more appropriate than a cervical fusion. The insurance adjuster denied the cervical fusion surgery, but did consider allowing a carpal tunnel release at my request, due to her cumulative trauma/repetitive motion disorder with left median neuropathy at the wrist documented by the EMG. Certainly, if she underwent the carpal tunnel surgery and her neck symptoms persisted, she could have the cervical fusion later through her general medical insurance. If she did eventually require a cervical fusion, this would not be related to her work injury but to her pre-existing degenerative disc disease and canal narrowing due to an injury three to four years prior to the reported work injury.
Based on the MRI scan, EMG testing and previous medical records, I was able to provide an alternative reason for her symptoms and make appropriate recommendations for treatment. Most important for the insurance adjuster, I was able to show that her symptoms did not result from a work-related event.
My Discoveries Saved the Claimant from Unnecessary Surgery
When confronted with this information, the claimant realized that her claim would not be considered compensable under the workers’ compensation statute. With her claim denied, the claimant refused any surgery. She was placed at maximum medical improvement and her case was closed.
Reviewing previous medical records, especially laboratory data, can be a challenging task. Lab results typically contain so many numbers that interpreting the information becomes somewhat difficult. For example, laboratory studies for cholesterol, triglycerides, blood sugars and electrolytes usually do not relate to a musculoskeletal injury. Because I had worked in a clinical laboratory, I immediately knew that results for protein, glucose and bacteria in cerebrospinal fluid could only indicate that a myelogram had been performed. My tenacity led me to persist in locating the source of this laboratory study and obtaining the related medical records.
My involvement in this case saved the claimant not only from an unnecessary surgical procedure, but from the wrong procedure. I strongly feel that if the cervical fusion had been performed, at least some of the symptoms would have continued. Cervical fusions are very delicate procedures, and numerous complications can occur as a result of bleeding, spinal cord injury, infection, anesthesia difficulties, etc.
My recommendations as a CLNC® consultant saved the workers’ compensation insurance carrier an estimated $125,000 in treatment costs, surgical costs, lost wages and PPI rating fees. I have since received many referrals from this insurance company. Whenever they even think an injured worker will require an independent medical examination, they almost always ask me to review the file first and provide an opinion as to causation, appropriateness of treatment and any recommendations for future care. They also ask that I determine the appropriate physician to perform the IME and schedule the appointment. Afterward, I review the physician’s IME report to be sure it adequately answers the insurance adjuster’s questions.
The lesson I learned from this case is that a claimant’s prior medical records can provide invaluable information to the CLNC consultant. Perseverance and attention to detail are required to find and interpret such medical records, but the results can be of huge benefit to both the client and the claimant.
Click here for Memorable Case guidelines and thought starters.