May 10, 2005

ABC INSURANCE COMPANY
P.O. Box 6079
ANYTOWN, USA
Attn: Joe Adjuster

CLAIMANT: Rodriguez, Henry
INSURED : Jon Jon
CLAIM # : 008060-3
D.O.I. : 10/31/04
ERI # : RDD021283

Dear Mr. Adjuster:

I have had the opportunity to review the medical record of Mr. Claimant. Included in the medical record were the following: application for benefits for Personal Injury Protection; health insurance claim forms and evaluations from W. Le, M.D., as well as Mary Smiley, M.D.; health insurance claim forms, as well as physical therapy evaluation, reevaluations, discharge an daily documentation from  North Physical Therapy  dated November 4, 2004 through February 17, 2005 for a total of 33 physical therapy visits.

HISTORY OF PRESENT ILLNESS: According to the medical records, this patient is a 21 year-old male who presented to the Emergency Room on October 31, 2004. He reported that he had been the restrained driver of a vehicle hit by another vehicle, which fled the scene. It is noted on multiple occasions in the Emergency Room documentation that there was no loss of consciousness, and in fact in the Emergency Room report of Donald Duck, M.D. on that date, it is noted that the patient complains of minimal soreness to the forehead area, although does not believe that he struck any objects and is certain that he did not lose consciousness.  Of interest, however, the patient did report to Dr. Le that he had both hit his head and lost consciousness on the date of that accident.

In the Emergency services documentation, it is noted that the most damage to the vehicle was in the drivers side rear with minor damage to the drivers compartment. He was taken by ambulance to Hospital where x-rays of his cervical spine and left shoulder were negative. Clinical impression was that of muscular neck and back pain, as well as a left shoulder contusion.

He presented to Dr. Le on November 3, 2004 for an initial medical evaluation. That day, he complained of pain in the neck, low back and shoulders, as well as headaches. He reported his pain was of a constant nature and shoulder pain was worsened by reaching, dressing, lying on his left side, as well as lifting.

Neurological examination was unremarkable. Musculoskeleltal examination was significant for stiff guarded movements in the cervical spine with moderate loss of pain in all directions and tenderness and spasm in the paracervical musculature. 

Thoracic range of motion was moderately diminished in all planes with stiff guarded movements as well, and tenderness and spasm in the lower right and left parathoracic musculature.  Lumbar range of motion was diminished to left and right side bending with tenderness and spasm in the lumbar spinous processes at the levels of L2 through L5.

He was able to forward bend to 45 degrees and straight leg raise was to 30 degrees bilaterally. Left shoulder range of motion was limited to abduction 135 degrees, flexion 120 degrees, internal rotation and external rotation were within normal limits. There was AC joint tenderness on the left, as well as tenderness in the right and left supraspinous fossa.

The plan at that time was made for physical therapy evaluation and treatment and the patient was given diagnoses of cervical, thoracic and lumbosacral sprain/strain, left shoulder strain and vascular headaches.

 The patient presented the next day to Physical Therapy for initial physical therapy evaluation complaining of pain at the level of 9/10 in the cervical and lumbar spine and 8/10 in the thoracic spine and left shoulder.  Joint play was noted to be decreased in the left shoulder at the level of 1/6, as well as the left scapula. 

There is increased tenderness and tone at the bilateral suboccipital musculature, upper trapezius, levator scapulae, sternocleidomastoid, mid and lower trapezius, rhomboids, quadratus lumborum, erector spinae from cervical to lumbar, subscapular area, and left serratus anterior, as well as the C2 through C7, L2 through L5, transverse processes, PSIS, sacrum and left subacromial and subdeltoid regions.

He is noted to have forward shoulder and head posture with decreased cervical lordosis and increased lumbar lordosis and decreased lumbar active range of motion. Upper and lower extremity myotomes are noted to be strong and painless, except for pain with cervical flexion and extension and lumbar pain with trunk flexion and extension.

Left shoulder range of motion was limited to 140 degrees flexion, 115 degrees abduction, 40 degrees external and 30 degrees internal rotation, which would represent quite a significant discrepancy from the evaluation of Dr. Le one day previous.  Left shoulder strength was decreased to 3+ to 4- in all planes.  Parascapular strength was also decreased in a like manner.  Cervical range of motion was measured at 10 to 25% of normal for all planes.  Lumbar range of motion was measured at 10 to 30% of normal for all planes and strength in the cervical and lumbar spine was assessed as 3+/5. 

Quadrant test was positive for the left cervical spine.  Asymmetric straight leg raise was positive for low back pain, as well as hamstring tightness at 20 degrees left and 30 degrees right.  Iliac compression test was positive and plan at that time was made for physical therapy intervention with long term goals set for six to eight weeks hence. 

It is noted the patient was given a home exercise program; however, there is no supporting documentation as to what this home exercise program contained.  There is no treatment documented for November 5, 2004.

The week of November 8th through 12th, the patient noted my neck is hurting and received moist heat and electrical muscle stimulation for 15 minutes to the cervical, thoracic and lumbar spine, moist heat to the left shoulder, massage to the cervical, thoracic and lumbar spine without any duration specified, and exercises include passive range of motion of the cervical spine in all planes, upper trapezius stretch, alternating isometrics for lower trunk rotation, single knee to chest, hamstring stretches and passive range of motion of the left shoulder for flexion and abduction. 

On November 18, 2004, there is no documentation of the care provided, and it says only to refer to the worksheets of the previous week for the current status.

The week of November 22nd through 24th, the patient noted, my neck and shoulder are stiff and received modalities and massage, and it is noted that massage was added to the left shoulder without any specific site or duration again. The exact same treatment was rendered as that of the last two weeks and that would indicate 7 visits with the exact same treatment rendered with regards to passive range of motion, manual and self stretching.

On December 2, 2004, the patient was reevaluated both by Dr. Le  and at  North Physical Therapy. To Dr. Le he noted that his back pain was worse, however, his left shoulder was feeling better. Musculoskeletal examination was significant for a moderate loss of range of motion in the cervical spine in all planes, which is exactly the same as that of the previous evaluation, with tenderness and spasm in the paracervical musculature. Thoracic range of motion was moderately decreased as well and the same plan as previous with tenderness and spasm again present in the parathoracic musculature. There was tenderness and spasm in the right greater than left paralumbar musculature. However, range of motion assessment was apparently not performed, except for that of forward bending, which was to 60 degrees. Straight leg raise was to 60 degrees bilaterally.  Left shoulder range of motion was measured at 160 degrees abduction, 150 degrees flexion, internal and external rotation were again within normal limits. There was no AC joint tenderness and plan at that time was made for continued physical therapy intervention. 

He was reevaluated that same day at North Physical Therapy and reported that his neck, back and left shoulder continued to be quite painful at that time noting extreme pain with abrupt cervical rotation. Joint play was measured as 2/6 for the left scapula, as well as the left glenohumeral joint. Cervical and lumbar strength were assessed as 4-/5 for flexion and extension. Range of motion was 30 to 40% of normal in the cervical spine and 30 to 50% of normal in the lumbar spine in all planes of motion that were measured. Left shoulder range of motion was 160 degrees flexion, 145 degrees abduction, 60 and 50 degrees external and internal rotation respectively, which would again represent quite a discrepancy between the two practitioners evaluations occurring this time on the exact same date. Left shoulder and parascapular strength were again decreased to 3+ to 4-/5 in all planes, and there was again increased tenderness and tone in the exact same sites as noted previously and at the same levels.

The plan at that time was for continued physical therapy intervention two to three times per week for an additional six to eight weeks, and there is no documentation of why this plan of care has been extended, as the original plan of care was only for a six to eight week duration.

The week of December 6th through the 8th, the patient noted my neck is sore and tight, help me, and received interferential electrical muscle stimulation to the cervical, thoracic and lumbar spine and left shoulder for 15 minutes, soft tissue mobilization versus massage to the suboccipital musculature, upper trapezius and cervical paraspinals, levator scapulae, quadratus lumborum, as well as an OA release.  He received active assistive versus passive range of motion and performed the exact same stretches he had been performing since November 8th. The only additions to exercise were lumbar extension, shoulder flexion and abduction and rows, and then these exact same exercises on January 12, 2005 with the only change being that of an increase in resistance periodically.

The week of December 13th through 16th, the patient had the same complaints and received the same modalities, joint mobilization versus massage, and the same stretches and range of motion exercises.

The week of December 20th through 23rd, the patient noted my shoulder still bothers me at times and received the same modalities with the addition of a mobilization to the left shoulder. Of interest, this patient had been noted to have decreased left shoulder range of motion and joint mobility documented for the previous seven weeks and this is the very first time that a mobilization of that shoulder occurred. He performed the exact same active assistive range of motion and stretches. The week of December 29, 2004, the patient had the same complaints and received the same treatment and he was reevaluated on January 3, 2005.

The patient was seen at North Physical Therapy for reevaluation on January 3, 2005 reporting his neck and back have improved with therapy, however, still reporting pain with quick bending and turning movements.  He noted that his left shoulder was still painful with overhead movements as well. Joint play was 2/6 with regards to the left scapular and left glenohumeral joint.  Cervical range of motion was now 50 to 75% of normal in all planes. Strength was 4/5. Lumbar range of motion was 60 to 70% of normal in all planes with strength 4/5.  Left shoulder range of motion was within 10 degrees of normal, except for abduction, which was limited to 160 degrees and strength was 4/5. Parascapular strength remained limited ranging from 3+ to 4/5.  There remained increased tenderness and tone at the same levels as the last reevaluation in the upper trapezius, levator scapulae, mid and lower trapezius, rhomboids, cervical, thoracic and lumbar paraspinals, subscapular area, cervical and lumbar spinous processes, PSIS, and left subacromial and subdeltoid bursa.  The plan at that time was made to continue therapy two to three times per week for an additional three to five weeks.

The week of January 3rd through 7th, there is no documentation of the treatment that was rendered.

The week of January 12th to 14th, the patient reported intermittent cervical, thoracic and lumbar discomfort. He continued to receive soft tissue mobilization, joint mobilizations to the left shoulder and the same active assistive range of motion and stretches he has been performing. The only additions were that of four Physioball exercises, which were then performed to the date of discharge.

The patient was seen by Dr. on January 13, 2005 for medical evaluation and it is not documented why the patient sought care with Dr. DD versus Dr. Le .  Physical examination at that time revealed diminished cervical range of motion with pain in all directions.  However, the specific range of motion or amount of range of motion loss is not documented.  There was spasm in the paracervical musculature, however, no tenderness.  Thoracic range of motion was full, however, with stiff guarded movements.  Lumbar range of motion was diminished with pain in all directions and stiff guarded movements, and spasm in the lumbar paraspinal musculature.  Left shoulder range of motion was diminished with pain at the end range.  Specific range of motion assessment was not made and plan at that time was made to continue physical therapy intervention for an additional four weeks.

The week of January 19th through 21st, the patient had the same complaints as previous and received the same treatment.

The week of January 27, 2005, again the same complaints and treatment were rendered. On February 3, 2005, the patient was again reevaluated at  North Physical Therapy reporting he continued to have neck and back pain with abrupt movements stating his left shoulder continued to improve.  Left scapular and glenohumeral joint mobility were now normal.  Cervical range of motion was now 80 to 90% of normal and strength was 4+/5. Lumbar range of motion was 75 to 90% of normal in all planes and strength 4 to 4+/5.  Shoulder range of motion was now within 5 to 10 degrees of normal in all planes. Strength was 4+/5, parascapular strength 4- to 4+/5.  There was 2/3 tenderness and tone at the bilateral upper trapezius, levator scapulae, rhomboids, thoracolumbar paraspinals, and C5 through C7 and L3 through L5 spinous processes.  The plan at that time was made for continued physical therapy intervention one to two times per week for an additional two to four weeks.  After this reevaluation, the same exact treatment was rendered to the date of discharge with the only change being incremental increases in resistance in several of the exercises performed.

There was no other progression, augmentation or change, and the patient was discharged from  North Physical Therapy on February 17, 2005. Physical examination was significant for a loss of 10% of cervical motion in some planes and up to 15% in the lumbar spine. Left shoulder range of motion was now normal. Strength was 4+/5. There is still minimal tenderness and an increased tone in the bilateral cervical, thoracic and lumbar erector spine, and at that time the patient was discharged from  North Physical Therapy.

There is also a discharge evaluation performed on February 17, 2005 by Dr. DD as well. After that day, I can find no further evidence of physical therapy intervention.

PAST MEDICAL HISTORY: Review of the medical record did not reveal any significant past medical history.

DIAGNOSIS: It is my opinion, based on the review of the medical record that this patient could have possibly sustained a cervical, thoracic and lumbar sprain/strain, as well as a left shoulder contusion as causally related to the motor vehicle accident, which he was involved in on October 31, 2004. His initial symptoms do appear to be consistent with this type of diagnosis.

PROGNOSIS: It is my opinion, based on the review of the medical record, that this patients prognosis is excellent. The patient is a young previously healthy male without medical co-morbidities and injury is limited to the soft tissue. It is the opinion of this physical therapist that these injuries have healed and will pose this patient no future limitations or permanency.

WORK STATUS: Review of the medical record indicated that this patient was employed as a mechanical assembler and the total amount of time lost from work was never specified.

DISABILITY STATUS: It is my opinion, based on a review of the medical record that it is reasonable to believe that this patient would have been totally disabled from the time of the accident on October 31, 2004 for a period of four to seven days maximally and partially disabled for an additional four to six weeks for activities including repetitive bending and twisting, heavy lifting and prolonged static postures.

REASONABLENESS OF TREATMENT: Review of the medical record indicates that this patient was followed at  North Physical Therapy from November 4, 2004 through February 17, 2005 for a total of 33 physical therapy visits. It was documented that the patient received a home exercise program on the date of initial physical therapy evaluation. This was not documented specifically and there was no supporting documentation. However, there was then no change, augmentation or progression with regards to this patients home exercise program over the entire course of treatment. It is a standard of care in physical therapy practice that a patients both in clinical and home exercise program should be modified, progressed and augmented if not on a treatment to treatment, then at least on a week to week basis, and this is clearly not done in the case of the claimant. In addition, the exact same stretches and range of motion exercises were performed in the clinic for months on end. All were very simple and appropriate for an independent home exercise program after a maximum of two to three treatment sessions. There was also continued utilization of manual muscle stretches and active assistive range of motion for 30 treatments and this was absolutely unnecessary. In addition, there was continued utilization of palliative modalities without any indication that these modalities were aiding in the resolution of this patients symptoms. For the first month and greater of treatment, this patient had the exact same complaints and yet the utilization of moist heat and electrical muscle stimulation and soft tissue massage/soft tissue mobilization continued. These should have been discharged with the selection of another treatment modality after the reevaluation performed on February 2, 2004. Furthermore, there was no documented duration of the soft tissue massage or soft tissue mobilization, and this is not acceptable for billing for reimbursement of skilled physical therapy services, which are billed in 15-minute units. The same simple exercises were performed repeatedly in clinic without any indication on any date that greater than one unit of skilled therapeutic exercise was rendered to this patient. In addition, performance of the exact same four exercises on the Physioball for greater than a four week duration certainly does not constitute four weeks of neuromuscular reeducation, especially given the simplicity of these exercises performed on the Physioball. In short, based on the documentation, there is no indication that 33 physical therapy treatments were at all warranted regarding the injuries sustained by this claimant in the October 31, 2004 motor vehicle accident. In addition, due to the repetitive nature of the care, the lack of progression and augmentation of the exercises, the continued performance of passive and then active assistive range of motion for 30+ treatments, manual muscle stretches for months on end, it is the recommendation of this physical therapist that no greater than 16 to 20 treatments at an absolute maximum would be considered reasonable, customary, medically necessary and appropriate.

REASONABLENESS OF FEES: It is the recommendation of this physical therapist that payment for moist heat be decreased to $25.00. On the date of November 4, 2004, payment for therapeutic exercise shall be denied, as there is no supporting documentation. Payment for all care rendered on November 5, 2004 shall be denied, as there is no supporting documentation. On all dates were greater than one unit of therapeutic exercise was billed one unit shall be denied secondary to the repetition of exercises performed in the clinic, many of which had been performed for literally months on end without change. Payment for soft tissue massage and soft tissue mobilization shall be summarily denied secondary to the lack of documentation regarding the duration of this treatment, which is unacceptable for billing purposes. Payment for moist heat and electrical muscle stimulation shall be denied after the reevaluation on December 2, 2004 secondary to the lack of subjective change and minimal objective progress that were documented, especially with regards to the increased tone and tenderness, which persisted in fact until even the February 3, 2005 reevaluation. Payment for physical therapy services shall be denied after the date of January 12, 2005. At that point, the patient had had 20 physical therapy visits and at that time should have been independent with a comprehensive home exercise program with instructions to use or cold as needed for palliative purposes. Certainly, there is no indication that 33 physical therapy treatments would be warranted given the nature of the soft tissue injuries sustained in this motor vehicle accident.

MAXIMUM MEDICAL IMPROVEMENT: It is my opinion, based on the review of the medical record that this patient has reached maximum medical improvement with regards to the injuries sustained in the motor vehicle accident occurring on October 31, 2004. It is the opinion of this physical therapist that this patient should experience no future limitations or permanency as a direct result of these injuries.

I certify that I am a licensed physical therapist in the Commonwealth of Massachusetts and have reached the above conclusion to a reasonable degree of medical certainty.

Subscribed and sworn this ____ day of ______ in the year _____ under the pains and penalty of perjury.


Sincerely,

SAMPLE
__________________________
  Physical Therapy Reviewer, MSPT, CDP