June 15, 2012
On July 1, 2011, we filed on behalf of the Medical Provider, Dr. Albert Skocik, a Petition for Review of Utilization Review Determination for the reasonableness and necessity of all chiropractic treatment, prescriptions, and referrals provided by Albert Skocik, D.C. from March 28, 2011, and into the future. Jane L. McBride, D.C. had issued a Utilization Review Determination concluding the treatment was not reasonable.
On August 24, 2010, the patient, Nate Innes (his name has been changed herein) had lifted steel beams and strapped the beams into a truck with chains. About 45 minutes later, he was in a work-related motor vehicle accident and injured his back. The MRI of the lumbar spine showed L5-S1 mild degenerative disc disease with broad-based mild diffuse disc protrusion most prominently centrally with minor caudal disc extrusion and mild compromise of the central spinal canal at this level. Dr. Jeffrey Finn had recommended lumbar epidural steroid injections. He performed a lumbar discogram that showed severe concordant pain with the provocation of the L5-S1 disc. Dr. McBride opined that all chiropractic and massage therapy treatment from March 28, 2011, and into the future is unreasonable and unnecessary. Dr. McBride stated that Dr. Skocik’s treatment did not show “significant” improvement.
Nate testified that on August 24, 2010, he sustained a work-related motor vehicle accident while employed as a truck driver for Shumaker Trucking. Earlier in the day, Nate moved boxes, straps, and binders that weighed more than 40 pounds. He followed another truck that came to an abrupt stop and rear-ended the truck. He experienced severe pain in his lower back a day after the accident.
Nate’s treatment consisted of adjustments to the lower back, stretching, hot and cold therapy with muscle stimulation, and deep tissue massage. Nate testified that Dr. Skocik’s treatment reduced his pain and the “deep tissue massage helped to relieve the pain, tightness, tenseness, and the stress”.
Nate returned to “light” duty work and was supposed to only work four hour days per Dr. Skocik’s restrictions. He ended up driving in excess of four hours at work. And performing lifting beyond his restrictions at the request of his boss.
On cross-examination, Dr. McBride was unaware that Nate continued working and had to lift 48-pound boxes at work. Dr. McBride would not comment on symptoms from working 14 hour days and whether work activities attributed to his symptoms. Dr. Skocik’s records mentioned Nate’s symptoms attributed to his ongoing work activities but Dr. McBride did not mention this in her report. Dr. McBride testified that Dr. Skocik did not utilize alternative treatment but admitted that Nate had an orthopedic evaluation with Dr. Balog and a discogram with Dr. Finn.
On cross-examination, Dr. McBride testified that the Bureau of Worker’s Compensation Medical Treatment Section prevented her from commenting on Nate’s work status. She testified that reviewers are asked to assume causality and not mention the work injury and this is outlined in the instructions to utilization reviewers. She was asked to identify the section but could not because there was no section that stated that a review cannot comment on Nate’s work status. Dr. McBride testified that the physical duties and work status of her patients would affect their length of treatment. At first, Dr. McBride would not comment whether a reviewer would take into consideration Nate’s work status and physical duties at work when opening the appropriate length of treatment. Dr. McBride was asked again if she would consider work status and physical duties when rendering the appropriateness and her response was, “I would want them to consider that.”
Dr. McBride testified the instructions given to her by the Bureau prevented her from commenting on Nate’s work status. The instructions to utilization review organization specifically states the following areas or issues are not subject to utilization Review under the Workers’ Compensation Act and therefore are not considered to be mentioned by the Reviewer as part of the review or determination report:
a. The causal relationship between the treatment under review and the employee’s work-related injury;
b. Whether the employee is still disabled;
c. Whether medical improvement has been obtained;
d. Whether the provider performed the treatment under review as a result of an unlawful self-referral;
e. The reasonableness of fees charged by the provider;
f. The appropriateness of the diagnostic or procedural codes used by the providers for billing purposes;
g. References to IME reports, judges’ decisions, or summaries prepared by the provider for the purpose of the utilization review; and
h. Other issues that do not directly relate to the reasonableness and necessity of the treatment under review.
These instructions made no reference that a reviewer cannot comment on work status and not discuss the injury. Dr. McBride’s assertions to the contrary were simply wrong. The Judge found this inaccuracy is compounded by the fact that she believes work status to be a relevant consideration, and wrongly cited the bureau’s instructions as justification for ignoring Nate’s work status. She testified she would want her patient’s work status taken into consideration if the reasonableness of her treatment was being reviewed.
Dr. McBride was unaware that Dr. Skocik prescribed lumbar epidural steroid injections and a TENS unit for lumbar support. Dr. McBride agreed that Nate had complicating problems to his lumbar spine that complicated the length of treatment. Dr. McBride was asked if she was aware that Dr.Skocik’s physical demands of testing showed Nate had a 150% improvement during treatment. Dr. McBride stated, “I don’t know when the date of NIOSH testing was” and “I need to know that sir before I can answer that”. Dr. McBride would not answer the question. Dr. McBride testified that she reviewed the NIOSH testing when rendering her report but, according to her, the test results failed to show improvement. Dr. McBride was asked what percentage in functional impairment would should improvement but she gave a non-responsive answer. Dr. McBride stated that after six months of care she would expect her patients to have 100% NIOSH improvement. Unknown to her, Dr. Skocik’s treatment with Nate resulted in 150% improvements in NIOSH testing. The physical demand test performed by Dr. Skocik on March 21, 2011, showed different levels of improvement in the arm lift from the low of 23% to a high of 182% on March 21, 2011. Dr. Skocik released Nate to work for driving routes that did not exceed four hours.
Dr. Skocik stated that Nate’s physical demands at work affected his treatment because work causes flare-ups and muscle spasms which prolong the treatment plan. Dr. Skocik testified that palliative care is appropriate treatment based on Nate’s pain levels because it increased his ability to function, NIOSH testing results showed an increase in Nate’s capabilities.
The Judge found the testimony of Nate to be credible and persuasive and accepted the same as fact. He found the medical opinions of Dr. Skocik to be credible, unequivocal, and persuasive and accepts the same as fact. The Judge found the chiropractic opinions of Dr. McBride and the URO to be not credible and rejected the same. Dr. McBride ignored the fact that Nate objectively responded well to treatments; misinterpreted treatment protocol; based her opinion on misinterpretations and/or errors; and failed to acknowledge or consider that Dr. Skocik’s treatment allowed Nate to return to work and function at work. Dr. McBride testified that the Bureau of Workers’ Compensation gave her instructions not to comment on Nate’s work status. The instructions to utilization reviewers contain no reference that utilization reviewers cannot comment on Nate’s work status. She incorrectly cites these instructions to ignore what she admits is a relevant consideration in determining the reasonableness of care.
The Judge found Dr. Skocik’s chiropractic treatment from March 28, 2011, and ongoing to be reasonable and necessary, based upon competent and credible evidence. The Judge Ordered the Defendant shall pay for the reasonable and necessary medical treatment of Nate’s work-related injury in accordance with the provisions of the Workers’ Compensation Act and the Defendant shall reimburse all litigation costs.
