Case Study: "Red Flags” in a Soft-Tissue MVA Claim
The nurse reviewer in the following case study observed a pair of patterns in the medical records for a Motor Vehicle Accident (MVA) that helped to serve as mitigate points in favor for the insurance adjuster. This article will cover the key details of the case and the patterns noticed by the nurse review and will discuss pre-DOL history of the patient, multiple large gaps in the medical records, inconsistent pain complaints, and objective clinical findings from the fact pattern. The takeaways from the case may be of interest to casualty adjusters and defense attorneys.
Facts of the case:
- The claimant was a 32-year-old restrained female driver involved in a sideswipe MVA in which the vehicle spun.
- She was transported by emergency medical service (EMS) to the emergency department (ED) and diagnosed with soft tissue injuries. She was neurologically intact with no evidence of head injury and exhibited a normal gait.
Mechanism of Injury (MOI)The MOI in the police report was the same as reported by the claimant. Moreover:
- The subjective complaints of the injured claimant aligned with the MOI,
- The areas of impact on the vehicle (see Figure 1) and the claimant’s body corresponded to subjective complaints, and
- The initial MOI correlated with the physician records/EMS.
The initial evaluation by the chiropractor noted subjective complaints of back pain, left shoulder pain, and bilateral knee pain secondary to MVA. The claimant was ambulatory at the scene, immobilized, and transported to the ER. The initial exam at the ED was positive for mild left shoulder tenderness, bilateral paraspinal tenderness, and left knee contusion without swelling or bruising.
There were multiple time lapses during the treatment timeline. Lapses in care can impede progress and healing, as well as suggest a less serious set of symptoms. A lumbar spine MRI was performed, and the claimant received bilateral sacroiliac facet joint injections for pain management. She continued treatment with pain management and made a demand of $250,000.
Figure 1 – Damage to the claimant’s vehicle.
Comparison of Pre- and Post-Date of Loss (DOL)No pre-DOL medicals were submitted for review. This is a significant “red flag” in several respects because:
- Pre-DOL medical records should be reviewed to establish a baseline of the claimant’s medical condition(s).
- It was noted that the claimant reported an MVA seven months prior to this loss. Review of records related to type of impact and treatment would be recommended to assist with the analysis of the current claim.
- The claimant had been referred to a neurosurgeon five months prior to being seen. The delay in follow through with referral and chiropractic treatment gaps is inconsistent with claimant reports of severe pain. Remember that severe pain is incapacitating and normally requires medical intervention with narcotics to function.
- Facet joint pain is an arthritic-like condition of the spine that is typically caused by degenerative changes in the facet joints producing pain. Cartilage within the joints break down, causing inflammation and pain. In this case, there is no indication the sacroiliac (SI) joints were injured in the accident. Additionally, the SI complaints were voiced six months after the DOL. Sacroiliac (SI) joint pain can be produced by abnormal gait patterns that can occur related to scoliosis.
The medical records in this case did not document improvement in symptoms to support injections, and the claimant's attorney informed the insurance adjuster that she was still treating. Pain management and injections were not recommended as related due to the extended gaps in treatment that were inconsistent with soft tissue healing.
InconsistenciesThe claimant began treatment after a three-week gap, allowing for intervening events to occur. While chiropractic treatment in absence of spinal manipulation is appropriate for soft tissue injuries to reduce pain and inflammation, according to MDGuidelines, frequency is up to 12 visits within six weeks of care.
The claimant did not exhibit any documented improvement throughout treatment. She reported that her pain produced severe symptoms that inhibited her activities of daily living. New reports of loss of consciousness (LOC) at time of the loss and inability to ambulate at the time of the loss were not consistent with prior documented facts of the loss.
- Referral for MRI of the lumbar spine is questionable as it relates to the date of loss as no acute pain with progressive neurological deficit was documented. The claimant reported increased pain after prolonged driving to travel to Florida. The claimant did not report radicular symptoms. Prolonged sitting can produce lumbar spine pain.
- Strapping performed would not appear related to the loss. Strapping (application of kinesiology tape) is recommended for knee arthritis; however, x-rays performed in the ER do not document any objective arthritis.
- The physical exam was essentially negative except for subjectively influenced decreased range of motion (ROM). No positive neuro or ortho testing was reported.
- Complaints of headache were non-specific and could be related to a variety of conditions. While headaches can be a referred symptom of cervical strain, the claimant should be improving three weeks following the accident as she was diagnosed with soft tissue injuries with no objective radicular findings. Post-accident referral to neurosurgery is questionable given the lack of objective findings.
Continued reports of severe pain with gaps in treatment were inconsistent. The differences between acute versus chronic radiological findings were critical to the defense. The MRI reported did not note any acute findings to support trauma related pathology. For acute pathologies the MRI signal is high intensity, while non-acute findings exhibit a low intensity signal.
Conclusions and TakeawaysBased on the impact and initial evaluation in the ER, the claimant suffered soft tissue cervical, thoracic, and lumbar injury with a left knee contusion. While the claimant attended 29 chiropractic visits over seven months, there were multiple large gaps in treatment that were inconsistent with normal injury resolution; for example, the claimant had a delay of five months after the referral to pain management.
- The claimant reported severe pain when seen seven months post-loss, which is inconsistent with the ability to perform activities of daily living.
- Gaps in treatment allow for intervening injuries to occur.
- The claimant had an MVA five months prior to this event with no submission of prior records.
- The nurse reviewer suggested an independent medical examination (IME ) may be beneficial as the plaintiff attorney indicated the claimant was still treating.
- EMS, ER, and six chiropractic visits appeared related to the loss. The gaps in treatment were not consistent with the reported symptoms.
- Large gaps in treatment amongst all the providers would typically indicate some level of resolution of the condition(s) and/or waxing and waning of chronic conditions.
- Records consistently documented subjective complaints with the absence of clear, consistent objective medical findings, including lack of neurological markers, as well as acute findings.
AcknowledgmentsWe would like to thank Kari Williamson for providing insight and expertise that greatly assisted this research.
Kari Williamson, BS, RN, LNCC, CCM, leads J.S. Held’s Medical Management & Bill Review Service Line. Kari is frequently invited to speak and publish as a leader in the legal nurse consultant field on emerging medical-legal and insurance claims issues, such as data mining, bill audits, medical reviews, internal or external medical assistance, claims education, and new ways to measure and improve outcomes. She writes for a variety of national and regional insurance and legal publications and often speaks to law firms, insurance groups, and other industry organizations.
Kari can be reached at firstname.lastname@example.org or +1 615 398 5229.