Wednesday, July 10, 2013

Literature LIterature Everywhere, without a stop to think

Based on a review of all the evidence and the arguments of the parties at the hearing, Respondent has failed to establish the lack of medical necessity for the disputed testing by a fair preponderance of the credible evidence. While Respondent did submit the specific pages from the articles referenced in the peer review report, it did not submit the entire article, and this makes the peer review physician’s reliance on this material less than persuasive. In addition, the peer review physician appears to have selectively referenced these articles, choosing to refer to a specific sentence or two, which is taken out of context, while ignoring statements in these articles that contradict the recommendation against reimbursement and which may actually support the medical necessity of this testing.
I am struck
Dr. Ehrlich’s addendums repeated the conclusions of his peer reviews and, although there was no indication that he actually viewed the MRI films or reports, he stated that “the MRI scan failed to reveal any lateralizing disc herniations.” His addendums are virtually identical. After reviewing the proof I am struck by how Dr. Ehrlich can claim that “strength, sensation and reflexes were unremarkable” at the physical exam of 7/8/10 yet can also claim that radiculopathy could have been diagnosed at that exam in view of the “unremarkable findings.” I am also disturbed by the dismissal of MRI findings by Dr. Ehrlich without his having reviewed the MRI reports or MRI films. All in all, I find that Dr. Ehrlich’s peer reviews are conclusive, inadequately supported by the medical facts and entirely unpersuasive. I have the same opinion about his addendums. Neither his peer reviews nor his addendums sufficiently showed that the disputed testing was a deviation from generally accepted standards of care.
On August 21, 2006, Dr Ehrlich submitted an addendum report for which he reviewed a letter of necessity dated July 14, 2006. This letter was not submitted for the arbitration. 2 Dr Ehrlich noted that “the testing was done to determine the extent of radiculopathy which would help in determination of injection and surgical intervention; that ‘a vague diagnosis of radiculopathy lacks the rigor to be expected from a specialist in physical medicine and rehabilitation. A specific diagnosis of radiculopathy would describe the particular nerve root. Such a diagnosis of specific radiculopathy would be made based upon clinical findings of neurological deficits along the distribution of a given nerve root. Invasive management considerations such as injections and surgery are not dependent upon electrodiagnostic testing following the reported injuries. Such considerations would be based upon treatment course and radiologic findings. Providing acupuncture has nothing to do with electrodiagnostic testing at all.” As will be seen from the discussion below in reference to Applicant’s proofs, Dr Ehrlich has misrepresented what was stated in them in reference to acupuncture, and they show that, in fact, his criteria were major considerations in the decision to perform the subject testing.  
[As a side note of interest, on July 14, 2008, for another case with the same issue, Respondent’s office provided the Recommended Policy for Electrodiagnostic Medicine issued by the American Association of Neuromuscular & Electrodiagnostic Medicine. It states that “a minimum evaluation (for radiculopathy) includes motor and sensory nerve conduction studies with needle EMG, and these studies should be performed by one physician supervising and/or performing all aspects of the study. (Applicant testified he did all testing himself.) Page 3 gives an interesting insight in reference to this, noting as follows:  
“Although a common problem such as tingling and numbness in the hand and arm (which could be due to lesions in the brain, spinal cord, cervical roots, brachial plexus, or nerves in the upper extremities) may be studied in a similar way, there is no universally accepted protocol...the EDX consultant must continually reassess the findings encountered during the performance of the testing...he does not ‘read’ needle EMGs, he is integrally involved in performing a detailed study.”]  
Dr Ehrlich informed that MRI results noted cervical disc herniation at C4-5 and lumbar herniation at l5-S1. These tests were performed March 1, 2006.  
Applicant provided an assignment, the bill, subject test finding, referral for the MRIs, initial evaluation report of December 7, 2005, and follow-up reports of February 24, March 29, and June 12, 2006. The initial complaints were of persistent neck, middle and lower back pain with referred pain, numbness/tingling into the right arm and leg, intermittent headache with dizziness, blurred vision in the right eye, numbness over the face.  
These symptoms continued on February 24, 2006. Dr Finkel’s initial neurological report of January 4, 2006, documented diagnostic impressions of cervical/lumbar radiculopathy, cerebral concussion and right trigeminal traumatic neuropathy, recommended electroencephalogram. Neurological examination had positive findings. The plan was for the studies to evaluate for disc pathology and radiculopathy. “The universal criteria for electrodiagnostic studies according to the Guidelines of the AAEM is radicular pain down the extremities lasting three weeks or more; a more definitive diagnosis will help determine if more invasive techniques such as epidural and/or nerve blocks or acupuncture are warranted. 
This was the exact course taken in this case.
A conclusion based on an inaccurate description.
In short, Respondent has apparently provided a conclusion based on an inaccurate description of what was contained in the medical citation relied on. Therefore, I find, as a matter of fact, that the lumbar support was medically necessary inasmuch as Respondent has failed to demonstrate a lack of medical necessity, as is their burden.

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