|
Doctors
DeGeorge and Gambale both graduated from Palmer College of Chiropractic
in Davenport, Iowa.
Presently, Drs. DeGeorge and Gambale are
the inventors of the Compression Extension Traction Table as well as the
Spine Aligner adjusting table. Three studies have been published (one at
SPINE and two at JMPT) from studies done at their office.
Drs. DeGeorge and Gambale have now
implemented a program to help other doctors gain more from their own
practices. |
AJCC Jan 2000 |
|
The IME Game: Reverse Denial Decisionsby Dwight DeGeorge, DC & Anthony Gambale, DC Most
Doctors of Chiropractic express serious stress and frustration over the
abuse of the IME process. Once a case has been stated for slated for an
IME, it usually is the kiss of death for that patient’s treatment
program at your office. I personally had all but given up on fighting to
get our claims paid. Dr. DeGeorge, instead of getting angry and
frustrated, set out to use the system that the insurance companies have
set up to his advantage. He has continued to refine our responses to IME
reports to the point where we actually are getting paid on most of our
cut off cases. I thought I would take you through one example of the IME
game. This particular case is representative of most and shows that you
can reverse a denial decision. The following are a series of
correspondences we had with an insurance company. The names have been
changed to maintain the privacy for all involved. November
25, 1998 Dear
Ms. Jones:
Jane Smith was first seen in this office on 11/25/98 for
examination and treatment of injuries she sustained in a motor vehicle
accident, which occurred on 11/24/98. Here at this office, Jane received
a complete orthopedic, neurological, x-ray, and chiropractic evaluation. DIAGNOSIS: 847.0
Cervical Sprain/Strain, 784.0 Headache, 729.1 Cervical Myalgia, 847.2
Lumbar Sprain/Strain, 737.34 Thoracic Myalgia, 724.2 Low Back Pain,
781.9 Abnormal Posture. TREATMENT
PROGRAM INITIAL
INTENSIVE CARE: 1.
Spinal manipulation to decrease nerve irritation and increase
mobility. 2.
Cryotherapy to reduce inflammation and pain. CORRECTIVE
CARE: 1.
Specific spinal adjustments to correct spinal misalignments. 2.
Therapeutic exercises to strengthen weakened muscles and aid in
maintaining adjustments. 3.
Traction to re-educate spinal ligaments, to also aid in
maintaining corrections.
Jane Smith has been totally disabled from participating in her
normal activities from 11/25/98 through the present time.
If you have any questions, please contact this office.
Sincerely,
Dr. Anthony Gambale
Dr. Dwight DeGeorge
ADVANCED CHIROPRACTIC
Dear
Ms. Jones:
Today I examined Jane Smith, a 53-year- old female, who was
involved in a motor vehicle accident on November 24, 1998. REPORTED
HISTORY
Ms. Smith states that on November 24, 1998, she was the
restrained front seat passenger of a vehicle that was at a complete stop
at a red light when it was hit from behind. The vehicle did not hit any
other vehicle or object. The examinee did not strike any body part. She
did feel her neck snap forward and backward. Within a minute, she had
neck and shoulder pain. She was driven home and the next day she
consulted Dr. DeGeorge, a chiropractor, who examined her, took x-rays
and began a course of chiropractic care consisting of manipulation and
ice, originally four days per week. She continued four days a week for a
few weeks, then three days a week to two days a week and currently she
sees Dr. DeGeorge approximately once or twice a week and states the care
has been very helpful.
The examinee is employed as a pediatric nurse in pediatric home
care. She missed one day’s worth of work and is doing her regular
work. Currently she reports mainly tightness in her neck and shoulder
radiating to the mid thoracic region. There were two incidences of arm
pain and hand pain but that has since resolved with no numbness or
parasthesias in her arms or legs, no headaches. She had significant
headaches initially from the accident. There is no motor weakness in the
arms or legs. Prolonged sitting bent over a desk will cause some
discomfort but the examinee has her desk and computer terminal set that
where she is pretty much at eye level so there is little neck flexion or
extension. The most painful position for her neck is prolonged looking
upward and also prolonged standing tends to aggravate her lower back. PAST
MEDICAL HISTORY
Her past history is significant for lower back injury. She had a
fall and three years later, hurt her back while lifting a patient. She
was treated by Dr. DeGeorge with excellent results. She states
emphatically that this car accident of November 24, 1998 did not
exacerbate her lower back. Thirty years ago, she was involved in a car
accident where she went through the windshield suffering a concussion,
cuts and abrasions. She was hospitalized for one day and that had healed
completely. She has no other medical problems. PHYSICAL
EXAMINATION
The examinee is 67 inches in height and she weighs 190 pounds.
She does hold her neck in a somewhat guarded position and the
shoulders are somewhat elevated. There is a reduced cervical lordosis
upon postural evaluation. There is mild tenderness over the anterior
cervical musculature, slightly more moderate tenderness over the lateral
musculature and there is slight tenderness over the cervical thoracic
junction and the posterior paravertebral musculature, also over the mid
bellies of the trapezius muscles, but spasm is absent.
Cervical ranges of motion was flexion 55° with pulling,
extension 45° with lower neck pain, rotation 80° bilaterally with
stiffness and lateral flexion 45° bilaterally with stiffness.
Cervical compression testing was not performed as the examinee
stated that she has had a long history, even prior to the car accident,
with her head being pressed causing neck and back spasms so we could not
perform this. Mild pulling was noted on combined flexion rotation and
also upon shoulder depression. Cervical distraction also caused some
discomfort in the upper back and this test was stopped.
Grip strength was normal. Rapid cervical flexion, which is the
Soto-Hall test, produced pulling in the upper thoracic region. Kemp’s
maneuver which is extension rotation, I primarily did the shoulders and
neck and the Kemp’s and this produced stiffness across the upper back.
There were no sensory or motor abnormalities in the upper
extremities. All shoulder ranges of motion were within normal limits
while cervical strength was normal.
X-rays brought in by the examinee, consisting of a cervical
series and also AP, lateral thoracic and AP, lateral lumbar, there is a
reduced lordosis in the cervical series. Flexion/extension views showed
reduced motion between C-4 and C-5 both on flexion and extension, that
is hypertonicity of that motor unit. The lumbar spine showed mild
degenerative changes in the lumbar facet joints, also some disc space
narrowing and anterior spur formation. DIAGNOSES
Hyperextension cervical sprain with cervical upper thoracic
myofascitis. Bilateral trapezius strain. CONCLUSIONS
Assessment, after examining Jane Smith, I believe that there is a
causal relationship between the November 24, 1998 accident and the
clinical course. The examinee has, in my opinion, responded very well to
Dr. DeGeorge’s care. There was a pre-existing low back injury, which
was not aggravated by this accident. The examinee does report a long
history of migraines which may have been somewhat exacerbated by this
accident. They have been helped by Dr. DeGeorge. Also the instability
and muscles spasms that occur when the examinee’s head is compressed
predates this accident.
The examinee, in my opinion, is at a pre-accident status as far
as the injury to her neck and upper back. Some residual tightness and
stiffness may persist for a while, but in my opinion, could be well
maintained and taken care of through home exercises. It is not uncommon
for exacerbations to occur.
I do not believe that any active care at this point is needed.
I feel that she is at an end result as far as the injury is
concerned. If the doctor can document any exacerbation because of the
accident, periodic treatment for that as needed may be required, but at
this point, I believe that she is at an end result and no further active
chiropractic care is needed.
There is a one-day period of total disability. There is no
partial or any disability at this point and I see no long-term
involvement regarding this examinee.
If you have any further questions, please do not hesitate to
contact me.
Sincerely,
IME REVIEW DOCTOR
Dr. Davis April
23, 1999 Dear
Ms. Jones:
This document is in response to an independent medical
examination performed on our patient Jane Smith on 3/18/99, by Dr.
Davis, D.C. Ms. Smith has been receiving treatment at our office for
injuries sustained in a motor vehicle accident on 11/24/98. She
presented at our office the day following her accident with symptoms of
headaches, shoulder pain, numbness in her left arm, mid-back pain, and
low back pain.
Upon initial examination in our office on 11/25/98, Ms. Smith
presented with decreased ranges of motion in all cervical and
thoracolumbar motion and was also extremely tender to the touch in those
regions. During the examination, we found the following tests to be
positive. In the neck region O’Donohue’s Maneuver was positive in
both active and passive ranges of motion indicating muscular as well as
ligamentous involvement. Foraminal Compression, Hyperflexion
Compression, Hyperextension Compression, Maximal Foraminal Encroachment
and Shoulder Depressor were positive on the left and right. In the
mid-back and low back O’Donohue’s Maneuver was also positive in
active and passive range of motion along with Minor’s Sign, Kemps Test
on the left and right, Ely’s Heel to Buttock Test on the left and
right, and Yeoman’s Test on the left and right.
We had taken X-rays on 11/25/98 of Ms. Smith’s neck, mid-back,
and low back regions observing for fractures, pathology, alignment and
stability. Ms. Smith’s X-rays revealed a partial reversal and complete
loss of the normal cervical curve. She also presented with forward head
carriage and significant degenerative disc disease though the majority
of her cervical spine. Ms. Smith also has moderate degenerative joint
disease in her thoracolumbar region and demonstrated a notable increase
of her lumbar curve combined with forward carriage of her pelvis.
Our documentation compared with Dr. Davis’s recommendations
does not seem sufficient. We understand it must be difficult for Dr.
Davis, or any IME practitioner, to diagnosis a patient’s status,
predict a care plan, and estimate proper healing time within such a
brief encounter. Fortunately, we have had past encounters and are
presently able to assess Ms. Smith’s progress each and every visit and
also with timely full re-examinations. To no fault of Dr. Davis, he does
not have this advantage, and we feel he has under estimated her
condition and therefore under estimated the necessary length of Ms.
Smith’s treatments.
In my opinion, there are many inconsistencies and estimations in
this report. One major inconsistency by Dr. Davis states (Page 3,
Conclusions, 2nd Paragraph), “The examinee, in my opinion, is at
pre-accident status as for as the injury to her neck and upper back.”
Meanwhile earlier in his report, he contradicted this statement by
noting (Page 2, 1st Paragraph, 2nd Sentence), “Currently she reports
mainly tightness in her neck and shoulder radiating to the mid thoracic
region.” He further noted (Page 2, Physical Examination, 2nd
paragraph, 1st Sentence), “She holds her neck in a somewhat guarded
position and the shoulders are somewhat elevated.” It is clear by
these statements and our documentation that Ms. Smith is clearly not at
pre-accident status. Further in his report, he documented areas of
tenderness in the cervical and thoracic areas of the spine and performed
various orthopedic tests. The large majority of his orthopedic tests
revealed positive findings and decrease ranges of motion, with various
combinations of pulling, stiffness, or pain associated with the tests.
It is extremely difficult for us to comprehend Dr. Davis’s opinion
that Ms. Smith is at pre-accident status for the multiple reasons stated
above.
Once again, there appears to be some discrepancy between the IME
report and our documentation. Dr. Davis states, “There were two
incidences of arm pain and hand pain but that has since resolved with no
numbness or paresthesias in her arms or legs, no headaches.”
Throughout the treatment of Ms. Smith, up to the date of the IME, she
had experienced a number of occasions of numbness in her left arm and
hand and headaches. Since the examination on March 18, 1999, Ms. Smith
has experienced exacerbation of her symptoms at various times. She has
experienced an exacerbation of her left arm numbness on 3/28/99 and
4/13/99 and her migraine headaches on 4/6/99 and 4/14/99. She also had
an exacerbation of her upper back pain from 3/26/99 though 3/31/99.
There are many complicating factors that have determined the
length of Ms. Smith’s treatment at our office to allow for proper
healing time. Ms. Smith has a significant reduction of the curve in her
neck, forward head carriage, and degenerative disc changes throughout
the cervical and lumbar spine. Loss of a normal curve is a common result
of trauma, such as a whiplash type injury that Ms. Smith experience on
11/24/98. Ms. Smith has also been diagnosed with a cervical sprain. It
is well documented throughout the literature that a ligamentous sprain
involves a more complex and longer healing time than just a muscular
strain alone. Other complicating factors are that Ms. Smith is a
pediatric nurse in home care. Her job requires her to stand for
prolonged periods to assist, support, or lift her patient from one area
to another. The job also
demands her to sit for long block of time at her desk performing
administrative duties. All of these activities aggravate and exacerbate
already comprised areas of her body. Ms. Smith has worked though her
injuries to assure that her daily financial needs are met.
She has also been taught home exercises in conjunction with her
treatment to aid in the healing process. Home exercises should not
merely be given as a substitution for chiropractic treatment as Dr.
Davis suggests.
The facts remain that Ms. Smith’s chiropractic treatment was
reasonable and necessary for her particular type of injuries and
symptoms. It is well documented the consistent improvement of postural
alignment, reduction of symptoms, increased range of motion, and
reduction of positive orthopedic tests. If her treatment were shortened
any amount, the possibility of her injuries becoming a permanent
disability would increase. We feel that Ms. Smith will have reached
maximal chiropractic improvement by 5-15-99. We have provided the
necessary avenue to allow normal and proper healing sequels.
Please feel free to contact our office to discuss this matter in
further detail. Sincerely,
Dr. Anthony Gambale
Dr. Dwight DeGeorge
ADVANCED CHIROPRACTIC
August
3, 1999 Dear
Dr. DeGeorge,
I previously forwarded your April 23, 1999 letter to Dr. Davis,
D,C, to review for an addendum to his impartial chiropractic
examination. The
following is Dr. Davis’s response:
“I can only go by what the patient tells me on what I find on
that date. Ms. Smith at that point reported mainly tightness in her neck
and shoulder radiating to the mid-thoracic region. She was not reporting
any pain on that date. She had stated in the past there were two
incidents of arm pain and hand pain, but that had resolved. She stated
she had no numbness or parasthesias in her arms and legs and no
headaches. She had significant headaches initially.
From what Ms. Smith had told me and from what symptoms she had
initially and what she had at the time of my evaluation, showed that she
had an excellent response to Dr. DeGeorge’s care. She was treated in
the past by Dr. DeGeorge for something totally unrelated to this
accident, and again had excellent results.
The findings that I saw on the physical examination were very
minimal, and I felt that when was present, that could have been
maintained on home exercises and stretching or heat applications and did
not need any active chiropractic care. I explicitly stated that there
could be exacerbations. If there was exacerbations, the patient should
return for care if the doctor could document the exacerbations of her
left arm pain and numbness on two occasions and flare-up of her migraine
headaches and upper back pain on other occasions. If in his opinion,
these were due to the accident and related to the accident, then
treatment, of course, would be warranted. If he can send me some notes
on those dates that she had exacerbations and related as being causally
related to the accident, then the treatment is obviously necessary and
related and would be required because the symptoms related to the
accident, but what I found on the date of examination was an excellent
response to Dr. DeGeorge’s care and there was no need for active
treatment at that time. So, in my opinion, she was at a medical end
result, but if he can document the exacerbations as related to the
accident, I would be happy to review them.
Very truly yours,
IME REVIEW DOCTOR
Dr. Davis June
21,1999 Dear
Ms. Jones:
We at Advanced Chiropractic are responding to your request for
additional information expounding upon Jane Smith’s periods of
exacerbation following Dr. Davis IME on 3/18/99.
When Dr. Davis preformed the IME, on 3/18/99, Ms. Smith’s left
arm numbness was asymptomatic. When referring to our daily soap notes,
Ms. Davis rated her left arm numbness as a 0 on a pain scale of 0-10, 10
being the most severe, the two days before and one day after the IME
(3/16/99, 3/17/99, & 3/19/99). Ms. Smith’s symptoms increased the
next couple of visits to a 4 and a 3 respectively. On the next visit on
March 26, 1999, Jane Smith experienced an exacerbation of her left arm
numbness and rated it an EIGHT from a 3.
Several visits after 3/18/99 her symptoms declined steadily over
the coarse of 6-8 treatments until on 4/12/99 and 4/13/99 she was once
again asymptomatic rating her pain at a 0. The following visit, Jane
experienced another exacerbation of her left arm numbness, rating a 6 on
4/14/99. Ms. Smith’s numbness symptoms had gradually declined to a 3
over a period of several weeks until she was discontinued on 5-21-99.
Jane also deals with periods of intense migraine headaches. Just
previous to the IME, Ms. Smith rated her headaches at a 0 and a 2,
respectively. After the IME, she rated her headaches in the range of 2
to 3 over the time period of 3/19/99 through 4/5/99. On April 6, 1999,
Ms. Smith related to us that she had a flair up of her migraine
headaches and rated it a 6. Jane experienced a period of remission for a
week at a pain rating of a 2 or 3 over that week’s duration. On
4/13/99, she had an exacerbation, now rating her migraine at an 8 and
this pain lasted over the next several days until 4/19/99, when she
rated her headache at a 4. Ms. Smith’s rating of her headache ranges
between a 4 and 0 over the next several weeks until she discontinued
treatment on 5-21-99.
Furthermore, Ms. Smith’s mid-back pain varied between a 4 and a
1 until the date of discharge except for the period between 3-23-99
through 3-31-99. Over the next four treatments, Jane experienced another
type of exacerbation, rating her mid-back pain at 6, 6, 6, and a 5
respectively.
These periods of exacerbation demonstrate the severity of her
various injuries and the lack of stability is clearly demonstrated.
If further information is needed, feel free to contact our office
of Advanced Chiropractic. Sincerely,
Dr. Anthony Gambale
Dr. Dwight DeGeorge
ADVANCED CHIROPRACTIC
July
19, 1999 Dear
Ms. Jones:
I spoke with you on the phone regarding an IME response that our
office submitted to you regarding the above-named patient. You had
stated in our conversation that we hadn’t addressed a key issue that
the IME doctor expressed concern with (regarding exacerbation of the
patient’s symptoms). Try as I might, I could not understand the point
that you were trying to make to me about how you felt that our IME
response, as well as written as it might be, did not answer his
question. Although, the doctor did address this point in the IME
response as I discussed with you, it was not until I got off the phone
and completely refamiliarized myself with the IME and IME response from
our office that I began to understand completely, what your point was.
The purpose of this note is to thank you for taking the time and
for being so patient in our discussion and in your response to my
questions. It was a learning experience for me and will only help us
improve upon the focus of our IME responses.
Again, thank you for taking the time out of what I am sure is a
very busy day to help me.
Sincerely,
C.A.
Advanced Chiropractic Dear
Dr. DeGeorge:
As you are aware, you previously submitted clinical documentation
to justify treatment that was cut off based on Dr. Davis’s IME of
3-18-99.
Dr. Davis reviewed your documentation and the following is his
assessment regarding the same:
“As requested, this is an addendum regarding the case of Jane
Smith, who I examined on March 18, 1999. I am in receipt of a note dated
June 21, 1999 from Dr. DeGeorge, regarding the case of Jane Smith.
In my addendum of July 29, 1999, I had stated that if they could
show exacerbation’s on the dates that the symptoms were causally
related to the automobile accident, I would review them, and if I felt
they were due to the accident, then indeed treatment was warranted. The
notes they do have here do indicate the same symptoms that were involved
with the accident. The examinee was treated for the symptoms but several
other visits apparently were required. One of the notations here had 6
to 8 treatments and she was again asymptomatic. She had another
exacerbation of pain, and she was treated. They do list here the
symptoms that were directly related to the automobile accident.
In one notation, he does state here that she discontinued
treatment on May 21, 1999. I am not sure why. He did not state why she
discontinued treatment. Was the examinee dissatisfied with the care or
did the examinee feel that they could do no more at that point? Whether
she has been treated since then I do not know. His notation does state
that the examinee discontinued treatment, apparently of her own accord,
on May 21, 1999.
His listing of these dates with the symptoms are related to the
accident, and that is what I had asked for. Since they are related to
the accident, they should have been treated as such. In my opinion, they
are clinically warranted. This could have been listed a significant time
ago, without the need for several addendums. Dr. DeGeorge could have
provided this rationale a significant time ago.
In any event, the rationale is there. The treatment is clinically
warranted and related to the motor vehicle accident and the examinee
should have received this treatment as such.
Based on the above, the Insurance Company will honor payment of
treatment from 3-26-99 to 5-10-99.
Should you have any questions, feel free to call me.
Very truly yours,
Dr. Davis
IME REVIEW DOCTOR
Dr. DeGeorge continues to prove that the system can work for you
if you do a good job from the start to finish with documentation. |