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CASE NO. 18 Z 600 15001 3 2 AMERICAN ARBITRATION ASSOCIATION NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z 600 15001 3 v. INS. CO. CLAIMS NO.: 30V538161 STATE FARM INSURANCE COMPANY DRP NAME: Herbert S. Alterman (Respondent) NATURE OF DISPUTE: Medical necessity AWARD OF DISPUTE RESOLUTION PROFESSIONAL I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP), designated by the American Arbitration Association under the Rules for the Arbitration of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New Jersey “Automobile Insurance Cost Reduction Act” as governed by N.J.S.A. 39:6A-5, et. seq., and, I have been duly sworn and have considered such proofs and allegations as were submitted by the Parties. The Award is DETERMINED as follows: Injured Person(s) hereinafter referred to as: JV 1. ORAL HEARING held on 1/5/04. 2. BOTH PARTIES APPEARED at the oral hearing(s) No one appeared telephonically. 3. Claims in the Demand for Arbitration were not amended at the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made by the parties regarding the issues to be determined (Stipulations, if any, set forth below). 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: JV was injured in an automobile accident on 3/2/02. Two days later, claimant examined him and found spasm, loss of range of motion, tenderness to palpation, and positive orthopedic tests in both the cervical and lumbar spines. Claimant treated JV from 3/4/02 to 4/4/03. Respondent denied payment for services rendered by claimant to JV on 9/19, 9/23, 10/4, and 10/11/02 based on physicians’ advisories. It cut off further chiropractic treatment on 10/31/02 based on the examination report of Kenneth Gross, DC. Claimant seeks to recover the bills incurred after the date of the cutoff to the end of treatment and for four earlier dates of service. On 9/19 JV complained of bilateral neck and upper back pain at a level of 7 on a scale of 1 to 10. Claimant found spasm and trigger points and provided treatment. On the following visit, JV complained of middle and lower back stiffness. His pain level remained the same. On 10/4 JV complained of neck pain and upper and low back stiffness. His pain level was the same. Claimant found spasm and trigger points. On 10/11, JV complained of head stiffness, neck and upper back stiffness. His pain level remained at 7. Claimant found spasm in the lower cervical, upper and lower thoracic regions, trigger points in the upper and lower cervical and regions, which were also tender to palpation. On 9/16/02, Michael Cornely, DC, denied precertification for the treatments requested by claimant from 9/12 to 10/12/02. He observed that there was some reduction in JV’s overall pain CASE NO. 18 Z 600 15001 3 3 and discomfort, but progress was slow. He noted that there was minimal documentation provided and concluded that, based on his experience, JV has had sufficient chiropractic treatment to receive maximum benefit. He recommended an independent medical examination. On 9/19/02, he again denied claimant’s precertification request for treaement for the same dates. In his denial he noted JV’s severe neck and back pain, spasm, and decreased ranges of motion. The reason for the denial was that JV had missed two defense examinations, the treatments fell outside the care paths, and they were not supported by exam findings. Dr. Gross examined JV on 9/24/02. JV complained of occasional neck and occasional lower back pain. The only abnormal findings were tenderness to palpation at the C6 segmental level on the right, a 6 degree decrease in right lateral flexion, and pain with extension of the dorso-lumbar spine. All other ranges of motion in the cervical and dorso-lumbar spines were normal; all related orthopedic and neurological examinations for both areas were normal; there was no spasm. He diagnosed JV with cervicalgia and concluded that further chiropractic treatment was not warranted and would offer JV no further medical improvement. Claimant’s daily notes for the four days of service in September and October 2002, all contain the same assessment of JV; i.e., that he “remains the same. The patient’s condition remains unchanged from the previous visit.” Each note reports JV’s pain level 7. With few exceptions, the same assessment and a pain level, is reported in claimant’s daily notes throughout his treatment. On 2 dates in November and December 2002, claimant reported that JV experienced exacerbations in his condition. On 1/8/03, the daily notes indicate that JV showed improvement. A similar notation is contained in the daily notes for other visits in January, March, and April. On 2 dates, the notes state that there was no improvement. However, virtually every daily note from 9/19/02 through the last treatment on 4/14/03 states that JV’s “assessment remains the same” and his “condition remains essentially unchanged since the previous treatment;” that his pain level was 7, and that examination revealed spasm and trigger points. Reviewing his treatment, claimant’s letter dated 9/23/03 states that JV continued to show progress and when the maximum benefit of chiropractic care had been derived, he was advised that he would require treatment from time to time. to obtain relief from aggravation of the original injury. Claimant’s letter dated 12/11/03 indicates that he treated JV 71 times and that his office notes show improvement in range of motion and decrease in cervical and lumbar spasm and that improvement was made with the treatments after the cutoff. It is difficult to reconcile the statements in claimant’s post-treatment letters with the statements and findings reported in his daily notes. Also, although claimant states that JV made improvement after the cutoff, that improvement is not reflected in the daily notes. The last note on 4/14/03 reports JV’s complaints of bilateral neck stiffness, bilateral upper back stiffness, bilateral middle back stiffness, bilateral lower back stiffness, a pain level of 7, and objective findings of spasm in the cervical and lumbar spines as well as trigger poi`nts in the thoracic region. The same complaints reported by claimant in September and October 2002. I conclude, therefore, that the conclusions expressed by Drs. Cornely and Gross were correct. I find that claimant has not carried the burden of proving, by preponderance of the credible evidence, that the treatment provided to JV on 9/19/02 and thereafter was not medically necessary, reasonable and causally related to the accident. 5. MEDICAL EXPENSE BENEFITS: Denied Provider Amount Claimed Amount Awarded Payable to CASE NO. 18 Z 600 15001 3 4 Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. 6. INCOME CONTINUATION BENEFITS: Not In Issue 7. ESSENTIAL Not In Issue 8. DEATH BENEFITS: Not In Issue 9. FUNERAL EXPENSE BENEFITS: Not In Issue 10. I find that the CLAIMANT did not prevail, and I award the following COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A. 39:6A-5h. (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): (C) INTEREST is as follows: This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. January 28, 2003 ________________________ Date Herbert S. Alterman, Esq. .
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