Motion for Expert Witness List in IRMA ENRIQUEZ, et al vs. REYNA MA SAUCEDO-BAZA| Trellis.Law

On December 18, 2019 a Request,Application was filed involving a dispute between Enriquez, Irma, Enriquez, Monica, and Saucedo-Baza, Reyna Ma, for MOTOR VEHICLE ACCIDENT in the District Court of Dallas County.

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FILED
3/1 7/2020 2:26 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
CAROLYN SELLERS DEPUTY

N0. DC-19-20140

IRMA ENRIQUEZ AND MONICA ENRIQUEZ IN THE DISTRICT COURT
PLAINTIFF,

VS. mmmmmmm
DALLAS COUNTY, TEXAS

REYNA MA SAUCEDO-BAZA
DEFENDANT. 14TH JUDICIAL DISTRICT

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE T0 PLAINTIFFS’
REQUEST FOR DISCLOSURE AND DESIGNATION 0F EXPERTS

Pursuant t0 TeX R. CiV. P. 194, Defendant serves the following First Supplemental
Response to Plaintiffs’ Request for Disclosure and Designation 0f Experts.

f. For any testifying expert:

1. The expert’s name, address, and telephone number;

2. The subj ect matter 0n Which the expert will testify;

3. The general substance 0f the expert’s mental impressions and opinions and
a brief summary of the basis for them, or if the expert is not retained by, employed by, 0r
otherwise subject to the control 0f the responding party, documents reﬂecting such
information;

4. Ifthe expert is retained by, employed by, or otherwise subj ect t0 the control
0f the responding party:

A. A11 documents, tangible things, reports, models, or data
compilations that have been provided to, reviewed by, or prepared by or for the
expert in anticipation of the expert’s testimony; and

B. The expert’s current resume 0r bibliography.

Response: Defendant hereby designates and reserves the right t0 call any expert Witness(es)
designated by any other party to this case, as well as any experts later designated
by any party t0 this case on any subject relevant to this litigation 0n Which the
witness is qualiﬁed t0 testify. In the event that any party t0 this cause has
designated any experts but has been or is subsequently dismissed for any reason or

fails t0 callany designated expert at the time 0f trial, Defendant speciﬁcally
reserves the right t0 call any such expert previously designated by that party.
Defendant further reserves the right t0 withdraw 0r de-designate any expert prior
t0 testimony and t0 positively aver that such previously designated expert Will not

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -1-
be called as a witness at trial and to redesignate same as a consulting expert Who
Will not be called by any party in this cause. Finally, Defendant reserves the right
to supplement this response as additional information concerning experts becomes
available.

Defendant further hereby designates as adverse expert Witnesses all expert
witnesses designated by Plaintiffs. Defendant reserves the right to rely upon 0r t0
offer, by direct examination or cross-examination, testimony obtained from those
experts and rebuttal experts, if any, designated by Plaintiffs. By this designation,
Defendant does not necessarily agree with, nor vouch for, the credibility of any
such Witnesses 0r their opinions, or the reliability, materiality, or admissibility of
information and/or tangible things produced by these individuals in general; by this
designation Defendant is simply reserving the opportunity t0 rely upon 0r elicit
certain opinions and/or evidence from these witnesses t0 the extent that it deems it

in its interest t0 d0 s0.

Such persons are expected t0 testify concerning Plaintiffs’ care and treatment. See
Plaintiffs’ Responses to Defendant’s Request for Disclosure for additional

information concerning such health—care providers including medical bills and
records relating to Plaintiffs.

First Supplemental Response:

Defendant hereby designates as expert Witnesses the following individuals:

Akshay Vakharia, MD
6263 Harry Hines Blvd,
Dallas, Texas 75235
214.648.5770

Dr. Vakharia is a Texas physician and board certiﬁed in pain medicine and anesthesiology
Who has reviewed Irma Enriquez’s medical records and other case materials provided to
him and is expected t0 testify regarding the extent 0f the injuries sustained by the Plaintiff
in the subj ect motor vehicle accident, the appropriate care and treatment for those injuries,
and the fair and reasonable cost of that treatment, both in the past and in the future, if
applicable, as set out in the attached report.

Ryan Robinson, DC
1100 S. Main Street, Ste. D
Grapevine, Texas 76051
817. 203.2184

Dr. Robinson is a chiropractor who has reviewed Irma Enriquez’s medical records and
other case materials provided to him, and is expected t0 testify regarding the extent of the
injuries sustained by the Plaintiffin the subj ect motor vehicle accident, the appropriate care

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -2-
and treatment for those injuries, and the fair and reasonable cost 0f that treatment, both in
the past and in the future, if applicable, as set out in the attached report.

Respectfully submitted,

CQW
Chad Kimble, Bar No. 24007483
State
Kyle Smith, State Bar No. 241025 12
D. Brent Beasley, State Bar No. 24082669
LAW OFFICE 0F CHAD KIMBLE, P.C.
1204 S. White Chapel Blvd.
Southlake, Texas 76092
eservice@chadkimblelaw.com
817.766.7488
817.423.7492 fax

ATTORNEY FOR DEFENDANT

CERTIFICATE 0F SERVICE

The undersigned certiﬁes that 0n the 17th day 0f March, 2020, a true copy of the foregoing
has been served 0n all parties in accordance With Rule 21a, Texas Rules of Civil Procedure.

CQW
Chad Kimble

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -3-
AKSHAY VAKHARIA, M.B.B.S., M.D. 12001 N. CENTRAL EXPRESSWAY
DIPLOMATE, AMERICAN BOARD OF INTERNAL MEDICINE SUITE 800
DIPLOMATE, AMERICAN BOARD OF AN ESTHESIOLOGY DALLAS, TX 75243
SUBSPECIALTY CERTIFICATION IN PAIN MEDICINE — ANESTHESIOLOGY (214) 750—61 1O
FAX —
(214) 750—5825

March 9, 2020

Mr. Chad Kimble
Low Chad Kimble, P.C.
Office of
1204 Sou’rh Whi’re Chapel Blvd.
Sou’rhloke, TX 76092

RE: Irma Enriquez
CLAIM#: 049330821 7
DATE OF INJURY: 02/21/18
CASE#: 21 070487
Do’re of Bir’rh: 04/12/71

Dear Mr. Kimble:

| hove had The opportunity ’ro review medical records on Ms. Irma Enriquez.

My opinion for based upon my Training and Treatment of personal po’rien’rs of which hove
’rhis evoluo’rion is |

experience of 25 years management My commen’rs on charges ore based on my personal experience
in pain
wi’rh my own clinic billing 0nd wi’rh healthcore company reimbursements as hove proc’riced chronic pain |

management for more Than 25 years. also hove experience teaching pain management courses GT UT
|

Sou’rhwes’rern 0nd also o’r ’rhe VA Medical Cen’rer.

| also work Gs c1 privo’re pain physician o’r ’rhe Texas Bock Ins’ri’ru’re 0nd Presbyterian Hospi’rols of Denton, Flower
Mound 0nd Plano as c1 privo’repain physician.

Comments on charges ore based on reimbursemen’r ro’res from my privo’re practice 0nd o’rher practices in The
oreo | hove seen Through my 25 years of experience in pain management.

SUMMARY OF MEDICAL RECORDS

The po’rienT was involved in o mo’ror vehicle accident on February 21, 2018, 0nd reportedly offer That she wen’r
’roThe Me’rhodis’r Dallas Medical CenTer ER for The complain’r of cervical pain. She menTioned There was no loss
of consciousness. The airbag wos no’r deployed. No head injury 0nd she had o side impoc’r. According To
Me’rhodis’r Dollos medical records, she had o pos’r medical his’rory significon’r for breos’r cancer. Pos’r surgical
surgery was breos’r surgery 0nd lymphodenecfomy. Social his’rory 0nd family history were benign. Allergies, she
wos allergic ’ro penicillin. Her blood pressure was 137/106, pulse was 89, respirations were 18, Tempera’rure was
97.2, and sa’rura’rion of 98% on room air. Her heigh’r was 5 fee’r 3 inches, 0nd weigh’r was 170 pounds. Physical
examination, she had cervical Tenderness present, bu’r range of movement was wi’rhin normal limi’r.
Neurologicolly, she was in’rGC’r. Her pregnancy ’res’r was negative. She was Taking Torodol 0nd Thereafter she
was discharged home wi’rh Motrin and Roboxin.

On February 22, 2018, ’rhe po’rien’r was seen a’r Perol’ro Chiropractic Clinic for evaluation for ’rhe complaint of

cervical, Thoracic, 0nd lumbosacrol pain. According ’ro ’rhG’r record all her histories were unchanged. Her
physical examination, she had cervical and Thoracic Tenderness presen’r 0nd lumbosocrol Tenderness present.
Cervical compression ’res’r, shoulder depression ’res’r, cervical distraction ’res’r, s’rroigh’r leg raise (SLR) ’res’r, Ely’s
’res’r, FABER’s, Kemp’s, and Nochlas were all posi’rive. Neurologicolly The was Benign po’rien’r in’roc’r.

examination. Therefore, ’rhey s’rar’red her wi’rh physical Therapy 0nd chiropractic maneuver 0nd They did X—roys
of ’rhe neck, Thoracic, and lumbosocrol areas. She was s’ror’red on chiropractic maneuver and physical Therapy
Irma Enriquez
March 9, 2020
CASE#: 21070487
Page 2 of 4

on February 26, 2018, and they continued until June 26, 2018. This date was the last time she had evaluation
and treatment by the chiropractor.

On March 26, 2018, the patient was seen by MDN Physician for the complaint of cervical, thoracic, and
lumbosacral pain and left shoulder pain. According to that record all histories were unchanged. Medication,
she was taking Tamoxifen and her weight was 160 pounds, while height the same 5 feet 3 inches. Physical
examination was cervical, thoracic, and lumbosacral tenderness present. Neurologically, the patient was
intact. Therefore, they diagnosed the patient with cervical, thoracic, and lumbosacral sprains, left shoulder
pain, posttraumatic headache, and they gave Decadron 4 mg IM and they gave the treatment medication
Mobic and Flexeril for pain control.

On March 30, 2018, the patient had Peralta Chiropractic Care followup. There was no new complaint. Physical
examination and all orthopedic tests were negative, however, she still continued to have chiropractic and
physical therapy until June 26, 2018, and they discharged the patient on June 26, 2018. Even though
evaluation on March 30, 2018, stated all orthopedic tests were negative, still they continued all the physical
therapy and chiropractic maneuver for the pain because the patient continued to have pain.

On April 23, 2018, the patient had an MRI of the cervical spine, which revealed C3-C4, C4-C5, C5-C6 disc bulge
and C6-C7 facet hypertrophy leading to neural foraminal stenosis. The MRI of the lumbosacral spine that she
had performed on the same day revealed L2-L3, L4-L5, and L5-S1 disc bulges, impinging the L4 nerve root
bilaterally and the L5-S1 disc was touching the S1 nerve root.

On April 26, 2018, the patient was seen by Miramar Interventional Pain Treatment Center for the complaint of
cervical pain that was radiating to both upper extremities as well as weakness and tingling sensation while the
lumbosacral pain was radiating to both buttocks and the lower extremities associated with weakness and
tingling sensation. According to their record, thoracic pain was still there, there was no radiation mentioned
anywhere by the chiropractor or even the MDN physician. According to Rafath Quraishi, M.D., from Miramar
Interventional Pain Center, on physical examination there was cervical, thoracic, and lumbosacral tenderness
present, weakness present over both upper extremities and lower extremities with paresthesia and there was
also decreased range of movement secondary to pain over both neck and the lumbosacral area and there
was also muscle spasm present. According to him Spurling test as well as SLR test both were positive bilaterally
and there was also tenderness present over both SI joints and decreased muscle strength of the lower
extremities. He stated this patient was already getting conservative treatment with medication as well as
physical therapy, therefore the patient should get a lumbar epidural steroid injection as well as bilateral SI joint
injections and he did it on the same day and also suggested that the patient should get a cervical epidural
steroid injection for the neck pain and upper extremity weakness. Also, he suggested to continue all
medication as well as physical therapy.

On June 26, 2018, the patient had a cervical x-ray which revealed no fractures or spondylosis, according to
Peralta Chiropractic Care, and there was spondylosis at multiple level. Lumbosacral x-ray revealed no fracture
or dislocation or arthritis present and thoracic x-ray revealed no fractures or spondylosis and questionable
gallstone and aortic arch uncoiling, therefore that needed to be evaluated by an ultrasound or an MRI as per
the chiropractor note. That was the last medical record I have available to review.

RESPONSE/OPINION

With regard to the billing, the patient had two MRIs performed, cervical as well as lumbosacral and they
charged $3,500 for each along with that they also charged $500 each for the MRI reading totaling $4,000 for
each MRI, which is inflated as the usual and customary rate is up to $800 to $1,000 maximum with reading of
the MRI. The charge for the cervical x-ray was $85, thoracic x-ray $70, lumbosacral x-ray $70, and right shoulder
x-ray $70 for the reading. They also charged $295 for the x-ray, and those charges were inflated as the usual
and customary rate for x-rays ranges between $40 to $50.
Irma Enriquez
March 9, 2020
CASE#: 21070487
Page 3 of 4

For the initial evaluation by Miramar Interventional Pain Treatment Center, they charged $595, which is inflated
as the usual and customary rate for CPT code 99203 is around $300 to maximum up to $400. They also charged
$6,606 for the injection of both SI joints and the lumbar epidural steroid injection, which is inflated as the SI joint
is the major joint injection and the usual and customary rate is around $250 to $300, while for the lumbar
epidural steroid injection the customary rate is usually $500 to $600, and even with the epidurogram the usual
and customary rate is around $100 more, therefore, $600 to $700. They also charged separately for fluoroscopy
$495, which is supposed to be included into the injection charges itself, and they also charge separately for
each medications, which should be included in the injection charge as well. Therefore, in reviewing overall all
the billing, all the charges were inflated by Dr. Quraishi.

In my opinion, in reviewing the medical records, overall the diagnostics and treatment was reasonable and
medically necessary for the control of pain, but all the billing and the charges were inflated as I previously
mentioned above, that is above the usual and customary rate and according to the CPT Reimbursement Rate.

With regard to future treatment, per the last available medical record by the chiropractor on June 7, 2018, the
patient was at maximum medical improvement and was released from care. As it stands, since there have
been no other visits in the past year and a half no future treatment should be reasonable and necessary at this
time. Should the patient experience any flare-ups, she may visit an interdisciplinary pain clinic for further
evaluation, however, as it stands at the current time no further treatment with regard to pain management is
needed at this time.

W
Thank you for the opportunity to review the medical records on Ms. Irma Enriquez.

Dictated, reviewed, opinion verified, and attested to by my original signature.

Sincerely,

Akshay Vakharia, M.B.B.S., M.D.
Diplomate, American Board of Internal Medicine
Diplomate, American Board of Anesthesiology
Subspecialty Certification in Pain Medicine –Anesthesiology
K1111

AV/ck/ANS/sam

The opinions rendered in this case are the opinions of the evaluator. This review has been conducted on the
basis of the medical records provided, with the assumption that the material is true and correct. If more
information becomes available at a later date, an additional service/report/reconsideration may be
requested.
Irma Enriquez
March 9, 2020
CASE#: 21070487
Page 4 of 4

SUMMARY OF RECORDS

 Texas Peace Officer’s Crash Report: Dallas Police Dept., 02/21/18
 Methodist Dallas Medical Center ED: Nicole Rall, D.O., 02/21/18
 Peralta Chiropractic: Edgar Peralta, D.C., 02/22/18 - 06/07/18,
 MDN Injury Care: Charles DeMarque, M.D./Camdi Ton, P.A., 03/26/18,
 Dallas Diagnostic Imaging Services: Rafath Quraishi, M.D., 04/23/18
 Miramar Interventional Pain Treatment Center: Rafath Quraishi, M.D., 04/26/18
 Coast to Coast Radiology Consulting: Kenneth Hansen, D.C., 06/26/18
 Black & White Copy Texas Driver License ID: Irma Enriquez
 Affidavit Concerning Authenticity of Medical Records, Coast to Coast Radiology Consulting: 11/12/19
 Affidavit Concerning Costs & Necessity of Services, Coast to Coast Radiology Consulting: 11/12/19
 Affidavit Concerning Authenticity of Medical Records, Miramar Interventional Pain Treatment Center:
01/16/20
 Affidavit Concerning Costs & Necessity of Services, Miramar Interventional Pain Treatment Center:
01/16/20
 Medical Lien, Dallas Diagnostic Imaging Services: 08/14/18
 Affidavit Concerning Authenticity of Medical Records, Dallas Diagnostic Imaging Services: 10/24/19
 Affidavit Concerning Costs & Necessity of Services, Dallas Diagnostic Imaging Services: 10/24/19
 Affidavit Concerning Authenticity of Medical Records, MDN, P.A.: 01/15/20
 Affidavit Concerning Costs & Necessity of Services, MDN, P.A.: 01/15/20
 Affidavit Concerning Authenticity of Medical Records, Peralta Chiropractic: 11/07/19
 Affidavit Concerning Costs & Necessity of Services, Peralta Chiropractic: 11/07/19
 Affidavit of Billing Records Custodian of Texas Physician Resources, LLP: 06/29/18
 Affidavit of Medical Records, Methodist Health System: 02/13/20
 Affidavit Concerning Costs & Necessity of Services, Methodist Dallas Medical Center: 06/15/18
 Plaintiff Irma Enriquez Responses & Objections to Defendant’s Request for Discovery: 02/21/20
 Medical & Billing Authorization for Disclosure of Protected Health Information To: Custodian of Records
for Healthcare Providers of Irma Enriquez: 02/21/20
 Itemized Statement: Peralta Chiropractic, Statement Date: 11/27/18, Dates of Service: 02/22/18 –
06/07/18
 Health Insurance Claim Form: MDN, Date of Service: 03/26/18
 Itemized Statement: Dallas Diagnostic Imaging Services, Statement Date: 04/24/18, Date of Service:
04/23/18
 Itemized Statement: Rafath Quraishi, M.D., Statement Date: 07/27/18, Date of Service: 04/26/18
 Itemized Statement: Coast to Coast Radiology Consulting, Statement Date: 07/08/18, Date of Service:
06/26/18
 Itemized Statement: Texas Physician Resources, LLP, Statement Date: 06/18/18, Date of Service: 02/21/18
 Itemized Statement: Methodist Dallas Medical Center, Date of Service: 02/21/18
 Color Photos: 5 pages
Akshay Vakharia, M.B.B.S., MD
CURRICULUM VITAE

Business Address: Department and Pain Management
of Anesthesiology
University of Texas Southwestern Medical Center at Dallas
5323 Harry Hines Boulevard
Dallas, Texas 75390-9068

Education and Deqrees:

1975 Pre—Med, Gujarat University, Gujarat, India

1980 MB BS (MD) Gujarat University, Gujarat, India

1985 MS General Surgery, Gujarat University, Gujarat, India

Residencies:

1987 — 1988 St. Elizabeth Hospital, Boston, MA Externship

1988 - 1989 St. Vincent Hospital, Worcester, MA Internal Medicine

1989 — 1991 Wayne State University School of Medicine, Pontiac, MI Internal Medicine

1991 — 1992 St. Joseph's Hospital Health Center, Syracuse, NY Anesthesiology

1992 — 1993 Medical college of Ohio, Toledo, OH Anesthesiology
Fellowship:

1994 University of Rochester School of Medicine, Rochester, NY, Pain Management

Honors and Awards:

1. 1964 Shreyes Scholar for Academic Excellence

2. 1966 Indian National Merit Scholar

Professional Employment:

6/95--5/96 Staff Anesthesiologist Methodist Hospital, Gary, IN
9/96—8/97 Staff Anesthesiologist Mainland Medical Center, Texas City, TX
9/97-8/06 Assistant professor UT Southwestern Medical Center, Dallas, TX
9/06-5/07 TX
Staff Anesthesiologist, Presbyterian Hospital of Plano, Denton,
6/07-03/09 Anesthesiologist & Pain Mgmnt Texas Back Institute, Denton, TX
3/08 — 12/08 North TX Pain Mgmnt Center, Presbyterian Hospital of Denton
1/09 to present Assistant professor, V.A. hospital, Dallas, TX
UT Southwestern medical center

Certification:

1987 FMGMS
1989 Flex
1991 Diplomate, American Board of Internal Medicine
1995 Diplomate, American Board of Anesthesiology
1996 and 2008 Subspecialty Certification in Pain Management, American Board of
Anesthesiology
2000 Certification for Acupuncture

Licensure:

Texas License

Professional Associations/Affiliations:

AMA, TMA, DCMS ASA, TSA, DCAS

Professional activitieslcommittees:

1997-2006 Pain Management Committee, PHHS
Summer STARS Student Mentor in clinical research regarding PENS therapy for
Pain Management

1998-2006 UT Southwestern Medical Center, Dallas, TX CEM Medical Student Course
Facilitator

1998- 2006 UT Southwestern Medical Center, Dallas, TX ACLS Instructor for Residents
UT Southwestern Medical Center, Dallas, TX

Community Activity:

1. Grand Awards Judge forMedicine and Health, Intel International Science and
Engineering Fair, Fort Worth, 1998 (UT Southwestern STARS Program also involved)

2. Physician for the North Texas Indian Association Charitable Clinic (mornings) and the
BAPS Temple (afternoons) in Farmers Branch on the 3rd Sunday of each month from
1999 to date

3. Judge, Science Fair Competition, Haggard Middle School, Dallas, January 1999

4. Judge, Science Fair Competition, Bethany Elementary School, Plano, February 2000

5. Judge, Science Fair Competition, Haggard Middle School, Dallas, January 2001
Lectures and Presentations:

1. “Cancer Pain” lecture, Pain Symposium, UT Southwestern Medical Center at Dallas,
Spring 1997

“Chronic Pain Management” lecture for the medical staff at St. Paul Medical Center,
Dallas, November 1999

“Chronic Pain Management for HIV Patients” lecture during the Johnson & Johnson Pain
Awareness Week, UT Southwestern Medical Center at Dallas, Spring 1999

“Chronic Pain Management” for anesthesiology residents at UT El Paso, March 2000

“Chronic Pain Management” for STARS College Students, UT Southwestern, May 2000

“Chronic Pain Management” for Dallas Academy of Internal Medicine, Dallas, Texas,
March 2002.

Research interests:

1. Chronic Neck Pain

2. Percutaneous Electrical Nerve Stimulation

Publications:

1. Ghoname EA, Craig WF, White PF, Ahmed H, Hamza MA, Gajraj NM, Vakharia AS, Noe
CE: The effect of stimulus frequency on the analgesic response to percutaneous
electrical stimulation: in patients with low back pain. Anesth Analg 1999; 88(4):841-6

Hamza MA, Ghoname E-SA, White PF, Craig WF, Ahmed HE, Gajraj NM, Vakharia AS,
Noe CE: Effect of the duration of electrical stimulation on the analgesic response in
patients with low back pain. Anesthesiology 1999; 91(6):1622—7

Hamza MA, White PF, Craig WF, Ghoname EA, Ahmed HE, Proctor TJ, Noe CE,
Vakharia AS, Gajraj N: Percutaneous electrical nerve stimulation: a novel analgesic
therapy for diabetic neuropathic pain. Diabetes Care 2000; 23:365-70

White PF, Craig WF, Vakharia AS, Ghoname EA, Ahmed E, Hamza A: Percutaneous
neuromodulation therapy: does the location of electrical stimulation effect the acute
analgesic response? Anesth Analg 2000; 91 :949-54

White PF, Ghoname EA, Ahmed HE, Hamza MA, Craig WF, Vakharia AS: The effect of
montage on the analgesic response to percutaneous neuromodulation therapy. Anesth
Analg 2001; 92:483-7

Gatchel RJ, Noe CE, Gajraj NM, Vakharia AS, Polatin PB, Deschner MD, Pulliam C:
Treatment carve—out practices: their effect on managing pain at an interdisciplinary pain
center. J Workers’ Comp 2001; 10:50-63

7. Gatchel RJ, Pulliam C, Robbins H, Deschner M, Gajraj NM, Vakharia AS: A
Noe CE,
preliminary study of multidimensional pain inventory profile differences in predicting
treatment outcome in a heterogeneous cohort of patients with chronic pain. Clin J Pain
2002; 18:139-43

8. Robbins H, Gatchel RJ, Noe C, Gajraj N, Polatin P, Deschner M, Vakharia A, Adams L:

A prospective one-year outcome study of interdisciplinary chronic pain management:
compromising its efficacy by managed care policies. Anesth Analg 2003; 97:156-62

Chapters in Booksllnvited ArticleslMiscellaneous:

1. Noe CE, NM, Vakharia A: Injection procedures, Occupational Musculoskeletal
Gajraj
Medicine: Function, Outcomes and Evidence. Edited by Mayer T, Gatchel R,
Polatin P. Philadelphia: Lippincott-Raven Publishers, 2000, pp 447-60

Abstract:

1. Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Vakharia AS, Gajraj NM, Noe
CE: Does the stimulus frequency affect the analgesic response to electrical stimulation?
Anesth Analg 1999; 88:8210.

2. Ghoname EA, Craig WF, White PF, Hamza MA, Ahmed HE, Gajraj NM, Vakharia AS,
Noe CE: The effect of the duration of electrical stimulation on the analgesic response.
Anesth Analg 1999; 88:821 1.

3. Ahmed HE, Craig WF, White PF, Hamza MA, Ghoname EA, Gajraj NM, Vakharia AS,
Noe CE: The analgesic effect of percutaneous electrical nerve stimulation (PENS) in
patients with chronic headaches. Anesth Analg 1999; 88:8270.

4. Abstract and presentation of paper of new modality of “Pulse radiofrequency lesioning
of mixed nerve for Neuropathic pain.” At ASRA meeting in Florida 2005.

Patents:

1. Received Provisional Patent for new LMA 2007 and Renewed in 2008,2009

2. Applied for new safe needle patent 2009 under review.

Research:

1. Preparing Application for IRB to review research study for comparing different outcome
between “Pulse Radiofrequency lesioning Vs regular Radiofrequency lesioning for facet
joint medial branch nerve 5/2010.
RYAN ROBINSON, D.C. 12001 N. CENTRAL EXPRESSWAY
DOCTOR OF CHIROPRACTIC SUITE 800
DALLAS, TX 75243
(214) 750—61 10
FAX —
(21 4) 750-5825

March 6, 2020

Mr. Chad Kimble
Low Chad Kimble, P.C.
Office of
1204 Sou’rh White Chapel Blvd.
Soufhloke, TX 76092

RE: Irma Enriquez
CLAIM #: 049330821 7
DATE OF INJURY: 02/21/18
CASE #: 21070481

Dear Mr. Kimble:

| hove had The opporTuniTy ’ro review medical records on Ms. Irmo Enriquez.

My name is Ryan Robinson, D.C., CCSP, om licensed by ’rhe SToTe of Texas Gs o Chiropractor. hove 5 years of
| |

experience Treating po’rienfs Gs o chiropractor in The DFW area, 0nd during The post 5 years hove also Treated |

potienTs in chiroproc’ric clinics in Plano, Grapevine, 0nd For’r Wor’rh, Texas. The po’rienTs hove Treo’red include |

hundreds of potienTs wi’rh complaints of pain in The spine 0nd ex’rremi’ries from moTor vehicle accidents. |

comple’red o posT graduate cer’rifiCOTion in sporTs in November of 2015, which enables me ’ro diagnose 0nd
’rreOT ’rroumo’ric injuries more effectively. wos named “Po’rien’r’s Choice Award Winner” in Grapevine by
|

Opencore in 2015, which unders’rond ’ro be o high level of disﬁnc’rion in honor of my service To The communi’ry
|

as o chiropractor.

My commen’rs on reasonable 0nd necessary allowances ore based Upon my years of experience in TreoTing
potienfs wi’rh such condi’rions. Many of The poTien’rs | hove deoIT 0nd deal wi’rh daily, hove high
wi’rh
deduc’ribles 0nd hos been necessary for me ’ro confoc’r
i’r
imaging cen’rers 0nd o’rher providers ’ro oscerToin
who’r would be The mosT appropriate referral po’r’rem for my po’rienTs, To assure They ge’r quoli’ry core Tho’r They
con afford. As a resul’r, hove experience in de’rermining usual 0nd cus’romory charges for The services on
|

which | comment

SUMMARY OF MEDICAL RECORDS

The po’rien’r is o female who was involved in c1 mo’ror vehicle occiden’r on February 21, 20] 8.

On February 22, 2018, ’rhe po’rien’r presen’red ’ro Perol’ro Chiropractic for evaluation cmd Treo’rmen’r of neck pain,
mid back pain, 0nd low back pain. Physical examination revealed res’rric’red ranges of mo’rion in ’rhe cervical
0nd lumbar spine 0nd Ief’r elbow 0nd posi’rive for pain. Orthopedic ’res’ring showed ’rhe following positive ’res’rs:
cervical dis’rroc’rion, mox compression, Jackson, Kemps, SLR, Nochlos, Fobere. Neurological ’res’ring was wi’rhin
normal limi’rs Throughout. X—roys were performed in ’rhe cervical, thoracic, lumbar spine 0nd righ’r shoulder 0nd
were reviewed by Kenneth Hansen, DC, DACBR who no’red The following in The repor’rs: Cervical: or’rhri’ric
changes, postural cmd biomechanicol alterations, re’rrolis’rhesis o’r C3—C4 0nd C4-C5. Righ’r Shoulder: wi’rhin
normal limi’rs. Thoracic cmd Lumbar: or’rhri’ric changes, postural, 0nd biomechanicol alterations.
Irma Enriquez
March 6, 2020
CASE #: 21070481
Page 2 of 5

On April 23, 2018, the patient presented to Dallas Diagnostic Imaging for an MRI scan of the cervical and
lumbar spine. The following was noted in the report: Cervical: C4-C5: large posterior central disc herniation
measuring 5mm. C3-C4: central posterior disc herniation measuring 3mm. Lumbar: L4-L5: central posterior disc
herniation measuring 4 mm with bilateral impingement of the exiting nerves. L2-L3: central posterior disc
herniation measuring 3mm. L5-S1: subligamentous disc herniation 2.5mm effacing the S1 nerve roots.

RESPONSE/OPINION:

In my professional opinion, the patient will not require any additional treatment for the injuries sustained in the
motor vehicle accident.

In reference to the use of a focused exam, the CPT Coding Manual requires three key components: focused
history, focused exam, and low level of medical decision-making. In addition, the problem severity should be
low, and physician time at least 20 minutes. From the documentation provided, these criteria have been met,
and the service is therefore necessary.

In reference to the use of x-rays on this patient, based on the mechanism of injury and the patients’ age, these
were both reasonable and necessary.

In reference to the use of electrical muscle stimulation, manual therapy, based on my clinical experience, this
modality has clinically been demonstrated to provide short-term pain relief and increase spinal mobility to
facilitate spinal manipulation. As stated in the article entitled “Management of neck pain and associated
disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa)
Collaboration”1, for acute neck pain (symptoms less than 3 months) electrotherapy is not recommended as a
therapeutic intervention. However, from my clinical experience, these provide a clinical benefit in the acute
stage of healing, but gives little relief outside of a “placebo effect” after the acute phase. Instead, patients
should be weaned off passive therapies and transitioned into active care, as the use of active care is
associated with a much better clinical outcome. Therefore, reimbursement is only reasonable and necessary for
up to the following date: March 15, 2018.

In reference to the use of mechanical traction, based on my clinical experience, this modality has clinically
been demonstrated to provide short-term pain relief and increase spinal mobility to facilitate spinal
manipulation. Based on the article entitled “Clinical Practice Guideline for Physical Therapy Assessment and
Treatment Patients with Nonspecific Neck Pain” 3, studies have concluded the level of evidence for this
treatment is very low and have no effects greater than placebo. Therefore, reimbursement is only reasonable
and necessary up to the following for up to the following date: March 15, 2018.

In reference to the Chiropractic Adjustment, from my experience with the diagnosis of this patient, a trial period
of treatment consisting of 6 to 8 visits in a time period of 2 to 3 weeks has been shown to provide an adequate
sample of the success of the treatment. If the chiropractor can demonstrate objective functional improvement
during the trial period, then up to 18 to 22 treatments over a period of six weeks is recommended. As stated in
the article entitled “Management of neck pain and associated disorders: A clinical practice guideline from the
Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration” 1, for acute neck pain (symptoms less
than 3 months) manipulation (CMT/Chiropractic Adjustment) is recommended as a therapeutic intervention.
However, if the patients’ objective symptoms are still present after 3 months of treatment, the patient should be
referred to additional providers. In this case, there was objective functional improvement during the trial period
of care. Therefore, reimbursement is both reasonable and necessary for the 20 visits.

In reference to the use of Therapeutic Exercises, based on my clinical experience with soft tissue related injuries,
I recommend up to ten sessions over an eight-week period. The practitioner should allow for fading of
treatment frequency from three visits per week to one or less, with an emphasis on active self-directed home PT.
If objective functional improvement during the first ten sessions, then I recommend up to eight to twelve more
sessions. Based on the article titled “pitfalls and accomplishments of guidelines for treatment of back problems”
Irma Enriquez
March 6, 2020
CASE #: 21070481
Page 3 of 5

sTudies hove concluded There
is in exfreme importance in healing To implemen’r exercise prescriptions for The

po’rienT ’ro Tolerance”. In ’rhis case, There wos objective functional improvemen’r during The
achieve oc’rivi’ry

’rriol period of core. Therefore, reimbursement is bo’rh reasonable 0nd necessary for The 2O visi’rs.

In reference ’ro The referral of The MRI scan of ’rhe lumbar 0nd cervical spine, in my professional opinion, This

service is worrcm’red when There is failure ’ro achieve success during conservative Treo’rmen’r, 0nd objective
findings from The ini’riol examination ore present. Typically, u’rilize o one—mon’rh duro’rion of Treo’rmen’r prior ’ro
s’rill |

was 3 mon’rhs of’rer ini’riol presentation
referring ou’r for fur’rher diagnostics. In This case, ’rhe referral for This service
’roThe clinic. However, There were no neurological symptoms no’red in ’rhe ini’riol examination. Examples of
neurological symptoms would be changes in deep Tendon reflexes, sensation, muscle grading in specific spinal
dermo’romes or myo’romes. Additionally, based on ’rhe or’ricle en’ri’rled “Imoging for low back pain: is clinical use
consistent wi’rh guidelines? A sys’remo’ric review 0nd me’ro—onolysis”4, po’rien’rs were referred for imaging
inappropriately due ’ro The lock of red flags almost 40% of ’rhe Time, 0nd almost 30% of The Time due ’ro no’r
allowing proper Time 0nd Treo’rmen’r ’ro become effective. Wi’rhou’r These findings, There was Iiﬁle medical
documen’ro’rion To worron’r This referral. Therefore, This referral was no’r reasonable or necessary.

CHARGES

The below depicts The amount
Iis’r billed, The reasonable 0nd necessary allowable Treatment, 0nd The ’ro’rol for
each:

Mechanical Traction $28.1 O $28.1 O X 6 $1 68.60
CMT 3-4 $54 $54 x 2O $1 ,080
EMS $30 $30 x 6 $1 8O
Cervical X-roys $64.80 $64.80 $64.80
Focused Exom $100 $100 $100
Total $1 ,593.4O

From my
experience wi’rh ’rhe fee schedules around The DFW area, ’rhe charges for ’rhe services below were CI
excessive. The
Ii’r’rle Iis’r below shows ’rhe omoun’r billed for each service 0nd CI range of ’rhe reasonable charges
for eoch4:

Therapeutic Exercises $1 06.80 per uni’r $40-$50 per uni’r x 2O
Lumbar MRI $3,500 $400-$7OO
Cervical MRI $3,500 $400-$7OO
Thoracic X—roys $1 50 $75-$1 OO
Lumbar X—roys $1 58 $75-$1 OO

The ’ro’rol reasonable charges for ’rhe necessary Treo’rmen’r ore between $2,543.40 0nd $2,793.40.

References:
1. Managemen’r of neck pain and ossocio’red disorders: A clinical practice guideline from ’rhe On’rorio
Pro’rocol for Traffic Injury Management (OPTIMG) Colloboro’rion. European Spine Journal. 201 6 March; 25:
2000—22.
2. Bigos SJ. Perils, pitfalls, 0nd accomplishments of guidelines for Treo’rmen’r of back problems. Neurol
Clin. 1999 Feb; 17(1):]79—92.
3. Bier JD, Schol’ren-Pee’rers WGM, S’rool JB, e’r 0|. Clinical practice quideline for physical Therapy
ossessmen’r cmd Treo’rmen’r in Do’rien’rs wi’rh nonspecificneck pain. Phys Ther. 2018; 98(3):] 62-1 71.
4. Nighbor, C. Our 19*“ Annual Fees & Reimbursemen’rs Survey Ready for Growth. Chiropractic Economics.
October 201 6. 38-52.
5. H.J. JenkinsAI. Imaging for low back pain: is clinical use consistent
e’r. wi’rh guidelines? A systematic
review 0nd me’ro-onolysis. The Spine Journal. 18 (2018). 2266-2277.
Irma Enriquez
March 6, 2020
CASE #: 21070481
Page 4 of 5

Thank you for the opportunity to review the medical records on Ms. Irma Enriquez.

Written, reviewed, opinion verified, and attested to by my original signature.

Sincerely,

D.G-
Ryan Robinson, D.C.
Doctor of Chiropractic
12373

RR/pl

RECORDS REVIEWED

 Texas Peace Officer’s Crash Report, 02/21/18
 Methodist Health System, 02/21/18
 Peralta Chiropractic February 22,26,27, March 1,6,15,19,23,27,29,30, April 1,3,5,10,13,16,17,19,24, May 1,
June 7, 2018
 MDN, Charles DeMarque, MD Medical Chart, 03/26/18
 Dallas Diagnostic Imaging Services, Rafath Quraishi, M.D.,04/23/18
 Miramar Interventional Pain Treatment Center, Rafath Quraishi, M.D., 04/26/18
 Coast to Coast Radiology Consulting, Kenneth N. Hansen, D.C., 06/14/18
 Medical Records Affidavit Ken Hansen, DC
 Cost and Necessity of Services Affidavit Ken Hansen, DC
 Medical Records Affidavit Miramar Interventional Pain Treatment Center
 Cost and Necessity of Services Affidavit Miramar Interventional Pain Treatment Center
 Medical Records Affidavit Dallas Diagnostic Imaging Services
 Cost and Necessity of Services Affidavit Dallas Diagnostic Imaging Services
 Medical Records Affidavit Peralta Chiropractic
 Cost and Necessity of Services Affidavit Peralta Chiropractic
 Medical Records Affidavit Methodist Health System
 Cost and Necessity of Services Affidavit Methodist Health System
 Plaintiff Irma Enriquez Responses and Objections to Defendants Request for Discovery
 Peralta Chiropractic Statement
 Dallas Diagnostic Imaging Services Statement
 Rafath Quraishi MD Statement
 Coast to Coast Radiology Statement
 Texas Physicians Resources Statement
 Methodist Health System Statement
 Vehicle Photos
Ryan Robinson D.C., CCSP

EDUCATION

January 2010 — April 2013 Parker University
Dallas, TX
Doctor of Chiropractic
Cum Laude
January 2010 — April 2012 Parker University
Dallas, TX

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Document Filed Date

March 17, 2020

Case Filing Date

December 18, 2019

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Request,Application: IRMA ENRIQUEZ, et al vs. REYNA MA SAUCEDO-BAZA

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