Preview
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
Exhibit D
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
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FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
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FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
Doctor's Pro ress Re ort C-4.2
Compensation
Board Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To
reports permanent impairment, useForm C-4.3.)
Please answer all questions completely, attaching extra pages if necessary, and submit
promptly to the Board, the insurance carrier and to the
patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so
may delay the payment of
necessary treatment, prevent the limely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize
vour Board authorization. You may also fill out this form online at www.wcb.ny.a
08/09/2021 - 08/09/2021
Date(s) of Examination:
WCB Case # (if known): G257 7fi85 Carrier Case #: 301933077210001
A. Patient's Information
1. Name: Itara Joseph A
2. Date o I 8 3. Soc . : 000-00-7713
Last Frst MI
4. Address (if changed from previous report): 520 West 56th Street New York NY 10019
NumberandSuest City State ZipCode
5. Patient's Account #: 80757
B. Doctor's Information
1. Your name: DeMarco Charles A
2. WCB Authorization #: 195433-8W
Last First MI
3. WCB Rating Code.COS 4. Federal Tax ID #:320073618 The Tax ID #is the (check one): OSSN Q EIN
5, Office address: 141 West 28Th Street Suite 500 New York NY 10001"6115
Nuberandstreet city Sale Zipcode
6. Billing group or practim name· University Orthopedins of FIY PLLC
7. Billing address: P O Box 5159 LIC NY 11105-5159
Number
andSueet city State 3Dcode
8. Office phone #: 212-924-6644 9. Billing phone # 718-777-1885 10. Treating Providers NPi # 1265434930
C. Billing Information
1. Employers insurance company: SEDGWICK CMS
2. Carrier Code #: W
3. Insurance company's address: P.O. BOX 14156 Lexington KY 40512-4156
. . . Number
andStreet city Sm:g asCode
4. Diagnosis or nature of disease or injury:
Enter ICD10 Code: ICD10 Descriptor:
(1) M75.112 Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic
(2) S43.432D Superior glenoid labrum lesion of left shoulder
(3)
(4) -. .....
Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below
by line.
Sd UsewCSCade.5
ace Leave Semicas
Procedures, orSuppBes
5sCode 5chages oeys/ coB EPcode service
where was
MM 00 YY MM 00 Yy ServiceEad MOD
08 09 21 08 09 21 24 29828 80 1,2 495 31 1 10001.6115
08 09 21 08 D9 21 24 29827 80 51 1,2 469 62 1 10001-6115
08 09 21 08 09 21 24 29823 80 59 1,2 413 18 1 10001-6115
08 09 21 08 09 21 24 29826 80 1,2 99 26 1 10001-6115
O Check here if services were provided by a WCB preferred provider organization
(PPO
. 1477 37
D. Examination and Treatment $ $
1. Describe any diagnostic test(s) rendered at this visit:
C-4.2 (10-15) Page 1 of 2 "E WomRS B a 4 S ESPEOPLE
POR
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
12 451m57
Patients Name:Itara Joseph A
Date of injury/onset of illness: 08/13/2019
2. List any changes revealed by your most recent exarnination in the following:
area of injury, type/nature of injury, patients subjective complaints
or your objective findings: increased pain and dysfunction left shoulder
........
3. List additional body parts affected by this injury, if any:
4. Based on your most.recent examination, list changes to the original treatment
plan, prescription medications or assistive devices, if any:
feft shoulder
surgery is warranated
5. Based on this examination, does the patient need diagnostic tests or referrals?
O Yes O No If yes, check all that apply:
Tests: Referrals:
¡ CT Scans O EMG/NCS ¡
Chiropractor
¡ internist/Family Physician
¡ MRI (Specify):
¡ Occupational Therapis
¡ Labs (Specify):
¡ Physical Therapist
¡ X-rays (Specify):
¡ Specialist in
O Other (Specify):
O
Other (Specify):
Important:Formc-4 AUTHshouldbeusedto requestanyspecialmadicalserviceover$1000or for thoseservices
TreatmentGuldlinesfor theback.neck.kneeandshoulder. requiringpre-authorizatlan
pursuantto theMedical
6. Describe treatment rendered today: * See attached operative report. Patient
underwent left shoulder surgery on 08/09/21 at Surgicare
of Nianhattan
7, When is patients next follow-up visit? D Within a week 1-2 wks O 3-4 wks O 5-6 wks D 7-B wks O _months Gas needed
E. Doctor's Opinion (based on this examination)
1. In your opinion, was the incident that the patient described the
competent medical cause of this injury/illness? Yes O No
2 Are the patients complaints consistent with his/her yes ¡ No
history of the injury/illness?
3. Is the patients history of the injury/illness consistent with your objective Yes D No ¤ N/A (no findinos at this time)
findings?
4. What is the percentage (0-100%) of 100.00
temporary impairment?
5. Describe findings and relevant diagnostic test results: See attached
F. Return to Work
1, Is patient working now? OYes No If yes, are there work restrictions?
¡ Yes O No If yes, describe the work restrictions:
How long win the work restrictions apply? U 1-2 days O 3-7 days O 8-14 days U 15+ days O Unknown at this time
2. Can the alient return to work? (check gnly one):
a. × The patient cannot retum to work because status post op pain
(explain)
b. ¡ The patient can return to work without limitations on
c. O The patient can retum to work with the
following limitations (check all that apply) on
O Bending/twisting O Lifting ¡ Sitting
O Cfirnbing stairs/ladders O Operating heavy equipment O Standing
¡ Environmental conditions O Operation of motor vehicles ¡ Use of public transportation
¡ Kneeling ¡ Personal protective equipment O Use of upper extremities
O Other (Specify):
Describe/quantify the limitations:
How long will the work limitations apply? O
1-2 days 3-7 days O 8-14 devs U 15+ days O Unknown at this time O N/A
3. With whom will you discuss the patients retum to work and/or limitations?
with patient U with patients employer N/A
4. Would the patient benefit from vocational rehabilitation?
¡Yes ¤ No
This form is signed under penalty of perjury.
Board Authorized Health Care Provider - Check one
I provided the services listed above.
I actively supervised the health-care provider named below who provided
these service
Providers name
Specialty
Board Authorized Health Care Provider signature:
Charles DeMarco Mp Physician 08n5/2021
Name Sionature Specially Date
C-4.2 (10-15) Page 2 of 2
www.wcb.ny.gov
POR
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
Operative Report
Facility: Surgicare of Manhattan
Patient Name: Itara, Joseph
MRN: 0033669
Date of Birth: 07/24/1974
Date of Operation: 08/09/2021
Surgeon: Steven Touliopoulos, MD
First Assistant: Charles Demarco, MD p
Preoperative Diagnosis: Post-traumatic left shoulder partial thickness rotator cuff tendon tear,
anterior shoulder instability, SLAP lesion, subacromial impingement syndrome, and rule out
further left shoulder internal derangement.
Pastoperative Diagnosis: Post-traumatic Ieft shoulder partial thickness rotator cuff tendon
tear, anterior shoulder instability with anterior labral fraying, SLAP lesion, and subacromial
: impingement syndrome.
Operation: Left shoulder diagnostic arthroscopy, arthroscopic repair of rotator cuff tendon
tear, arthroscopic stabilization via anterior capsulorrhaphy, arthroscopic proximal biceps
tenotomy and tenodesis, arthroscopic extensive debridement with debridement of anterior
labral fraying and debridement of SLAP lesion, and arthroscopic subacromial decompression.
Anesthesia Type: General anesthesia
Preoperative Antibiotics: Ancef 2 grams
Estimated Blood Loss: 3 cc
Complications: None
Specimens: None
Drains: None
Indications: The patient was under our care for a traumatic injury sustained to his left
shoulder. He had ongoing and significant shoulder pain and dysfunction despite the
conservative treatment that had been rendered to him. He reported that his lever of left
shoulder pain with activity was frequently 10/10 in intensity. In addition to pain, the patient
had significantrestriction of shoulder motion and strength which adversely affected activities of
daily living. The patient complained of difficulty lying on his affected side as well as difficulty
sleeping at night due to left shoulder pain. He reported weakness and difficulty raising his left
arm to shoulder level as wetl as difficulty lifting/carrying items of even light weight. He also
experienced symptoms of shoulder instability. The patient had been indicated for left shoulder
arthroscopy with indicated procedures. Risks, benefits, and alternatives were explained to the
patient and understood. The patient had realistic expectations with respect to surgical
outcome. He was aware of the success and failure rates of the proposed surgical procedures.
He was also aware that further left shoulder orthopedic intervention may be warranted at a
future time depending upon his clinical course and future shoulder symptomatology.
Operative Procedure: The patient was taken to the operating room where he was positioned
supine upon the operating room table. All bony prominences were well padded. Two grams of
PQR
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023
12 45106257
intravenous Ancef were infused as prophylactic antibiotic treatment. The patient underwent
general anesthesia which was carried out the anesthesiology team. The operative shoulder was
then examined under anesthesia. There was crepitus noted with range of motion testing of the
shoulder. There was gross and significant anterior shoulder instability upon stress testing under
anesthesia. There was no evidence of any significant posterior shoulder instability. There were
nosignificant mechanical restrictions to shoulder motion when examined under anesthesia.
The patient was repositioned into the beach chair position. Again, all bony prominences were
well padded. The shoulder and upper extremity were prepped and free draped in the usual
sterile fashion. The glenohumeral joint space was then injected with 30 cc of normal saline
employing a spinal needle. A standard posterior arthroscopic portal was created with a scalpel
blade and blunt trocar, through which an arthroscopic
Preview
FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 Exhibit D FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 8 Pgs Re 8 Pgs Transmitted eived, --·- D 451¾23 7 . 7 Pgs RecervecI, 7 Pgs Transmitted Page \ of O b lji w""""'"°" ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF °, NARIANCE AND INSURER'S·RES For addltIonal variance PONSE requests In thIt coseattach Forfo MG-2 Answer ah queaGona where MG-2,1, information la known. WCBCmu9msses |ctimAdrriahuercl&nicatercasal answmaco0M - Dad¾willinan Instain ememtmm....-----ovRh-___,-... Mas_--- PsMm .Sods0cAy9æ0-- UN Û,'.9" Ad¾u:.AOfeaLOGin.theaLAns.YartE,td010----,........-.....-......-................-...-,-.,-..-,..,...-,.. EmøoyersName 6 Addr4gg:....Mfr !$E3 AfGESint).M.Ighhj1192.,--...-,.......’.....--...-, haru‘sNemaaAd6ers..-...........M9M.9%-F-23.95)½.Ls0 nAS.UG-iM----...... 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F4 /NDAffleGNI0ri NYS Worltora' Coh1pentadon Boe Ed PO Be 6205 claghamton, NY 13902.5205 Enwil Fil)ng: webclaimsflfin g@web.ny.gov - Customer servicut (1177)632.4990 " Statawtds Fax: [877) 533-0337 hl0.2,0V-18)Pegn 2of 2 w wmour com a a :to oceanno®e eantonowetGRD Ebw:)0p wrmun|w " Mec6ggov .vnummutan see10.»umn httpr Ewww.sedgwicksr.comˆcMei HTML.5'prin¾duletunt 3/G/2021 PQR FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 Doctor's Pro ress Re ort C-4.2 Compensation Board Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To reports permanent impairment, useForm C-4.3.) Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the limely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize vour Board authorization. You may also fill out this form online at www.wcb.ny.a 08/09/2021 - 08/09/2021 Date(s) of Examination: WCB Case # (if known): G257 7fi85 Carrier Case #: 301933077210001 A. Patient's Information 1. Name: Itara Joseph A 2. Date o I 8 3. Soc . : 000-00-7713 Last Frst MI 4. Address (if changed from previous report): 520 West 56th Street New York NY 10019 NumberandSuest City State ZipCode 5. Patient's Account #: 80757 B. Doctor's Information 1. Your name: DeMarco Charles A 2. WCB Authorization #: 195433-8W Last First MI 3. WCB Rating Code.COS 4. Federal Tax ID #:320073618 The Tax ID #is the (check one): OSSN Q EIN 5, Office address: 141 West 28Th Street Suite 500 New York NY 10001"6115 Nuberandstreet city Sale Zipcode 6. Billing group or practim name· University Orthopedins of FIY PLLC 7. Billing address: P O Box 5159 LIC NY 11105-5159 Number andSueet city State 3Dcode 8. Office phone #: 212-924-6644 9. Billing phone # 718-777-1885 10. Treating Providers NPi # 1265434930 C. Billing Information 1. Employers insurance company: SEDGWICK CMS 2. Carrier Code #: W 3. Insurance company's address: P.O. BOX 14156 Lexington KY 40512-4156 . . . Number andStreet city Sm:g asCode 4. Diagnosis or nature of disease or injury: Enter ICD10 Code: ICD10 Descriptor: (1) M75.112 Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic (2) S43.432D Superior glenoid labrum lesion of left shoulder (3) (4) -. ..... Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line. Sd UsewCSCade.5 ace Leave Semicas Procedures, orSuppBes 5sCode 5chages oeys/ coB EPcode service where was MM 00 YY MM 00 Yy ServiceEad MOD 08 09 21 08 09 21 24 29828 80 1,2 495 31 1 10001.6115 08 09 21 08 D9 21 24 29827 80 51 1,2 469 62 1 10001-6115 08 09 21 08 09 21 24 29823 80 59 1,2 413 18 1 10001-6115 08 09 21 08 09 21 24 29826 80 1,2 99 26 1 10001-6115 O Check here if services were provided by a WCB preferred provider organization (PPO . 1477 37 D. Examination and Treatment $ $ 1. Describe any diagnostic test(s) rendered at this visit: C-4.2 (10-15) Page 1 of 2 "E WomRS B a 4 S ESPEOPLE POR FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 12 451m57 Patients Name:Itara Joseph A Date of injury/onset of illness: 08/13/2019 2. List any changes revealed by your most recent exarnination in the following: area of injury, type/nature of injury, patients subjective complaints or your objective findings: increased pain and dysfunction left shoulder ........ 3. List additional body parts affected by this injury, if any: 4. Based on your most.recent examination, list changes to the original treatment plan, prescription medications or assistive devices, if any: feft shoulder surgery is warranated 5. Based on this examination, does the patient need diagnostic tests or referrals? O Yes O No If yes, check all that apply: Tests: Referrals: ¡ CT Scans O EMG/NCS ¡ Chiropractor ¡ internist/Family Physician ¡ MRI (Specify): ¡ Occupational Therapis ¡ Labs (Specify): ¡ Physical Therapist ¡ X-rays (Specify): ¡ Specialist in O Other (Specify): O Other (Specify): Important:Formc-4 AUTHshouldbeusedto requestanyspecialmadicalserviceover$1000or for thoseservices TreatmentGuldlinesfor theback.neck.kneeandshoulder. requiringpre-authorizatlan pursuantto theMedical 6. Describe treatment rendered today: * See attached operative report. Patient underwent left shoulder surgery on 08/09/21 at Surgicare of Nianhattan 7, When is patients next follow-up visit? D Within a week 1-2 wks O 3-4 wks O 5-6 wks D 7-B wks O _months Gas needed E. Doctor's Opinion (based on this examination) 1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness? Yes O No 2 Are the patients complaints consistent with his/her yes ¡ No history of the injury/illness? 3. Is the patients history of the injury/illness consistent with your objective Yes D No ¤ N/A (no findinos at this time) findings? 4. What is the percentage (0-100%) of 100.00 temporary impairment? 5. Describe findings and relevant diagnostic test results: See attached F. Return to Work 1, Is patient working now? OYes No If yes, are there work restrictions? ¡ Yes O No If yes, describe the work restrictions: How long win the work restrictions apply? U 1-2 days O 3-7 days O 8-14 days U 15+ days O Unknown at this time 2. Can the alient return to work? (check gnly one): a. × The patient cannot retum to work because status post op pain (explain) b. ¡ The patient can return to work without limitations on c. O The patient can retum to work with the following limitations (check all that apply) on O Bending/twisting O Lifting ¡ Sitting O Cfirnbing stairs/ladders O Operating heavy equipment O Standing ¡ Environmental conditions O Operation of motor vehicles ¡ Use of public transportation ¡ Kneeling ¡ Personal protective equipment O Use of upper extremities O Other (Specify): Describe/quantify the limitations: How long will the work limitations apply? O 1-2 days 3-7 days O 8-14 devs U 15+ days O Unknown at this time O N/A 3. With whom will you discuss the patients retum to work and/or limitations? with patient U with patients employer N/A 4. Would the patient benefit from vocational rehabilitation? ¡Yes ¤ No This form is signed under penalty of perjury. Board Authorized Health Care Provider - Check one I provided the services listed above. I actively supervised the health-care provider named below who provided these service Providers name Specialty Board Authorized Health Care Provider signature: Charles DeMarco Mp Physician 08n5/2021 Name Sionature Specially Date C-4.2 (10-15) Page 2 of 2 www.wcb.ny.gov POR FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 Operative Report Facility: Surgicare of Manhattan Patient Name: Itara, Joseph MRN: 0033669 Date of Birth: 07/24/1974 Date of Operation: 08/09/2021 Surgeon: Steven Touliopoulos, MD First Assistant: Charles Demarco, MD p Preoperative Diagnosis: Post-traumatic left shoulder partial thickness rotator cuff tendon tear, anterior shoulder instability, SLAP lesion, subacromial impingement syndrome, and rule out further left shoulder internal derangement. Pastoperative Diagnosis: Post-traumatic Ieft shoulder partial thickness rotator cuff tendon tear, anterior shoulder instability with anterior labral fraying, SLAP lesion, and subacromial : impingement syndrome. Operation: Left shoulder diagnostic arthroscopy, arthroscopic repair of rotator cuff tendon tear, arthroscopic stabilization via anterior capsulorrhaphy, arthroscopic proximal biceps tenotomy and tenodesis, arthroscopic extensive debridement with debridement of anterior labral fraying and debridement of SLAP lesion, and arthroscopic subacromial decompression. Anesthesia Type: General anesthesia Preoperative Antibiotics: Ancef 2 grams Estimated Blood Loss: 3 cc Complications: None Specimens: None Drains: None Indications: The patient was under our care for a traumatic injury sustained to his left shoulder. He had ongoing and significant shoulder pain and dysfunction despite the conservative treatment that had been rendered to him. He reported that his lever of left shoulder pain with activity was frequently 10/10 in intensity. In addition to pain, the patient had significantrestriction of shoulder motion and strength which adversely affected activities of daily living. The patient complained of difficulty lying on his affected side as well as difficulty sleeping at night due to left shoulder pain. He reported weakness and difficulty raising his left arm to shoulder level as wetl as difficulty lifting/carrying items of even light weight. He also experienced symptoms of shoulder instability. The patient had been indicated for left shoulder arthroscopy with indicated procedures. Risks, benefits, and alternatives were explained to the patient and understood. The patient had realistic expectations with respect to surgical outcome. He was aware of the success and failure rates of the proposed surgical procedures. He was also aware that further left shoulder orthopedic intervention may be warranted at a future time depending upon his clinical course and future shoulder symptomatology. Operative Procedure: The patient was taken to the operating room where he was positioned supine upon the operating room table. All bony prominences were well padded. Two grams of PQR FILED: NEW YORK COUNTY CLERK 07/28/2023 02:56 PM INDEX NO. 152948/2020 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 07/28/2023 12 45106257 intravenous Ancef were infused as prophylactic antibiotic treatment. The patient underwent general anesthesia which was carried out the anesthesiology team. The operative shoulder was then examined under anesthesia. There was crepitus noted with range of motion testing of the shoulder. There was gross and significant anterior shoulder instability upon stress testing under anesthesia. There was no evidence of any significant posterior shoulder instability. There were nosignificant mechanical restrictions to shoulder motion when examined under anesthesia. The patient was repositioned into the beach chair position. Again, all bony prominences were well padded. The shoulder and upper extremity were prepped and free draped in the usual sterile fashion. The glenohumeral joint space was then injected with 30 cc of normal saline employing a spinal needle. A standard posterior arthroscopic portal was created with a scalpel blade and blunt trocar, through which an arthroscopic