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INDEX NO. 650307/2014
NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 12/12/2014
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
ALLSTATE INSURANCE COMPANY,
Plaintiff Index Number :650307/14
- Against - DEMAND FOR VERIFIED WRITTEN
INTERROGATORIES
GIANNI PERSICH, DPM
A/A/O TITO REYES,
Defendant.
Pursuant to section 3130 of the Civil Practice Law and Rules (CPLR), the following interrogatories are
hereby propounded to the Plaintiff, ALLSTATE INSURANCE COMPANY, to be answered by it, upon
oath, within twenty (20) days from the date hereof, in accordance with section 3133 of the same CPLR.
Each question shall be answered separately and fully and each answer shal! be preceded by the question
to which it responds.
)) State the name, title and office of the person making answers to the Interrogatories set below.
2) State the Federal EIN or tax ID number of Plaintiff and set forth a copy of the Plaintiff's W-9.
3) State the NAIC number of the Plaintiff and set forth a copy of the Plaintiff’s incorporation papers.
4) State whether Plaintiff is a foreign corporation:
a) If the answer to Question 4 is in the affirmative, state whether Plaintiff is authorized to engage in
business in New York under Section 1304(a)(4) of NY Business Corporation Law, which
provides that a foreign corporation may obtain authority in NY to engage in any lawful act or
activity that a corporation organized in NY can engage in, provided that the foreign corporation
“is not formed to engage in any act or activity requiring the consent or approval of any state
official, department, board, agency or other body without such consent or approval first being
obtained.”
b) If the answer to Question 4 and “4a” is in the affirmative, state whether Plaintiff is authorized to
engage in business and/or issue insurance policies in New York by its proper registration with the
New York State Education Department and/or with the New York State Department of Insurance.
c) If the answer to Question “4,” “4a,” and “4b,” is in the negative, state otherwise how Plaintiff is
authorized to conduct business and/or issue insurance policies in the State of New York.
5) State whether the Plaintiff has issued a New York Automotive Liability Policy containing a No-Fault
endorsement to Defendant’s assignor and/or the owner of the motor vehicle in which Defendant’s
assignor was riding and/or on the motor vehicle which struck Defendant’s assignor, indicating the
policy number and the policy period.
6) State whether Plaintiff received any No-Fault claims for benefits from or on behalf of Defendant’s
assignor,
a) If the answer to Question 6 is in the affirmative, state separately the date all such claims were
received and the dates and amounts each benefit, if any, were paid thereunder.
b) Jf the answer to Question 6 is in the affirmative, state whether the Plaintiff requested any
additional verification from the Defendant, the dates said information was requested, and if so,
set forth a true and complete copy of all such request.
i) If the answer to Question 6(b) is in the affirmative, separately state, for each question
contained in said verification request(s), the reason such was necessary in order to process
Defendant’s benefits.
ii) If the answer to Question 6(b) is in the affirmative, indicate whether the Plaintiff received
any correspondence from the Defendant in reply to its verification requests and if so, the
dates such information was received, attaching any and all such documentation.
7) State whether the Plaintiff received any No-Fault medical claims for benefits from or on behalf of
Defendant.
a) If the answer to Question 7 is in the affirmative, separately state the name of all such health
service providers, and the dates such were received,
b) If the answer to Question 7 is in the affirmative, state separately whether the above health service
provider was paid and if so, the date of such payment.
c) If the answer fo Question 7 is in the affirmative, set forth a true and correct copy of all
documents, INCLUDING MEDICAL REPORTS received by the Plaintiff from each of the other
health service providers rendering medical care to the Plaintiff's assignor.
8) Specify what claims No-Fault claims the Plaintiff has received by or on behalf of the Defendant’s
Assignor for injuries arising from the motor vehicle accident of December 1, 2011. For each claim
set forth:
a) The provider
b) The dates of service;
°) The date the claim was fully received, including any requested verification;
d) Whether any verification is pending;
e) Whether the claim is paid or unpaid; and
The date of payment.
9) State whether the Plaintiff received an Application for Benefit Form from or on behalf of the
Defendant’s assignor, including the date it was received, and if so, set forth a true and correct copy
thereof.
10) State whether the Plaintiff is in possession of a copy of a Motor Vehicle Accident Report of
Defendant’s assignor, including the date it was received, and if so, set forth a true and correct copy
thereof.
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11) State whether the Plaintiff is in possession of a copy of the Police Accident Report, including the date
it was received, and if so, set forth a true and correct copy thereof.
12) State whether the Plaintiff forwarded a Denial of Claim form to the Defendant’s assignor.
a) If the answer to Question 11 is in the affirmative, state the date it was sent, and set forth a true
and correct copy of the proof of mail.
b) If the answer to Question 11 is in the affirmative but does not relate to Defendant’s entire medical
bill, or was based in whole or in part upon the reasoning that the “fees are not in accordance with
the NYS fee schedule,” provide a detailed explanation of how the Plaintiff arrived at the sum
payable, including a breakdown of each reduction, and listing the procedure code, conversion
factor and region;
c) Specify what the average payment Allstate has made to other providers on claims in New Jersey
for CPT Codes 28730, 28737 and 28304 for both no-fault and non-no-fault claims; include copies
of payments that show the average payment.
13) If the answer to Question 11 is in the affirmative and the denial is based in whole or in part upon a
medical “peer” review from a doctor, nurse or other medical consultant or cost control unit or
organization, whether employed by or contracted with the Plaintiff, or otherwise, set forth a true and
correct copy of the same.
a) if the answer to Question 12 is in the affirmative, state whether the medical reviewer is licensed
to practice medicine in the State of New York, and if so, set forth a copy of the license and
registration.
b) State what medical records were considered by the reviewer prior to rendering the conclusion,
and attach a true and correct copy of all such reports,
¢) State what medical articles or treatises were considered by the peer reviewer prior to rendering
the conclusion and attach a true and correct copy of all such articles or relevant portions of such
treatises.
4) State whether the medical reviewer is an employee of the Plaintiff or an independent vendor.
e) if the medical reviewer is an independent vendor, state the name and address of this entity or
person, and indicate whether the same is a corporation.
) If the independent vendor is a corporation, state the date and place of incorporation, setting forth
a true and correct copy of the certificate of incorporation, including a list of the shareholders.
8) If the medical reviewer is an independent vendor, state whether there exists a contractual
agreement, whether oral or written, with the Plaintiff. If the contract is oral, state the substance of
the agreement; if the contract is written, set forth a true and correct copy of the same,
14) State whether any of the claims referred to herein above has been referred to a “Special Investigation
Unit,” or has been the subject of an investigation, and if so, indicate the basis for conducting such an
inquiry.
a) If the answer to Question 13 is in the affirmative, indicate on what date the investigation was
initiated, whether the investigation has been completed, and if so, on what date.
b) State the results of or any conclusions from this investigation, and attach copies of any reports
submitted to or on behalf of the Plaintiff as it relates to this inquiry.
15) State whether there was any correspondence between the Plaintiff and the Defendant and if so, set
forth true and correct copies of the same.
Dated: Garden City, New York
October 6, 2014
Yours, etc.
RUBIN & LICATESI, P.C.
By: Cae
ALAN M. ELIS, Esq.
tn. Gs
Attorneys for Defendant
591 Stewart Avenue - 4" Floor
Garden City, NY 11530
(516) 227-2662
To. PETER C, MERANI, P.C.
Attorneys for the Plaintiff
1001 Avenue of the Americas
Suite 1800
New York, New York 10018
(212) 629-9690
STATE OF NEW YORK )
) SS.°
COUNTY OF NASSAU )
Meredith Katzowitz, being duly sworn, deposes and says that I am not a party to the
action, am over 18 years of age and reside in Long Beach, New York.
On October 6, 2014, I served a true copy of the annexed DEMAND FOR VERIFIED
INTERROGATORIES, in the following manner:
x by mailing the same in a sealed envelope, with postage prepaid thereon, in a post-office
or official depository of the U.S. Postal Service within the State of New York, addressed
to the following last known address of the addressee(s) as indicated below:
TO
PETER C. MERANI, P.C.
Attorneys for the Plaintiff
1001 Avenue Of The Americas
Suite 1800
New York, New York 10018
(212) 629-9690
Mei ith Katzowitz
Sworn to before me on
Octoby pr 6, 2014
ALAN M. ELIS
Notary Public. State of New York
Qualified in Nassau Count
Commission Expires Jan, 03, tel3
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
ALLSTATE INSURANCE COMPANY,
Plaintiff Index. Number :650307/14
~ Against - REQUEST FOR EXPERT DISCLOSURE;
NOTICE OF REJECTION OF SERVICE BY
GIANNI PERSICH, DPM A/A/O TITO REYES, FACSIMILE OR EMAIL
Defendant.
GENTLEMEN:
PLEASE TAKE NOTICE, that pursuant to CPLR §3101(d), you are hereby directed to identify, state and
provide, to offices of the undersigned, located at 591 Stewart Avenue, Garden City, New York
11530,within twenty (20) days of receipt of this notice:
1) Identify by name and address each person whom you will call as an expert witness at the time of trial.
2) The qualifications of each person whom you intend to call as an expert witness at the time of trial.
3) The subject matter in reasonable detail upon which the expert is expected to testify.
4) A statement of the facts and opinions upon which the expert is expected to testify.
5) A detailed summary of those facts and opinions.
6) A resume’ and curriculum vitae of each expert upon whose testimony Plaintiff will rely upon at the
time of trial concerning the subject lawsuit,
PLEASE TAKE FURTHER NOTICE that the within is a continuing demand. In the event any of the
above items are obtained after service hereof, they are to be immediately furnished to this office.
PLEASE TAKE FURTHER NOTICE that upon the failure to produce, identify, state and/or provide the
aforesaid items at the time and place required in this request, a motion will be made for the appropriate
relief to this Court.
NOTICE OF REJECTION OF SERVICE BY FACSIMILE OR EMAIL
PLEASE TAKE NOTICE that inclusion upon our letterhead of information for transmission of
documents by electronic facsimile process (“FAX”) or electronic mail (“EMAIL”) is not to be deemed
consent to service of litigation papers by such method, any provision of law or statute to the contrary
notwithstanding; and
PLEASE TAKE FURTHER NOTICE that service of litigation papers in this or any other action upon the
undersigned by FAX or EMAIL will not be accepted and is not authorized.
Dated: Garden City, New York
October 6, 2014
Yours, etc.
RUBIN & LICATESI, P.C.
By:
AL.
Attorneys for Defendant
591 Stewart Avenue - 4" Floor
Garden City, NY 11530
(516) 227-2662
To PETER C. MERANI, P.C.
Attorneys for the Plaintiff
1001 Avenue Of The Americas
Suite 1800
New York, New York 10018
(212) 629-9690
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK.
ALLSTATE INSURANCE COMPANY,
Plaintiff Index Number : 650307/14
~ Against - NOTICE TO ADMIT
GIANNI PERSICH, DPM A/A/O TITO REYES,
Defendant.
PLEASE TAKE NOTICE, that pursuant to CPLR § 3123, each of the below-mentioned matters, of which
an admission is requested, shall be deemed admitted unless within twenty (20) days after service hereof,
the Plaintiff serves upon counsel to Defendant, a sworn statement denying specifically the matters of
which an admission is requested.
PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR § 3123, Plaintiff is hereby requested to
furnish to the undersigned counsel for Defendant, within twenty (20) days after service of this notice,
sworn written admission, verified pursuant to CPLR § 3020, of the truth of the following statements:
) GIANNI PERSICH, DPM, is licensed to practice medicine in the state of New York.
2) The Plaintiff, ALLSTATE INSURANCE COMPANY, issued a policy of insurance; that it was in
effect covering the accident underlying the within litigation, which occurred on December 1, 2011.
3) Exhibit “A” is a true and accurate copy of the subject assignment of benefits form for the Defendant’s
assignor, TITO REYES.
4) The Plaintiff, ALLSTATE INSURANCE COMPANY, received the subject assignment of benefits
form attached hereto as Exhibit “A” for the Defendant’s assignor, TITO REYES.
5) That the Assignor herein executed a valid assignment of benefits form which is attached hereto as
Exhibit “A,” and was received by the Plaintiff insurance company.
6) Exhibit “B” is a true and accurate copy of the reprinted subject bill(s) in dispute for services rendered
to the Plaintiff's assignor, TITO REYES, for May 8, 2012, in the total amount of $21,150.00.
1% That the reprinted bill in Exhibit B, in the amount of $21,150.00, was the bill in dispute in the
arbitration for which the Plaintiff secks a trial de novo.
8) That the amount in the bill submitted as Exhibit B was reduced to the amount of $14,035.00 in the
arbitration for which the Plaintiff seeks a trial de novo.
9) That the bills submitted as Exhibit B, have been reduced to the amount of $14,035.00 for the
purposes of this action.
10) The Plaintiff, ALLSTATE INSURANCE COMPANY, received the originals of subject bill(s) in
dispute, for the period of May 8, 2012, for services rendered by the Defendant to the Defendant's
assignor, TITO REYES, in the total amount of $21,500.00.
11) The Plaintiff, ALLSTATE INSURANCE COMPANY, timely received the subject bill(s) in dispute
(which are attached hereto as Exhibit “B”) for services rendered to the Defendant’s assignor, TITO
REYES, for services rendered by the Defendant to the Defendant’s assignor, TITO REYES on May
8, 2012, in the total amount of $21,500.00, within Forty-Five (45) days of the date(s) the services
billed were rendered.
12) That the subject medical records at issue, attached as Exhibit “C,” were timely sent to the Plaintiff,
ALLSTATE INSURANCE COMPANY.
13) That the subject medical records attached as Exhibit “C,” were received by the Plaintiff, ALLSTATE
INSURANCE COMPANY in the arbitration for which the Plaintiff seeks a trial de novo.
14) That the denials and explanations of benefits, which are attached as Exhibit “D,” are true and accurate
copies of the denials and explanations of benefits for the invoiced bills cited in each denial and
explanation of benefits, for the services rendered by the Defendant to the Defendant’s assignor, TITO
REYES on May 8, 2012, in the total amount of $21,500.00.
15) The Plaintiff, ALLSTATE INSURANCE COMPANY, did not issue any verification requests to the
Defendant in the above-captioned matter.
16) The Plaintiff, ALLSTATE INSURANCE COMPANY, did not remit payment for the subject bill(s)
in dispute (Exhibit “B”) for services rendered by the Defendant to the Plaintiff's assignor, TITO
REYES, on May 8, 20122008, in the total amount of $21,500.00, reduced to $14,050.00.
17) That the foregoing documents hereinafter attached may be entered into evidence without objection.
PLEASE TAKE FURTHER NOTICE, that failing to properly admit or deny the statements contained
herein shal! result in Defendant moving for an Order requiring to_pay Defendant and Defendant’s
counsel reasonable expenses incurred in making such proof, including attorney fees. See generally, CPLR
3123(c).
Dated: Garden City, New York
October 6, 2104
Yours, etc.
RUBIN & LICATESI, P.C.
By: th Mt
ALAN M. ELIS, Esq.
Attorneys for Defendant
591 Stewart Avenue - 4” Floor
Garden City, NY 11530
(516) 227-2662
To PETER C. MERANI, P.C.
Attorneys for the Plaintiff
1001 Avenue Of The Americas
Suite 1800
New York, New York 10018
(212) 629-9690
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ASSIGNMENT OF BENEFITS FORM
(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02)
i, . ("Assignor’) hereby assign to f (CH LFUX' Assignee")
(Print patient's hame) {Print hospital or health care provider name}
all rights priviteges and remedies to payment for health care services provided by assignee to which
tam
‘entitled under Article $1 (the No-Fault statute) of the Insurance
Law.
~e
The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and
shall not pursue payment directly from the Assignor fors ices provided by said Assignee for injuries sustained
due to the motor vehicle accident which occurred on
a (Print a
, ot withstanding any other agreement
ident date)
to the contrary.
This agreement may be
of coverage andfor viot: al ion ked By the assignee when benefits are not payable based upon the assignor’s lack
mn of a policy condition due fo the actions or conduct of the assignor.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR
PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO,
IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS,
SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR
CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENGY, THE DEPARTMENT OF MOTOR
VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSC BE SUBJECT TO A CIVIL PENALTY NOT TO EXGEED FIVE THOUSAND DOLLARS AND THE VALUE OF
THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION
.
Tike Roues (Print natne of Patient)
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(Print name of Provider) CO
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PLRA Uh Sekt 2F
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08/12/2012 4:48PH FAX FIB7T773180+ OR PERSICH 0002/0005
DR. GIANNI PERSICH
54 South Dean Street
Englewood, NJ 07631
201-862-9300
September 7, 2012
Allstate Property & Casualty Insurance Company
425 Essjay Road
Williamsville, NY 14221
Re: Tito Reyes
Claim No: 0227743390
Date of Accident: December 1, pu
Dear Sir/Madam.
This letter is in response to your denial of claim dated June 8, 2012, with respect to the
above-mentioned claim. Your denial is based on a peer review prepared by Dr. Maury
Harris on June 7, 2012, wherein he conciuded that the right ankle arthroscopy and
associated services performed on May 8, 2012 was not medically necessary. I
respectfully disagree with Dr. Harris’s conclusion.
Mr. Reyes is a 29 year-old-male, who sustainedi injuries as a result of a moto} f vehicle
i
accident that occurred on December 1, 2011. At the tim of the accident, Mr. Reyes was a
restrained driver in a motor vehicle that was negligently and violently struck by another
driver. He did not go to the emergency room and decided to rest at home, However, he
began to develop pain in the following days and sought medical treatment with Dr.
Abmed Elsoury, on December 7, 2012, due to complaints of pain in his back and/bilateral
ankles, He was prescribed pain medications and initiated physical therapy treatment at a
rate of three times a week. Unfortunately, physical therapy treatment did not help in
alleviating his bilateral ankles pain and he was referred to Dr. Thomas Scilaris for an
evaluation.
|
He sought treatment with Dr. Scilaris on January 19, 2012, due to complaints of bilateral
ankles pain. Physical examination of the right ankle that day, revealed point tenderness
along the medial and lateral gutters with dorsiflexion te neutral and planter flexion at 35
degrees. Dr. Scilaris recommended physical therapy treatment and ordered a right ankle
MRI. |
09/12/2012 4:49PM FAX 7187773180+ OR PERSICH 0003/0005
MRI films of the right ankle performed at Sharp View Diagnostic Imaging, P.C., on
February 1, 2012, revealed anterior talofibular and |tibiofibular as well as) deltoid
ligament injury, attenuation of the posterior tibialis tendon in the tarsal tunnel
compatible with partial tear, talonavicular capsule injury and joint effusion.
On February 17, 2012, Mr. Reyes was re-evalugted by Dr. Scilaris. Physical
examination of the right ankle revealed an anterior talofibular ligament and deltoid
ligament tear, as well as a posterior tibial tendon partial tear. He was diagnosed with
right ankle os trigonum posterior tibial tendon injury. Dr. Scilaris advised] him to
continue with physical therapy treatment. However, despite undergoing several months
of physical therapy, his pain persisted and worsened. Upon reevaluation by Dr] Scilaris
on March 22, 2012, he complained of persistent and severe pain in his bilateral ankles
more on the right side on the medial aspect. Physical examination of his right
day, demonstrated tenderness in the medial aspect in the region of the pos'
le that
tibialis
tendon and crepitus with circumduction. Due to the patient’s persistent and severe pain,
it
he was referred to my to my office for an evaluation.
Mr. Reyes sought treatment at my office on May 7, 2012. He complained of right ankle
pain along the medial aspect and course of the posterior tibial tendon. He described the
pain as severe, sharp and persistent, He stated that it:was aggravated by walking and
going up and down the stairs. Upon physical examination of his right ankle! he had
significant swelling tenderness to palpation on the medial malleolus, tendémess to
palpation on the anterior talofibular ligament, dorsiflexion was at 10 jdegrees,
ih
plantarflexion was at 20 degrees, inversion was at 5 de; eS, eversion was at 10/degrees,
ankle instability, edema, loss of height of medial longi t dinal arch, valgus deflection of
heel, weak and painful inversion of the foot against resistance. Due to the sever of the
patient’s symptoms, which occurred after his Decemb 1, 2011, accident, and hot prior
to that; surgical intervention was warranted and nece: . It was obviously evil it that
his symptoms were significant, He had failed a course jof conservative treatment, which
ineluded, physical therapy, activity modifications d medications for nearly five
months; therefore the last step would be a medial fumn arthrodesis to co the
deformity due to the trauma and rupture of the posterior tibial tendon. After a thorough
discussion and careful consideration of the various treatment options, risks and benefits
of each, including a right foot/ankle surgery, the pati “| elected to have the ry done
as soon as possible.
On May 8, 2012, I performed a right ankle/foot surgory on Mr. Reyes, which cluded:
Talo-navicular arthrodesis, cuneiform osteotomy, mill er arthrodesis with graft right
foot intraoperative fluoroscopy.
On May 10, 2012, June 21, 2012, July 9, 2012 and A\ Le 6, 2012, I re-ex: ds Mr.
Reyes post right foot arthrodesis. He was starting to ifoel better, has wound well
healed; there was post-operative edema, which was secondary to surgery and disuse, He
was using a fracture walker and a cane. I advised him to continue his Post-pperative
|
physical therapy treatment. i t
|
08/12/2012 4:50PK FAX T1IBTTTIIB0+ OR PERSICH 0004/0005
'
| |
I
|
i
Nonetheless, payment was denied for the May 10, 2912 surgery, based on
prepared by Dr. Maury Harris on June 7, 2012. Dr.
do an arthrodesis on an acute soft tissue injury to
peer review
i
is stated, “There is no justification to
@ foot/ankle; therefor it was not
medically necessary or causally related to the motor yehicle accident,” I strohgly disagree
:
with Dr. Harris. Mr. Reyes was asymptomatic from ri ight ankle pain prior to the December 1,
°
2011 accident. He was a restrained driver in a motpr vehicle that was ni ebligently and
violently struck by another driver, Since the accident, was suffering from significant pain
and mechanical instability in his bilateral ankles, morejon the right side, He developed right
ankle symptoms when the collision occurred, These symptoms clearly came as & result of the
motor vehicle accident and did not predate it. The patient certainly underwent a course of
conservative treatment before opting for surgery. Despite this, he con timed to be
symptomatic, and in fact, his symptoms did not resolve with physical therapy, , it got
worse. This particular case indicates that the claimant did demonstrate a plentiful amount of
time for progress to occur prior to undergoing surgery for his right anklc injury resulting
from the motor vehicle accident mentioned, however, his symptoms did not tesolve. The
intraoperative findings found at the time of surgery were consistent with the + echanism of
injury.
Also, in reference to Dr. Harris’s report, wherein he stated, “Surgery should be considered
only if symptoms persist after a functional rehabilitation program for the ankle.”| 1 would like
to point out to Dr. Harris that the patient did iindergo conservative eatment for
approximately five months prior to opting for surgery. It is obvious that physi therapy did
not yield any positive results. As I clearly stated above, due to the patient's sistent and
worsening right ankle symptoms and failure to respond to a course of conservative treatment
for five months, as well as physical exam findings, it}was indeed warranted dnd medically
necessary to proceed with the right foot/ankle surgery, to prevent further continued pain and
weakness for the remainder of his life. His right ankle symptoms were not i proving and
were continuing to disturb his lifestyle, It is my medical opinion with a reasondble degree of
[
medical certainty that the accident of December 1, 2011, caused the right ankd pores
patient, which necessitated the May 8, 2012 surgical intervention.
Next, “According to the AMA definition of “Medically Necessary” or “Medical Necessity”,
it shall mean health care services that a physician, exercising prudent clinidal judgment,
would provide to a patient for the purpose of preventihg, evaluating, diagnosihg or treating
an illness, injury, disease or its symptoms, and that are: a) in accordance ith generally
Preview
INDEX NO. 650307/2014 NYSCEF DOC. NO. 15 RECEIVED NYSCEF: 12/12/2014 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ALLSTATE INSURANCE COMPANY, Plaintiff Index Number :650307/14 - Against - DEMAND FOR VERIFIED WRITTEN INTERROGATORIES GIANNI PERSICH, DPM A/A/O TITO REYES, Defendant. Pursuant to section 3130 of the Civil Practice Law and Rules (CPLR), the following interrogatories are hereby propounded to the Plaintiff, ALLSTATE INSURANCE COMPANY, to be answered by it, upon oath, within twenty (20) days from the date hereof, in accordance with section 3133 of the same CPLR. Each question shall be answered separately and fully and each answer shal! be preceded by the question to which it responds. )) State the name, title and office of the person making answers to the Interrogatories set below. 2) State the Federal EIN or tax ID number of Plaintiff and set forth a copy of the Plaintiff's W-9. 3) State the NAIC number of the Plaintiff and set forth a copy of the Plaintiff’s incorporation papers. 4) State whether Plaintiff is a foreign corporation: a) If the answer to Question 4 is in the affirmative, state whether Plaintiff is authorized to engage in business in New York under Section 1304(a)(4) of NY Business Corporation Law, which provides that a foreign corporation may obtain authority in NY to engage in any lawful act or activity that a corporation organized in NY can engage in, provided that the foreign corporation “is not formed to engage in any act or activity requiring the consent or approval of any state official, department, board, agency or other body without such consent or approval first being obtained.” b) If the answer to Question 4 and “4a” is in the affirmative, state whether Plaintiff is authorized to engage in business and/or issue insurance policies in New York by its proper registration with the New York State Education Department and/or with the New York State Department of Insurance. c) If the answer to Question “4,” “4a,” and “4b,” is in the negative, state otherwise how Plaintiff is authorized to conduct business and/or issue insurance policies in the State of New York. 5) State whether the Plaintiff has issued a New York Automotive Liability Policy containing a No-Fault endorsement to Defendant’s assignor and/or the owner of the motor vehicle in which Defendant’s assignor was riding and/or on the motor vehicle which struck Defendant’s assignor, indicating the policy number and the policy period. 6) State whether Plaintiff received any No-Fault claims for benefits from or on behalf of Defendant’s assignor, a) If the answer to Question 6 is in the affirmative, state separately the date all such claims were received and the dates and amounts each benefit, if any, were paid thereunder. b) Jf the answer to Question 6 is in the affirmative, state whether the Plaintiff requested any additional verification from the Defendant, the dates said information was requested, and if so, set forth a true and complete copy of all such request. i) If the answer to Question 6(b) is in the affirmative, separately state, for each question contained in said verification request(s), the reason such was necessary in order to process Defendant’s benefits. ii) If the answer to Question 6(b) is in the affirmative, indicate whether the Plaintiff received any correspondence from the Defendant in reply to its verification requests and if so, the dates such information was received, attaching any and all such documentation. 7) State whether the Plaintiff received any No-Fault medical claims for benefits from or on behalf of Defendant. a) If the answer to Question 7 is in the affirmative, separately state the name of all such health service providers, and the dates such were received, b) If the answer to Question 7 is in the affirmative, state separately whether the above health service provider was paid and if so, the date of such payment. c) If the answer fo Question 7 is in the affirmative, set forth a true and correct copy of all documents, INCLUDING MEDICAL REPORTS received by the Plaintiff from each of the other health service providers rendering medical care to the Plaintiff's assignor. 8) Specify what claims No-Fault claims the Plaintiff has received by or on behalf of the Defendant’s Assignor for injuries arising from the motor vehicle accident of December 1, 2011. For each claim set forth: a) The provider b) The dates of service; °) The date the claim was fully received, including any requested verification; d) Whether any verification is pending; e) Whether the claim is paid or unpaid; and The date of payment. 9) State whether the Plaintiff received an Application for Benefit Form from or on behalf of the Defendant’s assignor, including the date it was received, and if so, set forth a true and correct copy thereof. 10) State whether the Plaintiff is in possession of a copy of a Motor Vehicle Accident Report of Defendant’s assignor, including the date it was received, and if so, set forth a true and correct copy thereof. > 11) State whether the Plaintiff is in possession of a copy of the Police Accident Report, including the date it was received, and if so, set forth a true and correct copy thereof. 12) State whether the Plaintiff forwarded a Denial of Claim form to the Defendant’s assignor. a) If the answer to Question 11 is in the affirmative, state the date it was sent, and set forth a true and correct copy of the proof of mail. b) If the answer to Question 11 is in the affirmative but does not relate to Defendant’s entire medical bill, or was based in whole or in part upon the reasoning that the “fees are not in accordance with the NYS fee schedule,” provide a detailed explanation of how the Plaintiff arrived at the sum payable, including a breakdown of each reduction, and listing the procedure code, conversion factor and region; c) Specify what the average payment Allstate has made to other providers on claims in New Jersey for CPT Codes 28730, 28737 and 28304 for both no-fault and non-no-fault claims; include copies of payments that show the average payment. 13) If the answer to Question 11 is in the affirmative and the denial is based in whole or in part upon a medical “peer” review from a doctor, nurse or other medical consultant or cost control unit or organization, whether employed by or contracted with the Plaintiff, or otherwise, set forth a true and correct copy of the same. a) if the answer to Question 12 is in the affirmative, state whether the medical reviewer is licensed to practice medicine in the State of New York, and if so, set forth a copy of the license and registration. b) State what medical records were considered by the reviewer prior to rendering the conclusion, and attach a true and correct copy of all such reports, ¢) State what medical articles or treatises were considered by the peer reviewer prior to rendering the conclusion and attach a true and correct copy of all such articles or relevant portions of such treatises. 4) State whether the medical reviewer is an employee of the Plaintiff or an independent vendor. e) if the medical reviewer is an independent vendor, state the name and address of this entity or person, and indicate whether the same is a corporation. ) If the independent vendor is a corporation, state the date and place of incorporation, setting forth a true and correct copy of the certificate of incorporation, including a list of the shareholders. 8) If the medical reviewer is an independent vendor, state whether there exists a contractual agreement, whether oral or written, with the Plaintiff. If the contract is oral, state the substance of the agreement; if the contract is written, set forth a true and correct copy of the same, 14) State whether any of the claims referred to herein above has been referred to a “Special Investigation Unit,” or has been the subject of an investigation, and if so, indicate the basis for conducting such an inquiry. a) If the answer to Question 13 is in the affirmative, indicate on what date the investigation was initiated, whether the investigation has been completed, and if so, on what date. b) State the results of or any conclusions from this investigation, and attach copies of any reports submitted to or on behalf of the Plaintiff as it relates to this inquiry. 15) State whether there was any correspondence between the Plaintiff and the Defendant and if so, set forth true and correct copies of the same. Dated: Garden City, New York October 6, 2014 Yours, etc. RUBIN & LICATESI, P.C. By: Cae ALAN M. ELIS, Esq. tn. Gs Attorneys for Defendant 591 Stewart Avenue - 4" Floor Garden City, NY 11530 (516) 227-2662 To. PETER C, MERANI, P.C. Attorneys for the Plaintiff 1001 Avenue of the Americas Suite 1800 New York, New York 10018 (212) 629-9690 STATE OF NEW YORK ) ) SS.° COUNTY OF NASSAU ) Meredith Katzowitz, being duly sworn, deposes and says that I am not a party to the action, am over 18 years of age and reside in Long Beach, New York. On October 6, 2014, I served a true copy of the annexed DEMAND FOR VERIFIED INTERROGATORIES, in the following manner: x by mailing the same in a sealed envelope, with postage prepaid thereon, in a post-office or official depository of the U.S. Postal Service within the State of New York, addressed to the following last known address of the addressee(s) as indicated below: TO PETER C. MERANI, P.C. Attorneys for the Plaintiff 1001 Avenue Of The Americas Suite 1800 New York, New York 10018 (212) 629-9690 Mei ith Katzowitz Sworn to before me on Octoby pr 6, 2014 ALAN M. ELIS Notary Public. State of New York Qualified in Nassau Count Commission Expires Jan, 03, tel3 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK ALLSTATE INSURANCE COMPANY, Plaintiff Index. Number :650307/14 ~ Against - REQUEST FOR EXPERT DISCLOSURE; NOTICE OF REJECTION OF SERVICE BY GIANNI PERSICH, DPM A/A/O TITO REYES, FACSIMILE OR EMAIL Defendant. GENTLEMEN: PLEASE TAKE NOTICE, that pursuant to CPLR §3101(d), you are hereby directed to identify, state and provide, to offices of the undersigned, located at 591 Stewart Avenue, Garden City, New York 11530,within twenty (20) days of receipt of this notice: 1) Identify by name and address each person whom you will call as an expert witness at the time of trial. 2) The qualifications of each person whom you intend to call as an expert witness at the time of trial. 3) The subject matter in reasonable detail upon which the expert is expected to testify. 4) A statement of the facts and opinions upon which the expert is expected to testify. 5) A detailed summary of those facts and opinions. 6) A resume’ and curriculum vitae of each expert upon whose testimony Plaintiff will rely upon at the time of trial concerning the subject lawsuit, PLEASE TAKE FURTHER NOTICE that the within is a continuing demand. In the event any of the above items are obtained after service hereof, they are to be immediately furnished to this office. PLEASE TAKE FURTHER NOTICE that upon the failure to produce, identify, state and/or provide the aforesaid items at the time and place required in this request, a motion will be made for the appropriate relief to this Court. NOTICE OF REJECTION OF SERVICE BY FACSIMILE OR EMAIL PLEASE TAKE NOTICE that inclusion upon our letterhead of information for transmission of documents by electronic facsimile process (“FAX”) or electronic mail (“EMAIL”) is not to be deemed consent to service of litigation papers by such method, any provision of law or statute to the contrary notwithstanding; and PLEASE TAKE FURTHER NOTICE that service of litigation papers in this or any other action upon the undersigned by FAX or EMAIL will not be accepted and is not authorized. Dated: Garden City, New York October 6, 2014 Yours, etc. RUBIN & LICATESI, P.C. By: AL. Attorneys for Defendant 591 Stewart Avenue - 4" Floor Garden City, NY 11530 (516) 227-2662 To PETER C. MERANI, P.C. Attorneys for the Plaintiff 1001 Avenue Of The Americas Suite 1800 New York, New York 10018 (212) 629-9690 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK. ALLSTATE INSURANCE COMPANY, Plaintiff Index Number : 650307/14 ~ Against - NOTICE TO ADMIT GIANNI PERSICH, DPM A/A/O TITO REYES, Defendant. PLEASE TAKE NOTICE, that pursuant to CPLR § 3123, each of the below-mentioned matters, of which an admission is requested, shall be deemed admitted unless within twenty (20) days after service hereof, the Plaintiff serves upon counsel to Defendant, a sworn statement denying specifically the matters of which an admission is requested. PLEASE TAKE FURTHER NOTICE, that pursuant to CPLR § 3123, Plaintiff is hereby requested to furnish to the undersigned counsel for Defendant, within twenty (20) days after service of this notice, sworn written admission, verified pursuant to CPLR § 3020, of the truth of the following statements: ) GIANNI PERSICH, DPM, is licensed to practice medicine in the state of New York. 2) The Plaintiff, ALLSTATE INSURANCE COMPANY, issued a policy of insurance; that it was in effect covering the accident underlying the within litigation, which occurred on December 1, 2011. 3) Exhibit “A” is a true and accurate copy of the subject assignment of benefits form for the Defendant’s assignor, TITO REYES. 4) The Plaintiff, ALLSTATE INSURANCE COMPANY, received the subject assignment of benefits form attached hereto as Exhibit “A” for the Defendant’s assignor, TITO REYES. 5) That the Assignor herein executed a valid assignment of benefits form which is attached hereto as Exhibit “A,” and was received by the Plaintiff insurance company. 6) Exhibit “B” is a true and accurate copy of the reprinted subject bill(s) in dispute for services rendered to the Plaintiff's assignor, TITO REYES, for May 8, 2012, in the total amount of $21,150.00. 1% That the reprinted bill in Exhibit B, in the amount of $21,150.00, was the bill in dispute in the arbitration for which the Plaintiff secks a trial de novo. 8) That the amount in the bill submitted as Exhibit B was reduced to the amount of $14,035.00 in the arbitration for which the Plaintiff seeks a trial de novo. 9) That the bills submitted as Exhibit B, have been reduced to the amount of $14,035.00 for the purposes of this action. 10) The Plaintiff, ALLSTATE INSURANCE COMPANY, received the originals of subject bill(s) in dispute, for the period of May 8, 2012, for services rendered by the Defendant to the Defendant's assignor, TITO REYES, in the total amount of $21,500.00. 11) The Plaintiff, ALLSTATE INSURANCE COMPANY, timely received the subject bill(s) in dispute (which are attached hereto as Exhibit “B”) for services rendered to the Defendant’s assignor, TITO REYES, for services rendered by the Defendant to the Defendant’s assignor, TITO REYES on May 8, 2012, in the total amount of $21,500.00, within Forty-Five (45) days of the date(s) the services billed were rendered. 12) That the subject medical records at issue, attached as Exhibit “C,” were timely sent to the Plaintiff, ALLSTATE INSURANCE COMPANY. 13) That the subject medical records attached as Exhibit “C,” were received by the Plaintiff, ALLSTATE INSURANCE COMPANY in the arbitration for which the Plaintiff seeks a trial de novo. 14) That the denials and explanations of benefits, which are attached as Exhibit “D,” are true and accurate copies of the denials and explanations of benefits for the invoiced bills cited in each denial and explanation of benefits, for the services rendered by the Defendant to the Defendant’s assignor, TITO REYES on May 8, 2012, in the total amount of $21,500.00. 15) The Plaintiff, ALLSTATE INSURANCE COMPANY, did not issue any verification requests to the Defendant in the above-captioned matter. 16) The Plaintiff, ALLSTATE INSURANCE COMPANY, did not remit payment for the subject bill(s) in dispute (Exhibit “B”) for services rendered by the Defendant to the Plaintiff's assignor, TITO REYES, on May 8, 20122008, in the total amount of $21,500.00, reduced to $14,050.00. 17) That the foregoing documents hereinafter attached may be entered into evidence without objection. PLEASE TAKE FURTHER NOTICE, that failing to properly admit or deny the statements contained herein shal! result in Defendant moving for an Order requiring to_pay Defendant and Defendant’s counsel reasonable expenses incurred in making such proof, including attorney fees. See generally, CPLR 3123(c). Dated: Garden City, New York October 6, 2104 Yours, etc. RUBIN & LICATESI, P.C. By: th Mt ALAN M. ELIS, Esq. Attorneys for Defendant 591 Stewart Avenue - 4” Floor Garden City, NY 11530 (516) 227-2662 To PETER C. MERANI, P.C. Attorneys for the Plaintiff 1001 Avenue Of The Americas Suite 1800 New York, New York 10018 (212) 629-9690 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) i, . ("Assignor’) hereby assign to f (CH LFUX' Assignee") (Print patient's hame) {Print hospital or health care provider name} all rights priviteges and remedies to payment for health care services provided by assignee to which tam ‘entitled under Article $1 (the No-Fault statute) of the Insurance Law. ~e The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor fors ices provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on a (Print a , ot withstanding any other agreement ident date) to the contrary. This agreement may be of coverage andfor viot: al ion ked By the assignee when benefits are not payable based upon the assignor’s lack mn of a policy condition due fo the actions or conduct of the assignor. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENGY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSC BE SUBJECT TO A CIVIL PENALTY NOT TO EXGEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION . Tike Roues (Print natne of Patient) CG) Tie & haz {Signature of Patient) Su] mg Yhahuay + | 5/2 L{2 (Bate of signature} Cian. PSRSitdy DPy (Print name of Provider) CO Teinatire- of Providers PLRA Uh Sekt 2F (Date of signature} . ¢ OYey AR 1/fO3 > 3.30, (Address of Provider) NYS FORM NF-AOB (Rev 1/2004) OCT. 17. 2512 11:12AM ,1 * NO. 48 P He18 —™ (1500. Aistate Insurence Company HEALTH INSURANCE CLAIM FORM Brooklyn NY T1234 PREYS rant mM, eens OL eNO NMETES goa Des. 2 eae SSR eas ~ temas ~~— Sith Sones soy = TEMG _textuns _| Ray ANE Coe Na FED a So Sm | 022v74a090 ied Reyes, Tito, STAR Gaon ARE aR Reyes, Tho, + Raa RY e [RES ESIE Segh Rods Highviay oe & Sar RR oe Cie S07 ae ange Hichway w laraoitya SE iny sage Mei nw Bmotlyn SE ——~ ine —— ~ fen 703, S97 S720 “oRSRRaNT ~ “Soi 5 ee aS ‘703-357 3720 - PRA Fae TERE RE RET ——— stvapramerannen' net an WM OD vec Binet eo 7 ony ying iropesinauacss ome Oraarn RAR AEDES mo es a Ro. ‘BENPLO ERE RAS DORR GS OTHER ARGENT? --— PEARCEOLAR REC Rave oh Moa NAR: “DRG ERAS ee oe wa. __| Mlstaie Insurance Campany FARE OR PROGaS Pa 8 came Bes on, Ta, PATENTS OBAUTHORIZ BRON ED CORGEATLRE ladies errebiocaen la repesimepan ol const ea ary roel tr wr tere DMANT Domes oMR TEE | Serie aos. ace, _Stqnatute on tte, pW auTe mans Signature cre fie = SE ara RR nae! CARE rome CATE SRT ET Reg era BONE | eSRERTON Ti RESO sn Giitionrtgernee Ms ee as Bor ae a SRR CLE ag FF cesoe = 7 “Ree Sars aaa sesungey awe xi SES ATTACHED OP REPORT wes ONO Br OR SRT GF ES ERE CARRY ane bones LOAD TEE <- — — —- PEER-REVIEW— Tz BS be ee fz SET TOR ORES GRESOICE & CR PRE SESS oB sor Sy oe Bo BE oe fephith Crean Retirees eee rapes PORE sseome SRP ‘Be. ones Tos” be 20ns be ahaa War i 650 8 CSS 7 —_.| wer ass L. GB Cie ewe Te Bey 18 ee eee 6850 oo 4 i Os “oesores aie Bay do 4 x ‘eee fi t 128578630 ® — - t -—-. weeny -— ee en ee ee ene 1 ee ee a tn RAN 77, Asher tay Ry UGB Bas com B.S Tn, ee ne 45 jg02071 Sa Btn Lan ~ ‘21150 69 rea arent 00 5 Z11500 thea Ks FIAR Epi Fea aOes Real butatany Sung! Foot Ankle Surgical Gianni Persich DEM heteen 54 Bean, 54. Dean Seat Englewood NJ C7631 Englawoud NY 07631 OS 10.2012- £1P = - ROTISOAS 1s T 21285726830 08/12/2012 4:48PH FAX FIB7T773180+ OR PERSICH 0002/0005 DR. GIANNI PERSICH 54 South Dean Street Englewood, NJ 07631 201-862-9300 September 7, 2012 Allstate Property & Casualty Insurance Company 425 Essjay Road Williamsville, NY 14221 Re: Tito Reyes Claim No: 0227743390 Date of Accident: December 1, pu Dear Sir/Madam. This letter is in response to your denial of claim dated June 8, 2012, with respect to the above-mentioned claim. Your denial is based on a peer review prepared by Dr. Maury Harris on June 7, 2012, wherein he conciuded that the right ankle arthroscopy and associated services performed on May 8, 2012 was not medically necessary. I respectfully disagree with Dr. Harris’s conclusion. Mr. Reyes is a 29 year-old-male, who sustainedi injuries as a result of a moto} f vehicle i accident that occurred on December 1, 2011. At the tim of the accident, Mr. Reyes was a restrained driver in a motor vehicle that was negligently and violently struck by another driver. He did not go to the emergency room and decided to rest at home, However, he began to develop pain in the following days and sought medical treatment with Dr. Abmed Elsoury, on December 7, 2012, due to complaints of pain in his back and/bilateral ankles, He was prescribed pain medications and initiated physical therapy treatment at a rate of three times a week. Unfortunately, physical therapy treatment did not help in alleviating his bilateral ankles pain and he was referred to Dr. Thomas Scilaris for an evaluation. | He sought treatment with Dr. Scilaris on January 19, 2012, due to complaints of bilateral ankles pain. Physical examination of the right ankle that day, revealed point tenderness along the medial and lateral gutters with dorsiflexion te neutral and planter flexion at 35 degrees. Dr. Scilaris recommended physical therapy treatment and ordered a right ankle MRI. | 09/12/2012 4:49PM FAX 7187773180+ OR PERSICH 0003/0005 MRI films of the right ankle performed at Sharp View Diagnostic Imaging, P.C., on February 1, 2012, revealed anterior talofibular and |tibiofibular as well as) deltoid ligament injury, attenuation of the posterior tibialis tendon in the tarsal tunnel compatible with partial tear, talonavicular capsule injury and joint effusion. On February 17, 2012, Mr. Reyes was re-evalugted by Dr. Scilaris. Physical examination of the right ankle revealed an anterior talofibular ligament and deltoid ligament tear, as well as a posterior tibial tendon partial tear. He was diagnosed with right ankle os trigonum posterior tibial tendon injury. Dr. Scilaris advised] him to continue with physical therapy treatment. However, despite undergoing several months of physical therapy, his pain persisted and worsened. Upon reevaluation by Dr] Scilaris on March 22, 2012, he complained of persistent and severe pain in his bilateral ankles more on the right side on the medial aspect. Physical examination of his right day, demonstrated tenderness in the medial aspect in the region of the pos' le that tibialis tendon and crepitus with circumduction. Due to the patient’s persistent and severe pain, it he was referred to my to my office for an evaluation. Mr. Reyes sought treatment at my office on May 7, 2012. He complained of right ankle pain along the medial aspect and course of the posterior tibial tendon. He described the pain as severe, sharp and persistent, He stated that it:was aggravated by walking and going up and down the stairs. Upon physical examination of his right ankle! he had significant swelling tenderness to palpation on the medial malleolus, tendémess to palpation on the anterior talofibular ligament, dorsiflexion was at 10 jdegrees, ih plantarflexion was at 20 degrees, inversion was at 5 de; eS, eversion was at 10/degrees, ankle instability, edema, loss of height of medial longi t dinal arch, valgus deflection of heel, weak and painful inversion of the foot against resistance. Due to the sever of the patient’s symptoms, which occurred after his Decemb 1, 2011, accident, and hot prior to that; surgical intervention was warranted and nece: . It was obviously evil it that his symptoms were significant, He had failed a course jof conservative treatment, which ineluded, physical therapy, activity modifications d medications for nearly five months; therefore the last step would be a medial fumn arthrodesis to co the deformity due to the trauma and rupture of the posterior tibial tendon. After a thorough discussion and careful consideration of the various treatment options, risks and benefits of each, including a right foot/ankle surgery, the pati “| elected to have the ry done as soon as possible. On May 8, 2012, I performed a right ankle/foot surgory on Mr. Reyes, which cluded: Talo-navicular arthrodesis, cuneiform osteotomy, mill er arthrodesis with graft right foot intraoperative fluoroscopy. On May 10, 2012, June 21, 2012, July 9, 2012 and A\ Le 6, 2012, I re-ex: ds Mr. Reyes post right foot arthrodesis. He was starting to ifoel better, has wound well healed; there was post-operative edema, which was secondary to surgery and disuse, He was using a fracture walker and a cane. I advised him to continue his Post-pperative | physical therapy treatment. i t | 08/12/2012 4:50PK FAX T1IBTTTIIB0+ OR PERSICH 0004/0005 ' | | I | i Nonetheless, payment was denied for the May 10, 2912 surgery, based on prepared by Dr. Maury Harris on June 7, 2012. Dr. do an arthrodesis on an acute soft tissue injury to peer review i is stated, “There is no justification to @ foot/ankle; therefor it was not medically necessary or causally related to the motor yehicle accident,” I strohgly disagree : with Dr. Harris. Mr. Reyes was asymptomatic from ri ight ankle pain prior to the December 1, ° 2011 accident. He was a restrained driver in a motpr vehicle that was ni ebligently and violently struck by another driver, Since the accident, was suffering from significant pain and mechanical instability in his bilateral ankles, morejon the right side, He developed right ankle symptoms when the collision occurred, These symptoms clearly came as & result of the motor vehicle accident and did not predate it. The patient certainly underwent a course of conservative treatment before opting for surgery. Despite this, he con timed to be symptomatic, and in fact, his symptoms did not resolve with physical therapy, , it got worse. This particular case indicates that the claimant did demonstrate a plentiful amount of time for progress to occur prior to undergoing surgery for his right anklc injury resulting from the motor vehicle accident mentioned, however, his symptoms did not tesolve. The intraoperative findings found at the time of surgery were consistent with the + echanism of injury. Also, in reference to Dr. Harris’s report, wherein he stated, “Surgery should be considered only if symptoms persist after a functional rehabilitation program for the ankle.”| 1 would like to point out to Dr. Harris that the patient did iindergo conservative eatment for approximately five months prior to opting for surgery. It is obvious that physi therapy did not yield any positive results. As I clearly stated above, due to the patient's sistent and worsening right ankle symptoms and failure to respond to a course of conservative treatment for five months, as well as physical exam findings, it}was indeed warranted dnd medically necessary to proceed with the right foot/ankle surgery, to prevent further continued pain and weakness for the remainder of his life. His right ankle symptoms were not i proving and were continuing to disturb his lifestyle, It is my medical opinion with a reasondble degree of [ medical certainty that the accident of December 1, 2011, caused the right ankd pores patient, which necessitated the May 8, 2012 surgical intervention. Next, “According to the AMA definition of “Medically Necessary” or “Medical Necessity”, it shall mean health care services that a physician, exercising prudent clinidal judgment, would provide to a patient for the purpose of preventihg, evaluating, diagnosihg or treating an illness, injury, disease or its symptoms, and that are: a) in accordance ith generally