Preview
FILED
3/6/2020 4:07PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Kevin Molden DEPUTY
N0. DC-19-17592
FRANCISCO GILES § IN THE DISTRICT COURT
PLAINTIFF, §
§
VS. § DALLAS COUNTY, TEXAS
§
BLANCA DIAZ §
DEFENDANT. §
1921‘") JUDICIAL DISTRICT
DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE T0 PLAINTIFF’S
REQUEST FOR DISCLOSURE AND DESIGNATION 0F EXPERTS
Pursuant t0 TeX R. CiV. P. 194, Defendant serves the following First Supplemental
Response to Plaintiff s 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 on 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, 0r otherwise subj ect t0 the control
0f the responding party:
A. A11 documents, tangible things, reports, models, 0r data
compilations that have been provided t0, reviewed by, 0r prepared by or for the
expert in anticipation 0f 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 call any 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 Plaintiff. Defendant reserves the right to rely upon 0r to
offer, by direct examination or cross-examination, testimony obtained from those
experts and rebuttal experts, if any, designated by Plaintiff. 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 itdeems it
in its interest t0 d0 s0.
Such persons are expected t0 testify concerning Plaintiff” s 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 Plaintiff.
First Supplemental Response:
Defendant hereby designates as an expert Witness the following individual:
Ryan Robinson, DC
1100 S. Main Street, Ste. D
Grapevine, Texas 76051
817. 203.2184
Dr. Robinson is a chiropractor who has reviewed Francisco Giles’ medical records and
other case materials provided to him, and isexpected to testify regarding the extent of 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 0f that treatment, both in
the past and in the future, if applicable, as set out in the attached report.
DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -2-
Respectfully submitted,
Chad Kimble, State Bar N0. 24007483
Kyle Smith, State Bar N0. 241025 12
D. Brent Beasley, State Bar N0. 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 OF SERVICE
The undersigned certifies that on the 6th a true copy of the foregoing
day of March, 2020,
has been served on all parties in accordance with Rule 21a, Texas Rules of Civil Procedure.
¢///%—
Kyle Smith
DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -3-
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 3,2020
Mr. Chad Kimble
Low Office of Chad Kimble, P.C.
1204 Sou’rh White Chapel Blvd.
Soufhloke, TX 76092
RE: Francisco Giles
CLAIM #: 0548037324
DATE OF INJURY: 06/03/1 9
CASE #: 21065593
Dear Mr. Kimble:
|hove had The opporTuniTy ’ro review medical records on Mr. Francisco Giles.
My name is Ryan Robinson, D.C., CCSP, |om licensed by The S’ro’re of Texas Gs o Chiroprocfor. | 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’rWor’rh, Texas. The poTienTs |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 wi’rh 0nd deal wi’rh daily, hove high
deduc’ribles 0nd hos
i’r
been necessary for me ’roconfoc’r imaging cen’rers 0nd o’rher providers To 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’ris o mole who was involved in c1mo’ror vehicle occiden’r on June 3, 20] 9.
On June 4, 201 9, The po’rien’rpresen’red ’ro Acciden’r & Injury Chiropractic for evoluo’rion 0nd Treo’rmen’r of neck
pain, mid back pain, 0nd Upper back pain. Physical examination revealed restricted ranges of motion in ’rhe
cervical 0nd Thorocolumbor spine 0nd positive for pain Throughout. Orthopedic Testing showed ’rhe following
posi’rive shoulder
’res’rs: depression, dis’rroc’rion,So’ro—Holl, cmd Volsolvo. Neurological ’res’ringwas wi’rhin normal
limi’rsThroughout X-roys were performed in The cervical, Thoracic spine 0nd were reviewed by Kenneth Lus’rik,
D.C., DACBR who no’red The following in ’rhe reports: postural ol’rero’rions.
On June 7, 2019, The po’rien’rpresented ’ro Whi’re Rock Open Air MRI for on MRI sccm of The cervical spine.
Kenne’rh Lus’rik,D.C., DACBR, read The scan 0nd no’red The following in The repor’r: Cervical: flo’r’reningof ’rhe
cervical Iordosis, desiccation of ’rhe C3-disc mo’reriol. A’r C3, shallow contained central disc protrusion 2 mm in
caliber wi’rh impression of ’rhe Thecol soc.
Francisco Giles
March 3, 2020
CASE #: 21065593
Page 2 of 5
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 detailed exam, the CPT Coding Manual requires three key components: detailed
history, detailed exam, and low level of medical decision-making. In addition, the problem severity should be
moderate, and physician time at least thirty 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, 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 the first 3 weeks of treatment.
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 up to the first 3 weeks of treatment.
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 first 22 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”
studies have concluded there is in extreme importance in healing to implement exercise prescriptions for the
patient to achieve activity tolerance 2”. In this case, the treating doctor did not prescribe this treatment until 3
weeks post initial presentation. I do not agree with this approach as it delays patient progress and slows
recovery. Therefore, these treatments are not reasonable or necessary based on the timing of their
implementation.
Francisco Giles
March 3, 2020
CASE #: 21 065593
Page 3 of 5
In reference ’roThe referral of The MRI scan of ’rhe cervical spine, in my professional opinion, This service is
worron’red when There is failure ’roachieve success during conservative Treo’rmen’r, 0nd objective findings from
examination
’rhe ini’riol ore s’rill
present. Typically, | o
u’rilize one—mon’rh duration of Treatment prior ’ro referring ouT
for fur’rher diognos’rics. In This case, The referral for Thisservice wos 3 days offer ini’riolpresentation To The clinic.
However, There were no neurological symptoms noted in The ini’riolexamination. 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: isClinical use consistent
wi’rh guidelines? A systematic review 0nd me’ro—onolysis”4, patients were referred for imaging inappropriately
due ’ro The lock of red flags almost 40% of ’rhe Time, 0nd almos’r 30% of The Time due ’ro no’r allowing proper Time
0nd Treo’rmen’r ’robecome effective. Wi’rhou’r These findings, There was Iifile medical documen’ro’rion To worron’r
’rhis referral. Therefore, This referral was no’r reasonable or necessary.
CHARGES
From my experience wi’rh The fee schedules around The DFW area, The charges for The services below were o
excessive. The
IiT’rle below shows The
Iis’r omoun’r billed for each service 0nd o range of The reasonable Charges
for e0ch3:
De’roiled Exam $325 $100-$1 75
Thoracic X—roys $333 $75-$1 OO
Cervical X-roys $463 $75-$1 OO
CMT 3-4 $1 06 $50—$65 x 22
Therapeutic Exercises $98 $40-$50
Mechanical Traction $55 $35-$45 x 11
EMS $54 $35—$45 x 11
Cervical MRI $2,998 $400-$7OO
The reasonable charges
’ro’rol for ’rhe necessary Treo’rmenT ore between $2,] 2O 0nd $2,795.
References:
1. Management of neck pain 0nd associated disorders: A clinical practice guideline from The On’rorio
Protocol for Traffic Injury Management (OPTIMO) Collaboration. European Spine Journal. 20] 6 March; 25:
2000—22.
2. Bigos SJ. Perils,pitfalls,0nd accomplishments of guidelines for Treo’rmenT of back problems. Neurol
Clin. 1999 Feb; 17(1):]79—92.
3. Bier JD, Schol’ren-Pee’rers WGM, S’rool JB, eT 0|. Clinical practice quideline for physical Therapy
assessment 0nd Treo’rmen’r in po’rien’rs wi’rhnonspecific neck pain. Phys Ther. 2018; 98(3):] 62-] 71.
4. Nighbor, C. Our 19*“ Annual Fees & Reimbursemen’rs Survey Ready for Grow’rh. Chiroprocfic Economics.
October 201 6. 38-52.
H.J. Jenkins e’r.AI. Imaging for low back pain: isclinical use consistent wi’rh guidelines? A sys’remo’ric review 0nd
me’ro—onolysis. The Spine Journal. 18 (201 8).2266—2277.
Francisco Giles
March 3, 2020
CASE #: 21065593
Page 4 of 5
Thank you for the opportunity to review the medical records on Mr. Francisco Giles.
Written, reviewed, opinion verified, and attested to by my original signature.
Sincerely,
D.G-
Ryan Robinson, D.C.
Doctor of Chiropractic
12373
RR/pl
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.
Francisco Giles
March 3, 2020
CASE #: 21065593
Page 5 of 5
RECORDS REVIEWED
Accident & Injury Chiropractic June 4,5,6,7,8,10,12,13,15,17,19,20,22,24,26,27, July
2,10,13,16,19,20,23,25,27, 2019
White Rock Open Air MRI June 7, 2019
Lone Star Radiology June 4, 2019
George Cole, DO Medical Chart
Affidavit of Necessity of Services/reasonableness of charges
Medical Records Affidavit Cole Wellness Center
Cost of Services Affidavit Cole Wellness Center
Business Records Affidavit Accident & Injury
Plaintiff’s Answers to Defendant Blanca Diaz’s Request for Disclosure
Plaintiff’s Objections and Answers to Defendant’s First Set of Interrogatories
Accident & Injury Statement
Lone Star Radiology Statement
White Rock Open MRI Statement
Cole Wellness Center 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
B.S. Health and Wellness
August 2007 — December 2009 University of Texas at Arlington
Arlington, TX
B.S. Exercise Science Clinical Research
August 2005 -May 2007 Howard College
Big Spring, TX
PROFESSIONAL EXPERIENCE
November 20 1 8-Present North American Consultants
Doctor 0f Chiropractic
Medical Expert
March 20 1 7-Present Robinson Family Chiropractic
Doctor 0f Chiropractic
Owner 0f Robinson Family Chiropractic
Saginaw, TX
October 20 1 6-Present MedCost Contain
Doctor 0f Chiropractic
Medical Expert
August 2016-Present MES Solutions
Doctor of Chiropractic
Medical Expert
August 2015- December 2015 Collin College Preston Ridge Campus
Adjunct Professor
Anatomy & Physiology
Frisco, TX
April 20 14-Present ExamWOrks
Doctor of Chiropractic
Medical Expert
March 2014-March 2017 SportMed Chiropractic, PLLC
Doctor of Chiropractic
Owner of SportMed Chiropractic, PLLC
Grapevine, TX
April 2013- June 2014 Vitality Sports Medicine
Doctor of Chiropractic
Plano, TX
August 2012- March 2013 Texas Health Centers
Dr. Stacy Harris and Dr. Jon Schweitzer
External Program
Chiropractic Intern
Fort Worth, TX
May 2012- August 2012 Parker University Wellness Clinic
Dr. Troy Liming
Chiropractic Intern
Dallas, TX
August 2009 – December 2009 Physical Therapy of Mansfield
Exercise Rehabilitation Intern
Mansfield, TX
LICENSES AND CERTIFICATIONS
December 2014 - Present Certified Chiropractic Sports Practitioner (CCSP)
American Chiropractic Board of Sports Physicians
May 2014 – Present Certified Medical Examiner
United States Department of Transportation
June 2013 – Present Texas Chiropractic License
Texas Board of Chiropractic Examiners
November 2012 - Present National Board of Chiropractic Examiners
April 2012 – Present Emergency Medical Response
American Red Cross
April 2012 – Present Emergency Oxygen Administrator
American Red Cross
April 2012 – Present CPR/AED for Professional Rescuers and Health
Care Providers
American Red Cross
PROFESSIONAL MEMBERSHIPS
December 2014 – Present American Chiropractic Board of Sports Physicians
May 2014 – Present United States Department of Transportation
National Registry of Medical Examiners
May 2013 – Present Texas Chiropractic Association
AFFILIATIONS
November 2014 – Present Texas Woman’s University
Chiropractor for Athletic Department
August 2015 – December 2015 Liberty Christian School
Chiropractor for Athletic Department
Preview
FILED 3/6/2020 4:07PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Kevin Molden DEPUTY N0. DC-19-17592 FRANCISCO GILES § IN THE DISTRICT COURT PLAINTIFF, § § VS. § DALLAS COUNTY, TEXAS § BLANCA DIAZ § DEFENDANT. § 1921‘") JUDICIAL DISTRICT DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE T0 PLAINTIFF’S REQUEST FOR DISCLOSURE AND DESIGNATION 0F EXPERTS Pursuant t0 TeX R. CiV. P. 194, Defendant serves the following First Supplemental Response to Plaintiff s 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 on 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, 0r otherwise subj ect t0 the control 0f the responding party: A. A11 documents, tangible things, reports, models, 0r data compilations that have been provided t0, reviewed by, 0r prepared by or for the expert in anticipation 0f 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 call any 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 Plaintiff. Defendant reserves the right to rely upon 0r to offer, by direct examination or cross-examination, testimony obtained from those experts and rebuttal experts, if any, designated by Plaintiff. 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 itdeems it in its interest t0 d0 s0. Such persons are expected t0 testify concerning Plaintiff” s 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 Plaintiff. First Supplemental Response: Defendant hereby designates as an expert Witness the following individual: Ryan Robinson, DC 1100 S. Main Street, Ste. D Grapevine, Texas 76051 817. 203.2184 Dr. Robinson is a chiropractor who has reviewed Francisco Giles’ medical records and other case materials provided to him, and isexpected to testify regarding the extent of 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 0f that treatment, both in the past and in the future, if applicable, as set out in the attached report. DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -2- Respectfully submitted, Chad Kimble, State Bar N0. 24007483 Kyle Smith, State Bar N0. 241025 12 D. Brent Beasley, State Bar N0. 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 OF SERVICE The undersigned certifies that on the 6th a true copy of the foregoing day of March, 2020, has been served on all parties in accordance with Rule 21a, Texas Rules of Civil Procedure. ¢///%— Kyle Smith DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -3- 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 3,2020 Mr. Chad Kimble Low Office of Chad Kimble, P.C. 1204 Sou’rh White Chapel Blvd. Soufhloke, TX 76092 RE: Francisco Giles CLAIM #: 0548037324 DATE OF INJURY: 06/03/1 9 CASE #: 21065593 Dear Mr. Kimble: |hove had The opporTuniTy ’ro review medical records on Mr. Francisco Giles. My name is Ryan Robinson, D.C., CCSP, |om licensed by The S’ro’re of Texas Gs o Chiroprocfor. | 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’rWor’rh, Texas. The poTienTs |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 wi’rh 0nd deal wi’rh daily, hove high deduc’ribles 0nd hos i’r been necessary for me ’roconfoc’r imaging cen’rers 0nd o’rher providers To 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’ris o mole who was involved in c1mo’ror vehicle occiden’r on June 3, 20] 9. On June 4, 201 9, The po’rien’rpresen’red ’ro Acciden’r & Injury Chiropractic for evoluo’rion 0nd Treo’rmen’r of neck pain, mid back pain, 0nd Upper back pain. Physical examination revealed restricted ranges of motion in ’rhe cervical 0nd Thorocolumbor spine 0nd positive for pain Throughout. Orthopedic Testing showed ’rhe following posi’rive shoulder ’res’rs: depression, dis’rroc’rion,So’ro—Holl, cmd Volsolvo. Neurological ’res’ringwas wi’rhin normal limi’rsThroughout X-roys were performed in The cervical, Thoracic spine 0nd were reviewed by Kenneth Lus’rik, D.C., DACBR who no’red The following in ’rhe reports: postural ol’rero’rions. On June 7, 2019, The po’rien’rpresented ’ro Whi’re Rock Open Air MRI for on MRI sccm of The cervical spine. Kenne’rh Lus’rik,D.C., DACBR, read The scan 0nd no’red The following in The repor’r: Cervical: flo’r’reningof ’rhe cervical Iordosis, desiccation of ’rhe C3-disc mo’reriol. A’r C3, shallow contained central disc protrusion 2 mm in caliber wi’rh impression of ’rhe Thecol soc. Francisco Giles March 3, 2020 CASE #: 21065593 Page 2 of 5 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 detailed exam, the CPT Coding Manual requires three key components: detailed history, detailed exam, and low level of medical decision-making. In addition, the problem severity should be moderate, and physician time at least thirty 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, 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 the first 3 weeks of treatment. 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 up to the first 3 weeks of treatment. 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 first 22 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” studies have concluded there is in extreme importance in healing to implement exercise prescriptions for the patient to achieve activity tolerance 2”. In this case, the treating doctor did not prescribe this treatment until 3 weeks post initial presentation. I do not agree with this approach as it delays patient progress and slows recovery. Therefore, these treatments are not reasonable or necessary based on the timing of their implementation. Francisco Giles March 3, 2020 CASE #: 21 065593 Page 3 of 5 In reference ’roThe referral of The MRI scan of ’rhe cervical spine, in my professional opinion, This service is worron’red when There is failure ’roachieve success during conservative Treo’rmen’r, 0nd objective findings from examination ’rhe ini’riol ore s’rill present. Typically, | o u’rilize one—mon’rh duration of Treatment prior ’ro referring ouT for fur’rher diognos’rics. In This case, The referral for Thisservice wos 3 days offer ini’riolpresentation To The clinic. However, There were no neurological symptoms noted in The ini’riolexamination. 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: isClinical use consistent wi’rh guidelines? A systematic review 0nd me’ro—onolysis”4, patients were referred for imaging inappropriately due ’ro The lock of red flags almost 40% of ’rhe Time, 0nd almos’r 30% of The Time due ’ro no’r allowing proper Time 0nd Treo’rmen’r ’robecome effective. Wi’rhou’r These findings, There was Iifile medical documen’ro’rion To worron’r ’rhis referral. Therefore, This referral was no’r reasonable or necessary. CHARGES From my experience wi’rh The fee schedules around The DFW area, The charges for The services below were o excessive. The IiT’rle below shows The Iis’r omoun’r billed for each service 0nd o range of The reasonable Charges for e0ch3: De’roiled Exam $325 $100-$1 75 Thoracic X—roys $333 $75-$1 OO Cervical X-roys $463 $75-$1 OO CMT 3-4 $1 06 $50—$65 x 22 Therapeutic Exercises $98 $40-$50 Mechanical Traction $55 $35-$45 x 11 EMS $54 $35—$45 x 11 Cervical MRI $2,998 $400-$7OO The reasonable charges ’ro’rol for ’rhe necessary Treo’rmenT ore between $2,] 2O 0nd $2,795. References: 1. Management of neck pain 0nd associated disorders: A clinical practice guideline from The On’rorio Protocol for Traffic Injury Management (OPTIMO) Collaboration. European Spine Journal. 20] 6 March; 25: 2000—22. 2. Bigos SJ. Perils,pitfalls,0nd accomplishments of guidelines for Treo’rmenT of back problems. Neurol Clin. 1999 Feb; 17(1):]79—92. 3. Bier JD, Schol’ren-Pee’rers WGM, S’rool JB, eT 0|. Clinical practice quideline for physical Therapy assessment 0nd Treo’rmen’r in po’rien’rs wi’rhnonspecific neck pain. Phys Ther. 2018; 98(3):] 62-] 71. 4. Nighbor, C. Our 19*“ Annual Fees & Reimbursemen’rs Survey Ready for Grow’rh. Chiroprocfic Economics. October 201 6. 38-52. H.J. Jenkins e’r.AI. Imaging for low back pain: isclinical use consistent wi’rh guidelines? A sys’remo’ric review 0nd me’ro—onolysis. The Spine Journal. 18 (201 8).2266—2277. Francisco Giles March 3, 2020 CASE #: 21065593 Page 4 of 5 Thank you for the opportunity to review the medical records on Mr. Francisco Giles. Written, reviewed, opinion verified, and attested to by my original signature. Sincerely, D.G- Ryan Robinson, D.C. Doctor of Chiropractic 12373 RR/pl 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. Francisco Giles March 3, 2020 CASE #: 21065593 Page 5 of 5 RECORDS REVIEWED Accident & Injury Chiropractic June 4,5,6,7,8,10,12,13,15,17,19,20,22,24,26,27, July 2,10,13,16,19,20,23,25,27, 2019 White Rock Open Air MRI June 7, 2019 Lone Star Radiology June 4, 2019 George Cole, DO Medical Chart Affidavit of Necessity of Services/reasonableness of charges Medical Records Affidavit Cole Wellness Center Cost of Services Affidavit Cole Wellness Center Business Records Affidavit Accident & Injury Plaintiff’s Answers to Defendant Blanca Diaz’s Request for Disclosure Plaintiff’s Objections and Answers to Defendant’s First Set of Interrogatories Accident & Injury Statement Lone Star Radiology Statement White Rock Open MRI Statement Cole Wellness Center 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 B.S. Health and Wellness August 2007 — December 2009 University of Texas at Arlington Arlington, TX B.S. Exercise Science Clinical Research August 2005 -May 2007 Howard College Big Spring, TX PROFESSIONAL EXPERIENCE November 20 1 8-Present North American Consultants Doctor 0f Chiropractic Medical Expert March 20 1 7-Present Robinson Family Chiropractic Doctor 0f Chiropractic Owner 0f Robinson Family Chiropractic Saginaw, TX October 20 1 6-Present MedCost Contain Doctor 0f Chiropractic Medical Expert August 2016-Present MES Solutions Doctor of Chiropractic Medical Expert August 2015- December 2015 Collin College Preston Ridge Campus Adjunct Professor Anatomy & Physiology Frisco, TX April 20 14-Present ExamWOrks Doctor of Chiropractic Medical Expert March 2014-March 2017 SportMed Chiropractic, PLLC Doctor of Chiropractic Owner of SportMed Chiropractic, PLLC Grapevine, TX April 2013- June 2014 Vitality Sports Medicine Doctor of Chiropractic Plano, TX August 2012- March 2013 Texas Health Centers Dr. Stacy Harris and Dr. Jon Schweitzer External Program Chiropractic Intern Fort Worth, TX May 2012- August 2012 Parker University Wellness Clinic Dr. Troy Liming Chiropractic Intern Dallas, TX August 2009 – December 2009 Physical Therapy of Mansfield Exercise Rehabilitation Intern Mansfield, TX LICENSES AND CERTIFICATIONS December 2014 - Present Certified Chiropractic Sports Practitioner (CCSP) American Chiropractic Board of Sports Physicians May 2014 – Present Certified Medical Examiner United States Department of Transportation June 2013 – Present Texas Chiropractic License Texas Board of Chiropractic Examiners November 2012 - Present National Board of Chiropractic Examiners April 2012 – Present Emergency Medical Response American Red Cross April 2012 – Present Emergency Oxygen Administrator American Red Cross April 2012 – Present CPR/AED for Professional Rescuers and Health Care Providers American Red Cross PROFESSIONAL MEMBERSHIPS December 2014 – Present American Chiropractic Board of Sports Physicians May 2014 – Present United States Department of Transportation National Registry of Medical Examiners May 2013 – Present Texas Chiropractic Association AFFILIATIONS November 2014 – Present Texas Woman’s University Chiropractor for Athletic Department August 2015 – December 2015 Liberty Christian School Chiropractor for Athletic Department