DEFN'S 1ST SUPPL RESP TO PLTF'S REQ DISCL/DESGN EXPERTS November 06, 2020

On July 24, 2020 a DEFN'S 1ST SUPPL RESP TO PLTF'S REQ DISCL/DESGN EXPERTS was filed involving a dispute between and for INJURY OR DAMAGE, OTHER INJURY OR DAMAGE in the District Court of Tarrant County.

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141-318176-20 FILED
TARRANT COUNTY
11/6/2020 10:28 AM
THOMAS A. WILDER
NO. 141-318176-20 DISTRICT CLERK

ROLANDO RUBIO, APRIL BURLESON, § IN THE DISTRICT COURT
INDIVIDUALLY AND AS NEXT OF FRIEND OF §
B.R., MINOR §
PLAINTIFFS, §
§ TARRANT COUNTY, TEXAS
VS. §
§
ALLSTATE FIRE & CASUALTY §
DEFENDANT. § 141ST JUDICIAL DISTRICT

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO PLAINTIFFS’
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS

Pursuant to Tex R. Civ. P. 194, Defendant serves the following First Supplemental
Response to Plaintiffs’ Request for Disclosure and Designation of Experts.

f. For any testifying expert:

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

2. The subject matter on which the expert will testify;

3. The general substance of 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, or
otherwise subject to the control of the responding party, documents reflecting such
information;

4. If the expert is retained by, employed by, or otherwise subject to the control
of the responding party:

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

B. The expert’s current resume or bibliography.

Response: Defendant hereby designates and reserves the right to call any expert witness(es)
designated by any other party to this case, as well as any experts later designated
by any party to this case on any subject relevant to this litigation on which the
witness is qualified to testify. In the event that any party to this cause has
designated any experts but has been or is subsequently dismissed for any reason or
fails to call any designated expert at the time of trial, Defendant specifically
reserves the right to call any such expert previously designated by that party.

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -1-
Defendant further reserves the right to withdraw or de-designate any expert prior
to testimony and to positively aver that such previously designated expert will not
be called as a witness at trial and to redesignate same as a consulting expert who
will not be called by any party in this cause. Finally, Defendant reserves the right
to supplement this response as additional information concerning experts becomes
available.

Defendant further hereby designates as adverse expert witnesses all expert
witnesses designated by Plaintiffs. Defendant reserves the right to rely upon or to
offer, by direct examination or cross-examination, testimony obtained from those
experts and rebuttal experts, if any, designated by Plaintiffs. By this designation,
Defendant does not necessarily agree with, nor vouch for, the credibility of any
such witnesses or 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 to rely upon or elicit
certain opinions and/or evidence from these witnesses to the extent that it deems it
in its interest to do so.

Such persons are expected to testify concerning Plaintiffs’ care and treatment. See
Plaintiffs’ Responses to Defendant’s Request for Disclosure for additional
information concerning such health-care providers including medical bills and
records relating to Plaintiffs.

First Supplemental Response:

Defendant hereby designates as expert witnesses the following individuals:

Dustin R. Leek, MD
5323 Harry Hines Blvd
Dallas, Texas 7539
214.648.3111

Dr. Leek is a Texas physician and board certified in physical medicine and rehabilitation
and pain medicine who has reviewed Rolando Rubio’s medical records and other case
materials provided to him, and is expected to testify regarding the extent of the injuries
sustained by the Plaintiff in the subject motor vehicle accident, the appropriate care and
treatment for those injuries, and the fair and reasonable cost of that treatment, both in the
past and in the future, if applicable, as set out in the attached report.

Edward Le Cara, DC
6805 Hillcrest Ave Ste. 208
Dallas, TX 75205
972.474.3612

Dr. Edward Le Cara is a chiropractor who has reviewed Rolando Rubio’s medical records
and other case materials provided to him, and is expected to testify regarding the extent of

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -2-
the injuries sustained by the Plaintiff in the subject motor vehicle accident, the appropriate
care and treatment for those injuries, and the fair and reasonable cost of that treatment, both
in the past and in the future, if applicable, as set out in the attached report.

Dustin R. Leek, MD
5323 Harry Hines Blvd
Dallas, Texas 7539
214.648.3111

Dr. Leek is a Texas physician and board certified in physical medicine and rehabilitation
and pain medicine who has reviewed April Burleson’s medical records and other case
materials provided to him, and is expected to testify regarding the extent of the injuries
sustained by the Plaintiff in the subject motor vehicle accident, the appropriate care and
treatment for those injuries, and the fair and reasonable cost of that treatment, both in the
past and in the future, if applicable, as set out in the attached report.

Edward Le Cara, DC
6805 Hillcrest Ave Ste. 208
Dallas, TX 75205
972.474.3612

Dr. Edward Le Cara is a chiropractor who has reviewed April Burleson’s medical records
and other case materials provided to him, and is expected to testify regarding the extent of
the injuries sustained by the Plaintiff in the subject motor vehicle accident, the appropriate
care and treatment for those injuries, and the fair and reasonable cost of that treatment, both
in the past and in the future, if applicable, as set out in the attached report.

Respectfully submitted,

____________________________________
Chad Kimble, State Bar No. 24007483
Kyle Smith, State Bar No. 24102512
D. Brent Beasley, State Bar No. 24082669
LAW OFFICE OF 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

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -3-
CERTIFICATE OF SERVICE

The undersigned certifies that on the 6th day of November, 2020, a true copy of the
foregoing has been served on all parties in accordance with Rule 21a, Texas Rules of Civil
Procedure.

____________________________________
Chad Kimble

DEFENDANT’S FIRST SUPPLEMENTAL RESPONSE TO
REQUEST FOR DISCLOSURE AND DESIGNATION OF EXPERTS -4-
DUSTIN R. LEEK, M.D. 12001 N. CENTRAL EXPRESSWAY
PHYSICAL MEDICINE AND REHABILITATION SUITE 800
PAIN MEDICINE DALLAS, TX 75243
(214) 750-6110
FAX - (214) 750-5825

September 28, 2020

Mr. Chad Kimble
Law Office of Chad Kimble, P.C.
1204 South White Chapel Blvd.
Southlake, TX 76092

RE: Rolando Rubio
CLAIM#: 0561720806
DATE OF INJURY: 09/20/19
CASE#: 21215593

Dear Mr. Kimble:

I have had the opportunity to review the medical records on Mr. Rolando Rubio.

I have been fully licensed to practice medicine in Texas since 2017. In that time, I completed a four-year
Residency in Physical Medicine & Rehabilitation (PM&R), a year of which included serving as Chief Resident. After
this, I completed a year-long ACGME-accredited Fellowship in Pain Management. In addition, I have gained
experience through maintaining extracurricular part-time employment over the last three years at two separate
community inpatient rehabilitation facilities, and another outpatient clinic focused on the treatment of patients
with opioid dependence. The practice of PM&R (and Pain Management) routinely involves caring for patients
with disease or injury to musculoskeletal and/or neurological systems and can require the use of radiological
imaging, electrodiagnosis, physical therapy, medications, injections, and other modalities. Ihave personally
ordered, performed, and reviewed these diagnostic and treatment interventions on thousands of patients.
Therefore, I am an expert in the evaluation and treatment aspects of this case.

My training across multiple practice settings, including private, county, and federal hospitals, has provided me
with an acute awareness of medical costs, both to the patient and to the system. Even now as I transition from
academics and part-time extra-curricular employment to a 100% private practice model for PM&R/Pain
Management, Ihave spent considerable effort dedicated to the understanding of local market trends and
(medical) business modeling with the goal of running a fair and competitive practice. As a result, I feel confident
in deciphering what is a reasonable charge and what is not.

“Reasonable amounts” are determined based on this experience and my current fee schedule, and have been
additionally cross-referenced to the usual, customary, and reasonable fees outlined in Medical Fees Directory,
edited and published by James Davis, 2020.

SUMMARY OF MEDICAL RECORDS

The patient was 40 years old when on September 20, 2019, he was involved in a motor vehicle accident. On
October 2, 2019, he established care with VIP Pain & Orthopedic, Zeshan Chaudhry, M.D. He complained of
severe cervical and thoracic pain with radiation into the shoulders and shoulder blades, and mild low back pain.
The pain was also noted to be interfering with his activities of daily living and was refractory to conservative care,
including rest, oral anti-inflammatory medication, and chiropractic intervention. Exam was notable for diffuse
tenderness to palpation throughout the cervical, thoracic, and lumbar spine, with bilateral C4-C5, C5-C6, and
T1-T8 pain with palpation and loading. There was no Spurling’s test or straight leg test documented. He was
otherwise neurologically intact. He was diagnosed with cervical and thoracic radiculopathy, sprain of the
Rolando Rubio
September 28, 2020
CASE#: 21215593
Page 2 of 4

ligaments of the cervical and thoracic spine, and low back pain. He was prescribed Naproxen and Zanaflex and
ordered to undergo X-rays of the cervical, thoracic, and lumbar spine.

X-ray Cervical Spine, October 5, 2019: “Normal examination of the cervical spine.”

X-ray Thoracic Spine, October 5, 2019: “Dextroscoliosis of the thoracic spine.”

X-ray Lumbar Spine, October 5, 2019: “Normal examination of the lumbosacral spine.”

On October 30, 2019, the patient underwent magnetic resonance imaging of the cervical and lumbar spine, as
ordered by his chiropractor, Chad Clawson, D.C.

MRI Cervical Spine, October 30, 2019: “Straightening of cervical lordosis. Stenosis spinal canal C5-C6
created by a posterior disc herniation without impinging the spinal cord. Anterior cord flattening
deformity noted. Posterior disc herniation at C6-C7 without creating stenosis. Benign intraosseous
hemangioma of the C4 and T2 vertebral bodies incidentally noted.”

MRI Lumbar Spine, October 30, 2019: “Posterior disc herniation at L4-L5, compressing anterior thecal sac
without creating central canal stenosis. A left intraforaminal disc herniation nearly impinging the exiting
left L4 nerve root. Annular narrowing and desiccation noted. Left facet joint hypertrophy and bilateral
facet joint effusions noted (L4-L5). Right subarticular recess stenosis at L5-S1 created by a disc herniation
nearly impinging the descending right S1 nerve root. Annular narrowing desiccation noted.”

On the November 13, 2019 follow-up, the patient now complained of moderate to severe cervical pain and
severe thoracic and lumbar pain. The pain was not described to radiate, but was reported to be worsened with
lifting and bending. Exam was notable for positive Kemp’s test, bilaterally. He was recommended to undergo
bilateral L4-L5, L5-S1 facet joint injections. On December 16, 2019, he underwent bilateral L4-L5, L5-S1 facet joint
injections without documented complication. On the January 2, 2020 follow-up, he reported greater than 50%
improvement in his lower back pain.

OPINION

I have reviewed all the medical records pertaining to this case, including the affidavits provided from Vertex
Interventional Physicians. My opinions will be based on the treatment and charges provided by Vertex
Interventional Physicians.

In this case, a 40 year-old male was involved in a motor vehicle accident, which resulted in severe and interfering
low back pain that was refractory to conservative care, including rest, medications, and chiropractic
intervention. His low back pain was noted to not radiate. His exam was positive for Kemp’s test bilaterally and he
was otherwise neurologically intact. The MRI of his lumbar spine demonstrated bilateral facet joint effusions noted
at L4-L5, which is suggestive of an acute pathology (versus chronic degeneration). Together, these findings are
consistent with facet-mediated lumbar spine pain, commonly resulting from a flexion/extension injury or whiplash
injury, such that may occur in a motor vehicle collision. Therefore, in my opinion lumbar facet injection was a
necessary next step offering.

In regard to the charges by Vertex Interventional Physicians:

On October 02, 2019, $850.00 was charged for a Level 3 new-patient evaluation. A reasonable charge may be
$329.31 – a difference of $520.69.

On November 13, 2019 and December 16, 2019, $650.00 was charged for a Level 3 follow-up visits. A reasonable
charge may be $212.85 – a difference of $437.15 per visit, or $874.30 in total.
Rolando Rubio
September 28, 2020
CASE#: 21215593
Page 3 of 4

On December 16, 2019, $17,100.00 was charged for bilateral 2-level facet injections, and $850.00 was charged
for anesthesia. A reasonable charge for bilateral 2-level facet injections may be $6,927.60 – a difference of
$10,172.40. A reasonable charge for anesthesia may be $250.00 – a difference of $600.00.

On January 02, 2020, $550.00 was charged for a Level 2 follow-up visit. A reasonable charge may be $133.53 – a
difference of $416.47.

Of the total $20,650.00 charged by Vertex Interventional Physicians, in my opinion $12,583.86 may be considered
outside the expected usual, customary, and reasonable charges for this region.

I declare that the information contained within this document was prepared and is the work product of the
undersigned, and is true to the best of my knowledge and information.

Thank you for the opportunity to review the medical records on Mr. Rolando Rubio.

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

Sincerely,

Dustin R. Leek, M.D.
Physical Medicine and Rehabilitation
Pain Medicine
R3129

DRL/ck

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.
Rolando Rubio
September 28, 2020
CASE#: 21215593
Page 4 of 4

SUMMARY OF RECORDS

 Hurst Police Department-Event Report, Minh X. Nguyen, 09/20/19
 Chiropractic Orthopedic, Physical, Chad A. Clawson, D.C., 09/26/19, 09/30/19, 10/03/19, 10/07/19,
10/08/19, 10/09/19, 10/14/19, 10/15/19, 10/17/19, 10/21/19, 10/22/19, 10/23/19, 10/28/19, 10/29/19,
11/04/19, 11/05/19, 11/06/19, 11/12/19, 11/14/19, 11/18/19, 11/19/19, 11/20/19, 11/25/19, 11/26/19,
11/27/19, 12/02/19, 12/04/19, 12/05/19, 12/09/19, 12/11/19, 12/12/19, 12/18/19, 12/19/19, 12/23/19,
12/31/19, 01/09/20
 VIP Pain & Orthopedic, Zeshan M. Chaudhry, M.D., 10/02/19, 11/13/19,12/16/19, 01/02/20
 MRI Centers of Texas, Albert G. Tesoriero, M.D., 10/05/19, 10/30/19
 Plaintiff’s Response to Defendant’s Request for Disclosure, 09/09/20
 Plaintiff, Rolando Rubio’s Responses and Objections to Defendant’s Request for Production, 09/11/20
 Medical Records Affidavit, Cheri Czajkowski, Custodian of Records for Vertex Interventional Physicians,
08/07/20
 Black & White Copy Texas Driver License, Rolando Erik Rubio, Jr., Iss: 08/18/15 Exp: 06/27/21
 Correspondence-Eric Reyes Law Firm, Eric R. Reyes, Atty., 11/25/19
 Plaintiff, April Burleson’s Responses and Objections to Defendant’s Request for Production, 09/11/20
 Plaintiff, April Burleson’s Answers and Objections to Defendant’s Fist Set of Interrogatories, 09/11/20
 Affidavit Concerning Cost and Necessity of Services, Cheri Czajkowski, Custodian of Records for Vertex
Interventional Physicians, 08/07/20
 Affidavit Concerning Cost and Necessity of Services, Lesley Valdespino, Custodian of Records for Vertex
Interventional Physicians, 03/11/20
 Medical Bill Affidavit of MRI Centers of Texas, Adriana Ledesma, Custodian of Records, 08/04/20
 Medical Bill Affidavit of MRI Centers of Texas, Adriana Ledesma, Custodian of Records, 07/04/20
 Medical Bill Affidavit of Dr. Chad A. Clawson, Jocelyn Zambrana, Custodian of Records, 07/27/20
 Medical Bill Affidavit of Dallas Radiology, PA, Ana Munoz, Custodian of Records, 08/04/20
 Itemized Statement, Vertex Interventional Physicians, Statement Date: 08/06/20, Date of Service:
10/02/19-01/02/20
 Health Insurance Claim Form-Vertex Interventional Physicians, 10/02/19-01/02/20
 Patient Ledger-MRI Centers of Texas, Ledger Date: 08/04/20, Date of Service: 10/05/19-10/30/19
 Health Insurance Claim Form-MRI Centers of Texas, 10/05/19-10/30/19
 Itemized Statement, Chad A. Clawson, M.D. Statement Date: 01/13/20, Date of Service: 09/26/19-
01/09/20
 Itemized Statement, Dallas Radiology, Statement Date: 07/31/20, Date of Service: 10/05/19-10/30/19
EDWARD C. LE CARA, D.C., PhD 12001 N. CENTRAL EXPRESSWAY
DOCTOR OF CHIROPRACTIC SUITE 800
DALLAS, TX 75243
(214) 750-6110
FAX - (214) 750-5825

September 29, 2020

Mr. Chad Kimble, P.C.
1204 South White Chapel Blvd.
Southlake, TX 76092

RE: Rolando Rubio
CLAIM #: 0561720806
DATE OF INJURY: 09/20/19
CASE #: 21215587

Dear Mr. Kimble:

I have had the opportunity to review medical records on Mr. Rolando Rubio. Although I have reviewed all the
provided medical records, I will only comment on the chiropractic treatment and referrals. I have been asked to
review the medical records and provide comment regarding the treatment from Chad Clawson, D.C. and if
treatment was reasonable and necessary with the injury sustained. In addition, was the billing from Dr. Clawson,
and the MRI Centers of Texas in regard to the treatment provided reasonable in regard to the usual and
customary fees, the necessity of referral for MRI and future treatment and costs.

SUMMARY OF MEDICAL RECORDS:

There was a first police department report noting a minor accident on September 20, 2019. Medical records on
September 26, 2019, from Dr. Clawson, indicated neck pain down to the lower back with no referral pattern into
the extremities. Examination on September 26, 2019, indicated normal deep tendon reflexes, weakness bilaterally
in deltoid, biceps, and triceps of 4/5. Positive for restriction in the cervical and lumbar spine with range of motion.
Positive orthopedic test. The patient noted he was driving on the road when suddenly a Toyota Yaris smashed
into him on the passenger side of the vehicle. This occurred on Friday September 20, 2019, around 5:30 p.m. the
claimant had immediate shock and anxiety. He complained of neck pain, headache, mid back pain, low back
pain, sleeping problem, and anxiety on the road.

The patient complained of neck, mid back, and lower back pain on September 26, 2019, with no referrals of
symptoms. The examination on that day revealed strong adequate muscle strength, normal deep tendon
reflexes, and normal dermatomes. Imaging included cervical, thoracic, and lumbar spine x-rays. X-ray on
October 5, 2019 of the cervical spine was performed. A two view of the thoracic spine and three views of the
lumbar spine. Normal examination of the cervical, thoracic, and lumbar spine were noted.

A consultation at VIP Pain & Orthopedic was performed on October 2, 2019. The consultation was signed by
Zeshan M. Chaudhry, M.D.

MRI scans of the cervical and lumbar spine were performed on October 30, 2019.

NECESSARY CHIROPRACTIC CARE:

Based on the review of the provided medical records, the claimant suffered a soft tissue injury on 9/20/2019 to
the neck, midback and lower back. Normally, soft tissue injuries should resolve within 8-12 weeks. In this case,
the claimant had a pre-existing spinal condition in the lower back pushing the required treatment to 12 weeks.
These underlying conditions included the following.
Rolando Rubio
September 29, 2020
CASE #:21215587
Page 2 of 7

Lumbar:
 Posterior disc herniation at L4-LS, compressing anterior thecal sac without creating central canal
stenosis.
 A left lntraforamlnal disc herniation nearly Impinging the exiting left L4 nerve root.
 Annular narrowing and desiccation noted.
 Left facet joint hypertrophy and bilateral facet joint effusions noted.

Cervical:
 Straightening of cervical lordosis
 Stenosis spinal canal CS-C6 created by a posterior disc herniation without impinging the spinal cord
 Anterior cord flattening deformity noted
 Posterior disc herniation at C6-C7 without creating stenosis
 Benign Intra osseous hemangiomata of the C4 and T2 vertebral bodies Incidentally noted

In my experience, these conditions in the cervical and lumbar spine were pre-existing as the findings are more
indicative of chronic wear and tear of the spine versus acute injury. Neck and lower back pain are common
areas where imaging studies occur, however recent studies suggest over one-third of people who have image
findings yet are asymptomatic. (Kim JH, Sharan A, Cho W, Emam M, Hagen M, Kim SY. The Prevalence of
Asymptomatic Cervical and Lumbar Facet Arthropathy: A Computed Tomography Study. Asian Spine J.
2019;13(3):417‐422. doi:10.31616/asj.2018.0235)

Positive findings such as these have been found in the literature to be existing even in non-symptomatic
subjects. For example, MRI’s were analyzed in 1211 health pain-free people, aged 20 to 70 years. Most people
presented with disc bulging (87.6%), which significantly increased with age in terms of frequency, severity and
number of levels. Even most people in their 20’s had bulging discs (73% of males and 78% of females).
(Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance
images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015;40(6):392‐398.
doi:10.1097/BRS.0000000000000775

The claimant did not have any radicular symptoms upon examination by Dr. Clawson or Dr. Chaudhry.
Therefore, the claimant’s complaints were an irritation of the joints of the cervical, lumbar and thoracic spine.

A 12-visit or 30-day trial of chiropractic care is reasonable to help claimants overcome pain and improve
function in situations like this. After 12-visits or 30 days, a re-evaluation should be performed to determine any
subjective or objective improvement. If the claimant is improving, a second trial of 12 visits or 30 days should be
initiated. If no change is noted, a change in treatment plan, referral for medical consultation or imaging should
be investigated. The treatment should be active in nature and wean off of passive modalities as soon as
possible (within 2 weeks). Active care (therapeutic exercise) should be initiated as soon as possible.

I believe the duration and frequency of chiropractic care was not medically necessary. In addition, not all the
fees were reasonable.

In this case, the following chiropractic treatment was reasonable and necessary:

Evaluations:
CPT code 99203 – (1 x $195 = $195)
CPT code 99213 every 30 days or 12 visits – (3 x $75 = $225). Every 30 days or 12 visits (whichever comes first) a re-
evaluation should be performed to document subjective and objective improvement.

Treatment:

CPT code 98941, Manipulative Therapy (24 units x $65 = $1560)
CPT code 97032, Electric Stimulation from 9/26/2019 – 10/13/2019 (2 weeks) for (7 units x $25 = $175)
Rolando Rubio
September 29, 2020
CASE #:21215587
Page 3 of 7

CPT code 97012, Mechanical Traction from 9/26/2019 – 10/13/2019 (2 weeks) for (7 units x $25 = $175)
CPT code 97110, Therapeutic Exercise (24 units x $55 = $1320)

Total Reasonable and Necessary Chiropractic Care: $3475

USUAL AND CUSTOMARY FEES:

The following treatment modalities were used in the chiropractic clinic:

Procedure Unit Price UCR fee
CPT code 99203, NP Examination $245 $195
CPT code 99213, Re-Examination $145 $85
CPT code 97140-59, Manual Therapy $55 $45
CPT code 97110, Therapeutic Exercise $71.53 $45
CPT code 97012, Mechanical Traction $30 $25
CPT code 97010, Hot/cold pack $15 $0
CPT code 97032, E-Stim (unattended) $70 $25
CPT code 98941, 3-4 Region Manipulation $95 $65
CPT code 97140, Manual Therapy $55 $45
CPT code 99080, Special Report $475 $150

Imaging:
CPT code 72052, Davis Series $228 $135
CPT code 72070 Thoracic Spine X-ray $156 $75
CPT code 72100, Lumbar Spine X-ray $180 $85
CPT code 72148, MRI Lumbar Spine $2,554 $545
CPT code 72141, MRI Cervical Spine $2,634 $545

My recommendations on the usual and customary fees for chiropractic services and physical therapy modalities
are derived from a UCR fee schedule compiled by the National Association of Professional Coders (NAPC).

Expenses beyond the recommended treatment are not reasonable because the treatment was not medically
necessary based on the available medical records.

NOT NECESSARY CHIROPRACTIC CARE:

Considering the claimant irritated the joints with soft tissue injury, no more than 24 chiropractic visits are
recommended. The following modalities and procedures were not medically necessary, or the medical records
provided did not substantiate the use of the following codes:

Passive modalities used in this case were CPT 97032 (Electrical Muscle Stimulation, CPT 97012 (Mechanical
Traction), CPT 9010 (Hot/Cold), and Manual Therapy (CPT 97140). Electrical stimulation is reasonable for the first
two weeks of care to help reduce pain and inflammation. There is insufficient documentation to support to use
of EMS or mechanical traction, for acute cervical, thoracic, lumbar, shoulder, or knee pain for extended periods
of time. As an industry standard, the use of passive modalities is not recommended beyond the second week of
treatment as it presents the inherent risk of negatively impacting a claimant’s ability to cope with condition by
promoting passive dependence. Instead, claimants should be weaned off passive therapies and transitioned
into active care. In this case, therapeutic exercise (CPT 97110) was initiated quickly. The use of active care is
associated with a much better clinical outcome. Therefore, allpassive modalities after two weeks are not
recommended. In addition, it is not recommended to use more than two passive modalities in a single treatment
session.
Rolando Rubio
September 29, 2020
CASE #:21215587
Page 4 of 7

When performing procedures which require direct doctor/patient, or therapist/patient contact, such as
therapeutic exercise (CPT 97110 and/or CPT 97530) the provider must follow the following format when
documenting the time component for the procedure:

1 unit = 8 through 22 minutes
2 units = 23 minutes through 37 minutes
3 units = 38 minutes though 52 minutes
4 units = 53 minutes through 67 minutes

As such, failure to document the time component for the procedure does not meet the documentation standard
required for reimbursement. When using therapeutic exercise, the treatment duration and frequency should be
up to 1 hour per session, 3 sessions per week. The practitioner should allow for fading of treatment frequency from
3 visits per week to 1 or less, with an emphasis on active self-directed home PT. According to the Centers for
Medicare and Medicaid Services, CPT coding manual, and the American Physical Therapy Association,
documentation to support skilled intervention is required. Demonstration of skilled care requires documentation
of the type and level of skilled assistance given to the patient, clinical decision making or problem solving, and
continued analysis of patient progress. The exercises provided in this case were simple exercises not requiring
skilled assistance.

Demonstration of skilled care may be documented by recording the type and amount of manual, visual, and/or
verbal cues used by the provider to assist the patient in completing the exercise completely and correctly. Skilled
care may also be documented through explanation regarding rationale for choosing the exercise and/or the
rationale for the continued use of the exercise. Another way of documenting skilled care may be to provide
documented observation regarding responses before, during, and after an exercise as well as the patient’s
response to the exercise. The services shall be of such a level of complexity and sophistication or the condition
of the patient shall be such that the services required can be safely and effectively performed only by a therapy
provider. Simply documenting that therapeutic exercise was performed without documentation of the type of
exercise, rational for continued use of the exercise, the type skilled assistance provided, supervising previously
taught exercises, or patients exercising independently on machines or exercise equipment, in the absence of
documentation describing the type of skilled assistance provided, does not meet the documentation standard
required for demonstrating a need for skilled intervention (https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medical- Review/Downloads/TherapyCapSlidesv10_09052012.pdf)

CPT code 97140 (Manual Therapy) was not medically necessary. The medical documentation failed to justify the
use of this code with CPT code 98941 (3-4 region manipulation). The CPT 98941 code is inclusive of all manual
therapy (and a brief examination) to all the regions treated unless specifically documented as ‘distinct and
separate’ area. In addition, this is a timed code and the medical documentation failed to document the time
component and therefore not medically necessary. The medical documentation states manual therapy was
performed to the thoracolumbar fascia which would be considered part of the lumbar region and thus
redundant.

CPT code 99080 was not medically necessary unless specifically requested by a party.

NECESSITY OF MRI REFERRALS

The referral for MRI of the cervical and lumbar spine were not medically necessary. There were no red flags in
the examination and no neurological findings present. The medical records do not describe the necessity of MRI
to manage the case.
Rolando Rubio
September 29, 2020
CASE #:21215587
Page 5 of 7

FUTURE TREATMENT AND COSTS

No future chiropractic care necessary. The claimant suffered a minor soft tissue injury. Soft tissue injuries should
resolve within 8 to 12 weeks. Considering the last treatment was January 9, 2020, the need for additional care is
not necessary. The recommendations for future care was based on imaging findings (MRI) which may be a
normal variant in the population.

RATIONALE FOR OPINION:

I have been a practicing chiropractor for over 19 years. I currently own and operate an integrated physical
medicine/rehabilitation practice in which we provide chiropractic treatment, medical management, and active
rehabilitation to victims of auto accidents, claimants suffering from sports injuries, and claimant’s requiring post-
surgical rehabilitation of the spine, shoulder, hip, knee, and ankle. During that time, I have become familiar with
billing and documentation requirements for chiropractic and physical therapy modalities, such as were used in
this case. I have been performing overutilization review consulting for over 8 years. My recommendations on the
usual and customary fees for chiropractic services and physical therapy modalities is derived from a UCR fee
schedule compiled by the National Association of Professional Coders (NAPC) and my own research.

A review of the provided medical and non-medical records, 19 years of clinical experience treating similar injuries
and the following scientific studies have influenced my clinical decision making in this case:

1. Baker GAF, Ronald J. Augat, Thomas J. Hawk, Cheryl. Algorithms for the Chiropractic
Management of Acute and Chronic Spine-Related Pain. Topics in Integrative Health Care. 2012;3(4).
2. Bussieres AE, Laurencelle L, Peterson C. Diagnostic Imaging Guidelines Implementation Study for
Spinal Disorders: A Randomized Trial with Postal Follow-ups. J Chiropr Educ. 2010;24(1):2-18.
3. Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging practice guidelines for musculoskeletal
complaints in adults--an evidence-based approach: introduction. J Manipulative Physiol Ther.
2007;30(9):617-683.
4. Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints
in adults-an evidence-based approach-part 2: upper extremity disorders. J Manipulative Physiol Ther.
2008;31(1):2-32.
5. Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal
complaints in adults--an evidence-based approach-part 1. Lower extremity disorders. J Manipulative
Physiol Ther. 2007;30(9):684-717.
6. Bussieres AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal
complaints in adults--an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther.
2008;31(1):33-88.
7. Rumball K, Jarvis J. Seat-belt injuries of the spine in young children. J Bone Joint Surg Br.
1992;74(4):571-574.
8. Taylor JA, Bussieres A. Diagnostic imaging for spinal disorders in the elderly: a narrative review.
Chiropr Man Therap. 2012;20(1):16.
9. Whalen W, Farabaugh RJ, Hawk C, et al. Best-Practice Recommendations for Chiropractic
Management of Patients With Neck Pain. J Manipulative Physiol Ther. 2019;42(9):635-650.
doi:10.1016/j.jmpt.2019.08.001

In addition to clinical experience, I have an earned PhD in Athletic Training and teach a Master’s level soft
tissue rehabilitation course. I am board certified in both rehabilitation and sports medicine. I teach continuing
education to physical therapists, chiropractors and strength and conditioning specialists internationally at least
1/month.

I served as a front-line medic in the United States Army where I spent most of my time stationed in an Emergency
Department at University of California at Davis Medical Center treating acute injuries. I have been a sideline
athletic trainer managing and treating traumatic injuries since 2004.
Rolando Rubio
September 29, 2020
CASE #:21215587
Page 6 of 7

I have been published in a peer reviewed scientific journal for my work on lumbar spine rehabilitation as the
primary researcher. I have been published as a secondary author in numerous peer reviewed scientific journals
in the topic of rehabilitation and clinical assessment, ultrasound imaging and MRI of the spine. In 2019, I wrote
two chapters for the National Academy of Sports Medicine’s corrective exercise specialist certification program
including thoracic spine and shoulder and elbow and wrist management.

** NO FURTHER OPINIONS **

Thank you for the opportunity to review the medical records on Mr. Rolando Rubio.

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

Sincerely,

Edward C. Le Cara, D.C., PhD
Doctor of Chiropractic
26890

ELC/ck:ANS/lea

SUMMARY OF RECORDS

 Hurst Police Department-Event Report, Minh X. Nguyen, 09/20/19
 Chiropractic Orthopedic, Physical, Chad A. Clawson, D.C., 09/26/19, 09/30/19,

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November 06, 2020

Case Filing Date

July 24, 2020

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