“Please Sir, I Want Some More”: Latest IAB Appeal Case in Delaware & the Inadequacy of UR Decisions

“Please Sir, I Want Some More”: Latest IAB Appeal Case in Delaware & the Inadequacy of UR Decisions

First, some good news.  The Roberts family has expanded by one.  I hope to have a picture of our newest addition in the coming days.  Another rescue cat-this one a kitten named "Cruiser" after the police vehicle which took him in style to the shelter.  He is 3 months old and strongly resembles Nutella Grace.  Right now the integration of another cat into the household not going so well.....alot of hissing on the part of Nuts Grace.  And some guttural sounds from her the likes of which I have never heard before..... my Easter dinner for 15 ought to be pretty interesting....:>)

Our case du jour-Monica Davis v. New Castle County Head Start, IAB# 1332825 (3/28/12) involves a UR appeal of a non-cert of left shoulder arthroscopic impingement surgery performed by Dr. Raisis.  Dr. Meyers and Dr. Raisis testified for the claimant and Dr. Sommers was the defense medical expert.  Bottom line is that the Board reversed and awarded the surgery....no surprise there, and you are likely wondering why this case is blog-worthy.

Here is what is scary, and this blog-worthy:

   Injury occurred on 1/27/09 and the surgery was performed 5/5/11

   The UR doctor did not have records from 3/5/09 through 1/5/11

   The UR doctor did not have a January 2011 MRI report and thus stated he did not know if there existed impingement at the AC joint

   The opinion of the DME doctor was, without a doubt, a non-event

The Board thus concluded that "the UR determination was based on a paucity of information."  And promptly reversed.  Hence the quote from Oliver Twist.

This UR system vexes me.  The system pretty much prohibits defense attorneys from assisting carriers with the UR submissions.  It would certainly seem that this UR submission was inadequate to say the least.  The system is not carrier-friendly, let's be frank.  I continue to maintain statistics and the rate at which non-certs of surgery are overturned by the Board is easily 90%, possibly more.....

So here's the thing: had this UR submission package been perfect-would the outcome have been any different?

Just sayin'........

Irreverently yours,
Cassandra Roberts

Delaware Detour & Frolic   Visit Delaware Detour & Frolic, a law blog by Cassandra Roberts

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