Academy of Chiropractic’s
Lawyers PI Program
Lawyers Meetings-Communications #8
From the Desk of:
NOTE: I am adding this to the Lawyers Meetings section of the consultations as this has to do with clinical competency and understanding how to function in a  medically responsible manner. A topic and concept that lawyers strongly look for in a medical expert.
"Preventing Denials and Destroyed Realtionsips"
Over this past weekend, I received a package of records from an attorney and a cover letter to review a "peer review" denial that he thought I might find interesting and to call him to discuss it. The denial was a simple straight forward denial on a chiropractor ordering both a cervical and lumbar EMG/NCV, it being performed by  neurologist. The test was denied and the peer review doctor wrote:
In the event that radiculopathy was suspected, there was no presentation of a differential diagnosis that warrants performing Invasive electrodiagnostic testing. There was no mention that there was a plan to use the results of the study to pursue more aggressive treatment on the claimant or how the anticipated test results would guide the management of the claimant's treatment program. In order for neurodlagnostlc testing to be medically justified, it must at least have an impact upon the course of the therapy a patient is receiving. This is not evident upon reviewing the medical records, as the records do not show that the performance of the neurodlagnostlc studies had significantly impacted the therapy and/or delivery of care to this Individual. Based on the records, the results of the studies, regardless of the findings, would not alter or impact the course of treatment or patient's outcome at that stage of the claimant's injuries. therefore they were not medically necessary.
When we reviews the report of the treating doctor, the examination revealed:
1. Manual motor strength: 5/5 throughout the entire bilateral upper and lower extremities
2. Deep tendon reflexes +2 throughout the entire bilateral upper and lower extremities
3. Sensation for light touch and pinprick was intact throughout the entire bilateral upper and lower extremities
4. Muscle tone was within normal limits throughout the entire bilateral upper and lower extremities
MRI Revealed: Small disc herniations at the C3-4, C7-T1 and T3-4 levels
Test Results: Evidence of bilateral C5-6 nerve root irritation
Note: when interpreting the results, there was a very minimal finding
1. Continue chiropractic care
2. Massage therapy
3. Further assessment for a trial of gentle axial traction as tolerated for relief of neurological impingement 
My questions are two-fold:
1. Why is an EMG/NCV indicated in the first place? There is no motor, sensory or reflexia aberration at any level.
2. How does a positive MEMG, even a questionable positive finding change care. This doctor ordered chiropractic, massage and traction. They were already being done. The ordering doctor was not considering any other type of care, or would have put his rationale in  his report, when he ordered the test. 
Here is the real issue; in your test orders, you MUST WRITE WHY you are ordering this, or any test. In this scenario, a positive MRI is not an indication for a cervical and lumbar EMG/NCV totaling $3400.00
This is a must with every test in order to prevent being denied and certifying your clinical rationale for the ordering any test or treatment. 
The lawyer, who I just hung up with on the phone (literally 1 second ago) just informed me that because this doctor "screwed up" he can no longer use him as an expert in this case and in the end, will cost him significantly when settlement time comes. Although the lawyer was polite over the phone to me, he inferred that he will NEVER use this doctor again...and this was his "go to" doctor. 
Remember, it is so hard to create the relationship and so easy to destroy it.
The last thing the lawyer said to me was " Thank you for your continuing educational services, I don't know what I would do without you. Can you please open another office?"
The moral of the story: Become the educational resource for the lawyers....GAME OVER
That is part of the message during your meeting with the lawyers.