Mark Kabins, M.D., Orthopedic spine surgeon

 Mark Kabins, M.D. spoke to a small group of claimants' attorneys last week to  talk about treatment of work-related spinal injuries.  Dr. Kabins, a long-time resident of Las Vegas, was a very animated and passionate speaker about  treating injuries  under workers' compensation  claims. He is a Diplomat of both the American Board of   Orthopedic Surgery and the American Board of Spine Surgery.  

I told  Dr. Kabins that many of my clients want to k now whether they should be asking for a transfer of care to a neurosurgeon,  or instead,  to an orthopedic surgeon,  when it appears that they may need a back or a neck surgery.  Dr. Kabin's response was to send the person to the doctor who is the best surgeon, regardless of what they list as their primary specialty.  Dr. Kabins then elaborated that his surgical practice is different from other local surgeons in that he does not pre-screen his patients so that only likely surgical candidates are scheduled.  Instead, he welcomes treatment of back strains where there are muscle rips at the ligaments, and he wants to be involved early in the treatment of such cases so that the patient can be properly educated about the diagnosis and become an active participant in their own healing process. 

Dr. Kabin's stated that about 15 to 30% of the lumbar injury cases referred to him really involve an injury at the SI joint level.   He also explained the difference between a lumbar bulge (either normal, or depicting an annular tear), and contrasted it with a disc  protrusion, which  he described as  a pimple-like subligamentous disc herniation.

 Dr. Kabins is a  fantastic  educator, and he justified the long wait times in his office for patients as being necessary in order to allow him whatever time is required to properly attend to individual patents.  His office manager, Brenda Cotton,  recommended calling ahead and discussing any particular time requirements you may have so as to reduce extended time in the waiting room.  Dr. Kabin's outstanding record of safe surgeries with excellent results should matter more than a quick appointment for injured workers looking to transfer care from the initial clinics.

Dr. Kabins also treats patients with injuries from California and Arizona who must be billed under those states' fee schedules.  Although he is currently on provider lists for many Nevada insurers and their third-party administrators, he is not opposed to  opening provider lists to any physician in good standing who is willing to accept the Nevada fee schedule.  He practices with Mary Ann Shannon, M.D., who specializes in upper extremity, hand and sports injuries.  John Reneau, M.D., is a physical medicine  and rehabilitation  physician with the  practice, called Las Vegas Orthopedics, Spine, and Rehabilitation.  Their office is located at 501 S. Rancho Dr., Suite I-67, Las Vegas, NV 89106.  Their phone is (702) 243-4700.

--Written by Virginia Hunt, Hunt Law Office

Low Back Pain: Work-Related or Not?

Most people, excluding  lawyers, are likely to tell you that it is an obvious fact that strenuous activity involving load on the back in occupations with heavy lifting, twisting, bending, and carrying  will cause more back injuries.  Athletes and medical  professionals are less likely to make the injury causation assumption, and will respond that people who use their bodies correctly for physical work are actually in better physical condition, with fewer back injuries than workers with sedentary jobs sitting in front of a computer all day.  Add to the discussion that  back pain is prevalent in the general population, with 80% of Americans seeking treatment for low back pain at some time, and it is difficult to get a consensus as to what  back injuries are work-related. 

     The AMA Guides to the Evaluation of Disease and Injury Causation by Melhorm and Ackerman, published in 2008 by the American Medical Association is a book dedicated primarily to assist health care providers when giving their opinion as to whether a condition is work-related or attributable to a specific event.  The authors use the catch phrase  "evidence-based' decision, and the book discusses the strengths and weaknesses of the available evidence considered reliable by experts in various medical specialties.  The book cautions that because each state establishes case precedents and has its own laws, what is considered acceptable evidence can vary widely.  A review of the Nevada Supreme Court decisions on low back injuries, does little to tell us where to neatly draw the line between a compensable low back injury and one that is not work-related. 

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Is Your Insurer Requiring a Psych Eval Before Authorizing Back Surgery?

There is a recent trend among insurers andtheir medical review companies to require a psychological evaluation before authorizing a low back surgery.  Neurospsychologist Louis Mortillaro, PhD is asked to do many of these evaluations for the purpose of determining whether the patient is likely to benefit from a back surgery.  Basically, the insurer doesn't want to pay for back surgery if the claimant is likely to continue to complain of back pain and want more medical care.  Dr. Mortillaro told me that occasionally the evaluation will reveal a more serious problem with drug addiction or a severe underlying psychiatric disorder that will only be exacerbated by a surgery.  

I haven't had any clients denied back surgery following a psychological evaluation.  However, most clients are upset initially that surgery has been delayed until this evaluation is scheduled and the insurer receives the report.  My clients have not found the evaluation to be too intrusive or unpleasant.  Thus far, the local psychologists hired to do these evaluations have been reputable and respective of injured workers.   

The concern that I have with this growing trend is that these psychological evaluation reports may be available to the employer.  Employers are copied on all determination letters by the insurer.  There are a few large, local employers that take a dim view of any employee who gets injured on the job and costs the employer increased work comp premiums.   I would hate to see these employers read sensitive information contained in a psychological report.   Because an insurer can require that and injured worker require a consultation as a condition of continued benefits,  an injured worker may not win an appeal if the worker refuses to attend the psych consult. However, I think an injured worker can require that the adjuster not disclose this report without a subpoena and good reason presented to an appeals officer if it involves a litigated issue. 

--Written by Virginia Hunt, Hunt Law Office

Common Spine Surgeries for Injured Workers

 Before an injured worker undergoes a neck or back surgery, he or she should be familiar with a few medical terms and what specific procedure the surgeon is recommending.   Ask your doctor to write down the name of the surgery, and have him explain exactly what will be done.  If you or your adjuster is requesting a second surgical opinion, make sure you understand whether the second surgeon is recommending a different approach.  The following are a few medical terms and procedures courtesy of materials from the Mayfield Clinic and local neurosurgeon Aury Nagy, M.D. :

  • Discectomy-  surgery to remove herniated disc material that is protruding through the disc wall and irritating the surrounding nerves causing pain.
  • Fusion- joining together two separate bones (vertebrae) to provide stability.       
  • ACDF (anterior cervical discectomy and fusion) - surgical procedure that removes a herniated or degenerative disc in the neck, and fusing the vertebrae above and below the disc space. The spine is approached from the front of the throat area.  The removed disc space is filled with a bone graft and the the vertebrae are immobilized with metal plates and screws.  Bone grafts may come from bone cells taken from your own hip, or from cadaver bone, or man-made substitutes.  Artificial disc replacement is also an option for some patients.  Both neurosurgeons and orthopedic surgeons do this surgery.
  • Foraminotomy-  surgical enlargement of the intervertebral foramen through which the spinal nerves pass.  Bone spurs, called osteophytes, that may be pressing on nerves may also be removed during this procedure.  
  • Posterior lumbar discectomy- surgery to move a herniated or degenerative disc in the lower spine where the surgeon approaches the spine from the back.  An open discectomy involves a 1-to 2-inch incision in the middle of the low back.  A minimally invasive discectomy has a very small entry wound. 
  • PLIF- posterior lumbar interbody fusion
  • ALIF- anterior lumbar interbody fusion where the surgeon accesses the spine through the abdominal area.
  • Laminectomy- this is the surgical procedure to drill a small hole through the lamina (a part of the bony vertebrae) so that the surgical can insert a surgical microscope to view and remove disc fragments.  It may be necessary to do on both sides (bilateral laminectomies).
  • OLIF-  Oblique lumbar interbody fusion.  This is a surgical procedure pioneered by local orthopedic surgeon Andrew Cash, M.D. where the surgeon enters the spine from the back, at an angle, near the pelvis and just above the iliac crest.  Read more about this in the article on Dr. Cash by Brian Sodoma in Las Vegas Life magazine, Spring 2013. 

    --Written by Virginia Hunt, Hunt Law Office




Is Your Insurer Requiring a Psych Eval Before Authorizing Back Surgery?

 There is a recent trend among insurers and their medical review companies to require a psychological evaluation before authorizing a low back surgery.  Neurospsychologist Louis Mortillaro, PhD is asked to do many of these evaluations for the purpose of determining whether the patient is likely to benefit from a back surgery.  Basically, the insurer doesn't want to pay for back surgery if the claimant is likely to continue to complain of back pain and want more medical care.  Dr. Mortillaro told me that occasionally the evaluation will reveal a more serious problem with drug addiction or a severe underlying psychiatric disorder that will only be exacerbated by a surgery.  

I haven't had any clients denied back surgery following a psychological evaluation.  However, most clients are upset initially that surgery has been delayed until this evaluation is scheduled and the insurer receives the report.  My clients have not found the evaluation to be too intrusive or unpleasant.  Thus far, the local psychologists hired to do these evaluations have been reputable and respective of injured workers.   

The concern that I have with this growing trend is that these psychological evaluation reports may be available to the employer.  Employers are copied on all determination letters by the insurer.  There are a few large, local employers that take a dim view of any employee who gets injured on the job and costs the employer increased work comp premiums.   I would hate to see these employers read sensitive information contained in a psychological report.   Because an insurer can require that and injured worker require a consultation as a condition of continued benefits,  an injured worker may not win an appeal if the worker refuses to attend the psych consult. However, I think an injured worker can require that the adjuster not disclose this report without a subpoena and good reason presented to an appeals officer if it involves a litigated issue. 

Are They Calling Your Herniated Disc a Lumbar Strain?

There is a renewed trend among particular self-insured employers and third-party administrators (TPA's) in Nevada to send a Notice of Claim Acceptance for "lumbar strain only" on  low back injury claims.  My fellow claimants'  attorneys are also noticing an increase in claims where adjusters are denying medical treatment for a herniated disc,  because the claim was accepted for a "lumbar strain" and the injured worker didn't file a timely appeal.  

For those workers who truly have a lumbar strain, a  claims acceptance letter for a "lumbar strain"  isn't likely to be a problem.    However, the the claims acceptance letter must be sent by the adjuster 30 days after getting the C-4  Claim for Compensation from the first doctor.  It isn't likely that the injured worker or even  the adjuster will know whether a low back injury is a strain or something else at that time. 

It's rare for a work comp adjuster to authorize a MRI  during the first 30 days of the claim, or even within the 70-day time to appeal the limiting language in acceptance letter.  A  MRI is necessary to diagnose a disc injury.  If a herniated disc is diagnosed later, the adjuster may refuse to authorize any treatment that isn't treatment for a lumbar strain.

 According to local neurosurgeon Aury Nagy, M.D., 70% of patients with lower back pain get better with physical therapy and steroids in about 6 weeks.  When the patient isn't better, an MRI is  done.  The MRI must be authorized by the adjuster.   If the MRI shows a herniated disc,  where the gel-like material within the disc is bulging or has ruptured and is pressing on a nerve, then a surgery may be necessary.  The patient may need a discectomy to remove the damaged disc.  If the  spine is also unstable, a fusion may also be necessary. 

Physicians must  ask the adjuster for authorization to do injections or to surgically treat a herniated disc.  Some adjusters are now including the "lumbar strain " language of almost every claim acceptance letter for low back injury.  Obviously, it isn't fair to the injured worker for the adjuster to deny requested treatment for a herniated disc that isn't diagnosed until later in the claims process.  The fact that adjusters are using this unfair tactic frequently now tells me that it is working for the adjusters.  Surprisingly few injured workers get legal help when this happens.

These are often winnable cases when the claimant files an appeal after hiring an attorney, even after the time has passed to appeal the "lumbar strain only" acceptance letter.  If your orthopedic surgeon or your treating neurosurgeon tells you that the adjuster denied authorization to treat your herniated disc because only a lumbar strain was accepted on your claim, get an attorney consultation immediately to discuss the facts of your particular case. 

--Written by Virginia Hunt, Hunt Law Office

Treating Pain with a Video Game

 Many of my clients with very severe injuries must learn to accept that they will live with pain the rest of their lives.  After they exhaust all that doctors have to offer and realize that there is no "fix", these clients either adapt and live reasonably happy and productive lives, or they stay miserable.  How individuals adapt and move forward while they feel pain every day is fascinating to me.  My job as a lawyer is not to provide medical treatment or medical advice, but I like to share what I learn on this subject.

I was watching the TV program Rock Center with Bryan Williams two weeks ago when a piece came on about a virtual reality video game that was created to distract patients' brains from sensing pain during painful medical treatments.  The show featured a disfigured service man who was severely burned and who had to endure excruciating procedures to treat his burns.  The usual opiate medications used to treat pain simply weren't enough.

The virtual reality  video game, called Snow World, had the burn patient wear headphones and a headset to immerse him in a peaceful, snowy landscape where he was required to lob snow balls at penguins and other animals.  An  MRI of the patient's brain  gave objective proof that the patient was truthful when he said that he felt significantly less pain when he was playing the video game. The show also featured researchers applying a  mildly painful heating device to the reporter's foot before and during her playing the video game.  She also was convincing in her statements that her pain was almost eliminated when she was focused on playing the game.  

If you would like to learn more about this, here is one link:

I intend to research this further and ask local pain management physicians whether they have any information about using this device to treat chronic pain, and who locally is using it.   The University of Washington link above also has research papers on using the game to treat post-traumatic stress disorder, and fear of spiders. Interesting.


Complex Regional Pain Syndrome

How to treat chronic pain was a topic addressed by several of the featured speakers at the WILG convention in Las Vegas this weekend.  (WILG is a non-profit organization that assists attorneys in advocating the rights of injured workers.)  Dr. Steven Simon, M.D. of the Kansas University Medical Group spoke about CRPS complex regional pain syndrome.  He defined CRPS as an inciting event (usually trauma, but sometimes  immobilization) to a a nerve that then moves into the spinal cord where it becomes a systemic  chronic pain problem. 

Dr. Simon stressed that the earlier the problem is diagnosed, the better the patent's chances were for a successful treatment orientation.   He acknowledged that many treating orthopedic physicians were not knowledgeable enough about treating  chronic pain systems consisting of depression,  anger, sleep deprivation, hormonal deprivation, and pain. When the patient doesn't get better and the cause of the problem is not readily identified using traditional diagnostic methods, the adjuster likewise becomes frustrated and schedules an independent medical exam. That results in more delays in getting the injured worker to an appropriate physician to treat the CRPS.   Many CRPS sufferers find that an attorney advocate is necessary to ensure proper treatment and a fair impairment evaluation.

--Written by

Sexual Problems May Be Related to Spinal Cord Injury

Many injured workers with severe spinal cord injuries are reluctant to mention to their treating physician that they have had sexual dysfunction since their work accident in Nevada.  Males in particular are embarrassed to bring up this topic with their doctors.  Unless the doctor initiates the discussion and directly asks about any sexual  problems, the problem isn't noted in the dictated reporting, and isn't treated.  And if the problem is permanent, the injured worker isn't properly evaluated for impairment.

It is very important that if you have had a serious spinal injury that you tell your treating physician about any loss of control of the bladder and/or bowels (involuntarily urinating or soiling yourself), any loss of sensation to your genitals and surrounding area, and any  inability to engage in usual sexual activity. 

Orthopedic surgeons, neurosurgeons, and physiatrists are busy doctors, and your appointment may already seem rushed without you bringing up an embarrassing problem .  However, you should not delay in asking the doctor about these symptoms.   If there is a nurse case manager that is present at doctors' visits, you might want to ask the nurse to allow you to speak to the doctor privately about a symptom that is bothering you.   You have the right to see the doctor alone.  Unless you speak up and tell your doctor who is treating your spinal injury about theses problems, nothing Will be done to investigate and find the right treatment.  

Once you do discuss the  problem, your spine doctor may want to refer you to a urologist for testing, or to your own primary care doctor to rule out other possible  non-industrial causes for your complaints.    Adjusters will usually pay for consultations to determine the cause of the problem if your spine doctor makes the request for a  consultation.  If it's found that the spinal cord injury isn't the cause, at least you will know what you need to do to treat the problem. 

If there is a direct causal connection between your work injury and loss of bladder or bowel control, or sexual dysfunction, your  permanent partial disability  (PPD) award could be significantly increased when you are rated under the AMA Guides to Evaluation of Impairment, Fifth edition.  The injured worker must be vigilant about having these impairments included in the rating.

Prescription Drugs and Nevada Workers' Comp Claims

Part A

The NCCI is an organization that keeps statistics on work injuries in the various states.  A recently released  August 2011 NCCI Research Brief by Lipton, Laws and Li  focused on prescription costs.  According to this study,  prescription drugs are 19% of the medical costs on an average claim.   The study showed that it was not the price of drugs that was responsible for increased prescription costs.  Instead, increased drug costs were attributable to doctors prescribing more drugs and more expensive drugs. Also responsible was the growing  trend in many states by treating doctors to sell prescription drugs in their offices.  Additionally, the study also found that physicians who sold drugs in their office were charging more for drugs than local pharmacies, 

This trend, which is particularly popular with California physicians,  hasn't caught on in Nevada yet,  According to NCCI's statistics, Nevada presently has lower prescription costs per medical claim than most other states, and relatively few doctors in Nevada sell the drugs they prescribe.  

The NCCI study did not suggest that doctors were doing anything wrong by selling prescription drugs to patients, or that they were wrong in selling drugs at prices higher than pharmacies. The study mentioned why  pharmacies are able to sell drugs at lower prices, and the study suggested that some doctors wanted to dispense small amounts of drugs for the benefit and convenience of their patients. The study listed wanting to make more money as a reason doctors were now dispensing prescriptions.  However, the study did not fully explore the subject of physician profits from this practice. 

The negotiated fees paid to doctors for their treatment of injured workers on Nevada claims seems ridiculously low to me. Unfortunately, some physicians try to make up for low rates by scheduling more and more  patients in a day.   In Nevada, most insurers won't keep a physician on their provider list unless the physician agrees to accept less than what the Nevada fee schedule allows. I wonder whether the profit margins earned by Nevada physicians  on workers' compensation claims will cause them  to start selling  prescription drugs to their patients.  

The NCCI study didn't delve into the ethics of physicians establishing  a secondary profit center at their offices selling prescribed medication to patients.  I haven't researched  this topic, so  I don't know whether there are existing rules or regulations that govern the conduct of physicians who do this.  It just doesn't seem  right to me, though. The study also found that doctors were prescribing more drugs and more expensive drugs.   Even if the physician is completely ethical, won't  patients wonder whether the physician is prescribing a particular medication just for the purpose of selling it?   Maybe I've been lucky with the physicians I've seen in La's Vegas for my own health care.  Many have given me free samples of prescribed medications so that  I could  avoid or reduce prescription costs.

For me, the NCCI Prescription Drug Study, 2011 Update, raised many questions about the future role of physicians on workers' compensation claims.  If Nevada physicians join the trend in dispensing prescriptions form their offices, it is likely that medical costs on the claim will increase.  Injured workers do not have to pay for prescriptions on an open, accepted claim in Nevada.  However, if claims costs increase for insurers,  insurers will be looking for ways to save money.  That could mean  rushing the injured worker  through second-rate medical care, denying authorizations for diagnostics or treatment, or trying to short-change the claimant on his PPD award or his vocational program.

Stay tuned for Part B on Prescription Drugs and how to handle problems obtaining necessary prescriptions on your claim.  Meanwhile, I would like to hear your opinions on the subject of physicians selling prescription drugs that they prescribe. 



Delays in Getting Medical Care on Your Nevada Work Comp Claim

Delays in getting medical care authorized are the reason most injured workers contact me for help on their claim.  Here is some additional information about treatment delays and what  you can do to get proper medical care on time on your  Nevada workers' compensation claim.  

  • An insurer won't authorize expensive tests like MRI's or EMG/nerve conduction studies until the insurer decides to accept your claim.  The adjuster has 30 days to accept or deny the claim.   If the claim is denied, no tests or further treatment will be authorized.
  • Prior authorization must be sent by your treating doctor to the adjuster for diagnostic tests (other than in-office x-rays), physical therapy, consultations with other doctors, or for surgical procedures. 
  • The adjuster has 5 working days to respond to a doctor's request for authorization pursuant to NRS 616.157.
  • Insurers can delay treatment or tests by scheduling an injured worker for a consultation or an independent medical exam with a doctor chosen by the adjuster.  The adjuster can suspend your benefits for non-cooperation if you don't attend this appointment.  NRS 616C.140.
  • The insurer can delay authorizing treatment or diagnostic testing until the requesting doctor  provides the adjuster with his dictated medical report.
  • The insurer might have a medical review done of the request.
  •  An adjuster should copy you on any denial of the requested treatment or test. and give appeal rights instead of just notifying the doctor of the denial.  NAC 616C.091(3).
  •   If you moved outside of Nevada, the insurer won't  authorize medical care with an out-of-state doctor until the insurer is sure that the doctor will accept what the Nevada medical fee schedule allows for office visits and treatment. 
  •  What you can do:
  1. Make sure that your doctor faxed the request for prior authorization to the adjuster.
  2. If the adjuster hasn't acted within 5 working days, and doesn't give you a reason for the delay, you may file a complaint with the DIR, with a copy to the adjuster. Some adjusters will then respond, not wanting to deal with a DIR investigation. See NAC 616C.092. 
  3.   File an appeal if you have requested a transfer of doctors or some particular treatment. File appeals of any medical review doctor's opinion denying the requested treatment or test.    You may appeal an insurer's failure to respond to your written request after 30 days.
  4.  You may ask your doctor for help by having him talk to the adjuster to explain why treatment or testing is necessary.
  5.  Make sure that your out-of-state doctor will accept the Nevada fee schedule before you ask the adjuster to allow treatment with that doctor.
  6.  Get legal help if there are delays that  prevent you from getting the medical care you need now for all of your injuries.  Most attorneys do not charge for an initial consultation.


Should You Get a Second Opinion Before Having a Spinal Fusion?

Most industrial insurers will schedule injured workers for a second opinion before authorizing an orthopedic surgeon or a neurosurgeon's request to do a spinal fusion.  It is a good idea, even if the insurer isn't requiring it, to get a second opinion on whether a spinal fusion is the best treatment for you.  Many injured workers  immediately agree with their treating physician's recommendation for a fusion because they are still in pain after physical therapy and a course of medication, or because  injections didn't work.  A fusion surgery is not something that should be done simply because a patient is still in pain and the doctor doesn't know else to do.  It should be done only after careful consideration of all treatment options and only if there are clear-cut objective indications for this surgery.

Some injured workers mistakenly believe that that their benefits will be terminated if they don't agree to have surgery. An adjuster cannot terminate benefits solely because a claimant decides not to have a surgery.    The adjuster may close a claim  because the doctor has exhausted all treatment options.    The adjuster will  not  let a claim remain open indefinitely while  a claimant takes months to decide whether to have surgery or not.  However, most adjusters will agree to allow a second opinion if the adjuster hasn't already decided to get one.

If you feel that you are being pressured into making a rushed decision on having a spinal fusion by your treating doctor, discuss this with the adjuster and request that he schedule a second surgical consultation.  Remember that you may request a copy of the insurer's provider list to see what other spine surgeons are on the the insurer's provider list.  Do some research so that you are informed about the surgeons before you request a particular one, or before the insurer chooses a second opinion physician for you. 

Great Explanation of CRPS

See attached video for a great explanation of how someone with CRPS (complex regional pain syndrome) experiences pain.

Hope for Chronic Pain Sufferers

Last week, I had lunch with Dr. Mel Pohl, M.D., the Medical Director of Las Vegas Recovery Center, and his Admissions Coordinator,  Jackie Pippin.  The Las Vegas Recovery Center is a small, private facility that offers a  chronic pain recovery program.  While most chronic pain management treatment for injured workers involves ongoing prescription pain medication, injections and surgeries,  this program focuses on medically detoxifying the individual from all opioids and then treating the physical and emotional pain with an intensive inpatient treatment program.  That is  followed by outpatient care  modeled on twelve-step recovery programs.  The program uses an individual, multidisciplinary approach that includes physical therapy, biofeedback, chiropractic, Pilate's, acupuncture, and yoga.   Dr. Pohl writes about alternative  treatments in his book A Day Without Pain.

Dr. Pohl told me that this isn't a program for every injured worker with chronic pain.  He acknowledged that some injured workers are able to use opioid medications without  developing dependence and compulsive use behaviors.  He also knew that it was very difficult to obtain authorization from industrial insurers for an expensive inpatient treatment for drug dependency caused by a work injury. He and Jackie impressed me as compassionate people who were sincerely committed to finding solutions to how to treat chronic pain, particularly  when it also involves addiction to opioid medications. 

 For more information on the Chronic Pain Recovery Program at the Las Vegas Recovery Center, contact Jackie Pippin at or (702) 290-6928.

Complex Regional Pain Syndrome: It's Real!

Formerly called RSD (reflex sympathetic dystrophy),  CRPS ( complex regional pain syndrome)  is a  type of pain  thought to be caused by an injury or abnormality in the nerve pathway.  It typically causes a  burning sensation, and hypersensitivity to touch  somewhere in the arms or legs.   If not treated early, it may spread from one limb to another.  This diagnosis  strikes terror in the hearts of adjusters, because  the length of time the claimant will need treatment is unpredictable.  

CRPS has always been a controversial medical diagnosis, with the AMA Guides authors taking the view that scientifically, there is no discernable cause of this pain.  The doctors who contribute to the Guides Newsletters suggest that there is an overriding psychological component to CRPS as opposed to an identifiable, underlying  physical nerve problem.  Essentially, the national doctors who are establishing the rules for rating permanent impairment question whether CRPS is a real health condition or a form of malingering.

 Not a lot has changed over the years as to  how injured workers with the diagnosis of complex regional pain syndrome (CRPS) are treated.  After months of trying to get an accurate diagnose of their pain complaints, the injured worker must then grapple with a component of the workers' compensation medical community' that views CPRS as  a fictional illness that is encouraged by lawyers. 

I am not a doctor, and cannot diagnose anyone with anything.  That said, however, I can say from personal experience that I have had, and continue to have, clients who are hard-working, sane people who have this dreadful, very real pain disorder.  I have observed that the sooner the injured worker is assigned to a physician who is experienced in treating CPRS, the better the chances for  a successful reduction in pain and return to full function. For more information on diagnosis and treatment, please review theNational Institute of Neurological Disorders and Stroke  fact sheet. 

Help for Chronic Pain

I came across another website that offers information on treating chronic pain, as well as a comprehensive list of other websites with additional help for people dealing with injuries or illnesses that cause chronic and long-lasting pain. There may be something useful for you here, particularly the kit offered for tracking and measuring your pain.  You might also want to read the articles on how to better communicate what you are experiencing and feeling with regard to your pain when meeting with your doctor.  As you know, so much of treating chronic pain involves trial and error, both with prescription medications and lifestyle changes until the person does not feel overwhelmed and controlled by pain.  I am always looking for useful tips or information to share with injured workers, so please feel free to send me your comments.

Getting Medication After Claim Closure


Prescription BottlesWhen the adjuster sends a letter, either scheduling a rating evaluation, or simply closing the claim, No additional medical treatment will be authorized.  That means that the insurer will also stop paying for any medication refills, and will not authorize return visits to the doctor for more medication.  If the injured worker's treating doctor reports that the patient will need ongoing medication, then this issue needs to be discussed and resolved with the adjuster before the appeal time (70 days) runs on claim closure.  Additionally, if an injured worker accepts a permanent partial disability award in a lump sum, any appeal the injured worker has filed on claim closure to obtain ongoing medication will be dismissed.

Nevada statutes and regulations governing workers' compensation claims do not address what the insurer's obligations are to provide ongoing medication after the treating doctor recommends that that claim be closed. The best way to deal with this issue is to negotiate with the adjuster to reach a reasonable agreement.  Assuming the treating doctor makes it very clear that ongoing medication is necessary, many insurers are willing to pay for medication for at least a year after the claim is closed and are agreeable to letting the injured worker receive his PPD award also. Insurers are usually only willing to do that when the injury is very serious.  If the insurer agrees to ongoing medication for a year, the insurer will want to make a new determination after a year after asking the doctor whether more ongoing medication is necessary. 

Other insurers take a more obstinate stance and refuse under any circumstances to pay for any medication or doctors' visits after claim closure. The injured worker can appeal the claim closure letter, and try to persuade a hearings or appeals officer  to order the insurer to provide ongoing medication.  While it is possible to obtain such an order, the problem is that this appeals process takes months.  Again, the injured worker can not take his permanent partial disability award in a lump sum while the claim closure/medication issue is being litigated.  Many injured workers cannot afford to let their award money sit with the insurer while trying to get ongoing medication through the appeals process.

Obtaining ongoing medication after claim closure is difficult, and most injured workers will be unable to obtain it without an attorney.  If the injured worker is able to obtain it without an attorney,  it is essential that any agreement obtained from the adjuster be in writing.  Adjusters change frequently, and an oral agreement will not be enforceable. 


What Is a Physiatrist?

One type of physician that injured workers commonly encounter is the physiatrist,  also known as a physical medicine and rehabilitation (PM & R) physician.   While the name  sounds similar to a psychiatrist,  a  physiatrist  treats physical injuries as opposed to mental or behavioral problems. A surgeon may refer her patient to a physiatrist after a surgery when additional physical therapy is recommended.  Or, a physician who sees an injured worker in a clinic setting for the first couple of visits may refer the patient to a physiatrist when it appears that the injury  may require  more care over several weeks or  months.  

Physical medicine and rehabilitation (PM&R), or physiatry  is a branch of medicine which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Physiatrists must complete four years of medical school,  one year of internship and three years of residency.   Physiatrists specialize in restoring optimal function to people with injuries to the muscles, bones, tissues, and nervous system. 

A physiatrist who treats an injured worker usually coordinates the medical care if several specialty physicians are required to treat different injured body parts.  If surgery has already occurred, or no surgery is necessary, the physiatrist may order physical therapy or may prescribe medication while the patient recovers from his injuries. When the patient is stable and does not need more treatment, the physiatrist may then order a functional capacity evaluation (FCE) to assist him in determining the patent's permanent work restrictions.  Finally, the physiatrist tells the adjuster whether the injured worker should be rated for permanent impairment or not. 

 If you are not satisfied with the physiatrist that is currently treating you for your work injury, you may be entitled to change physicians. Click here to read more about changing physicians.


Physician Progress Reports- Nevada Work Comp Info

After every visit to a treating doctor, the injured worker should make sure that he or she leaves with a copy of  a physician progress report (PPR).  Most doctors who are on insurers' provider lists use the DIR- approved physician progress report form.  However, some doctors have forms on their own stationery that  have the same information, but in a different lay-out.  If the nurse or assistant checking you out after the doctor's visit does not offer you a copy of the PPR, please insist that they give you a copy before you leave.  Then read the PPR before you leave the doctor's office to make sure that the information is correct and that you understand what the doctor has written..  A copy of  this form will be sent to the adjuster handling your worker's compensation claim, and a copy is often sent to your employer.

The top portion of this form states in abbreviated medical terms what your injury and diagnosis is.   If you have injured more than what is stated in this section of the form, you should have a discussion with the doctor to make sure that he or she has examined and noted all body parts that were injured and that need treatment. 

The second section of the form is important when the doctor releases you from care.  In that section, the doctor checks boxes that state that  you are, or are not, ratable and may have suffered a permanent disability.  If the doctor checks "no" to those two boxes, the adjuster is not likely to schedule you for a permanent partial disability evaluation, which is necessary to receive a settlement for your injury.

The section entitled "Treatment plan" often tells you whether the doctor will be requesting approval for MRI's, more physical therapy, or a referral to a specialist.    Hopefully, your doctor's staff will then follow-up with the proper authorization request form so that the treatment plan is approved and put into motion.

The bottom third of the PPR is very important and tells the injured worker whether the doctor has taken you off work completely (totally temporarily disabled), or whether the doctor has given you work restrictions.    If the doctor gives you temporary work restrictions, it is your responsibility to give a copy of the PPR with these restrictions  to your employer and ask whether your employer has work available within these restrictions.    Keep in mind that a copy of this PPR goes to your adjuster, and if the employer tells the adjuster that light duty work is available,  the adjuster will not continue to pay bi-weekly  TTD benefits to you.

Read the PPR before you leave the doctor's office to make sure you know whether the doctor has released you to  full duty or with temporary work restrictions.  Often injured workers misunderstand what their doctors verbally tell them about returning to work.  You need to know what the doctor writes on the PPR, and if you disagree with what the doctor writes, you want to calmly and politely ask to speak to the doctor again to get a clarification before leaving the doctor's office.

Some doctors tell injured workers that they are prohibited by Nevada law from taking an injured off work completely.  That is false information.  The doctor has a legal obligation to provide care for his patients regardless of who is paying for his services.  Many doctors, however, feel pressure from adjusters and case managers to give work restrictions instead of taking injured workers off work completely for extended periods of time.   So long as the employer provides work within whatever restrictions the doctor gives on the PPR, the injured worker must show up for work, or take leave without pay if available, or use whatever sick leave is available.   The only other recourse the injured worker has is to request a change of physicians to a more caring doctor.



Knee and Shoulder Injuries at Work

 Work-related traumatic injuries to knees and shoulders are common. These are two of the most complex joints in the body.  If an injured worker is not getting better with physical therapy, reduced activity, and drugs to reduce inflammation, the initial treating physician may then order a MRI to better diagnose injury to the ligaments, tendons, and cartilage. The clinic physician  may also refer the patient to an orthopedic physician.  An injured worker may ask for a specific orthopedic physician on the insurer's provider list. 

Nevada workers in occupations that require extensive kneeling, heavy lifting, squatting and climbing are at risk of  meniscal tears to the knees.  (The menisci are pads of cartilage that act as cushions between the femur and tibia bones, and they help distribute body weight and minimize friction within the knee joint.)  Most meniscal repairs can be done at an out-patient surgical center with an instrument called an arthroscope that creates only small scars.   Recovery time is usually quick, and  if a partial meniscectomy is done, a 1% whole person permanent partial disability award is given.  If you have had a knee surgery on your accepted workers compensation claim and the insurer tries to close your claim without a rating evaluation, you should consult with an attorney right away.

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Little Change to Rules on Choice of Physician

The 2009 legislative session was preoccupied with the economic crisis,  the state budget, and an unprecedented number of bills vetoed by the governor, the majority of which  were promptly reaffirmed by the state assembly and senate. Injured workers seeking reforms didn't stand much of a chance to make significant changes in this climate.   However, Assembly Bill 281 made some minor reforms to NRS 616C.090, the law allowing insurers to establish exclusive providers lists from which injured workers must choose a treating doctor. 

Section 3 to A.B. 281 clarifies that an injured worker may request an alternative choice of physician from the insurer's provider list without the insurer's approval , if the alternative choice is made within 90 days after the injury.   However, expect insurers whose initial denial of the claim is overturned to continue to argue that the injured worker has no right to choose an alternative treating physician after 90 days, even if it takes more than 90 days to get the claim accepted after a lengthy appeals process.

This bill also clarifies that an injured worker may request an alternative physician from the insurer's provider list after 90 days, and if the insurer denies this request, it must give a specific , written reason for denying the request .  In other words, the insurer can no longer deny the request simply because the request was made  90 days after the injury.  

I think the most helpful change to the law is the addition of a provision in section 3 that a written request for a change of physician that includes the name of the new physician (who is on the insurer's provider list), will be deemed granted if no action is taken on the request by the insurer within 10 days. Whether the insurer can subsequently issue a written denial with appeal rights under this amendment will undoubtedly be the subject of debate during  future appeals .

Two years ago, in Valdez v. Employers Insurance Company of Nevada, 123 Nev. Adv. Op. 21 (2007), the Nevada Supreme Court held that injured workers with accepted workers compensation claims have no substantive right to choose a treating physician, and can be required to treat with physicians contracted by the insurer or employer to provide care.    The court went on to state in that case that the Nevada legislature may retroactively change the manner in which an injured worker may select a physician, and may impose limits on that selection procedure.   The recent amendment to the law  on selection of an alternative physician takes a little bit of the sting out of the Valedez ruling. This amendment became effective July 1, 2009.