FILED
`3/1/2023 12:40 PM
`JOHN F. WARREN
`COUNTY CLERK
`DALLAS COUNTY
`
`CAUSE NO. CC-22-05426-D
`
`IN THE COUNTY COURT
`
`AT LAW NO. 4
`
`DALLAS COUNTY, TEXAS
`
`ALEXIS STEVENS,
`PLAINTIFF,
`
`VS.
`
`PABLO MORALES,
`DEFENDANT.
`
`DEFENDANT’S NOTICE OF FILING COUNTER AFFIDAVIT OF
`VIVEK MEHTA, M.D.
`
`TO:
`
`ALEXIS STEVENS, by andthrough Plaintiff(s)’ attorney of record, Matthew Sercely,
`3300 Oak Lawn Avenue, 3rd Floor, Dallas, TX 75219
`
`PABLO MORALES, hereinafter referred to as Defendant whether one or more, pursuant
`
`to Rules 803(6) and 803(7) and 902(10) of the Texas Rules of Civil Evidence and pursuant to the
`
`applicable sections of the Texas. Civ. Prac. & Remedies Code, Sec. 18.001, files the attached
`
`Counter Affidavit of VIVEK MEHTA, M.D. along with the attached 20 pages of records.
`
`VIVEK MEHTA, M.D. is employed by INSPE. A true and correct copy of these records are
`
`attached hereto.
`
`Stevens vs. Morales
`DEFENDANT’S NOTICE OF FILING AFFIDAVIT OF [ENTER AFFIANT’S NAME]
`0619715286.1
`
`PAGE1
`
`

`

`Respectfully submitted,
`
`LISA CHASTAIN & ASSOCIATES
`
`fsDrone
`
`
`
`ANTHONY M. DEGUERRE
`TBN: 24127392
`
`P.O. Box 655441
`Dallas, TX 75265
`
`E-Service Only: DallasLegal@allstate.com
`(214) 659-4310
`(877) 678-4763 (fax)
`
`ATTORNEY FOR DEFENDANT(S)
`PABLO MORALES
`
`Stevens vs. Morales
`DEFENDANT’S NOTICE OF FILING AFFIDAVIT OF [ENTER AFFIANT’S NAME]
`0619715286.1
`
`PAGE 2
`
`

`

`CERTIFICATE OF SERVICE
`
`I hereby certify that a true and correct copy of the foregoing has been served in
`
`compliance with Rules 21 and 21a of the Texas Rules of Civil Procedure on the _Ist__ day of
`
`March, 2023, to:
`
`THOMPSON LAW LLP
`MATTHEW SERCELY
`State Bar No.
`msercely@triallawyers.com
`RYAN L. THOMPSON
`State Bar No. 24046969
`rthompson@tnallawyers.com
`3300 Oak Lawn Avenue, 3rd Floor
`Dallas. Texas 75219
`Tel. (214) 755-7777
`Fax. (214) 716-0116
`ATTORNEYSFOR PLAINTIFF
`
`Edrave
`
`
`
`ANTHONY M. DEGUERRE
`
`Stevens vs. Morales
`DEFENDANT’S NOTICE OF FILING AFFIDAVIT OF [ENTER AFFIANT’S NAME]
`0619715286.1
`
`PAGE 3
`
`

`

`ALEXIS STEVENS,
`Plaintiff(s),
`
`CAUSE NO. CC-22-05426-D
`
`IN THE DISTRICT COURT
`
`VS.
`
`AT LAW NO.4
`
`PABLO MORALES,
`Defendant(s).
`
`DALLAS COUNTY, TEXAS
`
`DEFENDANT PABLO MORALES
`CONTROVERTING AFFIDAVIT OF VIVEK MEHTA, MD.
`
`Onthis day personally appeared Vivek Mehta M.D. whobeing personally known to me and duly
`
`sworn on his oath deposes and says:
`
`1.My name is Vivek Mehta. I am over 21 years of age, am of sound mind and body,
`
`and have never been convicted of any felony or criminal offense. I am a licensed
`
`physician, and have been practicing for approximately 37 years. I am authorized to
`
`makethis affidavit.
`
`2.1 was asked to review the available records and to opine regarding the Necessity of past
`
`treatments and on recommended future treatments at Momentum Spine and Joint. I
`
`have received and reviewed copies of the affidavits and medical records produced by
`
`Plaintiff Alexis Stevens pertaining to services provided by Momentum Spine and
`
`Joint.
`
`3. Based upon my knowledge, skill, experience,
`
`training, education, and other
`
`expertise, copy of my written report is attached hereto. This written report gives
`
`comprehensive details of my opinions and impressions in reviewing, as well as a
`
`summary of the factual basis for my opinions.
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 1 of 16
`
`

`

`My nameis Vivek Mehta, M.D. I am a licensed Medical Physician in the state of Texas and
`am Board Certified in Anesthesiology, also subspecialty Board Certified in Pain
`Medicine through the American Board of Anesthesiology. The opinionsin this report are
`based on my 37 years of experience as a Physician with nearly 20 years ofpractice of Pain
`Medicine.
`
`Mycredentials include the following leading positionsin the past.
`
`I. Assistant Professor Dept of Anesthesiology and Pain Medicine, University of Miami,
`Miami Florida.
`2. Director Pain Management Teaching Program
`VA Medical Center, Miami, Florida
`3. Clinical and Administrative Director of Center for Comprehensive Pain Medicineat
`Trinity Mother Frances, Tyler TX
`4. Director Pain Management Texas Health Arlington Memorial Hospital, Arlington, Texas
`5. Currently Director GlobalInstitute of Spine and Joint Care, Arlington, Texas.
`
`In my practice experience, I have evaluated and treated thousands of patents with similar
`conditions as those described herein, with musculoskeletal conditions such as acute and
`chronic pain.
`
`Pain medicine involves the diagnosis and management of non-operative management of
`patients with acute and chronic pain complaints, judicious use of medications for analgesic
`purposes, including anti-inflammatory agents, muscle relaxers, and opiates, if need be;
`ordering radiology examinations, including MRIsto evaluate pathological conditions,
`interpret EMGs(electromyography) to objectively assess neuromuscular conditions, and other
`interventions, such as interventional pain procedures form basic trigger point injections to
`advanced procedures such as implantation of a spinal cord stimulator to an implantable
`intrathecal pump. Treatment is based on personal experience, as well as the ODG and
`evidence-based Pain Treatment Guidelines.
`I order and/or perform these treatments,
`diagnostics, and interventions as part of my practice. Therefore, I am an expert in the
`evaluation and treatment aspects of this case.
`
`The aboveis true for file entire spectrum of care and interventions with which I work. I am
`qualified to comment on the reasonableness and necessity of the services provided to
`Plaintiff at the time and place that the services were provided.
`
`I was asked to review the available records and to opine regarding the: Necessity of past
`treatments and on recommendedfuture (LESI & Cervical Facet Injection) at Momentum
`Spine and Joint.
`
`In preparation of this affidavit and the attached report incorporated herein by reference, I
`reviewed and considered the following records:
`Records from
`Texas Health Plano;
`Momentum Spine and Joint
`Chiro Concepts of McKinney
`PT concepts of McKinney
`
`Page 2 of 16
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`

`

`Please note that I did not examine the referenced individual.
`
`Under Section 18.001 (f) of the Texas Civil Practice and Remedies Code, I state, after
`reviewing the records presented and the affidavits filed by Plaintiff, and based on injuries
`alleged by Plaintiff to have occurred in the incident made the subject of this lawsuit, here are
`my findings-
`
`MY SPECIFIC OPINIONS AND BASES ARE BELOW.
`
`SUMMARY OF MEDICAL RECORDS OF STEVENS ALEXIS DOB 08/29/62.
`
`Basedon the records available for review to me the course and timeline of treatmentis as
`follows
`
`1. INITIAL VISIT TEXAS HEALTH PLANO ER 03/20/21
`
`THPCIER ROOM#: 13
`
`Chief Complaint: MVC
`
`First Provider Contact Date and Time: 03/20/2021 1821
`
`HPI
`6:21 PM Alexis Stevensis a 58 y.o. female who comesto the ED via EMS s/p MVCthis evening. P was a restrained
`passenger when she had a head-oncollision with the other car. Negative airbag deployment. Negative LOC. Pt states
`her husband wasdriving a pickup truck. Pt compiains of pain throughoutherleft side. She denies CP or abdominal
`pain. There are no other symptomsatthis time.
`
`During this encounter, my scribe and | used appropriate PPE given the possibility of any potential communicable
`diseases. The pt wasin a maskfor the duration my encounters with them. PPE included as per current guidelines.
`maintained at least a 6 ft distance except for a brief physical exam.
`
`|
`
`CT Spine Cervical, WO IV Contrast (CT SPINE CERVICAL WO CON)
`Resulted: 03/20/21 1905, Result status: Final result
`[1082254038]
`Ordering provider: Franklin, Jonathan Dayal, MD 03/20/21 1829 Order status: Completed
`Resulted by: Small, Andrew Buchanan, MD
`Filed by: Interface, Oruradiant 03/20/21 1907
`Performed: 03/20/21 1840 - 03/20/21 1903
`Accession number: PC364294-21
`Resulting lab: RAD PHP
`Narrative:
`HISTORY: Neck injury and pain and motor vehicle collision
`
`COMPARISON: Nene
`
`CT sean of the cervical spine done according to ALARA. Technical quality: Technical quality: adequate.
`FINDINGS:
`
`Skull base and craniccervical junction are intact. No cervical spine fracture seen.
`TEXAS HEALTH PLANO
`Stevens, Alexis
`6200 WEST PARKER ROAD
`-MRN: 2000065619, DOB: 8/29/1962, Sex: F
`Adm: 3/20/2021, D/C: 3/20/2021
`Printed by SMITHJO3 at 9/5/22 10:27 AM
`Page 46
`
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 3 of 16
`
`

`

`Multilevel cervical spondylosis is advanced for age.
`
`The prevertebral soft tissues are unremarkabte.
`
`Apices are clear.
`
`Impression:
`IMPRESSION:
`
`1. No cervical spine fracture.
`
`RL 6200
`
`Electronically signed by Drew Smali, MD at 3/20/2021 7:05 PM
`
`
`Resulted: 03/20/21 1900, Result status: Final result
`CT Head, WO IV Contrast (CT HEAD WO CON)[1082254037]
`Ordering provider: Franklin, Jonathan Doyal, MD 03/20/21 1829 Order status: Completed
`Resulted by: Small, Andrew Buchanan, MD
`Filed by: Interface, Oruradiant 03/20/21 1904
`Performed: O3/20/21 1842 - 03/20/21 1903
`Accession number: PC364292-21
`Resulting lab: RAD PHP
`Narrative:
`HISTORY:injury headache motor vehicle collision4
`COMPARISON: none
`
`TECHNIQUE:
`
`CT scan of the head performed. Contiguous axial CT images were obtained from the skull base through the vertex without
`intravenous contrast. Study was interpreted and a report was generated within 1 hour of the acquisition of the Images CT scan done
`according to ALARA Technical quality: Technical quality: adequate.
`FINDINGS:
`
`There Is no mass effect or midline shift. There is no evidence of intraparenchymal hemorrhage or extra-axial collections. Ventricles
`and sulci are age-appropriate. No focal hypodensities to suggest trans cortical infarct.
`
`Paranasal sinuses and mastoid air celis are normally aerated.
`Impression:
`IMPRESSION:
`
`1. No acute intracranial abnormalities.
`
`Today’s Visit (continued)
`Daath
`* Motorvehicle accident,initial encounter
`*
`teft upper limb pain
`> Lett leg pain
`
`‘8 imaging Tests
`CT Head, WO IV Contrast (CT HEAD WO CON)
`CT Spine Cervical, WO iV Contrast (CT SPINE CERVICAL WO CON)
`Foot. Left 3 Views (FOOT 3 VIEWS LT)
`Knee, Left 3 Views (KNEE 3 VIEWS LT)
`Shoulder Complete Left 2 View Minimum (SHOULDER 2 VIEWS LT)
`Tibia/Fibula, Left 2 Views (TIBIA / FIBULA 2 VIEWS LT)
`
`( Oane Today
`EKG INTERPRETATION
`
`& Medications Given
`morphine Last given at 708 PM
`ondansetron (Zofran) | ast yiven at 707 PM
`
`Your End of Visit Vilas
`
`;
`
`‘
`
`» Blood Pressure
`144/87
`Oxygen Saturation
`“100%
`
`frmperane
`‘
`&
`einporal
`Artery)
`«oo
`
`Pulse
`89
`
`Respoeaitiae
`12
`
`What's Next
`You Cunently have So UPCOMING appowmtmoents scheduled
`
`wm ED Treatment Team
`Proweder
`Role
`Frankiln, Jonathan Doyal, MD
`Attending Provider
`
`Fees
`03/20/21 1616
`
`fa
`-
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`a eye ee et
`
`

`

`Assessments
`1. Sprain of ligaments of cervical spine,initial encounter - $13.4XXA (Primary)
`2. Pain in thoracic spine - MS4.6
`3. Sprain of ligaments of lumbarspine,initial encounter - S33.5XXA
`4, Pain ofleft breast - N64.4
`5. Acute pain due to trauma - G89.114
`6. Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter - V89.2XXD
`7. Decreased activities of daily living (ADL) - R68.89
`
`Given the mechanism ofinjury and temporal correlation of symptom onset following the accident, the patient's pain
`and associated symptomsare in reasonable medical probability a direct result of the accident. Patient presents with
`unresolved acute pain symptoms consistent with diagnoseslisted abovethat are impairing daily function and
`decreasing quality oflife. Patient continues to suffer daily pain from multiple pain generators. Recommend continued
`conservative care forall areas of pain in addition to treatmentplan detailed below. All patient questions were invited
`and answered.
`
`DIAGNOSTICS AND RECORDS REVIEWED:
`Records Requested: ER Presby Records, CT Scans, and X-ray.
`
`PLAN:
`
`Will recommend continued conservative managementatthis time. Goals are to restore normal function, relieve pain
`and symptoms, and reduce medication dependency.
`
`MEDICATION: Recommendcontinued use of analgesics. Discontinue Meloxicam.
`“Medications prescribed as below.
`
`THERAPY:Refer to Chiro/PT for evaluation and treatment.
`
`|, AW , transcribed sections of this progress note.
`
`Treatment
`1, Others
`Stop PredniSONE
`Stop Hydrocodone-Acetaminophen
`Start Naproxen Tablet, 500 MG, 1 tablet with food or milk as needed, Orally, every 12 hrs, 30 days, 60 Tablet, Refills
`
`top Meloxicam
`Refill Cyclobenzaprine HCI Tablet, 10 MG, 4 tablet at bedtime as needed, Orally, Once a day, 30 days, 30 Tablet,
`Refills 0
`
`0 S
`
`Revaluation on 4/6/21
`
`Assossments
`1. Sprain of ligaments of cervical spine, initial encounter - $13.4XXA (Primary)
`2. Pain in thoracic spine - M54.6
`3. Sprain ofligaments of lumbarspine, initial) encounter - $33.5XXA
`4, Pain ofleft breast - N64.4
`5. Acute pain due to trauma - G89.11
`
`
`Provider: AMIT ASOPA, MD
`
`Date: 04/06/2021
`
`Revaluation
`
`Assessments
`
`okow
`
`1. Sprain of ligaments of lumbarspine, initiat encounter - S$33.5XXA (Primary)
`2. Traumatic spondylopathy, lumbar region - M48.36
`. Traumatic spondylopathy, lumbosacral region - M48.37
`. Radiculopathy, cervical region - M54,12
`. Other cervical disc displacement, cervicothoracic region - M50.23
`6. Sprain ofligaments of cervical spine, initial encounter - $13.4XXA
`7, Pain in thoracic spine - M54.6
`8, Pain ofleft breast - N64.4
`9. Acute pain due to trauma - G89.11
`10. Person injured in unspecified motor-vehicte accident, traffic, subsequent encaunter - VB9.2XXD
`11. Decreasedactivities of daily living (ADL) - R68.89
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 6 of 16
`
`

`

`Revaluation
`
`Assessments
`1. Sprain ofligaments of lumbarspine,initial encounter - S33.5XXA(Primary)
`2. Traumatic spondylopathy, lumbar region - M48.36
`3. Traumatic spondylopathy, lumbosacral region - M48.37
`4, Radiculopathy, cervical region - M54.12
`5. Other cervical disc displacement, cervicothoracic region - M50.23
`6. Sprain ofligaments of cervical spine,initial encounter - S13.4XXA
`7. Pain in thoracic spine - M54.6
`8. Pain of left breast - N64.4
`9. Acute pain due to trauma - G89.11
`10. Person injured in unspecified motor-vehicle accident,traffic, subsequent encounter - V89.2XXD
`11. Decreased activities of daily living (ADL} - R68.89
`
`Patient continuesto suffer daily pain from multiple pain generators. Recommend continued conservative careforall
`areasofpain in addition to treatment plan detailed below.All patient questions were invited and answered.
`
`\
`
`MOM EN TUM
`“SPINE & JOINT
`
`STEVENS, ALEXIS S$
`58Y old Female, DOB: 08/29/1962
`10317 CANYON LAKE VW, MCKINNEY, TX-75072-8970
`Home: 972-832-7703
`Surgeon: ZESHAN CHAUDHRY, MD
`
`06/18/2021
`
`ZESHAN CHAUDHRY, MD
`
`OPERATIVE REPORT
`
`Pre-op. Diagnosis:
`SPRAIN AND STRAIN OF BACK $33,5XXD
`
`Post-op. Diagnosis:
`1.Sameas pre-op diagnosis
`
`Details of Procedure:
`TITLE OF PROCEDURE:LumbarFacet JointInjection at the LEFT L4-L5 & L5-Si Facets Under Fluoroscopic Guidance.
`ANTOTHECTA MAC
`
`
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page7 of 16
`
`

`

`3. EXAMINATION AT CHIRO CONCEPTS OF MCKINNEY04/02/21
`
`Chart Notes
`Alexis Stevens
`
`Patient: Stevens, Alexis
`
`Ins Co: Thompson Law
`
`Date
`
`04/02/2021
`
`Acct #: 7958
`
`Pol #:
`
`Provider DR. Tyler Rottinghaus, D.C
`
`Subjective:
`Alexis Stevens is a female barn 8/29/1962.
`
`240 Adriatic Pkwy sulte 200
`McKinney, TX 760702604
`Phone: 972-369-1471
`Fax: 214-377-6243
`
`DOB: 08/29/1962
`
`Insured ID:
`
`Patient has nat been seen in the clinic or by its physicians; therefore, is considered a new patient.
`
`CHIEF COMPLAINT:radiating neck pain, headaches, post concussive
`
`mid back an low back
`
`HISTORY OF PRESENTILLNESS:
`
`-Patient Symptoms: sharp, achy,tingling, shoating, numbnesspain.
`
`-Date of First Symptom: 3/20/2021
`
`-How Incident Occurred: motor vehicle collision (MVC)
`
`Alexis was the front passengerof a vehicle that was involved in a motorvehicle collision at the intersectionof Dailas
`Parkway and Alpha. Alexis stated that anothervehicle ran a red light and collided with the front of their vehicel.
`Alexis stated that she was wearing a seatbelt at the time of the collision and reported that the airbags did not deploy
`after the collision. Alexis stated that she has been having a difficult time recalling the details of the collision. She was
`transported to the ER (Presbyterian in Plano) where she had a CT scan performed. After further evaluation and
`treatment she was released from care at the ER and prescribed pain medication. Alexis stated that after being
`released from care at the ER she has continuedto suffer from strong post concussive symptoms (headaches,
`nausea, dizziness, fogginess, difficulty concentrating), radiating neck pain down herleft arm, mid back and tow back
`discomfort. She was unable to work from 3/22/2021-3/29/2021 as a result of the collision. Due to her continued
`discomfort she is seeking further treatment at ChiroConcepts of McKinney.
`
`Alexis was in no discomfort prior ta the callision. The symptoms she developedafter the collision are unlike any
`symptoms she felt previously in her lifetime,
`
`-Location of Symptoms:throughout entire body extending from upper cervical spine to lumbosacraljunction, cervical
`spine radiates down primarily left arm
`
`Diagnosis M54.12: Radiculopathy, cervical region
`F07.81: Postconcussional syndrome
`G44.319: Acute post-traumatic headache,not intractable
`$16.1XXA:Strain of muscle, fascia and tendon at neck level, init
`$29.012A: Strain of back wall of thorax
`$39.012A: Strain of lower back
`M54.2: Cervicalgia
`M54.5: Low back pain
`M54.6: Pain in thoracic spine
`M46.1: Sacroiliitis, not elsewhere classified
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 8 of 16
`
`

`

`5S. FINDINGS OF THE IMAGING STUDIES (NON-CONTRAST MRI OF
`LUMBAR, THORACIC AND CERVICAL SPINE)
`
`Lumbar spine MRI
`impression:
`L4-5 right central/subarticular 4 mm disc herniation.
`
`Electranically signed:
`Or. J. Piko
`Report contentorbilling questions? Call Dallas Radiology, PA: 866-931-3811
`
`Thoracic Spine MRI
`Impression:
`Ne significant thoracic abnormality is identified.
`
`Electronically signed:
`Dr. J. Piko
`Repart contentor billing questions? Cafl Dallas Radiology, PA: 866-931-3811
`
`Cervical spine MRI
`
`impression:
`C4-5 central and right subarticular bilobed disc herniatians and intermediate grade central canal stenosis.
`CS-6 left central and right subarticular bilobed disc herniations and Intermediate grade central canal stenosis.
`Disc bulging at C2-3 and C6-7.
`
`Electronically signed:
`Dr. J. Pike
`Report content orbilling questions? Call Dallas Radiology, PA: 866-931-3811
`
`OPINION/ANALYSIS:
`
`I was askedto review the available records and to opine regarding
`
`¢ Medical Necessity ofthe Facet Joint injection treatments given at Momentum Spine and
`Joint.
`¢ Medical Necessity of further guidance for LESI and Cervical Facet Intra articular
`injections
`
`Anatomyand Physiology of Facet Joints.
`
`The facetjoints (zygapophyseal joints) are located throughout the spine and vary in size and shape
`depending on the vertebral level. They are synovial joints formed by the articular processes
`between two adjacent vertebrae. The superior vertebrae provide the inferior articular process, and
`the inferior vertebrae provide the superior articular process.
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 10 of 16
`
`

`

`4. EXAMINATION AT PT CONCEPTS OF MCKINNEY
`
`PT Concepts of Mckinnay
`240 Adriatic Pkwy, Ste 200
`McKinney, TX 75070-8278
`Phone: (972)369-1471
`Fax: (214)377-6243
`
`Physical Therapy
`initial
`.
`.
`Examination
`
`Patlent Name: Stevens, Alexis
`Date of Birth: 08/29/1962
`Referring Physician(s}: Rotlinghaus , Tyler DC
`
`Visit No.:
`
`1
`
`Dateof Initial Examination: 05/06/2021
`Injury/OnseVChange of Status Date: 03/20/2021
`Diagnosis;
`(CD10: M54.5: Low back pain, M25.552: Pain in
`oft hip, M5S4.2: Cervicaigia, M25.512: Pain in left shoulder,
`M75.42: Impingement syndromeofleft shoulder, M54.6: Pain in
`thoracic spine
`(CD10: M54.5: Low backpain,
`Treatment Diagnosis:
`25.552: Pain in left hip, 54.2: Cervicaigia, M25.512: Pain in
`left shoulder, M75.42: Impingement syndromeof laft shoulder,
`M54.6; Pain in thoracic spine
`
`Subject
`Treatment Side: Left
`History of Present Conaltion/Mechanism of Injury: Patient was involvad in an MVC on 3/20/21. She was the passenger in
`ihe front seat when their carhit a vehicle that ran a fed light. She was not bracing on impact. She was takentc the hospital
`where ee did not revealfractures. Sha reparts L shoulder and thigh pain as well. She gets headaches towards the end of
`ihe day. Sleep has been irregular due to waking up due to L hip and thigh pain, Patient works at a tax office andis al a
`computer mast of har day,
`Primary Concern/Chief Complaint: Patient reports she has increased L Ihigh pain after about 15 minutes of walking asit
`stifens up and loosens up whenshesits and rests. She will get increased L shoulder and neck pain if she raads on her
`computer for tanger periods of time or when she does house work. Her low back is her biggest pain which increases when she
`stands or movesfor longer periods of time.
`Before the Injury/onsat/change of status date, the patient was able to perform the following activities:
`Changing & Maintalning Body Position:
`Carrying, Moving & Handilng Objects:
`Current Functional Limitations:
`Changing & Maintaining Body Position:
`Carrying, Moving & Handling Objects:
`Pain Location: low back
`Pain Scale: Worst: Best: Current: 6
`Pain Description: Sharp
`Pain Follow-up Plan: HEP
`Aggravating Factors: Standing, Walking, Sit to stand, Bending
`
`Assessment
`Assessment/Diagnosis: Patient is a 58 y/o female who has been referred to physical therapy for lumbar, cervical, |. shoulder,
`and L hip pain she acquired after being involved in an MVC two months ago. She has pain with prolonged periods ofsitting or
`standing. She presents with restriclions of the L hip flexors and L shoulderinternal ratators. She also damonstrates weakness
`of the care, L shoulder, and L hip stabilizers. Patient will benefit from skilled physical therapy to address functional deficits.
`Patient Clinical Presentation: The clinical presentation is stable and/or uncomplicated.
`Patient Education: Patient was educated on diagnosis, prognosis, and HEP. They verbalized understanding.
`Following the evaluation and extensive patient education regarding diagnosis, prognosis, and treatment goals, the patient
`(parent/guardian, power of attorney holder) actively participated in the crealion of the current goals and agrees to the current
`treatment plan.
`Rehab Potential: Good
`Contraindications to Therapy: None
`Patient Problems:
`- Prolongedsitting/standing
`Short Term Goals:
`1: (1 Week) | Patient to ba compliant with initial HEP.
`Long Term Goals:
`1: (6 Weeks) | Patient to display 50% improved thoracic rotation ROM.
`2: (4 Weeks) | Patient fo demonstrate 4+/5 L shoulder external rotation strength.
`3: (6 Weeks) | Patient to demonstrate 4+/5 iaower abdominal strength.
`4: (4 Weeks) | Patient to demonstrate 4/5 L lower trap strength.
`5: (6 Weeks) | Patient to demonstrate 5/5Lhip flexor strength.
`6: (8 Weeks) | Patient to telerate 60 minutes of standing without increasing cervical pain.
`7: (6 Weeks) | Patient to be independent with HEP upon D/C.
`8: (6 Weeks) | Patient able to return to work without pain or deficits.
`9: (8 Weeks) | Patient to tolerate 60 minutesofsitting without increasing R hip pain.
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 9 of 16
`
`

`

`5. FINDINGS OF THE IMAGING STUDIES (NON-CONTRAST MRI OF
`LUMBAR, THORACIC AND CERVICAL SPINE)
`
`Lumbar spine MRI
`Impression:
`L4-5 right central/subarticular 4 mm disc herniation.
`
`Electronically signed:
`Dr. J. Piko
`Report content orbilling questions? Call Dallas Radiology, PA: 866-931-3811
`
`Thoracic Spine MRI
`Impression:
`No significant thoracle abnormality is identified.
`
`Etectronically signed:
`Dr.J. Piko
`Report contentorbilling questions? Call Dallas Radiology, PA: 866-931-3811
`
`Cervical spine MRI
`
`Impression:
`c4-5 central and right subarticular bilobed disc herniations and intermediate grade central canal stenosis.
`CS-6 left central and right subarticular bllobed disc herniations and Intermediate grade central canal stenosis.
`Disc bulging at C2-3 and C6-7.
`
`Electronically signed:
`Dr. J. Pika
`Report contentorbiiling questions? Call Dallas Radiology, PA: 866-931-3811
`
`OPINION/ANALYSIS:
`
`I was askedto review the available records and to opine regarding
`
`e Medical Necessity ofthe Facet Joint injection treatments given at Momentum Spine and
`Joint.
`e Medical Necessity of further guidance for LESI and Cervical Facet Intra articular
`injections
`
`Anatomy and Physiology of Facet Joints.
`
`Thefacet joints (zygapophyseal joints) are located throughoutthe spine and vary in size and shape
`depending on the vertebral level. They are synovial joints formed by the articular processes
`between two adjacent vertebrae. The superior vertebrae provide the inferior articular process, and
`the inferior vertebrae provide the superiorarticular process.
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 1U of 16
`
`

`

`Additional features include the articular cartilage overlying the facet of each articular process,
`followed by a layer of the synovial membrane and a tough outer fibrous layer overlying the
`membrane.It is estimated that the joint space has a capacity of 1 to 2 ml.
`
`The facet joint has many functions, including limiting excessive motion, distributing the axial
`load, and preventing displacement from forward and rotational movementsofthe intervertebral
`joint. Facet joint innervation comes from the medial branch ofthe posterior ramusofthe spinal
`nerve. With each facet joint, sensory information is provided through dual innervation from the
`spinal nerve at the same level and one level above.
`
`It is estimated that facet joint pain is the source of pain in up to 67% of patients with neck pain,
`48% of patients with thoracic pain, and up to 45% of patients with low back pain. Dueto therich
`innervation of the synovium, it is thought that pain arising from the facet joint stems from injury
`or inflammation from degenerative arthritis, capsular distension or defects, instability, and
`impinged nerves secondary to osteophytes.
`
`Nociceptive nerve fibers, autonomic nerve fibers, substance p nerve fibers, and inflammatory
`mediators such as prostaglandins and cytokines haveall been implicated in playing a role in facet
`joint pain. Amongstthe different types offacet joint pain etiologies, degenerative osteoarthritis is
`the most common cause. Other causes of facet joint pain include degenerative spondylolisthesis,
`rheumatoid arthritis, ankylosing spondylitis, and septic arthritis.
`
`Based on the U.S. Department of Health & Human Services publication, Noninvasive
`Treatments for Neck and Low Back Pain: Current State of the Evidence, by the Agency for
`Healthcare Research and Quality; February 2016, uncomplicated, non-radicular
`cervical and low back pain is optimally managed by various conservative treatment options
`before proceeding to interventional procedures or surgery. Best practices includetrials of
`several non-invasive, nonpharmacological, and other therapies prior to proceeding with spinal
`injections. When a patient complains of neck and back pain following a motor vehicle
`accident, a pain management professional must obtain a detailed history, perform a
`thorough physical examination and evaluate all the available diagnostic tests to arrive at a
`proper diagnosis. Based upon a well- thought diagnosis, a pain management professional must
`then engage in medical decision-making to design an appropriate treatment plan tailored to
`the unique needs of each patent in consideration of the balance of the risks and the benefits to
`the patent. The decision of which, if any, types of treatment are appropriate for a patent, as
`well as the level, frequency, and duration of the various treatments, should be individualized
`with maximum consideration for safety. This individualized decision must consider the
`patent’s unique circumstances, including his or her (a) Age; (b) Social, family, and medical
`history; (c) Physical condition, limitations, and abilities; (d) Location, nature, and severity of
`the injury and symptoms; and (e) Response to any previous treatment.
`
`Treatment plans should generally start with conservative care that is not invasive, such as
`antinflammatory medications, muscle relaxants, adjuvants, chiropractic care, and/or
`physical therapy, which may benefit patents by healing their injuries and relieving their
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`Page 11 of 16
`
`

`

`Second-Line Pharmacotherapy:
`e Duloxetine. Indicated for the treatment of chronic musculoskeletal
`pain. It is an antidepressant and may haveadditional potential benefits
`for patents in whom there is coexisting depression.
`e Tricyclic antidepressant Nortriptyline is preferred,
`dueto its tolerability, Third-Line Pharmacotherapy:
`e Gabapentin
`Topicals
`
`7. Multimodal care for chronic low back pain - psychological and mind-body therapies, as
`well as movement-based treatment. Forall patients with chronic neck pain, multimodal
`care combining exercise with other therapies has most consistently demonstrated benefit.
`8. Cognitive-behavioral therapy (CBT).
`9. Continue to exercise through a physical therapy provider or another appropriate exercise
`program. Particular exercises that are found to be beneficial include mind-body
`exercise therapies, such as Tai Chi, Qigong, and yoga. These therapies are appropriate for
`patents of all ages and fitness levels and can be performed concurrently with CBT.
`
`The definite diagnosis of Facet Joint Syndrome as the cause of Low Back Pain vs Muscle spasms,
`Myofascial Syndromeas the cause of same pain presentation, is usually not possible clinically.
`
`Hence in such situations where a patient has had NonSpecific Mechanical Acute /Subacute low
`back pain for more than 8 weeks, with lack of definite radiological findings, most Pain
`ManagementPhysicians including myself start with Trigger Point Injections in the local area, 2-3
`times, 1 week apart.
`
`Acupuncture /TP injections often can giverise to relief comparable to more advancedinterventions
`like the Facet Intra articular Injections or Medial Branch Nerve Blocks. Theyare safe, require no
`anesthesia hence the potential complications ofit are avoided.
`
`If acupuncture/ TP injections fail and the symptoms remain constant, Facet interventions with the
`added complication risk of anesthesia can be justified. I would like to emphasize here that there
`are no clear guidelines established that TP injections are a must before Facet interventions.
`
`On detailed review of the available records of Momentum Spine, it is my reasonable
`medical opinion within a reasonable degree of medical certainty: The Facet Joint
`injections, at the time, provided at Momentum Spine and Joint on 6/18/21 were not
`medically necessary.
`
`Going with the same analysis the future recommendation for Cervical Facet Injections
`based on the treatment stage on 7/12/21 is not medically necessary.
`
`I would like to emphasize here that my analysis of the necessity of future treatmentsis
`based ontheclinical datatill the date of recommendation of future treatments.
`
`A patient’s clinical situation can change and hence the treatments must be warranted to
`the best interest of the patient based on thorough assessmentof the clinical continuum.
`
`Page 13 of 16
`
`Alexis Stevens vs. Pablo Morales
`Defendant Pablo Morales Controverting Affidavit of Vivek Mehta, M.D.
`
`

`

`REGARDING THE DIAGNOSIS OF RADICULOPATHY
`
`Lumbar Radiculopathy was diagnosed at Momentum Spine. The diagnoses are not
`supported by objective evidence at the time and place the services were provided.
`
`results in
`inflamed nerve root
`Radiculopathy occurs when a compressed or
`neurological deficits, such as abnormal deep tendon reflexes, numbness, weakness,
`loss of strength and possible muscle atrophy, and specific electrodiagnostic changes.
`Radiculopathy must be compared to radicular pain and referred pain. Radicular pain is a
`particular type of neurogenic pain that occurs when pain radiates from an inflamed or
`compressed nerve root or dorsal root ganglion. Radicular pain follows a predictable
`distribution based on dermatomal/myotomalpatterns resulting from a conduction block. For
`example, a