Contemporary Orthopedics PLLC v. Allstate Property & Casualty Insurance (8/10/2010)
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After receiving physical therapy, the patient still complained of shoulder pain. A prior MRI showed only tendinopathy, but based on a clinical examination, the treating physician believed the patient suffered from a labral tear and ordered a left shoulder arthroscopy. The insurance carrier denied payment for the surgery arguing it was not medically necessary—the physician conducting peer review made this conclusion on the basis of the MRI, which failed to indicate the presence of a tear. To rebut, however, the applicant submitted a post-operative diagnosis and report, and on the basis of this report, the arbitrator concluded that the prior MRI had been wrong and surgery was indeed medically necessary.


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