LCP Report

Board Certified Orthopedic Surgeon
LIFE CARE PLAN
Prepared for Ms. XXXXXXXXXXXXXXXXX

by XXXXXXXX, Board Certified Orthopedic Surgeon Certified Life Care Planner
September 20, 2023
1
Table of Contents
1. Overview .............................................................................................................................................. 4
1.1 Executive Summary ...................................................................................................................... 4
1.2 Life Care Planning & Life Care Plans .......................................................................................... 4
1.3 Biography of Author ..................................................................................................................... 5
1.4 Framework: A Life Care Plan for Ms. XXXXXXXXXXXXXXXXX......................................... 5
2. Summary of Records........................................................................................................................... 7
2.1 Summary of Medical Records....................................................................................................... 7
3. Interview & Examination ................................................................................................................. 21
3.1 History of Present Injury/Illness ................................................................................................. 21
3.2 Physical Examination: ................................................................................................................ 21
3.3 Current Symptoms: Neck pain, upper back pain, and lower back pain. ..................................... 21
3.4 Activities of Daily Living: .......................................................................................................... 22
3.5 Review of Systems:..................................................................................................................... 22
3.6 Past Medical History: .................................................................................................................. 22
3.7 Past Surgical History: ................................................................................................................. 22
3.8 Injections:.................................................................................................................................... 22
3.9 Family History: ........................................................................................................................... 23
3.10 Allergies: ..................................................................................................................................... 23
3.11 Drug and Other Allergies: ........................................................................................................... 23
3.12 Medications: ................................................................................................................................ 23
3.13 Assistive Device: ........................................................................................................................ 23
3.14 Social History: ............................................................................................................................ 23
3.15 Education History: ...................................................................................................................... 23
3.16 Professional/Work History:......................................................................................................... 23
3.17 Habits: ......................................................................................................................................... 23
3.18 Tobacco use: ............................................................................................................................... 23
3.19 Alcohol use: ................................................................................................................................ 23
3.20 Illicit drugs: ................................................................................................................................. 23
3.21 Avocational Activities: ............................................................................................................... 23
3.22 Residential Situation: .................................................................................................................. 23
3.23 Transportation: ............................................................................................................................ 23
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3.24 Household Responsibilities: ........................................................................................................ 23
4. Central Opinions ............................................................................................................................... 23
4.1 Diagnostic Conditions................................................................................................................. 23
4.2 Consequent Circumstances ......................................................................................................... 24
5. Future Medical Requirements ......................................................................................................... 27
5.1 Physician Services ...................................................................................................................... 28
5.2 Routine Diagnostics .................................................................................................................... 28
5.3 Medications ................................................................................................................................. 28
5.4 Laboratory Studies ...................................................................................................................... 28
5.5 Rehabilitation Services ............................................................................................................... 28
5.6 Equipment & Supplies ................................................................................................................ 28
5.7 Environmental Modifications & Essential Services ................................................................... 28
5.8 Acute Care Services .................................................................................................................... 28
6. Cost/Vendor Survey .......................................................................................................................... 28
6.1 Methods, Definitions & Discussion ............................................................................................ 29
7. Cost Analysis ..................................................................................................................................... 49
7.1 Definition & Discussion of Quantitative Methods ..................................................................... 49
7.2 Summary Restatement of Central Opinions................................................................................ 50
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1. Overview
1.1 Executive Summary

This Life Care Plan (this “Report”) has been prepared for Ms. XXXXXXXXXXXXXXXXX, a
23-year-old, right-hand dominant female who sustained multiple injuries to her head, neck, upper
back, low back, right and left shoulder after motor vehicle collision on June 10, 2022.
The total nominal value of Ms. XXXXXXXX’s future medical requirements, as formulated in
this life care plan, and which pertain to her relevant diagnostic conditions and disabilities =
$1,621,532.47.
1.2 Life Care Planning & Life Care Plans
1.2.1 Life Care Planning
Life care planning is a process of applying objective methodological analysis to formulate

diagnostic conclusions and opinions regarding physical and/or mental impairment and disability
for the purpose of determining care requirements for individuals with permanent or chronic
medical conditions.
According to the tenets, methods and best practices advocated by the American Academy of
Physician Life Care Planners, a life care planner’s primary objective is to achieve the Clinical
Objectives of Life Care Planning by answering the Basic Questions of Life Care Planning.
The Clinical Objectives of Life Care Planning:
1. Diminish or eliminate physical and psychological pain and suffering.
2. Reach and maintain the highest level of function given an individual’s unique
circumstance.
3. Prevent complications to which an individual’s unique physical and mental conditions
predispose them.
4. Afford the individual the best possible quality of life in light of their condition1.
The Basic Questions of Life Care Planning:
1. What is a subject’s condition?
2. What medically-related goods and services does a subject’s condition require?
3. How much will the medically-related goods and services cost over time?2
1
American Academy of Physician Life Care Planners, A Physician’s Guide to Life Care Planning: Tenets, Methods, and Best
Practices for Physician Life Care Planners, American Academy of Physician Life Care Planners, Austin, Texas, 2017.
2
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1.2.2 Life Care Plans
Life care plans are comprehensive documents that objectively identify the residual medical
conditions and ongoing care requirements of ill/injured individuals, and they quantify the costs of
supplying these individuals with requisite, medically-related goods and services throughout
probable durations of care.
The content and structure of a life care plan, and the methods used to produce it, are based upon
comprehensive assessments, interviews and/or examinations, research and analysis, and
published methodologies and standards of practice.
Life care plans are objective works that provide material evidence regarding the existence,
significance and validity of an individual's medical conditions. They provide litigators, insurance
companies, trusts and courts with a qualified, quantitative, and reference able basis upon which to
assess and substantiate the monetary value of an individual's future medical needs.3
1.3 Biography of Author (REDACTED)
1.4 Framework: A Life Care Plan for Ms. XXXXXXXXXXXXXXXXX
1. It is my hope this life care plan will serve as a guide for Ms.
XXXXXXXX, and/or her family, case managers and health care providers.
This life care plan has been formulated to provide optimal medical care in
an effort to accomplish the Clinical Objectives of Life Care Planning.
2. This life care plan employs an anticipatory (preventative) model of care,

and its formulation relies upon reasonable degrees of medical probability.
It should be understood; this life care plan is not a prescription for care.
Rather, it represents a logical model of care which anticipates the
medically-related goods and services that will likely be required by Ms.
XXXXXXXX throughout her probable duration of care. This life care plan
may be utilized as a case management tool, and for the purpose of
substantiating appropriate medically-related financial reserves.
3. My best effort has been made to consider and utilize all past medical,
social, psychological, educational, vocational, and rehabilitation data to the
extent they are available and applicable. When possible, the goals and
desires of Ms. XXXXXXXX and/or her family are expressed within this
life care plan, if they are known, and if I believe they support her best
interests. To accomplish the Clinical Objective of Life Care Planning, I
have relied upon my education, training, skill, and professional experience
as a practicing physician, Board Certified orthopedic surgeon and Certified
Independent Medical Examiner.
3
Gonzales JG, Zotovas A. Life Care Planning: A Natural Domain of Physiatrist. PM&R: The Journal of Injury Function and
Rehabilitation. 2013; Volume 6, Issue 2, 184 – 187
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4. Consideration has been afforded to prospective phase changes due to aging
and the progression of Ms. XXXXXXXX’s relevant diagnostic conditions
and disabilities. Employing an anticipatory/preventative model of care, I
have also considered probable complications likely to be associated with
Ms. XXXXXXXX’s diagnostic conditions, disabilities and/or
comorbidities.
5. This Life Care Plan presumes that optimal medical care positively
affects life expectancy and overall health outcomes for individuals with
lifelong and/or long-term medical conditions, as optimal medical care is
presumed to mitigate many potential risk factors and complications
associated with Ms. XXXXXXXX’s known medical conditions.
6. I consider all future medical requirements in this Life Care Plan’s Cost
Analysis medically necessary, and I consider them specifically attributable
to the medical conditions which resulted from Ms. XXXXXXXX’s
accident, which is reported to have occurred on June 10, 2022.
7. It is my opinion Ms. XXXXXXXX will have progressive symptoms, as well as, physical
and psychological impairments and disabilities, which require lifelong medical care.
8. It is my professional medical opinion that Ms. XXXXXXXX’s diagnostic conditions and

consequent circumstances will adversely impact her vocational and avocational activities
and opportunities, as well as her and her family’s general quality of life.
The opinions and conclusions expressed herein reflect my opinions and conclusions at the time
this Life Care Plan was prepared. I hereby expressly reserve the right to modify and/or amend
my opinions and/or conclusions should additional information become available, or should it
become necessary for me to supplement and/or update this Report in the future, or should I have
an opportunity to perform an in-person interview and examination of Ms. XXXXXXXX.
Please do not hesitate to contact me if you have any questions.
XXXXXXXX, MD
Board Certified Orthopedic Surgeon
Certified Life Care Planner
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2. Summary of Records
This Summary of Records (“Summary”) is a chronological synopsis of Ms.
XXXXXXXXXXXXXXXXX’s medical records, and other relevant documents, presented first
by facility, and then by treating physicians and/or other relevant medical personnel. For the
purpose of determining Ms. XXXXXXXXXXXXXXXXX diagnostic conditions and consequent
circumstances, I have reviewed and considered the medical records and/or other records
summarized herein.
2.1 Summary of Medical Records
2.1.1 Sources
1. Cedars Sinai- Los Angeles, CA.
Sharon Tang, M.D.
Karen Williams, R.N.
Elizabeth Jackson, R.N.
Patrick Reyes
2. Anil Date, M.D. – Canyon County, CA.

Anil Date, M.D.
3. Elyasi Chiropractic- Los Angeles, CA.

Pouriya Elyasi, D.C.
4. United Medical Imaging- Los Angeles, CA.

Quazi Zubair Al-Tariq, M.D.
5. TBI Specialist- Los Angeles, CA.

Jonathan Joseph Eskenazi, M.D.
Emmanuel Marseille, P.A.
6. NILA- Los Angeles, CA.

Cameron Adams, M.D.
7. Elite Spine and Pain Institute- Los Angeles, CA.

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Ben Shamloo, M.D.
Bahman Shamloo, M.D.
8. Shin Imaging Center- Los Angeles, CA.

Omid Jafari, M.D.
Jin Seung, M.D.
9. Bio Health Surgical Institute- Santa Monica, CA.

Ben Shamloo, M.D.
Bahman Shamloo, M.D.
10. Mao Medical Group- Los Angeles, CA.

Shan Mao, L.Ac. M.S.
11. Elite Medical Clinic- Los Angeles, CA.

Houman Kashani, M.D.
2.1.2 Chronological Synopsis of Medical Records

Medical Summary
June 10, 2022: Ms. XXXXXXXX had an emergency visit with Sharon Tang, M.D. at Cedars
Sinai and complained of dizziness and headaches. Physical examination was performed and
she was diagnosed with the following:
Diagnosis:
1. Motor vehicle accident, initial encounter.
2. Concussion without loss of consciousness, initial encounter.
Plan: The doctor prescribed acetaminophen (Tylenol) and ondansetron (Zofran). The doctor also
recommended cutting back on using phone and television. Ms. XXXXXXXX was discharged on
the same day.
June 13, 2022: Ms. XXXXXXXX had a telemedicine visit with Anil Date, M.D. and
complained of dizziness, headaches, and tension, tightness and soreness in neck, lower back,
right and left shoulder. The intensity of pain was rated 7 on the scale of 1-10. Physical
examination was performed and she was diagnosed with the following:
Diagnosis:
1. Motor vehicle accident- V89.2XXA.
2. Acute pain- G89.1
3. Muscle spasms- M62.830.
4. Post- traumatic headache- G44.309.
5. Brain concussion- S06.0X0A.
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6. Dizziness- R42.
7. Neck pain- M54.2.
8. Low back pain- M54.5.
9. Right shoulder pain- M25.511.
10. Left shoulder pain- M25.512.
Plan: The doctor prescribed Tramadol, Naprosyn and Flexeril, and referred to chiropractor,
acupuncture, extra massages and physical therapy for neck and shoulder pains. The doctor
recommended MRI of brain, right shoulder, left shoulder, cervical spine and lumbar spine all
without contrast. The doctor further recommended to follow-up.
June 14, 2022: Ms. XXXXXXXX had a chiropractic consultation evaluation visit with Pouriya
Elyasi, D.C. at Elyasi Chiropractic and complained of headache with dizziness, ringing in ears,
sleep disturbances, and pain in neck, upper/ mid back, lower back, and bilateral shoulders. The
intensity of neck pain was rated 8 on the scale of 1-10 and the intensity of lower back pain was
rated 9 on the scale of 1-10. Physical examination was performed and she was diagnosed with
the following:
Diagnosis:
1. Acute post- traumatic headache- G44.319.
2. Dizziness- R42.
3. Sprain of ligaments of cervical spine- S13.4XXA.
4. Radiculitis, cervical spine- M54.12.
5. Strain of muscles, fascia and tendon at cervical region- S16.1XXA.
6. Pain in thoracic spine- M54.6.
8. Sprain of ligaments of lumbar spine- S33.5XXA.
9. Lumbar radiculitis- M54.16.
10. Strain of muscles, fascia and tendon at lumbar region- S39.012A.
11. Acute pain due to trauma- G89.11.
12. Muscle spasm- M62.40.
Plan: The doctor recommended slight/ moderate chiropractic manipulation to the cervical,
thoracic and lumbar spine along with electrical stimulation, ultrasound therapy, soft tissue
mobilization, laser therapy and mechanical traction 2-3 times a week.
June 15, 2022: Ms. XXXXXXXX had a neurological consultation visit with Jonathan Eskenazi,
M.D. at TBI Specialist and complained of left-sided headaches associated with nausea, dizziness,
imbalance, ringing in ears, pain in neck radiating to shoulders and upper back, bilateral shoulders
and arm, pain in upper back, lower back radiating to legs, and pain in left hand. The intensity of
headaches was rated 8 on the scale of 1-10 and the intensity of lower back, shoulder and arm
pain was rated 7 on the scale of 1-10. Physical examination was performed and she was
diagnosed with the following:
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Diagnosis:
1. Traumatic brain injury with loss of consciousness.
2. Post-concussive syndrome.
3. Rule out traumatic disequilibrium syndrome.
4. Post-concussive headache.
5. Post-traumatic neck strain with radiation r/o radiculopathy.
6. Lower back spasms.
Treatment provided: VAT combo with ENG and vestibular exercises.

Plan: The doctor recommended greater and lesser occipital nerve block and trigger point
injections, chiropractic therapy, and pain management consultation for upper and lower back
pain. The doctor also recommended for advance MRI of the brain without contrast with SWI and
DTI and volumetric analysis, MRI of cervical spine and EMG NCS r/o radiculopathy. The doctor
further recommended for neurological follow-up in 2-3 months.
June 15, 2022: Ms. XXXXXXXX visited Neurological Institute of Los Angeles (NILA) and
underwent an EEG obtained by Jonathan Joseph Eskenazi, M.D. The findings revealed a normal
EEG study in the wake and drowsy state.
June 16, 2022: Ms. XXXXXXXX had a consultation visit with Ben Shamloo, M.D. at Elite
Spine and Pain Institute and complained of pain in bilateral neck, upper back and lower back
radiating to bilateral elbows and legs to feet. The intensity of neck and upper back pain was rated
7 on the scale of 1-10. Physical examination was performed and she was diagnosed with the
following:
Diagnosis:
1. Status post MVA.
2. Cervical spondylosis.
3. Cervical radiculitis.
4. Myofascial pain.
5. Lumbar spondylosis.
6. Lumbar radiculitis.
Plan: The doctor ordered cervical and lumbar MRI, and prescribed Mobic and tizanidine. The
doctor recommended mild physical therapy for neck and low back, to continue chiropractic
treatment and to continue physical therapy at home.
June 27, 2022: Ms. XXXXXXXX visited Neurological Institute of Los Angeles (NILA) and
underwent EMG/ Nerve Conduction Study obtained by Cameron Adams, M.D. The findings
revealed a normal study.
June 27, 2022: Ms. XXXXXXXX visited TBI Specialist and underwent the following
procedures performed by performed by Jonathan Joseph Eskenazi, M.D.
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Procedures performed:
1. Cervical paraspinal, trapezius and splenious bilateral trigger point injections.
2. Nerve block, bilateral greater and lesser occipital nerve block.
July 01, 2022: Ms. XXXXXXXX visited United Medical Imaging and underwent MRI of the
Cervical Spine without Contrast, MRI of the Left Shoulder without Contrast, MRI of the
Right Shoulder without Contrast, and MRI of the Lumbar Spine without Contrast obtained
by Quazi Zubair Al-Tariq, M.D. The findings revealed the following:
MRI of the Cervical Spine without Contrast: No significant disc herniation with no significant
central canal or neural foraminal stenosis.
MRI of the Left Shoulder without Contrast: Tenosynovitis of the long head of the biceps
tendon.
MRI of the Right Shoulder without Contrast: Tenosynovitis of the long head of the biceps
tendon.
MRI of the Lumbar Spine without Contrast:
1. A 2.1 mm posterior disc bulge at L2-L3. No significant facet arthropathy. No significant
2. A 3.2 mm posterior disc bulge at L3-L4. No significant facet arthropathy. Mild central
canal stenosis and mild bilateral neuroforaminal narrowing.
3. A 2.8 mm posterior disc bulge at L4-L5. No significant facet arthropathy. Mild to
moderate central canal stenosis and mild bilateral neuroforaminal narrowing.
4. A 2.5 mm posterior disc bulge at L5-S1. There were congenitally short pedicles. No
significant facet arthropathy. Moderate central canal stenosis and mild bilateral
neuroforaminal narrowing.
July 15, 2022 through November 03, 2022: Ms. XXXXXXXX had a consultation visit with
Ben Shamloo, M.D. at Elite Spine and Pain Institute and complained of pain in bilateral neck,
bilateral upper back, bilateral lower back, bilateral elbows, bilateral legs and feet. The intensity
of neck and upper back pain was rated 7 on the scale of 1-10. Physical examination was
performed and she was diagnosed with the following:
Diagnosis:
1. Status post MVA.
4. Myofascial pain.
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MRI of the Cervical Spine without Contrast, MRI of the Left Shoulder without Contrast, MRI of
the Right Shoulder without Contrast, and MRI of the Lumbar Spine without Contrast dated July
01, 2022 were reviewed.
Plan: On July 15, 2022, the doctor recommended to schedule for bilateral L3-4, L4-5, L5-S1
transforaminal injection and to consider bilateral shoulder PRP injection. The doctor also
recommended continuing physical therapy, chiropractic care and supplements. On August 26,
2022, the doctor recommended obtaining procedure report of bilateral shoulders, to consider
bilateral shoulder PRP injections and to continue physical therapy for neck and low back and
chiropractic care. The doctor also recommended to follow-up in 2 weeks. On September 26,
2022, the doctor recommended to schedule for bilateral PRP injection, and L3-4, L4-5, L5-S1
disco gram for endoscopic laser micro discectomy. The doctor also recommended obtaining MRI
of lumbar spine, to continue physical therapy, chiropractic care and supplements. On November
03, 2022, the doctor recommended to schedule for L3-4, L4-5, L5-S1 disco gram for endoscopic
laser micro discectomy. The doctor also recommended obtaining MRI of lumbar spine, to
continue physical therapy, chiropractic care and supplements.
July 18, 2022 through October 18, 2022: Ms. XXXXXXXX had a chiropractic re-evaluation
visit with Pouriya Elyasi, D.C. at Elyasi Chiropractic and complained of headache with
dizziness, ringing in ears, sleep disturbances, and pain in neck, upper/ mid back, lower back, and
bilateral shoulders. Physical examination was performed and she was diagnosed with the
following:
Diagnosis:
1. Acute post- traumatic headache- G44.319.
2. Dizziness- R42.
3. Sprain of ligaments of cervical spine- S13.4XXA.
4. Radiculitis, cervical spine- M54.12.
5. Strain of muscles, fascia and tendon at cervical region- S16.1XXA.
8. Sprain of ligaments of lumbar spine- S33.5XXA.
9. Lumbar radiculitis- M54.16.
10. Strain of muscles, fascia and tendon at lumbar region- S39.012A.
Plan: On July 18, 2022 and August 24, 2022, the doctor recommended continuing with
chiropractic care and physiotherapy. The doctor also recommended to follow-up with neurologist
and pain management specialist. On October 18, 2022, the doctor advised to continue with pain
management specialist and neurologist for bilateral lower extremities.
August 09, 2022: Ms. XXXXXXXX visited Shin Imaging Center and underwent MRI of the
Brain without Contrast, Volumetric; Diffusion Tensor Imaging Analysis of the Brain and
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MRI of the Brain without Contrast obtained by Omid Jafari, M.D. The findings revealed the
following:
MRI of the Brain without Contrast, Volumetric: Parenchymal and cortical grey matter
volumes were within normal statistical variations.
Diffusion Tensor Imaging Analysis of the Brain:
1. Many of the analysed white matter structures demonstrate mean fractional anisotropy
within the normal range (above 10th percentile) of an age- matched normative database.
2. Asymmetry of the corticospinal tract, superior longitudinal- arcuate fasciculus and
cingulum were approaching abnormal (between the 1st and 10th percentile of the
normative mean).
3. Traumatic brain injury can lower symmetry levels and manifest in brain asymmetry that
deviates from a normal state.
MRI of the Brain without Contrast:

1. Cavum septum pellucidum, more prevalent in the setting of traumatic brain injury.
2. Non-specific 6 mm foci of T2/ FLAIR hyper intensity involving the left posterior
periventricular white matter, unclear etiology.
3. Foci of old post- traumatic micro hemorrhage involving the inferior left frontal lobe.
4. Increase in perivascular space burden, which can be seen in the setting of mild traumatic
brain injury.
5. Questionable susceptibility artefact seen involving the right orbit and globe likely
artefact.
6. No acute infract. No acute intracranial hemorrhage.
August 10, 2022: Ms. XXXXXXXX visited Bio Health Surgical Institute and underwent
bilateral lumbar transforaminal steroid injection at L3-4, L4-5 and L5-S1 levels under
fluoroscopy performed by Ben Shamloo, M.D.
August 25, 2022: Ms. XXXXXXXX had an office visit with Jonathan Eskenazi, M.D. at TBI
Specialist and was diagnosed with the following:
Diagnosis:
2. Diffuse axonal injury.
3. Post- concussive syndrome.
4. Traumatic disequilibrium syndrome.
5. Post- concussive headache.
6. Post- traumatic neck strain with radiation r/o radiculopathy.
Plan: The doctor referred for CT scan of brain.

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November 03, 2022: Ms. XXXXXXXX had an office visit with Shan Mao, L.Ac. M.S. at Mao
Medical Group and complained of pain in neck, upper mid-back with stiffness and lower back
pain radiating to the bilateral lower extremities. Physical examination was performed and she
was diagnosed with the following:
Diagnosis:
1. Cervicalgia- M54.2.
2. Cervical sprain/ strain- S16.1XXA.
4. Lumbar sprain/ strain- S33.5XXA.
5. Lumbago- M54.40.
6. Lumbar radiculopathy- M54.16.
MRI of the Cervical Spine and MRI of the Lumbar Spine dated July 01, 2022 were reviewed.
Plan: The doctor ordered treatment including Acupuncture, Acupressure and Infrared
emphasizing active Myofascial (soft tissue) therapy 2 times a week till February 21, 2023. The
doctor further recommended to continue stretching regime.
November 09, 2022: Ms. XXXXXXXX visited Shin Imaging Center and underwent CT scan of
the Brain without Contrast obtained by Omid Jafari, M.D. The findings revealed the following:
1. No acute intracranial hemorrhage.
2. The previously visualized susceptibility artefact in the right orbit and globe was likely
artificial in etiology. No abnormalities were seen on CT of the head.
December 07, 2022: Ms. XXXXXXXX visited Bio Health Surgical Institute and underwent the
following procedures performed by Bahman Shamloo, M.D.:
1. Level L3-4, L4-5 and L5-S1 level disco gram.
2. Intraoperative fluoroscopy.
December 28, 2022: Ms. XXXXXXXX had a neurological consultation visit with Jonathan
Eskenazi, M.D. at TBI Specialist and complained of headaches associated with dizziness,
imbalance, and ringing in ears, feeling depressed, difficulty in concentrating and focusing and
pain in neck. Physical examination was performed and she was diagnosed with the following:
Diagnosis:
14
MRI of the Brain without Contrast, Volumetric; Diffusion Tensor Imaging Analysis of the Brain
and MRI of the Brain without Contrast dated August 09, 2022 were reviewed.
Plan: The doctor recommended repeating greater and lesser occipital nerve block and trigger
point injections and repeating VAT combo with ENG and vestibular exercises. The doctor also
recommended to consult pain management for neck, upper back and lower back pain, for a
neuropsych evaluation and to follow-up in 2-3 months.
December 28, 2022: Ms. XXXXXXXX visited TBI Specialist and underwent the following
procedures performed by Jonathan Joseph Eskenazi, M.D.
1. Bilateral greater and lesser occipital nerve block.
2. Bilateral cervical (cervical paraspinal, trapezius and splenious) trigger point injection.
January 10, 2023: Ms. XXXXXXXX had an office visit with Anil Date, M.D. for pre-operative
clearance. Physical examination was performed and she was diagnosed with the following:
Diagnosis:
1. Pre-operative clearance- Z01.818.
2. Low back pain- M54.5.
Plan: The doctor recommended Ms. XXXXXXXX to be NPO except medications past midnight
on the day of the procedure and recommended not to take naproxen 5 days prior to surgery.
January 18, 2023: Ms. XXXXXXXX visited Bio Health Surgical Institute and underwent the
following procedures performed by Bahman Shamloo, M.D.:
1. L3-4 percutaneous endoscopic decompression with radiofrequency.
2. Intraoperative fluoroscopy.
February 09, 2023 through May 11, 2023: Ms. XXXXXXXX had a consultation visit with
Bahman Shamloo, M.D. at Elite Spine and Pain Institute and complained of pain in bilateral
neck, bilateral upper back, elbows, bilateral lower back, bilateral legs and feet. The intensity of
neck and upper back pain was rated 7 on the scale of 1-10. Physical examination was performed
and she was diagnosed with the following:
Diagnosis:
1. Status post motor vehicle accident.
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4. Myofascial pain.
5. Bilateral shoulder pain.
MRI of the Cervical Spine without Contrast, MRI of the Left Shoulder without Contrast, MRI of
the Right Shoulder without Contrast, and MRI of the Lumbar Spine without Contrast dated July
01, 2022 were reviewed.
Plan: On February 09, 2023, the doctor prescribed Tizanidine and recommended at-home
chiropractic treatment with lumbar traction twice a week for 6 weeks. The doctor also
recommended continuing physical therapy with home training exercises, to continue
acupuncture, chiropractic care and supplements. The doctor further recommended to follow-up
in 2 weeks. On March 07, 2023, the doctor prescribed Mobic and Tizanidine, and recommended
to consider repeating lumbar MRI. The doctor also recommended continuing at home
chiropractic treatment, physical therapy with home training exercises, acupuncture and
supplements. On March 16, 2023, the doctor prescribed Medrol pack, ordered MRI of lumbar
spine (STAT) and referred to spine surgeon. The doctor recommended chiropractic treatment
with lumbar traction, and continuing acupuncture, at home physical therapy and supplements. On
April 13, 2023, the doctor prescribed Medrol pack, referred to spine surgeon, and recommended
bilateral L3-4, L4-5and L5-S1 transforaminal injection. The doctor also recommended
chiropractic treatment with lumbar traction, and continuing acupuncture, at home physical
therapy and supplements. On May 11, 2023, the doctor referred to spine surgeon, and
recommended chiropractic treatment with lumbar traction, and continuing acupuncture, at home
physical therapy and supplements.
February 22, 2023: Ms. XXXXXXXX had a consultation visit with Jonathan Eskenazi, M.D. at
TBI Specialist and complained of headaches associated with dizziness, imbalance, ringing in
ears, occasional blurred or double vision, eye pain, ear pain, sensitivity to light or sound, feeling
depressed, difficulty in concentrating and focusing, and pain in neck radiating to shoulders and
lower back pain radiating to right leg. Physical examination was performed and she was
diagnosed with the following:
Diagnosis:
6. Post- traumatic neck strain.
16
Plan: The doctor recommended greater and lesser occipital nerve block and trigger point
injections, a neuropsych evaluation, and to repeat VAT combo with ENG and vestibular
exercises. The doctor also recommended to follow-up with chiropractic therapy, pain
management and for a neurologic follow-up in 2-3 months.
March 06, 2023: Ms. XXXXXXXX had a chiropractic consultation evaluation visit with
Pouriya Elyasi, D.C. at Elyasi Chiropractic and complained of lumbar spine pain with radiation
to bilateral lower extremities with numbness and tingling sensations in bilateral lower extremities
associated with muscular spasm. The intensity of pain was rated 7-9 on the scale of 1-10.
Physical examination was performed and she was diagnosed with the following:
Diagnosis:
1. Acute post-operative pain- G89.18.
2. Lumbar radiculopathy- M54.16.
Plan: The doctor recommended treatment including Electrical Stimulation, Ultrasound Therapy,
Soft Tissue Mobilization (Manual Therapy), Laser Therapy, Mechanical Traction, Therapeutic
Exercises and Therapeutic Activities twice a week for 6 weeks.
March 16, 2023: Ms. XXXXXXXX had an office visit with Bahman Shamloo, M.D. at Elite
Spine and Pain Institute and was diagnosed with the following:
Diagnosis:
1. Status post motor vehicle accident.
2. Status post lumbar endoscopic discectomy.
Plan: The doctor ordered MRI of the lumbar spine without contrast.
April 04, 2023: Ms. XXXXXXXX visited United Medical Imaging and underwent MRI of the
Lumbar Spine without Contrast obtained by Quazi Zubair Al- Tariq, M.D. The findings
revealed the following:
1. A 2.5 mm posterior disc bulge at L2-L3. There was mild facet arthropathy. There was
mild bilateral neural foraminal narrowing. The central canal was patent.
2. A 3.6 mm posterior disc bulge at L3-L4. There was no significant facet arthropathy.
There was mild bilateral neural femoral narrowing. The central canal was patent.
mild central canal stenosis and mild bilateral neural foraminal narrowing.
17
4. A 3.5 mm posterior disc bulge at L5-S1. There was mild facet arthropathy. There was
mild to-moderate central canal stenosis and mild bilateral neural foraminal narrowing.
April 12, 2023: Ms. XXXXXXXX had a final re- examination visit with Pouriya Elyasi, D.C. at
Elyasi Chiropractic and complained of lumbar spine pain. Physical examination was performed.
Plan: The doctor recommended to follow-up with the micro discectomy surgeon. Ms.
XXXXXXXX has reached the maximum benefit from the conservative treatment in the form of
chiropractic and physiotherapy.
April 26, 2023: Ms. XXXXXXXX visited Bio Health Surgical Institute and underwent bilateral
lumbar transforaminal steroid injection at L3-4, L4-5, and L5-S1 levels under fluoroscopy
performed by Bahman Shamloo, M.D.
May 11, 2023: Ms. XXXXXXXX had a neurological consultation visit with Jonathan Eskenazi,
M.D. at TBI Specialist and complained of headaches on the back of her head associated with
blurry vision, dizziness, imbalance, difficulty in concentrating and focusing, pain in neck and
lower back radiating to legs. The intensity of headaches and lower back pain was rated 7 on the
scale of 1-10, and the intensity of neck pain was rated 6-8 on the scale of 1-10. Physical
examination was performed and she was diagnosed with the following:
Diagnosis:
Plan: The doctor recommended continuing greater and lesser occipital nerve block and trigger
point injections and for a pain management consultation. The doctor also recommended a
neuropsych evaluation, repeating VAT combo with ENG and vestibular exercises, and a
neurological follow-up in 6 months.
May 11, 2023: Ms. XXXXXXXX visited TBI Specialist and underwent the following
procedures performed by Jonathan Joseph Eskenazi, M.D.
1. Bilateral greater and lesser occipital nerve block.
2. Bilateral cervical paraspinal, trapezius and splenious trigger point injections.
18
July 06, 2023: Ms. XXXXXXXX had an office visit with Houman Kashani, M.D. at Elite
Medical Clinic for pre-operative examination for lumbar spine surgery. Physical examination
was performed.
Ms. XXXXXXXX underwent Electrocardiogram and X-Ray of Chest, 2 views. The findings
revealed the following:
Electrocardiogram: Normal EKG.
X-Ray of Chest, 2 views: Normal exam.
July 06, 2023: Ms. XXXXXXXX visited Shin Imaging Center and underwent X-Ray of Chest,
2 views obtained by Jin Seung, M.D. The findings revealed the following:
1. No acute cardiopulmonary disease.
2. Scoliosis suspected.
August 28, 2023: Ms. XXXXXXXX visited TBI Specialist and underwent bilateral greater and
lesser occipital nerve block performed by Jonathan Joseph Eskenazi, M.D.
• Noteworthy Consideration
2.1.2.1 Diagnostics
June 15, 2022
EEG: The findings revealed a normal EEG study in the wake and drowsy state.
June 27, 2022
EMG/ Nerve Conduction Study: The findings revealed a normal study.
July 01, 2022
MRI of the Cervical Spine without Contrast: No significant disc herniation with no significant
MRI of the Left Shoulder without Contrast: Tenosynovitis of the long head of the biceps
tendon.
MRI of the Right Shoulder without Contrast: Tenosynovitis of the long head of the biceps
tendon.
MRI of the Lumbar Spine without Contrast: The findings revealed the following:
1. A 2.1 mm posterior disc bulge at L2-L3. No significant facet arthropathy. No significant
2. A 3.2 mm posterior disc bulge at L3-L4. No significant facet arthropathy. Mild central
canal stenosis and mild bilateral neuroforaminal narrowing.
19
3. A 2.8 mm posterior disc bulge at L4-L5. No significant facet arthropathy. Mild to
moderate central canal stenosis and mild bilateral neuroforaminal narrowing.
4. A 2.5 mm posterior disc bulge at L5-S1. There were congenitally short pedicles. No
significant facet arthropathy. Moderate central canal stenosis and mild bilateral
neuroforaminal narrowing.
August 09, 2022
MRI of the Brain without Contrast, Volumetric: Parenchymal and cortical grey matter
volumes were within normal statistical variations.
Diffusion Tensor Imaging Analysis of the Brain: The findings revealed the following:
1. Many of the analysed white matter structures demonstrate mean fractional anisotropy
within the normal range (above 10th percentile) of an age- matched normative database.
2. Asymmetry of the corticospinal tract, superior longitudinal- arcuate fasciculus and
cingulum were approaching abnormal (between the 1st and 10th percentile of the
normative mean).
3. Traumatic brain injury can lower symmetry levels and manifest in brain asymmetry that
deviates from a normal state.
MRI of the Brain without Contrast: The findings revealed the following:
1. Cavum septum pellucidum, more prevalent in the setting of traumatic brain injury.
2. Non-specific 6 mm foci of T2/ FLAIR hyper intensity involving the left posterior
periventricular white matter, unclear etiology.
3. Foci of old post- traumatic micro hemorrhage involving the inferior left frontal lobe.
4. Increase in perivascular space burden, which can be seen in the setting of mild traumatic
brain injury.
5. Questionable susceptibility artefact seen involving the right orbit and globe likely
artefact.
6. No acute infract. No acute intracranial hemorrhage.
November 09, 2022
CT scan of the Brain without Contrast: The findings revealed the following:
1. No acute intracranial hemorrhage.
2. The previously visualized susceptibility artefact in the right orbit and globe was likely
artificial in etiology. No abnormalities were seen on CT of the head.
April 04, 2023
MRI of the Lumbar Spine without Contrast: The findings revealed the following:
20
mild bilateral neural foraminal narrowing. The central canal was patent.
2. A 3.6 mm posterior disc bulge at L3-L4. There was no significant facet arthropathy.
There was mild bilateral neural femoral narrowing. The central canal was patent.
mild central canal stenosis and mild bilateral neural foraminal narrowing.
4. A 3.5 mm posterior disc bulge at L5-S1. There was mild facet arthropathy. There was
mild to-moderate central canal stenosis and mild bilateral neural foraminal narrowing.
July 06, 2023
Electrocardiogram: Normal EKG.

X-Ray of Chest, 2 views: The findings revealed the following:
1. No acute cardiopulmonary disease.
2. Scoliosis suspected.
3. Interview & Examination
I obtained the information presented herein during my examination of Ms. XXXXXXXX, which
took place on__________. My interview and examination of Ms. XXXXXXXX was performed
to obtain information which can be used in conjunction with the information I obtained from her
medical records and/or other relevant documents for the purpose of determining her diagnostic
conditions and consequent circumstances.
3.1 History of Present Injury/Illness
Ms. XXXXXXXXXXXXXXXXX was involved in a motor vehicle accident which took place
on June 10, 2022 in the City of Beverly Hills at 1:30 PM on 6th Street. She was in a Lyft and had
a driver. She was sitting as a passenger on the rear passenger’s side. Ms. XXXXXXXX was
wearing her seatbelt. Airbags did not deploy. She was blacked out from the accident and had loss
of consciousness. Since then, she has been having severe dizziness and headaches rated as 7/10.
There is tension, tightness, and soreness in neck, right and left shoulder, and low back all rated as
7/10. All signs and symptoms are new since the accident.
3.2 Physical Examination:
3.3 Current Symptoms: Neck pain, upper back pain, and lower back pain.
3.3.1 Physical Symptoms: Aching and stabbing.
3.3.2 Functional Symptoms: Pain with lifting, carrying, bending, walking, squatting
Emotional symptoms: sad Activities of daily: she has difficulty with chores, sleep,
exercise and lifting, carrying, bending, mopping, sweeping and trash.
3.3.3 Emotional Symptoms:
21
3.4 Activities of Daily Living:
3.5 Review of Systems:
3.5.1 General: Pain.
3.5.2 Neurologic: Normal
3.5.3 Orthopedic: pain in her low back, upper back and neck.
3.5.4 Cardiovascular: Normal.
3.5.5 Integumentary: Normal.
3.5.6 Respiratory: Normal.
3.5.7 Digestive: Normal.
3.5.8 Urinary: Normal.
3.5.9 Circulation: Normal.
3.5.10 Behavioral: Normal.
3.6 Past Medical History:
Anxiety and depression.

3.6.1 General: None.
3.6.2 Neurological: None.
3.6.3 Orthopedic: None.
3.6.4 Cardiovascular: None.
3.6.5 Integumentary: None.
3.6.6 Respiratory: None.
3.6.7 Digestive: None.
3.6.8 Urinary: None.
3.6.9 Circulation: None.
3.6.10 Behavior: None.

3.7 Past Surgical History:
Liposuction.
3.8 Injections:
None
22
3.9 Family History:
Diabetes.
3.10 Allergies:
None
3.11 Drug and Other Allergies:
As above.
3.12 Medications:
3.13 Assistive Device:

None.
3.14 Social History:
None.
3.15 Education History:
3.16 Professional/Work History:
3.17 Habits:
None
3.18 Tobacco use:
None.
3.19 Alcohol use:
None.
3.20 Illicit drugs:
None.
3.21 Avocational Activities:
None
3.22 Residential Situation:
3.23 Transportation:
3.24 Household Responsibilities:
4. Central Opinions
4.1 Diagnostic Conditions
23
For the purpose of Life Care Planning, a diagnostic condition can be defined as an
impairment, which according to the American Medical Association’s Guides to the
Evaluation of Permanent Impairment, 5th Edition, is defined as “a loss of use, or a
derangement of any body part, organ system or organ function.”4
The following represents my professional medical opinion regarding Ms. XXXXXXXX
diagnostic conditions, as they pertain to Ms. XXXXXXXX relevant cause of injury:
• Diagnostic Condition 1: Level L3-4, L4-5 and L5-S1 level disco gram.
• Diagnostic Condition 2: L3-4 percutaneous endoscopic decompression with
radiofrequency.
4.2 Consequent Circumstances
4.2.1 Disabilities
According to the American Medical Association’s Guides to the Evaluation of
Permanent Impairment, 5th Edition, a disability is defined as “an alteration of an
individual’s capacity to meet personal, social, or occupational demands because of an
impairment.5
It is my professional medical opinion that the disabilities specified herein are
attributable to Ms. XXXXXXXX relevant impairments, as presented in Section 4.1.
• Decreased ability--reaching/looking up
• Decreased ability work with regular duties
4.2.2 Probable Duration of Care

This formulation of Ms. XXXXXXXX Probable Duration of Care has been performed by me,
XXXXXXXX, for the purpose of formulating this life care plan. In formulating Ms.
XXXXXXXX Probable Duration of Care, I have applied my best professional efforts; I have
considered published literature; and I have relied upon my education, training, skill and
professional experience as a practicing medical doctor, Board Certified Orthopedic Surgeon and
Certified Life Care Planner, as well as a reasonable degree of medical probability.
The methodology I have employed to formulate Ms. XXXXXXXX Probable Duration of Care is
that which is advocated by the American Academy of Physician Life Care Planners. This
methodology requires a physician life care planner to:
1. Establish a subject’s Average Residual Years.
2. Use Average Residual Years to calculate a subject’s Life Expectancy.
4
Cocchiarella, Linda, and Gunnar B. J. Anderson, Guides to the Evaluation of Permanent Impairment, Fifth Edition, American Medical
Association, 2000.
5
Cocchiarella, Linda, and Gunnar B. J. Anderson, Guides to the Evaluation of Permanent Impairment, Fifth Edition, American Medical
Association, 2000.
24
3. Formulate Adjustments to Life Expectancy (if any).
4. Use Adjustments to Life Expectancy (if any) to calculate Projected Residual Years.
5. Use Projected Residual Years to calculate Projected Life Expectancy.
6. Determine Probable Duration of Care using the following methodological sequence:
a. If a physician life care planner makes no Adjustment to Life

Expectancy, and a physician life care planner believes a subject
will require life-long care, then Probable Duration of Care =
Average Residual Years.
b. If a physician life care planner makes an Adjustment to Life

will require life-long care, then Probable Duration of Care =
Projected Residual Years.
c. If a physician life care planner makes no Adjustment to Life

will require less-than-life-long care, then Probable Duration of
Care = the amount of time within Average Residual Years, during
which a subject will receive active medical care, as specified
within a life care plan’s Future Medical Requirements.
d. If a physician life care planner makes an Adjustment to Life

will require less-than-life-long care, then Probable Duration of
Care = the amount of time within Projected Residual Years, during
which a subject will receive active medical care, as specified
within a life care plan’s Future Medical Requirements.6
4.2.2.1 Average Residual Years

To establish Ms. XXXXXXXX Average Residual Years, I have relied upon The National Vital
Statistics Reports, United States Life Tables 2020, Volume 69, Number 12, published by the
National Center for Health Statistics, a part of the United States Department of Health & Human
Services.
The National Vital Statistics Reports (NVSR), United States Life Tables provides age ranges to
determine Average Residual Years (“Expectation of Life at Age ‘X’”), e.g. 54 – 55, 55 – 56, and
so on. Because Ms. XXXXXXXX is beyond her 23rd birth date, and had not yet reached beyond
her 24th birth date Ms. XXXXXXXX falls into the NVSR’s 20 - 25 age range classification. The
National Vital Statistics Reports, United State Life Tables “Expectation of Life at Age X’” for the
20 - 25 age range classification = 57.62.7
6
7
Arias, E. (2020). United States Life Tables 2020. The National Vital Statistics Reports, Volume 69, Number 12. Retrieved from
http://www.cdc.gov/nchs/products/life_tables.htm
25
In accordance with methodology advocated by the American Academy of Physician Life
Care Planners, I have rounded Ms. XXXXXXXX “Expectation of Life at X” to the nearest
whole number. Therefore, Ms. XXXXXXXX Average Residual Years = 57.62.
4.2.2.2 Life Expectancy
According to the methodology advocated by the American Academy of Physician Life Care
Planners:
• Life Expectancy = Current Age + Average Residual Years8
• Ms. XXXXXXXX’s Current Age = 23.
• Ms. XXXXXXXX Average Residual Years = 57.62.
Therefore Ms. XXXXXXXX Life Expectancy = 23 + 57.62 = 80.62.
4.2.2.3 Adjustments to Life Expectancy
In formulating Adjustments to Ms. XXXXXXXX Life Expectancy, I have considered the

potential impact of Ms. XXXXXXXX’s:
• Diagnostic Conditions
• Disabilities
• Pre-existing comorbidities
• Other comorbidities (whether caused by or adversely affected by Ms. XXXXXXXX

relevant injuries/illnesses)
• Adverse lifestyle behaviors/mental health conditions
• Associated conditions and/or consequences
• Pre-existing and/or newly developed conditions
• Family health history
• Unique risk factors, whether caused by, or adversely affected by Ms. XXXXXXXX
relevant injuries/illnesses, or whether they result from preexisting or recently developed
comorbidities
8
Practices for Physician Life Care Planners, American Academy of Physician Life Care Planners, Austin, Texas, 2017
26
In addition, I have also considered how receiving care which is specifically designed to mitigate
Ms. XXXXXXXX unique risk factors may mitigate the deleterious effects of such risk factors on
her Life Expectancy. I also presume the provision of optimal care will have a mitigating influence
on the deleterious impact of Ms. XXXXXXXX unique risk factors on her Life Expectancy.
In consideration of the potential impact of the factors expressed above, and in my effort to
formulate a medically probable Projected Duration of Care, it is my opinion Ms. XXXXXXXX
Average Residual Years will not be impacted. I have therefore, made a 0.0% adjustment to Ms.
XXXXXXXX Average Residual Years.
4.2.2.4 Probable Duration of Care
As previously stated, it is my opinion Ms. XXXXXXXX will have progressive symptoms, as

well as, physical and psychological impairments and disabilities, which require lifelong medical
care.
According to the methodology advocated by the American Academy of Physician Life Care
Planners, in cases in which a physician Life care planner makes no Adjustment to Life
Expectancy, and a physician Life care planner believes a subject will require lifelong care, then
Probable Duration of Care = Average Residual Years.9
Therefore Ms. XXXXXXXX Average Residual Years = 57.62 years, the Probable Duration of
Care upon which this Life Care Plan is based.
5. Future Medical Requirements
The future medical requirements specified herein are intended to address the diagnostic
conditions and consequent circumstances specified in Section 4 of this Life Care Plan.
The future medical requirements specified herein are grouped into care categories, in which the
names of the specific care item(s) are presented, and in applicable cases, are accompanied by
relevant CPT, HCPC, and DRG codes. Asterisks (“*”) in the place of codes for any item(s)
denote item(s) for which coding was either not possible, (e.g. in the case of nursing and attendant
care, environmental modifications, essential services, etc.), or in cases in which coding is not
applicable, as it relates to using such codes to perform a cost/vendor survey for the purpose of
obtaining unit costs that can be used within this Life Care Plan’s Cost Analysis [e.g. in the case
of medications, in which it is possible to assign National Drug Codes (“NDC codes”) to
medication items, but in which case it is not possible to use such codes to obtain data-correlated
cost information, such as Usual, Customary and Reasonable (UCR) cost data].
I have formulated Ms. XXXXXXXX future medical requirements based upon my education,
training and professional experience as a practicing physician, Board Certified Orthopedic
Surgeon.
9
Practices for Physician Life Care Planners, American Academy of Physician Life Care Planners, Austin, Texas, 2017
27
I have employed a reasonable degree of medical probability as a primary
criterion in the formulation of my medical recommendations, and I have made
such recommendations with the intent of accomplishing the following Clinical
Objectives of Life Care Planning:
1. Diminish or eliminate Ms. XXXXXXXX physical and psychological pain and suffering.
2. Reach and maintain the highest level of function given Ms. XXXXXXXX unique
circumstances.
3. Prevent complications to which Ms. XXXXXXXX unique physical and mental

conditions predispose her.
4. Afford Ms. XXXXXXXX the best possible quality of life in light of her condition.
5.1 Physician Services

See cost table
5.2 Routine Diagnostics

See cost table
5.3 Medications
See cost table
5.4 Laboratory Studies

See cost table
5.5 Rehabilitation Services

See cost table
5.6 Equipment & Supplies

See cost table
5.7 Environmental Modifications & Essential Services

See cost table
5.8 Acute Care Services

See cost table
6. Cost/Vendor Survey
The purpose of this Cost/Vendor Survey (the “Survey”) is to enhance the transparency of this
Life Care Plan’s Cost Analysis.
28
This Survey is presented in two sections:
1. The Methods, Definitions & Discussion section discloses the methods and parameters
used to perform this Survey.
2. The Cost Data Sample exhibits all unit costs and other source-specific information
obtained during this Survey that are employed in this Life Care Plan’s Cost Analysis.
6.1 Methods, Definitions & Discussion
6.1.1 Survey Method10
1. In cases in which vendors/providers are specified (e.g. in cases in which specific Acute
Care Services are to be performed at specified facilities, or in cases in which a life care
plan’s subject, his/her family member(s), care giver(s), treating physician(s), et al. specify
particular physician(s) they are currently seeing and/or wish to see in the future), then the
costs associated with the specified vendor(s)’/provider(s)’ provision of such
goods/services are cited in this Life Care Plan’s Vendor Survey, and these values are used
as unit costs for respective line items in this Life Care Plan’s Cost Analysis (assuming it
is possible to obtain such cost information from the specific vendor(s)/provider(s) in
question).
2. In the absence of specific vendors/providers being specified, or in cases in which specific

vendor(s)/provider(s) are specified, but from whom it is not possible to obtain cost
information, then Usual, Customary & Reasonable (UCR) cost data is sourced, cited in
this Life Care Plan’s Vendor Survey, and used for applicable line items in this Life Care
Plan’s Cost Analysis (assuming it is possible to obtain UCR data from within the Geo-Zip
region I assigned to Ms. XXXXXXXX probable location of care (Geo-Zip region
“90020”), or in the absence of the availability of such data, by relying upon UCR data
obtained from within alternative Geo-Zip regions located within a 35 mile radius of Ms.
XXXXXXXX probable location of care.
3. In the absence of preferred vendors/providers being specified, or in cases in which specific

vendor(s)/provider(s) are specified, but from whom it is not possible to obtain cost
information, and in the absence of UCR data being available for relevant Geo-Zip regions
and/or for specific future medical requirements, then cost data in this Survey has been
sourced via world-wide web, and/or telephone inquiry from vendors/providers located
within a 35 mile radius of Ms. XXXXXXXX probable location of care. In all cases in
which it was reasonably practical to obtain such information; an attempt was made to
obtain at least 3 discrete costs from 3 discrete sources, all of which are exhibited (along
with the direct contact information for all vendors/providers from which such cost data
was obtained) in this Life Care Plan’s Cost Data/Vendor Sample. Averages (arithmetic
10
29
means) for each future medical requirement were then calculated, and the arithmetic mean
values were used as the unit costs for respective line items in this Life Care Plan’s Cost
Analysis.
4. When sourcing cost data via world-wide web, this Vendor Survey has also included cost
data from national online medication, durable equipment and other vendors, e.g.
CVS.com, Walgreens.com, Drugstore.com, etc. without affording consideration to the
national vendor’s actual location, relative to Ms. XXXXXXXX probable location of care.
In cases in which cost data is sourced from such vendors, it has been treated in the same
manner as cost data sourced from vendors located within my previously specified 35
miles’ radius of Ms. XXXXXXXX probable location of care, i.e. such data is cited in this
Life Care Plan’s Vendor Survey, along with relevant vendor information. The values of
such data were then used in the calculation of arithmetic means which constitute unit costs
for respective line items in this Life Care Plan’s Cost Analysis.
5. In cases in which particular medically-related goods/services require sourcing multiple

data in order to formulate the cost of a single future medical requirement, e.g. as in the
case of an acute care service, such as a surgery in which a cost for an actual surgical
procedure, and a cost for a patient’s hospitalization may not be able to be sourced as a
single value, then values for each individual cost component were obtained, and then
summed to calculate a total unit cost for the particular acute care service in question.
When obtaining costs in such circumstances, I first looked for the specification of any
preferred vendors/providers, and in the absence of such specification/availability, I looked
for UCR data, and in the absence of available UCR data, I have sought to obtain cost data
from individual vendors/sources via the World Wide Web and/or direct telephone inquiry.
All sources from which any component costs were obtained are cited in this life care
plan’s vendor survey, and the values of such component costs have been summed to
establish consolidated unit costs for respective line items.
6.1.2 Definitions & Discussion
• Probable Location of Care & Proximity
Prices of medically-related goods and services can vary based upon

geographic location. The geographic scope of this survey is generally
defined as a specified radius from the subject’s primary residence.
Primary residence (“probable location of care”) is defined by a GeoZip
locator.
Geographic scope is defined as a 35-mile radius; and the probable location of care is
defined using Geo-Zip locator: 90020.
• Usual Customary & Reasonable (UCR) Cost Data
According to the American Medical Association’s UCR Definition: AMA Policy H-

385.923:
30
1. “Our AMA adopts as policy the following definitions:
a. ‘usual’; fee means that fee usually charged, for a given
service, by an individual physician to her private patient
(i.e., her own usual fee);
b. a fee is 'customary' when it is within the range of usual

fees currently charged by physicians of similar training
and experience, for the same service within the same
specific and limited geographical area; and
c. a fee is 'reasonable' when it meets the above two criteria

and is justifiable, considering the special circumstances
of the particular case in question, without regard to
payments that have been discounted under governmental
or private plans.
2. Our AMA takes the position that there is no relationship between the Medicare fee
schedule and Usual, Customary and Reasonable Fees.”11
• Context4healthcare
Usual Customary & Reasonable cost data in this Life Care Plan is sourced from
Context4HealthCare, Inc. Context4 Healthcare is an independent, disinterested, 3rd-
party provider of medical cost data which is endorsed and recommended by the Texas
Medical Association in their essential text, Business Basics for Physicians:
“Fees for service should be fair and reasonable for the medical specialty and
according to community standards. Practice managers or administrators can
perform a fee schedule analysis to determine whether physicians’ fees are in line
with market rates. Fee schedule information by specialty and location is available
for purchase at www.context4healthcare.com/data-products/physician-fee-
reports.”
Context4 Healthcare’s UCR Database is the largest publicly available database of its kind
in the United States; and its UCR database is used by hundreds of healthcare
organizations across the United States, including by some of the nation’s largest payers,
such as insurance companies.
According to Context4Healthcare, its database contains approximately 70 percent of all
health care charges submitted for payment in the United States. Context4 Healthcare’s
UCR Database is representative of charges for a national population of providers,
representing a variety of contractual arrangements between payers and providers, and it is
11
https://policysearch.ama-assn.org/policyfinder/detail/Policy%20H-385.923%20?uri=%2FAMADoc%2FHOD.xml-0-3242.xml
31
large enough to support statistically reliable and valid estimates at small levels of
geographic disaggregation, i.e. within small groups of zip codes.
Context4Healthcare’s UCR Database incorporates data from approximately one billion
de- identified medical bills, obtained every six months from a variety of sources-
primarily from companies that provide electronic billing and claims processing services to
health care providers. Context4Healthcare’s statistical model uses the latest two years of
data, which it adjusts for inflation every six months.
Context4Healthcare’s UCR Database is arrayed in percentiles from the 25th through the
95th percentile, and is divided into more than 320 Geo-Zip regions around the country to
account for regional differences in healthcare costs.
Context4Healthcare is one of the longest-standing providers of UCR data, and it has been
a leader in UCR fee analysis for over 25 years. Context4Healthcare is led by a team of
highly skilled physicians, statisticians, programmers, software engineers, and executives:
www.context4healthcare.com/about/our-management-team.
• UCR Percentiles & “UCR 80”
UCR data as maintained by Context4Healthcare is organized into “conversion factors.”
These conversion factors are commonly used within the healthcare payer industry for the
purpose of establishing benchmarks by which to filter submitted charges.
“UCR 80” is a shorthand reference to the 80th UCR percentile. Historically, it has been
customary for healthcare insurance providers to use “UCR 80” as a standard benchmark
against which to measure the acceptability of charges.
In addition to its relatively ubiquitous application by healthcare payers, use of UCR 80 is
also mandated by various states and federal agencies, for example:
1. The use of UCR 80 is mandated by the Texas State Legislature to resolve
disagreements between out-of-network healthcare providers and insurers.
2. The State of New York has enacted a statute to prevent “surprise bills” and
defines the “usual and customary cost” as “the eightieth percentile of all
charges for the particular health care service performed by a provider in the same
or similar specialty and provided in the same geographic al area”.
3. The United States Veterans Administration (“VA”) has mandated that “reasonable
charges for medical care or services provided or furnished by VA to a veteran”
use the “80th percentile of community charges,” with “community” defined
using a 3- digit Geo-Zip parameter.
4. To protect the interests of the United States Taxpayer, in non-worker’s

compensation cases, the United States Center for Medicare and Medicaid Services
(CMS) requires UCR 80 to be used to quantify the value of Medicare Set-aside
32
Allocations (MSA ’s) (which the CMS has historically referred to as life care
plans).
• Employing UCR Data
In order to obtain appropriate UCR cost data, it is necessary to define two basic
parameters:
1. A Geo-Zip code that specifies a geographic region.
2. Specific CPT (Current Procedural Terminology) codes, or specific DRG
(Diagnosis-Related Group) codes, or specific HCPCS (Healthcare Common
Procedure Coding System) codes.
As previously stated, I have selected Geo-Zip 90020, which defines Ms. XXXXXXXX
probable location of care.
UCR Data, as provided by Context4Healthcare is structured into “modules”, which
include
“Medical”, “Outpatient Facility”, “Inpatient Facility”, “Anesthesia”, and “HCPCS”.
The future medical requirements specified in this Life Care Plan have been coded for the
purpose of soliciting UCR data from relevant UCR modules.
a. CPT codes have been assigned to future medical requirements in this life care plan
to solicit UCR cost data contained in the Medical Module. Such items include
professional service fees, e.g. physician services, routine diagnostics, laboratory
services, etc.
b. CPT codes have also been assigned to future medical requirements in this life care
plan to solicit UCR cost data contained in the Outpatient Facility Module. Such
items would include outpatient facility fees, e.g. acute care services performed in
outpatient hospital settings, ambulatory surgical centers, etc.
c. DRG codes have been assigned to future medical requirements in this life care
plan to solicit UCR cost data contained in the Inpatient Facility Module. Such
items would include inpatient facility fees, e.g. acute care services performed in
inpatient facilities, including inpatient hospitalizations, in-patient admissions
(“stays”), etc.
d. CPT codes have been assigned to future medical requirements in this life care plan
to solicit UCR cost data contained in the Anesthesia Module for anesthesia-related
fees, such as minimal, moderate, and deep sedation.
e. HCPCS codes have been assigned to future medical requirements in this life care
plan to solicit UCR cost data contained in the HCPCS Module. The HCPCS
Module contains cost data for services not included in the Current Procedural
Terminology (CPT) codes, e.g. durable medical equipment and supplies such as
33
mobility devices, hospital beds, injection supplies, orthotics and prosthetics, and
other services such as ambulance services, hearing and speech pathology services,
etc.
34
Appendix A
Total Expenditures for XXXXXXXXXXXXXXXXX
Table Table Title Total Cost Projection
Number
1 Routine Medical Evaluations $133,341.31
2 Therapeutic Evaluations $45,315.82
3 Therapeutic Modalities $134,422.85
4 Diagnostic Testing $239,602.92
5 Equipment and Aids $9,644.88
6 Pharmacology $69,144.00
7 Future Aggressive Care/Surgical Intervention $548,737.64
8 Home Care/Home Services $215,729.28
9 Labs $13,325.76
10 Durable Medical Equipment/Aids for Independent $48,051.01
Function
11 Other $164,217.00
Total Cost Projection $1,621,532.47
35
Routine Medical Evaluations- Table 1
Routine Start End Year Frequency Cost Per Annual Lifetime Comments Recommended
Medical year year s (per year) Visit Cost Total by:
Evaluations
Orthopedic 23 80.62 57.62 1 $393.23 $393.23 $22,657.91 XXXXXXXX,
Surgeon (99214) M.D.
Primary care physician 23 80.62 57.62 2 $393.23 $786.46 $45,315.82 XXXXXXXX,

(99214) M.D.
Pain Management 23 80.62 57.62 2 $393.23 $786.46 $45,315.82 XXXXXXXX,

evaluation M.D.
(99214)
Allowance 23 80.62 57.62 1 $348.00 $348.00 $20,051.76 Follow-up XXXXXXXX,
for additional with M.D.
specialist additional
specialist
(PM&R –
Rehab)
Total: $133,341.31
Source: Physician Fee Reference 2019 & author experience and knowledge regarding reasonable fees for those items noted
and Context4health.
CPT codes: 99204 as an example, although actual CPT may vary depending upon treating physician and other conditions at the time
the service is received.
36
Therapeutic Evaluations- Table 2
Therapeutic Start End Years Frequency Cost Annual Lifetime Comments Recommended
Evaluations year Year (Per Per Cost Total by:
Year) Visit
Physical therapy 23 80.62 57.62 2 $393.23 $786.46 $45,315.82 To regain XXXXXXXX,
evaluation (99214) functional M.D
mobility
Total: $45,315.82
Source: Physician Fee Reference 2019 & author experience and knowledge regarding reasonable fees for those items
noted and context4heath
CPT codes: 99214 as an example, although actual CPT may vary depending upon treating physician and other conditions at the
time the service is received.
37
Therapeutic Modalities- Table 3
Therapeutic Start End Years Frequency Cost Annual Lifetime Comments Recommended
Evaluations year Year (Per Per Cost Total by:
Year) Visit
Physical 23 80.62 57.62 12 visits $194.41 $2,332.92 $134,422.85 To regain XXXXXXXX,
therapy yearly on functional M.D
(97110, average mobility
97010,
97032,
97035)
Total: $134,422.85
Source: Physician Fee Reference 2019 & author experience and knowledge regarding reasonable fees for those items
noted and context4heath.
CPT codes: 97010, 97110, 97140, and 97113 as an example although actual CPT may vary depending upon treating physician
and other conditions at the time the service is received.
38
Diagnostic Testing-Table 4
Diagnostic Start End Years Frequency Cost Per Annual Lifetime Comments Recommended
Testing year Year (Per Year) Item Cost Total by:
CT scan of the 23 80.62 57.62 Once every 5 $945.20 $189.04 $10,892.48 Evaluate and XXXXXXXX,
brain without Years monitor M.D
contrast. condition
(70450)
MRI of brain 23 80.62 57.62 Once every 3 $2,143.66 $714.55 $41,172.37 Evaluate and XXXXXXXX,
without Years monitor M.D
contrast condition
(70551)
MRI of the 23 80.62 57.62 Once every 3 $2,019.86 $673.28 $38,794.39 Evaluate and XXXXXXXX,
right shoulder Years monitor M.D
without condition
contrast
(73221)
Left shoulder Years monitor M.D
without condition
contrast
(73221)
lumbar spine Years monitor M.D
without condition
contrast
(72148)
MRI of 23 80.62 57.62 Once every 3 $2,441.28 $813.76 $46,888.85 Evaluate and XXXXXXXX,
cervical spine Years monitor M.D
without condition
contrast
(72141)
39
X-ray of chest, 23 80.62 57.62 Once every 2 $149.37 $74.68 $4,303.06 Evaluate and XXXXXXXX,
2 views. years. monitor M.D
(71046) condition
EMG 23 80.62 57.62 Once for $2,380.14 n/a $2,380.14 Evaluate and XXXXXXXX,
(95864) cervical spine monitor M.D
condition
NCV 23 80.62 57.62 Once for $717.78 n/a $717.78 Evaluate and XXXXXXXX,
(95909) cervical spine monitor M.D
condition
EMG 23 80.62 57.62 Once for $2,380.14 n/a $2,380.14 Evaluate and XXXXXXXX,
(95864) lumbar spine monitor M.D
condition
NCV 23 80.62 57.62 Once for $717.78 n/a $717.78 Evaluate and XXXXXXXX,
(95909) lumbar spine monitor M.D
condition
Allowance 23 80.62 57.62 Once every 5 $500.00 $100.00 $5,762.00 Evaluate and XXXXXXXX,
for Years monitor M.D
additional condition
studies as
needed
Total: $239,602.92
Source: Physician Fee Reference 2019 & author experience and knowledge regarding reasonable fees for those items noted
and context4health.
CPT codes: 71020, 23350, 72100 as an example, although actual CPT may vary depending upon treating physician and other
conditions at the time the service is received.
Equipment and Aids- Table 5
40
Equipment Start End Years Frequency Cost Annual Lifetime Comments Recommended
and Aids year Year (Per Year) Per Cost Total by:
Item
Allowance for 23 80.62 57.62 1 $124.00 $124.00 $7,144.88 XXXXXXXX,
various (heating pad, M.D.
ice pack, topical pain
cream)
Home exercise 23 80.62 57.62 Once over $2,500.00 n/a $2,500.00 One-time XXXXXXXX,
equipment such as a lifetime allowance M.D.
bands and weights for
purchasing
home
exercise
equipment,
used for
improving
therapeutic
outcome
Total: $9,644.88
Sources:
https://www.walgreens.com/store/c/-exercise-equipment-and-accessories/ID=377159-tier3 context4health
Pharmacology – Table 6
Pharmacology Start End Years Frequency Cost Annual Lifetime Comments Recommende
year Year (Per Year) Cost Total d by:
41
General 23 80.62 57.62 Yearly $1,200 $1,200.00 $69,144.00 Can XXXXXXXX
Allowance allowance include , M.D.
opioid
analgesics,
muscle
relaxants,
anti-
inflammato
ry,
medication
for
neuropathi
c pain
Total: $69,144.00
42
Future Aggressive Care/Surgical Intervention- Table 7
Procedure Start End Years Frequency Cost Annual Lifetime Comments Recommended
year Year (Per Year) Cost Total by:
PRP of right 23 80.62 57.62 6 in a life $5,000.00 n/a $30,000.00 XXXXXXXX,
shoulder time M.D.
PRP of left 23 80.62 57.62 6 in a life $5,000.00 n/a $30,000.00 XXXXXXXX,
shoulder time M.D.
Cervical Epidural 23 80.62 57.62 allow 3 $13,510.88 $20,266.32 $202,663.20 XXXXXXXX,
steroid injection every 2 M.D.
under anesthesia years for
(62321, 64479, 10 yrs.
99152)
Lumbar epidural 23 80.62 57.62 allow 3 $12,679.92 $19,019.88 $190,198.80 XXXXXXXX,
steroid injection every 2 M.D.
under anesthesia years for
(62323, 64483, 10 yrs.
99152)
Cervical trigger 23 80.62 57.62 Once $4,991.81 $1,663.93 $95,875.64 XXXXXXXX,
point injections. every 3 M.D.
(20552, 20553) years.
Total: $548,737.64
Source(s): Physician Fee Reference 2019 and author experience and knowledge regarding reasonable fees for those
items noted and context4health
https://www.mdsave.com/f/procedure/trigger-point-tendon-injections-in-office/47150?q= trigger+point_tendon+injections+(in+office)
&type=procedure context4health
Home Care/Home Services – Table 8

Item Start End Years Frequency Cost Annual Lifetime Comments Recommended
43
year Year (Per Year) Cost Total by:
Housekeeping 23 80.62 57.62 2 hours $21 $2,184.00 $125,842.08 Assistance XXXXXXXX,
services weekly on per with M.D.
average hour household
chores due
to physical
impairments
Personal 23 80.62 57.62 (6mths) $60 $1,560.00 $89,887.20 XXXXXXXX,
trainer/exercise 1xper per M.D.
physiologist week visit
Total: $215,729.28
Source(s): Author experience and knowledge regarding reasonable fees for those items noted.
https://www.genworth.com/aging-and-you/finances/cost-of-care.html
LABS- TABLE 9
44
Tests Start End Years Frequency Cost Annual Lifetime Comments Recommended
year Year (Per Year) Per Cost Total Total:by:
$13,325.76
Item
CBC (85025) 23 80.62 57.62 Once a $48.37 $48.37 $2,787.07 XXXXXXXX,
year M.D.
CMP 23 80.62 57.62 Once a $114.73 $114.73 $6,610.74 XXXXXXXX,

(80053) year M.D.
Venipuncture 23 80.62 57.62 Once a $24.86 $24.86 $1,432.43 XXXXXXXX,

(36415) year M.D.
Urine drug 23 80.62 57.62 Once a $43.31 $43.31 $2,495.52 XXXXXXXX,

screen year M.D.
(81007)
Durable Medical Equipment/Aids for Independent Function- Table 10
Recommendation Start End Years Frequency Cost Annual Lifetime Comments Recommended
year Year (Per Year) Per Cost Total by:
Item
Hand held shower 23 80.62 57.62 Every 5 years $42.50 $8.50 $489.77 XXXXXXXX,
M.D.
Shower 23 80.62 57.62 Every 5 years $96.50 $19.30 $1,112.06 XXXXXXXX,
chair/transfer M.D.
bench with back
& rails
Elevated toilet 23 80.62 57.62 Every 5 years $76.95 $15.39 $886.77 XXXXXXXX,
seat with rails M.D.
Blood pressure 23 80.62 57.62 Every 5 years $55.10 $11.02 $634.97 XXXXXXXX,
machine M.D.
45
Gait/transfer belt 23 80.62 57.62 Every 3 years $35.00 $11.66 $671.84 XXXXXXXX,
M.D.
Medical alert 23 80.62 57.62 Every 3 years $35.00 $11.66 $671.84 XXXXXXXX,
bracelet M.D.
Feeding/writing 23 80.62 57.62 Yearly $150.00 $150.00 $8,643.00 XXXXXXXX,
utensils allowance M.D.
Electric hospital 23 80.62 57.62 Every 10 $1,250.00 $ 125.00 $7,202.50 XXXXXXXX,
bed with rails with years M.D.
mattress
Electric hospital 23 80.62 57.62 Yearly, 10% $125.00 $125.00 $7,202.50 XXXXXXXX,
bed maintenance of cost M.D.
(except
during
replacements)
Pressure reduction 23 80.62 57.62 Every 5 years $282.00 $56.40 $3,249.76 XXXXXXXX,
mattress overlay M.D.
Assistive 23 80.62 57.62 Allowance $1,500.00 $300.00 $17,286.00 XXXXXXXX,
technology aids once every 5 M.D.
years
Total: $48,051.01
46
Other -Table 11
Recommendation Start End Years Frequency Cost Annual Lifetime Comments Recommended
year Year (Per Year) Per Item Cost Total by:
Nurse Case 23 80.62 57.62 Average 3 $75/hour x $2,700.00 $155,574.00 XXXXXXXX,

Manager hours/month 3 M.D.
hours/month
x12
months/year
x 57.62
years
Brain injury 23 80.62 57.62 Yearly n/a n/a n/a XXXXXXXX,
support group M.D.
Home exercise 23 80.62 57.62 Allowance $1,500.00 $150.00 $8,643.00 XXXXXXXX,
equipment every 10 M.D.
(i.e., exercise years
bike, exercise
pulley, exercise
weights)
47
Total: $164,217.00
Comments: A Nurse Case Manager is recommended to assist in coordinating Ms. XXXXXXXX’s medical care and associated
services. A Nurse Case Manager has experience in coordinating medical treatment among multiple providers, educating Ms.
XXXXXXXX and her family regarding her medical care, and assessing for complications. A Nurse Case Manager is an absolute
necessity for Ms. XXXXXXXX, especially understanding the psychological concerns and complications/secondary diagnoses. It is
recommended that Ms. XXXXXXXX and her family be involved in a brain injury support group for emotional support and
educational resources. Home exercise equipment is recommended for caregivers to assist Ms. XXXXXXXX with maintaining an
optimum level of functioning and reduce complications /secondary diagnosis.
48
7. Cost Analysis
This Cost Analysis (“Analysis”) quantifies the nominal monetary value of providing Ms.
XXXXXXXX with the medically-related goods and services specified in Section 5, Future
Medical Requirements.
7.1 Definition & Discussion of Quantitative Methods
7.1.1 Nominal Value
This Analysis quantifies all costs in nominal value, or “today’s dollars”, and it does not account
for the time value of money, i.e. it does not account for inflation or discounts to formulate future
and/or present values.
7.1.2 Accounting Methods
This Analysis quantifies the value of future medical requirements by employing Cash Method
Accounting, in which values are accounted for within periods in which cash outflows associated
with the acquisition of future medical requirements are forecast to occur.
7.1.3 Variables
7.1.3.1 Independent Variables
To quantify this life care plan’s future medical requirements, this cost analysis considers the
following independent variables:
1. Start Date (Starting period)
2. Quantity
3. Interval
4. Duration
5. Unit Cost
7.1.3.2 Dependent Variables
From the preceding independent variables, the following dependent variable is derived:
1. Frequency = (Quantity ÷ Interval)
7.1.3.3 Unit Costs
49
• In cases in which Usual Customary & Reasonable (UCR) data has been
employed, single value unit costs, as specified in this Life Care Plan’s
Cost/Vendor Sample are employed.
• In cases in which multiple prices have been sourced from independent

vendors/providers, unit costs = arithmetic means. An arithmetic mean =
the sum of the values in the sample ÷ the number of values in the sample.
• In cases in which multiple component costs have been sourced to constitute a single item,
e.g. a surgery consisting of multiple components, all component costs are summed into a
consolidated, single value.
7.1.3.4 Counts & Conventions
All quantities, intervals, and durations employed in this Cost Analysis are exhibited within the
heading of each future medical requirement contained in this cost analysis. All variables
pertaining to time correlate to the Gregorian Calendar.
7.2 Summary Restatement of Central Opinions
7.2.1 Relevant Diagnostic Condition Affecting Necessity of Future Care
• Diagnostic Condition 1: Level L3-4, L4-5 and L5-S1 level disco gram.
• Diagnostic Condition 2: L3-4 percutaneous endoscopic decompression with
radiofrequency.
7.2.2 Relevant Disabilities Affecting Necessity of Future Care
• Decreased ability to perform or maintain traditional roles within family,

relationships or other social units.
• Decreased ability to interact and/or socialize with family, and/or friends and
acquaintances.
• Decreased physical function affecting a loss of vocational capacities/opportunities.
• Decreased ability to participate in social avocational activities, i.e. participation in

activities with others e.g. participation in sports, etc.
• Decreased external mobility e.g. travel, etc.
• Decreased ability to perform household services e.g. inside housework, food cooking &
clean- up, caring for and maintaining pets, home and vehicles, household management,
shopping for household, obtaining services for household, travel for household activities,
etc.
50
• Decreased ability to participate in personal avocational activities e.g.
personal hobbies, pastimes, interests, etc.
7.2.3 Probable Duration of Care Metrics
• Name XXXXXXXXXXXXXXXXX
• Date of Birth XXXXXXXXXXX
• Date of Injury June 10, 2022
• Present Date September 20, 2023
• Current Age 23
• Average Residual Years 57.62
• Average Life Expectancy 80.62
• Projected Duration of Care 57.62
51

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Board Certified Orthopedic Surgeon

LIFE CARE PLAN

Prepared for Ms. XXXXXXXXXXXXXXXXX

September 20, 2023

1.1 Executive Summary

1.2 Life Care Planning & Life Care Plans

1.2.1 Life Care Planning

Life care planning is a process of applying objective methodological analysis to formulate

1.3 Biography of Author (REDACTED)

1.4 Framework: A Life Care Plan for Ms. XXXXXXXXXXXXXXXXX

2. This life care plan employs an anticipatory (preventative) model of care,

8. It is my professional medical opinion that Ms. XXXXXXXX’s diagnostic conditions and

2.1 Summary of Medical Records

2. Anil Date, M.D. – Canyon County, CA.

3. Elyasi Chiropractic- Los Angeles, CA.

4. United Medical Imaging- Los Angeles, CA.

5. TBI Specialist- Los Angeles, CA.

6. NILA- Los Angeles, CA.

7. Elite Spine and Pain Institute- Los Angeles, CA.

8. Shin Imaging Center- Los Angeles, CA.

9. Bio Health Surgical Institute- Santa Monica, CA.

10. Mao Medical Group- Los Angeles, CA.

11. Elite Medical Clinic- Los Angeles, CA.

2.1.2 Chronological Synopsis of Medical Records

Treatment provided: VAT combo with ENG and vestibular exercises.

MRI of the Brain without Contrast:

Plan: The doctor referred for CT scan of brain.

June 15, 2022

June 27, 2022

EMG/ Nerve Conduction Study: The findings revealed a normal study.

July 01, 2022

August 09, 2022

November 09, 2022

April 04, 2023

July 06, 2023

Electrocardiogram: Normal EKG.

3. Interview & Examination

3.6 Past Medical History:

Anxiety and depression.

3.6.2 Neurological: None.

3.6.3 Orthopedic: None.

3.6.4 Cardiovascular: None.

3.6.5 Integumentary: None.

3.6.6 Respiratory: None.

3.6.7 Digestive: None.

3.6.8 Urinary: None.

3.6.9 Circulation: None.

3.6.10 Behavior: None.

3.13 Assistive Device:

3.24 Household Responsibilities:

4.1 Diagnostic Conditions

4.2 Consequent Circumstances

• Decreased ability work with regular duties

4.2.2 Probable Duration of Care

a. If a physician life care planner makes no Adjustment to Life

b. If a physician life care planner makes an Adjustment to Life

c. If a physician life care planner makes no Adjustment to Life

d. If a physician life care planner makes an Adjustment to Life

4.2.2.1 Average Residual Years