Martinez v. Pacific Coast Construction · 38 documents
Document Workspace
Medical · 18
QME Report — Dr. Singh
Post-Surgical FCE
MRI Lumbar — Jun 2023
Operative Report — Apr 2024
Filings · 9
IMR Decision — Reversed
UR Denial — Surgery
Hearings · 4
MSC Continuance — Jun 10
Correspondence · 7
Zurich Demand — Apportionment
Agreed Medical Examination Report
Workers' Compensation — State of California
Examiner: Anil Singh, M.D., Board-Certified Orthopedic Surgery
Claimant: Eduardo Martinez | DOB: 06/15/1978
Claim No.: ADJ-2023-04471 | Date of Injury: 03/14/2023
Examination Date: January 8, 2024 | Report Date: February 15, 2024
Employer: Pacific Coast Construction, Inc. | Carrier: Zurich American Insurance
Claimant: Eduardo Martinez | DOB: 06/15/1978
Claim No.: ADJ-2023-04471 | Date of Injury: 03/14/2023
Examination Date: January 8, 2024 | Report Date: February 15, 2024
Employer: Pacific Coast Construction, Inc. | Carrier: Zurich American Insurance
I. Introduction and Purpose
I was asked to evaluate Mr. Eduardo Martinez, a 45-year-old male, employed as a structural ironworker at Pacific Coast Construction, Inc., who sustained injuries on March 14, 2023. The purpose of this examination is to provide an independent medical opinion regarding the nature and extent of his injuries, current level of permanent impairment, causation, apportionment, and work restrictions per the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition.
II. Records Reviewed
Records reviewed include Cedars-Sinai Long Beach emergency records (03/14/2023), initial PTP treatment notes from Dr. Manuel Ramirez (04/02/2023 – 12/15/2023), MRI Lumbar Spine (06/15/2023), RFA for lumbar surgery (08/22/2023), UR Denial (09/10/2023), and IMR Decision (03/01/2024). A total of 31 documents were reviewed.
III. Medical History
Mr. Martinez reports no prior low back injuries or treatment prior to the date of injury. He states he was in good health and performing full duties at the time of the industrial accident. He denies any prior lumbar spine treatment, imaging, or diagnosed conditions. The claimant provides a credible and internally consistent history.
IV. Examination Findings
Lumbar Spine: Flexion limited to 40° (normal 60°). Extension limited to 15° (normal 25°). Positive straight leg raise at 45° right, negative left. Tenderness to palpation at L3-L4 paravertebral musculature. Right lower extremity weakness in extensor hallucis longus, 4/5.
Right Shoulder: Forward flexion 140° (normal 180°). External rotation limited to 50°. Positive Neer impingement sign. No crepitus. Strength testing 4/5 supraspinatus. Hawkins-Kennedy positive.
V. Diagnosis
1. L3-L4 intervertebral disc herniation, severe, with right-sided neural foraminal stenosis and radiculopathy — industrial causation, direct mechanism (fall 03/14/2023).
2. Right shoulder impingement syndrome with partial rotator cuff involvement — industrial causation, direct mechanism.
3. Pre-existing: No evidence of pre-existing lumbar pathology documented in records reviewed.
2. Right shoulder impingement syndrome with partial rotator cuff involvement — industrial causation, direct mechanism.
3. Pre-existing: No evidence of pre-existing lumbar pathology documented in records reviewed.
VI. Impairment Rating — AMA Guides 5th Edition
| Body Region | Method | Raw WPI | Apportionment | Adjusted WPI |
|---|---|---|---|---|
| Lumbar Spine | DRE IV | 22% | 0% (no pre-existing) | 22% |
| Right Shoulder | ROM/Strength | 8% | 0% | 8% |
| Combined | AMA Combined | 28% | ||
Note: MMI has NOT been reached as of the date of this examination. Surgery has been authorized per IMR decision. A post-surgical addendum will be required to establish final impairment ratings.
VII. Apportionment
I find no basis for apportionment to a pre-existing condition. My review of all available records reveals no documentation of prior lumbar complaints, treatment, imaging, or diagnosed lumbar pathology before the date of injury. The carrier's claim of 30% pre-existing apportionment is unsupported by the medical record as presented to me.
VIII. Work Restrictions
Post-surgical status: No heavy lifting (>10 lbs) pending surgical recovery. No prolonged standing/walking >30 minutes without break. No climbing, kneeling, crawling, or working at heights. Restrictions subject to modification pending post-surgical FCE.
Respectfully submitted,
Anil Singh, M.D.
Board-Certified Orthopedic Surgery
AME Orthopedics & Spine, Los Angeles, CA
License #: CA-G-72841 | QME #: CA-8831-2019
Date: February 15, 2024
Anil Singh, M.D.
Board-Certified Orthopedic Surgery
AME Orthopedics & Spine, Los Angeles, CA
License #: CA-G-72841 | QME #: CA-8831-2019
Date: February 15, 2024
People
Eduardo Martinez
Claimant
Dr. Anil Singh, MD
AME · Orthopedics
Dr. Manuel Ramirez, MD
Primary Treating Physician
Diagnoses
L3-L4 Disc Herniation
Severe · Industrial causation
R. Shoulder Impingement
Industrial causation
No Pre-Existing Condition
Per records reviewed
Impairment Findings
22% WPI — Lumbar
DRE Category IV · Pre-surgery
8% WPI — R. Shoulder
ROM/Strength method
0% Apportionment
No pre-existing basis found
Key Dates
Mar 14, 2023
Date of injury
Jan 8, 2024
QME examination date