UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF MICHIGAN

STATE FARM MUTUAL AUTOMOBILE

INSURANCE

COMPANY,

)

)

)

)

Plaintiff, )

)

v. ) Case No.

)

) PLAINTIFF DEMANDS

)

)

TRIAL BY JURY

LOUIS N. RADDEN, D.O. and SPINE

SPECIALISTS OF MICHIGAN, P.C.

)

)

)

)

)

Defendants. )

COMPLAINT

State Farm Mutual Automobile Insurance Company (“State Farm”) for its

Complaint (“Complaint”) alleges as follows:

I. NATURE OF THE ACTION

1. This action seeks to recover money that Defendants Louis N. Radden,

DO (“Dr. Radden”) and Spine Specialists of Michigan, P.C. (“Spine Specialists”)

fraudulently obtained through the submission of thousands of medical bills and

supporting documentation to State Farm for medically unnecessary examinations,

pain-management injections, and related procedures, which were purportedly

provided to individuals (“patients”) involved in motor vehicle accidents and

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eligible for insurance benefits under State Farm policies. (Dr. Radden and Spine

Specialists are referred to collectively as “Defendants.”)

2. As discussed below, Dr. Radden falsely purports to legitimately

examine and diagnose patients, and then prescribes three types of painmanagement injections – epidural steroid injections (“ESIs”), facet injections

(“FIs”), and medial branch blocks (“MBBs”). The bills and supporting

documentation that Dr. Radden submits for these services through his company,

Spine Specialists, are fraudulent because: (a) Dr. Radden does not perform

legitimate examinations of the patients; (b) the patterns in Dr. Radden’s

documented findings and diagnoses are based upon templates, are predetermined,

and are not credible; (c) the injections purportedly performed by Dr. Radden are

not performed because they are indicated or medically necessary, but are

performed pursuant to a predetermined protocol that is designed to enrich

Defendants; (d) the injections purportedly performed by Dr. Radden expose

patients to undue and serious risks, including paralysis and death, by unnecessarily

exposing them to the dangers of invasive procedures in and around spinal

structures, and potentially dangerous levels of steroids and unnecessary anesthesia;

(e) Dr. Radden’s alleged use of epidurography in conjunction with all the ESIs that

he performs is not done because it is indicated or medically necessary, but to

enrich Defendants; (f) Dr. Radden does not use sufficient contrast to perform a

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legitimate epidurogram, does not maintain a radiographic image from the alleged

epidurogram, does not prepare a specific, detailed report of his findings for any

epidurogram, and directs that bills be submitted to State Farm that improperly

unbundle the billing codes to submit separate charges for epidurograms and

fluoroscopy, improperly increasing the aggregate charges for these procedures; (g)

Dr. Radden improperly directs his company, Spine Specialists, to submit bills to

State Farm for a contrast material that Dr. Radden does not use to justify

substantially inflated charges; and (h) Dr. Radden routinely makes disability

findings with no documented basis or rationale for such findings.

3. Defendants’ purported services were not intended to legitimately

evaluate and treat patients. Instead, they were designed and carried out to: (a)

enrich Defendants by maximizing their collection of the patients’ No-Fault

Benefits; and (b) inflate the value of personal injury claims to curry favor with

referral sources, including a small group of personal injury attorneys (“PI

Attorneys”) with whom Defendants appear to have substantial relationships.

4. Defendants’ scheme began at least as early as 2007, has continued

uninterrupted since that time, and accelerated substantially in June 2011 when

Defendants moved into their own suite, in which Dr. Radden purportedly performs

the medically unnecessary injections and related services. As a direct and

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proximate cause of Defendants’ scheme, State Farm has paid Defendants more

than $400,000.

5. State Farm brings this action seeking a declaratory judgment that it is

not liable for Defendants’ unpaid pending bills for examinations, pain-management

injections, and related procedures. This action also asserts common law claims for

fraud and unjust enrichment, as well as statutory claims under 18 U.S.C. § 1962(c)

(“RICO”) to recover actual damages of more than $400,000 paid to Defendants,

plus treble damages and costs, including reasonable attorneys’ fees.

6. State Farm has not been reimbursed by the Michigan Assigned Claims

Facility, the Michigan Catastrophic Claims Association, or any other source for

any of the claims at issue in this case.

II. JURISDICTION AND VENUE

7. Pursuant to 28 U.S.C. §1332(a)(1), this Court has jurisdiction over all

causes of action because the matters in controversy exceed the sum or value of

$75,000, exclusive of interest and costs, and are between citizens of different

states. Pursuant to 28 U.S.C. § 1331, this Court also has jurisdiction over the cause

of action brought under 18 U.S.C. § 1961 et seq. because it arises under the laws of

the United States.

8. Pursuant to 28 U.S.C. §1367(a), this Court also has supplemental

jurisdiction over causes of actions that are so related to the cause of action over

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which it has original jurisdiction that they form part of the same case or

controversy.

9. Pursuant to 28 U.S.C. §1391(a), venue is proper in this district

because Defendants reside here, and a substantial part of the events or omissions

that gave rise to the causes of action occurred here.

III. THE PARTIES

A. Plaintiff

10. State Farm Mutual Automobile Insurance Company is a citizen of the

State of Illinois. It is incorporated under the laws of the State of Illinois, with its

principal place of business in Bloomington, Illinois. It is licensed and engaged in

the business of insurance in Michigan.

B. Defendants

11. Defendant Louis N. Radden, DO resides in and is a citizen of the State

of Michigan. Dr. Radden is a Michigan-licensed doctor of osteopathic medicine

and has been the owner of Spine Specialists since its creation in February 2007.

Since that time, Dr. Radden knowingly caused to be submitted thousands of bills

and related documentation through his company, Spine Specialists, to State Farm

in the claims described in part in the charts attached hereto as Exhibits 1A-1B and

2-3.

12. Defendant Spine Specialists of Michigan, P.C. is a citizen of the State

of Michigan. It is a professional service corporation owned by Dr. Radden and

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organized under the laws of the State of Michigan. Its registered office address is

listed as 28426 West Eight Mile Road, Farmington Hills, Michigan. All of the

bills and supporting documentation at issue in this case were submitted to State

Farm by Spine Specialists at the direction of Dr. Radden.

IV. ALLEGATIONS COMMON TO ALL COUNTS

A. First-Party Claims for Payment Under The No-Fault Act

13. Under the Michigan No-Fault Act, insurers are required to pay

personal protection insurance benefits, including “allowable expenses consisting of

all reasonable charges incurred for reasonably necessary products, services and

accommodations for an injured person’s care, recovery or rehabilitation,” when

those benefits are causally connected to an “accidental bodily injury arising out of

the ownership, operation, maintenance or use of a motor vehicle” (hereinafter,

“No-Fault Benefits”). MCL §§ 500.3105, 3107(1)(a). For the reasons described

herein, the charges at issue were not for reasonably necessary medical services for

an injured person’s care, recovery, or rehabilitation, and Defendants knew it.

B. Third-Party Tort Claims for Non-Economic Loss Under The No-Fault

Act

14. Under the Michigan No-Fault Act, individuals who are not at fault for

the accidents underlying their claims can also potentially recover: (a) noneconomic losses, such as for pain and suffering, from the drivers who were at fault

for the accident (“At-Fault Drivers”) through a claim for bodily injury (a “BI

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Claim”), only in limited situations, including if the individual has suffered serious

impairment of body function, see MCL §500.3135; or (b) if recovery under the BI

Claim is insufficient, from the individual’s own insurance company through an

uninsured or underinsured motorist claim (a “UM Claim”).

15. An individual has suffered serious impairment of body function when

the general ability to conduct the course of his or her normal life has been affected

because of the injury. A determination of whether an individual has suffered

serious impairment of body function requires an analysis of the totality of the

circumstances, including: (a) the nature and extent of the impairment, (b) the type

and length of treatment required, (c) the duration of the impairment, (d) the extent

of any residual impairment, (e) the prognosis for eventual recovery, and (f)

whether there is “objective manifestation” of the injury.

16. Most patients whose claims are at issue are or were represented by a

small group of PI Attorneys who have used Defendants’ bills and supporting

documentation to support inflated BI and UM claims. The PI Attorneys stand to

profit from the inflated value of these claims because they typically take a

percentage of the recoveries for their fees. Therefore, the higher the value of the

claim, the higher the potential fees for the PI Attorneys.

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C. The Legitimate Diagnosis and Treatment of Neck and Back Pain

17. When a patient complains of neck and back pain following a motor

vehicle accident, a licensed professional must obtain a detailed history and perform

a legitimate examination to arrive at a proper diagnosis of the patient’s condition.

Based upon a legitimate diagnosis, a licensed professional must then engage in

medical decision-making to design a legitimate treatment plan tailored to the

unique needs of each patient.

18. The decision of which, if any, types of treatment are appropriate for a

patient, as well as the level, frequency, and duration of the various treatments

should be individualized. This individualized decision must consider the patient’s

unique circumstances, including his or her: (a) age; (b) social, family, and medical

history; (c) physical condition, limitations, and abilities; (d) the location, nature,

and severity of the injury and symptoms; and (e) response to any previous

treatment.

19. Treatment plans should generally start with conservative care that is

not invasive, such as anti-inflammatory medications, chiropractic care, and/or

physical therapy, which may benefit patients by healing their injuries and relieving

their symptoms with minimal associated risks and costs. If patients’ symptoms are

not relieved through conservative care, other forms of treatment may be

appropriate to relieve their symptoms, including various kinds of injections and

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other procedures designed to reduce pain and other symptoms caused by

inflammation, irritation, or other conditions. As with any other treatment option,

whether to perform any kind of injection or other procedure should be tailored to

the unique circumstances of each patient.

D. The Legitimate Use of Injections, Including ESIs, FIs, and MBBs.

20. A provider may perform injection procedures to allow for the

therapeutic treatment of chronic pain in areas of the spine (lumbar, thoracic, and

cervical), as well as joints (facet, shoulder, hip, wrist, etc.), and to diagnose the

source of the back, neck, and limb pain. Because injection procedures are

invasive, involve the injection of steroids into the body, and may require the use of

sedation, they present associated risks as well as increased costs to patients.

Therefore, injections should be performed only when appropriate indications are

present and a provider determines that they are medically necessary to diagnose

and/or treat pain generators in and around the spine, to alleviate pain in order to

facilitate conservative care, or to alleviate pain after conservative care has failed or

is not an option. Three common types of spine injection procedures are ESIs, FIs,

and MBBs.

21. Common clinical indications for ESIs are nerve-related pain radiating

from the neck into the shoulders or arms or from the lower back into the buttocks

or legs. In these patients, a careful physical examination is required to evaluate for

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associated sensory, motor, or reflex deficits in the involved limb(s) to help guide

treatment and establish baseline status before initiating invasive treatment.

Normally, these clinical findings and indications are correlated with radiologic

evidence (e.g., MRIs) of nerve-root irritation, inflammation, or compression at

spinal levels that are consistent with the distribution of the patients’ nerve-related

pain and/or physical examination findings and that may be attributable to

pathologies in and around the nerve roots.

22. There are three basic kinds of ESIs – interlaminar, caudal, and

transforaminal injections – that may be performed to relieve a patient’s symptoms

by introducing steroid medications into the epidural spaces surrounding the

vertebral levels at which the suspected pain generating pathologies exist. An

interlaminar injection involves the insertion of the needle into the posterior

epidural space between two adjacent vertebral lamina and delivering anesthetic and

steroids, which then typically spread to epidural spaces above and below the

injected space. A caudal injection involves the insertion of the needle through the

sacral hiatus (a small boney opening just above the tailbone) to deliver anesthetic

and steroids that typically spread to epidural spaces above the injected space. A

transforaminal injection involves the insertion of the needle into the intervertebral

neural foramen. In a transforaminal injection, the provider injects the anesthetic

and steroid into the area referred to as the “nerve sleeve,” which allows the steroid

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to travel up the sleeve and into a targeted epidural space. While there is an

increased level of technical expertise required to perform transforaminal injections,

this type of injection allows for greater precision in targeting with medications the

source of the patient’s pathology, which results in a more concentrated delivery of

the steroid into the affected area. As discussed below, Dr. Radden virtually always

performs interlaminar ESIs, not the caudal, or more targeted, skill-intensive

approach of transforaminal ESIs.

23. A patient who receives minimal or no relief from an initial ESI is less

likely to benefit from a second round of ESIs. Likewise, if a patient receives

minimal or no relief from an initial and second round of ESIs, it is even less likely

that the patient will benefit from additional rounds of ESIs. Therefore, based upon

the associated risks and costs, as a general matter ESIs should not be repeated

without an interval assessment of the patient’s response and unless the patient

appears to get more than minimal relief from earlier ESIs.

24. Facet joints are located on the back of the spine on each side where

two vertebrae meet. The facet joints provide stability and permit the spine to bend

and twist. Facet joints, which contain cartilage between bones, are surrounded by

a sac-like capsule filled with a synovial fluid that reduces the friction between

bony surfaces. Inflammation, irritation, swelling, arthritis, or other pathologies in

and around the facet joints may cause pain. Medial branch nerves carry sensory

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signals, including pain, from the facet joints and the muscles around those joints to

the brain.

25. The common indications for FIs and MBBs are chronic pain that is

primarily concentrated in the back or neck. The indications for FIs and MBBs are

different from the indications for ESIs (i.e., primarily radicular pain correlated with

radiologic evidence of some form of nerve root pathology).

26. FIs are performed by injecting anesthetics and steroids directly into

the facet joints that are the suspected pain generators. A patient who receives

minimal or no relief from an initial FI is less likely to benefit from a second round

of FIs. Likewise, when a patient receives minimal or no relief from an initial and

second round of FIs, it is even less likely that the patient will benefit from

additional rounds of FIs. Therefore, based upon the associated risks and costs, as a

general matter FIs should not be repeated without an interval assessment of the

patient’s response and unless the patient appears to get more than minimal relief

from earlier FIs.

27. As an alternative to FIs, MBBs are commonly performed by injecting

an anesthetic onto the medial branch nerves that carry sensory impulses, including

pain, from a suspected pain-generating facet joint to the brain. If the patient

receives relief of back or neck pain from the MBB that lasts for the expected

duration of the anesthetic, the provider will then typically prescribe a

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radiofrequency neurotomy or similar procedure in which the medial branch nerves

that carry pain signals from the pain-generating facet joint to the brain are

thermally ablated to block the pain. If a MBB does not provide relief, it suggests

that the related facet joint or joints are not the pain generators. Therefore, it is

important to precisely assess the patient’s response to determine the future course

of treatment.

28. To assist with the appropriate needle placement, ESIs, FIs, and MBBs

are typically performed under fluoroscopic guidance. Fluoroscopy is a radiological

imaging technique used to obtain real-time images of the internal structures of a

patient to help guide the path and proper placement of the needle during an

injection. When fluoroscopic guidance is used, a physician inserts a needle into

the targeted area, a contrast is then injected, and a picture is taken, which the

physician uses to confirm the needle is in the correct position. Once it is

confirmed that the needle is in the correct position, the injection can be performed.

29. An epidurography is a separate diagnostic procedure involving the

injection of contrast material into the epidural space when performing injections.

Epidurography is not indicated or medically necessary to ensure appropriate needle

placement because fluoroscopy is more than sufficient for this purpose. Therefore,

epidurography is typically indicated if there is a concern regarding conditions,

pathologies, or structural abnormalities in and around the spine that might affect

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the flow of steroids into the targeted space. To bill for an epidurography under

CPT Code 72275, the procedure must be medically necessary and include both a

permanent image recording and a separate, detailed report summarizing the

findings of the epidurogram examination.

30. Because ESIs, FIs, and MBBs entail the insertion of needles into areas

in and around the spine and ESIs and FIs often include the use of steroids, these

injections involve potentially serious risks and substantially increased costs for the

patient. Therefore, ESIs, FIs, and MBBs should not be performed unless they are

medically necessary, and if they are performed, attempts should be made to

minimize the risks and costs. The risks associated with these injection procedures

include those associated with the patient’s exposure to ionizing radiation and

sedation, the side-effects and complications from steroids (e.g., increased blood

sugar, increased blood pressure, immunity reduction, adrenal suppression,

psychosis, acute and chronic changes to the skin and bones such as fractures,

avascular necrosis, and osteoporosis), and the direct procedure risks from the

injection such as bleeding, infection, nerve injury, paralysis, and even death.

Moreover, the costs associated with injection procedures can be substantial, as

evident in Defendants’ average charges, which for cervical and lumbar injections

involving ESIs accompanied by two-level, bilateral FIs typically exceeded $14,500

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per procedure. (Exs. 2-3, Lumbar and Cervical Injection Procedures Charts, Total

Billed columns.)

31. As discussed next, Dr. Radden did not perform legitimate exams, did

not make legitimate findings, and did not legitimately diagnose patients. Instead,

despite the associated risks and costs, the uniform patterns in Dr. Radden’s

purported findings, diagnoses, and injections were predetermined and designed to

enrich Defendants by performing and billing substantial amounts to State Farm to

exploit the unlimited No-Fault Benefits available to patients for services that were

not indicated or medically necessary, and to curry favor with PI Attorneys by

inflating the value of the BI and UM claims.

32. Although the indications for ESI and FIs are different, Dr. Radden

prescribed and performed these injections together on the same dates of service

and without regard to the patients’ responses to previous treatments (including the

same injections from other providers), or whether conservative care had failed or

was still an option. Moreover, although ESI, FIs, and MBBs should not be

repeated absent more than minimal pain relief, Dr. Radden nearly always repeats

injections and yet fails to ever meaningfully examine and document patients’

responses to previous injection procedures, or offer any credible medical basis that

justifies the reasons for his decision to repeat an injection procedure.

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E. The Fraudulent Examinations

33. The scheme begins with Dr. Radden’s fraudulent examination of

patients, including allegedly taking patients’ history, performing physical exams,

reaching diagnoses, and arriving at a treatment plan. Specifically, Dr. Radden

purports to examine the patients and then creates a report that supposedly details

the patient’s subjective complaints, and Dr. Radden’s examination findings,

diagnoses, and recommended treatment plan (“Exam Reports”). Dr. Radden uses

the Exam Reports to justify the medically unnecessary ESIs, FIs, and MBBs.

34. The Exam Reports do not reflect the patient’s true subjective

complaints, actual examination findings, a legitimate diagnosis, or a medically

necessary treatment plan. The Exam Reports are based on the boilerplate language

contained in various templates prepared by Defendants (“the Templates”). The

Exam Reports reflect uniform patterns that are predetermined and not credible.

(Exhibits 4-6, Sample Exam Report Templates (emphasis added within); Exhibits

7-9, Sample Exam Reports (emphasis added within).)

35. As set forth in the chart attached hereto as Exhibit 1A, when Dr.

Radden purports to perform a lumbar examination, the Exam Reports reflect that

nearly every patient allegedly reports that: (a) his or her low back pain is

“radiat[ing]”; (b) his or her pain “is better with lying down, worse with sitting and

standing”; (c) she or he complains of “leg weakness, tiredness and a positive

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shopping cart sign”; and (d) she or he “denies any saddle anesthesia, urinary

incontinence or retention.” (Ex. 1A; see also Ex. 7 at 1; Ex. 8 at 1; Ex. 9 at 1.)

36. As set forth in the chart attached hereto as Exhibit 1B, when the initial

examination involves a lumbar examination, Dr. Radden’s findings are the same

for nearly all patients: (a) the patient is alert and oriented times three; (b) his or her

leg lengths are equal; (c) his or her hips and gait are normal; (d) “[t]here are no

signs of decompression, kyphosis scoliosis[,] or pelvic tilt”; (e) the patient has

positive posterior midline tenderness, positive paramedian tenderness to the left

and right in the lower lumbar spine; (f) he or she “is able to lateral bend to the left

and right”; (g) the patient has a normal neurologic exam of “5/5 in the bilateral

lower extremities with hip flexors, quadriceps, tibialis anterior, EHL[,] and

gastroc/psoas complex”; (h) “[t]here are no sensory deficit in the L1 to S1

distributions”; (i) the patient’s “[d]eep tendon reflexes are +2/4 for quadriceps and

Achilles, no clonus”; and (j) he or she has vascular scores of “+2/4 for the dorsalis

pedis and post tibialis.” (Ex. 1B, see also Ex. 7 at 3; Ex. 8 at 3; Ex. 9 at 2-3.)

37. As set forth in the chart attached hereto as Exhibit 1A, when Dr.

Radden purports to perform a cervical examination, the Exam Reports reflect that

nearly every patient allegedly reports that: (a) his or her neck pain is “radiat[ing]”;

(b) his or her pain is “better with the arm at the side, worse with overhead

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activity”; and (c) she or he “denies any trouble with fine motor movements.” (Ex.

1A; see also Ex. 7 at 2; Ex. 8 at 2; Ex. 9 at 1-2.)

38. As set forth in the chart attached hereto as Exhibit 1B, when the initial

examination involves a cervical examination, Dr. Radden’s findings are the same

for nearly all patients: (a) the patient is alert and oriented times three; (b) his or her

leg lengths are equal; (c) his or her hips and gait are normal; (d) he or she has

positive posterior midline tenderness and positive paramedian tenderness to the left

and right in the lower cervical spine; (e) the patient has a normal neurologic exam

of “5/5 in the bilateral upper extremities with deltoid, biceps, triceps, wrist flexors,

wrist extensors, finger flexors, finger extensors[,] and intrinsics”; (f) there are no

sensory deficits in the C5 to T6 distributions; (g) the patient’s deep tendon reflexes

are +2/4 for biceps, triceps, brachioradialis; and (h) the patient’s vascular exam is

normal with radial and ulnar pulses. (Ex. 1B; see also Ex. 7 at 3-4; Ex. 8 at 3-4;

Ex. 9 at 2-4.)

39. These predetermined complaints and findings are used to support Dr.

Radden’s predetermined diagnosis of strains/sprains, facet syndrome, and disc

herniations (see Exs. 1A and 1B), in addition to other diagnoses that may be made

for some patients, to support his recommendation for and performance of cervical

and lumbar injections. Dr. Radden’s initial diagnoses are non-specific, and even if

he receives additional information concerning patients’ conditions (e.g., imaging

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studies), Dr. Radden never attempts to correlate his initial diagnosis to that

additional information or arrive at a more specific diagnosis.

40. Dr. Radden also routinely finds that patients are “disabled from

replacement services,” without ever documenting the basis or specific rationale for

his findings. These disability determinations allow Dr. Radden to curry favor with

PI attorneys by increasing the value of the patients’ claims.

41. Given the uniform patterns appearing among all of the Exam Reports,

the Exam Reports do not reflect legitimate descriptions of patients’ pain or the

results of a legitimate examination, but instead reflect predetermined findings that

Dr. Radden uses to justify his decision to subject patients to medically unnecessary

ESIs, FIs, and MBBs. The prevalence and uniformity of the patient complaints,

findings, and diagnoses are simply not credible.

42. Furthermore, despite the increased risks and costs to patients, Dr.

Radden uses his predetermined pattern of patient complaints, findings, and

diagnoses to support his recommendation and performance of injections, often

without regard to the patient’s medical history, including whether the injections

might be medically necessary to facilitate conservative care, to alleviate pain after

conservative care has failed or is not an option, or based upon the timing, type, and

the patient’s response (or lack thereof) to prior injections.

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43. As discussed next, the Exam Reports do not reflect the legitimate

examinations of patients, but are part of Defendants’ predetermined protocol.

Defendants designed the Exam Reports to support injection procedures that are not

medically necessary and are prescribed without regard to the substantially undue

risks and costs to the patients.

F. The Fraudulent Treatment Recommendations

44. Based upon Dr. Radden’s predetermined reports of patient complaints,

findings, and diagnoses, Dr. Radden subjects patients to a uniform protocol of

injections that is predetermined, is not tailored to the unique needs of any patient,

does not evaluate or respond to any changes in the patients’ conditions, and

subjects patients to substantial undue risks and costs.

45. Specifically, as reflected in the charts attached hereto as Exhibits 2-3,

Dr. Radden begins his uniform predetermined injection protocol by initially

recommending and then performing a series of three lumbar and/or cervical

injections typically spaced only two weeks apart. Even if any of the initial

injection recommendations were truly indicated for any patient based upon a

legitimate exam and diagnosis, which they were not in the case of Dr. Radden,

peer-reviewed medical literature and professional medical society guidelines

clearly establish there was no legitimate basis for Dr. Radden to uniformly

recommend and perform a series of three injections.

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46. According to guidelines published by the North American Spine

Society, the American Academy of Physical Medicine and Rehabilitation, the

American Academy of Pain Medicine, the Anesthesia Patient Safety Foundation,

the American Society of Interventional Pain Physicians, and the International

Spine Intervention Society, a routine series of three injections, like those

recommended and performed by Dr. Radden, is never indicated. In fact, State

Farm is not aware of any professional medical society guidelines that support a

routine series of three injections. Instead, patients should be examined and

assessed after each injection, to determine if another injection is warranted.

47. Until approximately the spring or summer of 2013, Dr. Radden

followed one uniform predetermined protocol for cervical and lumbar injections.

Specifically, as reflected on the chart attached hereto as Exhibit 2, for lumbar

injections, on each visit Dr. Radden performed interlaminar ESIs at either the L4-5

or L5-S1 levels of the spine, along with bilateral FIs at two levels. According to

his reports for these lumbar injection procedures, Dr. Radden injected 80 mg. of

Depo-Medrol, along with 2 cc of saline and 1 cc of .25% Marcaine with

epinephrine into the targeted epidural space – either L4-5 or L5-S1 – plus 80 mg.

of Depo-Medrol and 1 cc of .25% Marcaine with epinephrine into the targeted

bilateral facet joints at each of two levels. As a result, Dr. Radden’s protocol,

which was not performed because it was medically necessary in the first place,

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involved the injection of at least 160 mg. of the steroid Depo-Medrol into each

patient during each lumbar injection procedure.

48. Similarly, until approximately the spring or summer of 2013, as

reflected on the chart attached hereto as Exhibit 3, for cervical injections, on each

visit Dr. Radden performed interlaminar ESIs at either the C6-7 or C7-T1 levels of

the spine, along with bilateral FIs (and, on most occasions, MBBs) at two levels.

According to his reports for these cervical injection procedures, Dr. Radden

injected 80 mg. of Depo-Medrol, along with 1 cc of saline into the targeted

epidural space – either C6-7 or C7-T1 – plus 80 mg. of Depo-Medrol and 1 cc of

.25% Marcaine with epinephrine into the targeted bilateral facet joints and/or

related medial branch nerves at each of two levels. This means that Dr. Radden’s

protocol, which was not performed because it was medically necessary in the first

place, involved the injection of at least 160 mg. of the steroid Depo-Medrol into

each patient during each cervical injection procedure.

49. Because the indications for ESIs are different from the indications for

FIs and MBBs, it is rarely indicated that they should be performed on the same

date of service for any patient. Yet, until approximately the spring or summer of

2013, Dr. Radden’s predetermined protocol was to perform ESIs and FIs together

on nearly all lumbar injection visits, and ESIs, along with both FIs (and, on most

occasions, MBBs) together on nearly all cervical injection visits. (Exs. 2-3.)

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50. Furthermore, FIs are indicated to treat neck or back pain stemming

from facet joints. MBBs are typically indicated to determine if a specific facet

joint is a pain generator by having patients record their responses for several hours

after the block, while the anesthetic is actively blocking the nerves. Because

MBBs and FIs are done for different reasons, it is rarely indicated that FIs and

MBBs should be performed together. Yet, until approximately the spring or

summer of 2013, Dr. Radden’s predetermined protocol was to perform MBBs and

FIs together on nearly all cervical injection visits where patients received cervical

ESIs. (See generally Ex. 3, Cervical Injection Procedures Chart.)

51. In addition, if an MBB provides relief and indicates that a particular

facet joint is a pain generator, standard practice is to perform radiofrequency

neurotomy or similar procedure to thermally ablate the medial branch nerves that

carry sensory impulses, including pain, from the suspect facet joint to the brain.

This is done because it is known to provide much longer relief of a patient’s pain

and does not carry risks of repeated injections of steroids. Yet, until approximately

the spring or summer of 2013, Dr. Radden never performed a radiofrequency

neurotomy or similar procedure on any of the patients at issue in Exhibits 2 and 3.

52. As set forth in the charts attached hereto as Exhibits 2 and 3, in

approximately the spring or summer of 2013, Dr. Radden changed his uniform

predetermined protocol for injections to start typically with two or more rounds of

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ESIs before proceeding to FIs and, at times, MBBs. (Exs. 2-3, Lumbar and

Cervical Injection Procedures Charts.)

53. As discussed above, before a provider repeats an ESI, there should be

documentation that the patient received more than minimal pain relief from the

preceding injection procedure. However, Dr. Radden’s predetermined injection

protocols, before and after the spring or summer of 2013, involved multiple rounds

of injections (with each injection typically repeated every two weeks) for nearly all

patients with no meaningful attempt to determine the patient’s response or lack

thereof to any of the injections. Indeed, Dr. Radden fails to ever meaningfully

examine and document patients’ responses to injection procedures, or offer any

credible medical basis that justifies the reasons for his decision to repeat an

injection procedure.

54. For example, Dr. Radden performed a series of six rounds of

injections on a 24-year-old male patient injured in an motor vehicle accident. In

particular, Dr. Radden performed three lumbar ESIs accompanied by multiplelevel, bilateral FIs, and three cervical ESIs accompanied by multiple-level, bilateral

FIs and MBBs. The patient testified that he had told Dr. Radden that he had

already received three lumbar injections from another provider, which failed to

provide him with any pain relief whatsoever. (Exhibit 10, 4/16/2013 Tr., at 24-26.)

Nonetheless, Dr. Radden recommended additional ESIs at L4-5 along with FIs at

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L4-S1, which he performed on January 30, February 13, and February 27, 2013

without conducting any interval examinations between the injections. (Exhibit 11,

1/14/2013 Exam Report, at 2; 1/30/13, 2/13/13, & 2/27/13 Procedure Notes.) The

patient testified that Dr. Radden never explained the risks of the procedures, but

simply told the patient that he needed the injections to “stop pain.” (Ex. 10,

4/16/2013 Tr., at 29.) The patient received no pain relief from any of the lumbar

injections performed by Dr. Radden and saw only a “little improvement” in his

range of motion after receiving the third round of cervical ESIs and FIs (which

were also accompanied by MBBs at the same levels). (Id. at 29-32.) In short,

there was no appropriate basis upon which to perform the first injection procedure,

or any of the other procedures that followed.

55. Likewise, on September 6, 2011, Dr. Radden performed a series of

lumbar ESIs at L4-L5, with multiple-level, bilateral FIs at L4-L5 and L5-S1, on a

22-year-old male patient. (Ex. 12, 9/6/11, 9/21/11, and 10/12/11 Procedure Notes,

at 3-4, 7-8, 11.) Three days before the injection procedure, the patient’s low back

pain was documented as an 8 out of 10 in treatment notes from a chiropractor. (Id.,

9/3/11 Associated Note, at 1.)

56. The chiropractor examined the patient again during an office visit two

days after the first injection procedure – on September 8, 2011 – and documented

that the patient’s low back pain was now 9 out of 10. In other words, the patient’s

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low-back pain had become worse, not better, after the injection procedure. (Id.,

9/8/11 Associated Note, at 5.) Nevertheless, without documenting the patient’s

response to the first injection, Dr. Radden performed a second round of ESI and

FIs at the same lumbar levels approximately two weeks later on September 21,

2011. (Id., 9/21/11 Procedure Note, at 7-8.) The very next day, a chiropractor

examined the patient, noted that the patient had “sharp pain generalized in the

lower back,” and reported the pain level in the lower back was 8 out of 10. (Id.,

9/22/11 Associated Note, at 9.) Again, however, without documenting the

patient’s response to the second injection, Dr. Radden proceeded with a third round

of ESI and FIs at the same lumbar levels on October 12, 2011. (Id., 10/12/11

Procedure Note, at 11.) After the third round of injections, on October 15, 2011,

the chiropractor again examined the patient, reported that the patient was still

experiencing lumbar pain, and noted “his lumbar region pain is feeling unchanged

from the last visit. . . .” and had “low back pain at 8. . . .” (Id., 10/15/11 Associated

Note, at 12.) Finally, after subjecting the patient to three rounds of injections, Dr.

Radden purportedly examined the patient on October 31, 2011, and stated that the

injections “helped his back and leg complaints minimally,” as the patient “still

complains of back. . . pain.” (Id., 10/31/2011 Exam Report, at 14.) In short,

although the patient never received any significant pain relief from the first round

of lumbar injections, let alone the two rounds that followed, Dr. Radden subjected

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the patient to three rounds of injections, despite having failed to conduct and

document any interval assessment of the patient’s response to the procedures to

determine whether a subsequent injection would provide more than minimal relief.

57. Dr. Radden examined the patient again on January 16, 2012, and

again found that the patient “continu[ed] to complain of low back pain and lower

extremity radicular symptoms” with [l]umbar spine range of motion [] decreased to

75 percent of normal.” (Id., 1/16/12 Exam Report, at 16-17.) Although the first

round of lumbar injections failed to provide the patient with any pain relief, Dr.

Radden nonetheless scheduled the patient for another series of lumbar ESIs at L4-5

with multiple-level, bilateral FIs at L4-5 and L5-S1 on January 31, 2012, February

29, 2012, and March 14, 2012. (Id., 1/31/12, 2/29/12, and 3/14/12 Procedure

Notes, at 19, 22, 25.) Again, Dr. Radden performed these injections without

examining and documenting the patient’s response to the first or second injection

procedure. Once again, however, medical records prepared by a chiropractor

reflect that the patient’s lumbar back pain remained 8 out of 10 after each injection

procedure. (See id., 2/2/12 Associated Note, at 20 (“lower back condition has not

changed” and “low back pain at 8”); id., 3/6/12 Associated Note, at 23 (“lumbar

region pain is feeling unchanged from last visit” and “low back pain at 8”); id.

3/15/12 Associated Note, at 26 (same).) Incredibly, on May 23, 2012, despite the

fact that the patient did not experience any pain relief from the six rounds of ESI at

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L4-5 and six bilateral FIs at levels L4-5 and L5-S1, Dr. Radden once again

recommended that the patient undergo another round of ESIs at L4-5 with bilateral

FIs at L4-S1. (Id., 5/23/12 Exam Report, at 28-30.)

G. Dr. Radden’s Inappropriate Use of Epidurograms for All ESIs

58. Epidurography is a separate diagnostic procedure involving the

injection of contrast into the epidural space, and must include both a permanent

image recording and a separate, detailed report summarizing the findings of the

examination under CPT Code 72275. Epidurography is not indicated or medically

necessary to ensure appropriate needle placement or epidural delivery of contrast

because fluoroscopic guidance is more than sufficient for this purpose. Therefore,

epidurography is generally indicated if there is a concern regarding conditions,

pathologies, or structural abnormalities in and around the spine that may be missed

by the preceding MRI or CT scans or may affect the flow of steroids into the

targeted space.

59. As part of Dr. Radden’s predetermined injection protocol, he purports

to perform and bill for an epidurography nearly every time he performs an ESI.

(Exs. 2-3, Lumbar and Cervical Injection Procedures Charts, “Epidurogram”

Column.) Dr. Radden performs the epidurograms pursuant to his predetermined

injection protocol, not because they are medically necessary for the patients.

Indeed, Dr. Radden: (a) does not document any indication for the epidurograms;

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(b) purportedly performs them with only 1 cc of Isovue – an amount that would

likely not be sufficient for a legitimate epidurogram; (c) repeats the epidurograms

on nearly every ESI visit without documenting any indication for repeating it; (d)

does not keep any images of the alleged epidurograms; (e) does not create a

separate, detailed report of his findings; and (f) improperly unbundles the billing

codes and charges that Spine Specialists submitted to State Farm at the direction of

Dr. Radden by billing separate charges for the fluoroscopy and epidurograms,

which, at best, should be bundled into a single charge.

H. Dr. Radden’s Inappropriate Use of Sedation During Injection

Procedures

60. For patient safety, minimal levels of sedation should be used when

performing injections and verbal communication should be maintained with the

patient. In fact, in many instances physicians can safely perform ESIs, FIs, and

MBBs without the use of any sedation. A patient who is not heavily sedated may

function as a secondary monitor during the injection procedure and may be able to

prevent potentially catastrophic injury arising from a misplaced needle, among

other things, by complaining about pain or parethesias. While sedatives may be

appropriate for some patients to help lessen their anxiety, minimum levels of

sedation should be used based on the unique needs and circumstances of each

patient. The routine use of sedation on patients is therefore not the standard of

care.

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61. Dr. Radden, however, almost always performs injections procedures

on patients who are sedated by a certified registered nurse anesthetist (“CRNA”)

working under Dr. Radden’s direction. In fact, Dr. Radden has testified it is part of

his predetermined protocol to sedate patients before performing injection

procedures, regardless of whether it is medically necessary to do so. (Ex. 13,

8/17/2011 Deposition of L. Radden, at 15.) Dr. Radden has testified that he

automatically provides monitored sedation for all injection procedures “[u]nless

the patient requests that they don’t want anesthesia.” (Ex. 14, 5/8/12 Deposition of

L. Radden, at 28.)

62. From June 2011 and continuing until November 2012, Ambulatory

Anesthesia Associates, PC billed for nearly all of the sedation services provided by

its CRNAs during the injection procedures performed at Defendants’ Bingham

Farms office. However, in late 2012, several CRNAs previously associated with

Ambulatory Anesthesia Associates, PC became associated with a different sedation

provider – namely, American Anesthesia Associates, LLC. Since early 2013 to

present, American Anesthesia Associates, LLC has provided and billed for the

majority of sedation services provided at the Bingham Farms office.

63. While it is uncertain at this time the nature of the relationship between

Dr. Radden, American Anesthesia Associates, LLC, Ambulatory Anesthesia

Associates, PC, and the CRNAs who worked for or were affiliated with these

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entities, Dr. Radden’s decision to sedate all patients, regardless of their unique

circumstances, facilitated charges from these entities for services that were

performed pursuant to Dr. Radden’s predetermined protocol, not because such

services were medically necessary to address the needs of any particular patient.

This exposed patients to increased risks of sedation, and increased risks of

procedures performed under sedation.

I. The Fraudulent Procedure Notes

64. Much like his Exam Reports, Dr. Radden’s documentation of

injection procedures (“Procedure Notes”) are boilerplate and not credible. In

particular, Dr. Radden prepares two types of Procedure Notes for patients receiving

lumbar and cervical injections. These Procedure Notes, which were submitted to

State Farm, supposedly document the injections performed on each patient on each

visit. Neither the Exam Reports described above nor the Procedure Notes provides

a specific anatomic diagnosis to justify the location of the ESIs, FIs, or MBBs.

65. Until approximately the spring or summer of 2013, Dr. Radden used

nearly identical Procedure Notes for all patients upon whom he performed lumbar

injections. (Ex. 15, Sample Lumbar Injection Procedure Notes.) In fact, while

there were several areas where the specific lumbar levels were handwritten, the

Procedure Notes did not vary materially from one patient to the next. (See

generally id.) In the Procedure Notes, Dr. Radden diagnoses nearly all patients

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receiving lumbar injections with the same preoperative and postoperative

diagnoses of lumbar disc herniation, facet syndrome, and lumbar spondylosis. (Ex.

2, Lumbar Injection Procedures Chart.) Thus, neither his Exam Reports, nor his

Procedure Notes provide a specific anatomic diagnosis to justify the procedures he

performs.

66. The Procedure Notes also contained boilerplate language about the

“Operative Procedure,” which for nearly all lumbar patients reflected the

predetermined protocol of an ESI, epidurogram, fluoroscopy, and bilateral FIs at

two levels. (Ex. 15, Sample Lumbar Injection Procedure Notes.) Moreover, until

approximately the spring or summer of 2013, for patients receiving lumbar

injections, the Operative Procedure in Detail section in the Procedure Notes

repeated for all patients the following language:

(Id.) With the exception of the specific lumbar levels, which were almost always

either L4-5 or L5-S1, all Procedures Notes for lumbar ESI patients were the same.

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67. Similarly, until approximately the spring or summer of 2013, Dr.

Radden used nearly identical Procedure Notes for all patients upon whom he

performed cervical injections. (Ex. 16, Sample Cervical Procedure Notes.) In fact,

while there were several areas where the specific cervical levels were handwritten,

the Procedure Notes did not vary materially from one patient to the next. (Id.) In

the Procedure Notes, Dr. Radden diagnoses nearly all patients receiving cervical

injections with the same preoperative and postoperative diagnoses of cervical disc

herniation, cervical stenosis, cervical facet syndrome, and cervical spondylosis.

(Ex. 3, Cervical Injection Procedures Chart.) Thus, neither his Exam Reports, nor

his Procedure Notes provide a specific anatomic diagnosis to justify the procedures

he performs.

68. The Procedure Notes also contained boilerplate language about the

“Operative Procedure,” which for nearly all cervical patients reflected the

predetermined protocol of an ESI, epidurogram, fluoroscopy, and bilateral FIs and

MBBs at two levels. (Ex. 16, Sample Cervical Injection Procedure Notes.)

Moreover, until approximately the spring or summer of 2013, for patients receiving

cervical injections, the Operative Procedure in Detail section in the Procedures

Notes repeated for all patients the following language:

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(Id.) With the exception of the cervical levels, which were almost always either

C6-7 or C7-T1, all Procedures Notes for cervical ESI patients were the same.

69. As noted above, in approximately the spring or summer of 2013, Dr.

Radden changed his uniform predetermined protocol for both cervical and lumbar

injections to start typically with two or more rounds of ESIs before proceeding to

FIs and, at times, MBBs. Thus, the Procedure Notes reflecting the change in Dr.

Radden’s uniform predetermined protocol for both cervical and lumbar injections

do not show ESIs being performed on the same dates of service as FIs and MBBs.

However, with the exception of the lumbar and cervical levels, the Procedure

Notes otherwise do not vary materially from one patient to the next, nor does Dr.

Radden ever meaningfully examine and document patients’ responses to earlier

injection procedures, or offer any credible medical basis that justifies the reasons

for his decision to repeat an injection procedure.

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J. All of The Above Procedures Were Done To Support Fraudulent

Charges.

70. The purported services described above were designed and carried out

to enrich Defendants by maximizing their collection of patients’ No-Fault Benefits.

71. After a lumbar injection procedure, Dr. Radden, through his company,

Spine Specialists, typically submitted charges of $2,000 for the lumbar ESI, $9,000

for two-level, bilateral FIs ($4,500 for each bilateral FI), $1,400 for the

epidurogram, $300 for the fluoroscopy, $375 for the surgical tray, $600 for the

contrast, and $880 for the steroid. Thus, the total charges for a lumbar injection

procedure typically exceeded $14,500. (See Ex. 2, Lumbar Injection Procedures

Chart, Total Billed column.)

72. Similarly, after a cervical injection procedure, Dr. Radden, through

his company, Spine Specialists, typically submitted charges of $2,000 for the

cervical ESI, $9,000 for two-level, bilateral FIs and MBBs ($4,500 for each

bilateral FI accompanied by an MBB at the same levels), $1,400 for the

epidurogram, $300 for the fluoroscopy, $375 for the surgical tray, $600 for the

contrast, and $880 for the steroid. Thus, the total charges for a cervical injection

procedure typically exceeded $14,500. (See Ex. 3, Cervical Injection Procedures

Chart, Total Billed column.)

73. Dr. Radden also caused to be submitted the fraudulent charges for the

fees associated with the anesthesia services, as these services were performed at his

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direction pursuant to his predetermined protocol, not because such services were

medically necessary. The charge for the anesthesia used during the injection

procedures typically was approximately $400 for each date of service. (See Exs. 2-

3.)

74. As discussed above, Defendants’ scheme began in 2007, but increased

exponentially once Dr. Radden purchased his own office location in June 2011. In

particular, between 2007 to June 2011, Dr. Radden, through his company, Spine

Specialists, billed State Farm for only 51 dates of service involving injection

procedures. However, since June 2011, Dr. Radden performed more than 530

dates of service involving injection procedures, almost all of which took place at

his Bingham Farms office.

75. Moreover, as noted above, when Dr. Radden performs ESIs, he nearly

always directs Spine Specialists to submit charges for epidurography and

fluoroscopy, along with the various charges associated with all of the injections.

Setting aside that Dr. Radden’s documentation does not justify his decision to

subject any patient to an epidurogram (or an ESI for that matter), there should not

have been a separate bill for fluoroscopy (which was billed under CPT code

77003) when he performed an epidurogram. CPT code 72275, the code for

epidurography, includes fluoroscopic guidance as part of the description of the

procedure. Thus, the submission of charges for both an epidurogram and

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fluoroscopy improperly unbundled the billing codes in order to inflate the total

charges for Dr. Radden’s services.

76. Moreover, in the few instances in which Dr. Radden performed only

an FI on a patient, there should not have been a separate bill for fluoroscopic

guidance under CPT code 77003. CPT code 77003 is not separately reportable

because the CPT code for FIs includes the use of image guidance in the code

description.

77. In addition, the bills submitted by Spine Specialists at the direction of

Dr. Radden used a false billing code to justify an inflated $600 charge associated

with Dr. Radden’s purported use of a contrast. Specifically, Dr. Radden’s own

documentation for ESI procedures states that he used the contrast Isovue. (Exs.

15-16, Sample Lumbar and Cervical Injection Procedure Notes.) The appropriate

billing code for Isovue is Q9947. On several occasions in 2007 and once in 2010,

Dr. Radden charged $15 for his purported use of Isovue under Q9947. However,

shortly after Dr. Radden moved into his own suite in the summer of 2011, the bills

submitted to State Farm for his services reflected a substantially higher charge of

$600 for his purported use of a “gadolinium-based magnetic resonance contrast

agent” under the code A9579. None of Dr. Radden’s documentation suggests the

use of a gadolinium-based magnetic resonance contrast agent or otherwise supports

the use of the much higher charge submitted under A9579.

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K. State Farm’s Reasonable Reliance

78. Defendants are obligated legally and ethically to act honestly and with

integrity. Yet, Dr. Radden caused Spine Specialists to submit bills and

documentation that are fraudulent in that they represent that services were actually

rendered and were medically necessary when, in fact, they either were not

performed or were performed pursuant to a predetermined protocol and not

because they were medically necessary. The bills and documentation were

designed and carried out to enrich Defendants by maximizing their collection of

the patients’ No-Fault Benefits.

79. State Farm is under statutory and contractual duties to promptly pay

No-Fault Benefits for medically necessary services. The bills and supporting

documentation submitted to State Farm in support of the fraudulent charges at

issue, combined with the material misrepresentations described above, were

designed to cause, and did cause, State Farm to rely on them.

80. As a result, State Farm has incurred damages of more than $400,000

in benefits paid based upon the fraudulent charges.

V. CAUSES OF ACTION

FIRST CLAIM FOR RELIEF

COMMON LAW FRAUD

(Against All Defendants)

81. State Farm incorporates, adopts, and re-alleges as though fully set

forth herein, each allegation in Paragraphs 1 through 80 above.

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82. Defendants intentionally and knowingly made false and fraudulent

statements of material fact to State Farm by submitting, and causing to be

submitted, at Dr. Radden’s direction, thousands of bills and related documentation

that are fraudulent and contained false representations of material fact. The bills

and related documentation submitted to State Farm at Dr. Radden’s direction were

fraudulent in that they represented that: (a) Dr. Radden performed legitimate

examinations of patients, when in fact he did not; (b) Dr. Radden provided

medically necessary pain-management injections, anesthesia services, and related

procedures to patients, which were individually tailored to each patient’s unique

needs, when in fact the pain-management injections, anesthesia services, and

related procedures either were not performed or were performed pursuant to a

predetermined protocol, designed to enrich Defendants by maximizing collection

of the patients’ No-Fault Benefits and not because they were medically necessary;

(c) Dr. Radden’s use of epidurography in conjunction with all the ESIs that he

performed was medically necessary, when in fact the epidurography either was not

performed or was performed pursuant to a predetermined protocol, not because it

was medically necessary for the patients; (d) charges submitted under billing code

A9579 were appropriate because Dr. Radden had used a gadolinium-based

magnetic resonance contrast agent during injection procedures, when in fact none

of his documentation suggests the use of a gadolinium-based magnetic resonance

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contrast agent or otherwise supports Defendants’ charges under A9579; (e) the

separate charges for epidurograms and fluoroscopy were appropriate when in fact

the code for epidurography includes fluoroscopic guidance as part of the

description of the epidurography procedure and the submission of charges for both

an epidurogram and fluoroscopy improperly unbundled the billing codes; (f) when

Dr. Radden performed only an FI on a patient, it was appropriate to bill separately

for fluoroscopic guidance under CPT code 77003 when in fact CPT code 77003

was not separately reportable because the CPT code for FIs includes the use of

image guidance in the code description; and (g) Dr. Radden’s disability findings

were supported by a documented basis and rationale, when in fact these findings

were rendered pursuant to a predetermined protocol and are not supported by a

documented basis and rationale. The bills, documentation, and the corresponding

mailings are described in part in Exhibits 1A-1B and 2-3, attached hereto.

Representative samples of these bills and supporting documentation are attached as

Exhibits 4-9, 11-12, and 15-16.

83. Defendants knew that the above-described misrepresentations made to

State Farm relating to the purported examinations, pain-management injections,

anesthesia services, and related procedures were false and fraudulent when they

were made.

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84. Defendants made the above-described misrepresentations and engaged

in such conduct to induce State Farm into relying on the misrepresentations.

85. Because of its reliance on these misrepresentations, State Farm has

incurred damages of more than $400,000.

86. The willful, reckless, and/or wanton conduct of Defendants entitles

State Farm to exemplary damages.

WHEREFORE, State Farm demands judgment against Defendants for

compensatory damages, exemplary damages, costs, and other such relief as this

Court deems equitable, just, and proper.

SECOND CLAIM FOR RELIEF

VIOLATION OF 18 U.S.C. §1962(c)

(Against Defendant Louis N. Radden, M.D.)

87. State Farm incorporates, adopts, and re-alleges as though fully set

forth herein, each allegation in Paragraphs 1 through 86 above.

88. Spine Specialists is a corporation and an “enterprise” (the “Office

Enterprise”), as that term is defined in 18 U.S.C. § 1961(4), that engages in, and

the activities of which affect, interstate commerce.

89. Defendant Dr. Radden is and has been employed by and/or associated

with the Office Enterprise.

90. Since at least February 2007 and continuing uninterrupted to the

present, Dr. Radden has knowingly conducted and/or participated, directly or

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indirectly, in the conduct of the Office Enterprise’s affairs through a pattern of

racketeering activity consisting of repeated violations of the federal mail fraud

statute, 18 U.S.C. §1341, based upon the use of United States mails to submit to

State Farm thousands of bills and documentation that are fraudulent for

examinations, pain-management injections, anesthesia services, and related

procedures which either were not performed or were not medically necessary and

individually tailored to the unique needs of each patient. Specifically, the bills and

related documentation Dr. Radden caused to be submitted to State Farm were

fraudulent in that they represented that: (a) Dr. Radden performed legitimate

examinations of patients, when in fact he did not; (b) Dr. Radden provided

medically necessary pain-management injections, anesthesia services, and related

procedures, to patients, which were individually tailored to each patient’s unique

needs, when in fact the pain-management injections, anesthesia services, and

related procedures either were not performed or were performed pursuant to a

predetermined protocol, designed to enrich Dr. Radden by maximizing collection

of the patients’ No-Fault Benefits and not because they were medically necessary;

(c) Dr. Radden’s use of epidurography in conjunction with all the ESIs that he

performed was medically necessary, when in fact the epidurography either was not

performed or was performed pursuant to a predetermined protocol, not because it

was medically necessary for the patients; (d) charges submitted under billing code

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A9579 were appropriate because Dr. Radden had used a gadolinium-based

magnetic resonance contrast agent during injection procedures, when in fact none

of his documentation suggests the use of a gadolinium-based magnetic resonance

contrast agent or otherwise supports charges under A9579; (e) the separate charges

for epidurograms and fluoroscopy were appropriate when in fact the code for

epidurography includes fluoroscopic guidance as part of the description of the

epidurography procedure and submission of charges for both an epidurogram and

fluoroscopy improperly unbundled the billing codes; (f) when Dr. Radden

performed only an FI on a patient, it was appropriate to bill separately for

fluoroscopic guidance under CPT code 77003 when in fact CPT code 77003 was

not separately reportable because the CPT code for FIs includes the use of image

guidance in the code description; and (g) Dr. Radden’s disability findings were

supported by a documented basis and rationale, when in fact these findings were

rendered pursuant to a predetermined protocol and are not supported by a

documented basis and rationale.

91. The bills and the corresponding mailings, which comprise the pattern

of racketeering activity identified through the date of this Complaint, are described

in part in Exhibits 1A- 1B and 2-3, attached hereto. Representative samples of

these bills and supporting documentation are attached as Exhibits 4-9, 11-12, and

15-16.

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92. State Farm has been injured in its business and property by reason of

the above-described conduct in that it has paid more than $400,000 based upon the

fraudulent charges associated with examinations, pain-management injections,

anesthesia services, and related procedures.

WHEREFORE, State Farm demands judgment against Defendant Dr.

Radden for compensatory damages, together with treble damages, costs and

reasonable attorneys’ fees pursuant to 18 U.S.C. §1964(d), plus interest, and any

other relief the Court deems just and proper.

THIRD CLAIM FOR RELIEF

UNJUST ENRICHMENT

(Against the All Defendants)

93. State Farm incorporates, adopts, and re-alleges as though fully set

forth herein, each allegation in Paragraphs 1 through 92 above.

94. State Farm conferred a benefit upon Defendants by paying their

claims and these Defendants voluntarily accepted and retained the benefit of those

payments.

95. Because Defendants knowingly submitted charges for examinations,

pain-management injections, and related procedures that were either not rendered

or not medically necessary and individually tailored to the unique needs of each

patient, the circumstances are such that it would be inequitable to allow them to

retain the benefit of the monies paid.

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96. As a direct and proximate result of the above-described conduct, State

Farm has been damaged and Defendants have been unjustly enriched by more than

$400,000.

WHEREFORE, State Farm demands judgment against Defendants for

compensatory damages plus interest and costs and for such other relief as the Court

deems equitable, just, and proper.

FOURTH CLAIM FOR RELIEF

DECLARATORY JUDGMENT

(Against Defendant Spine Specialists of Michigan, P.C.)

97. State Farm incorporates, adopts, and re-alleges as though fully set

forth herein, each allegation in Paragraphs 1 through 96 above.

98. This is an action for declaratory relief pursuant to 28 U.S.C. §2201.

99. There is an actual case and controversy between State Farm, on the

one hand, and Defendant Spine Specialists, on the other hand, as to all charges for

examinations, pain-management injections, and related procedures that have not

been paid. State Farm contends that Defendant Spine Specialists is not entitled to

reimbursement for any of these charges, which exceed $75,000.

100. Because Defendants made false and fraudulent statements and

otherwise engaged in the above-described fraudulent conduct with the intent to

conceal and misrepresent material facts and circumstances regarding each claim

submitted to State Farm, Defendant Spine Specialists is not entitled to

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reimbursement for any unpaid charges associated with the examinations, painmanagement injections, and related procedures of patients.

WHEREFORE, State Farm respectfully requests a judgment declaring that

Defendant Spine Specialists is not entitled to reimbursement for any of the unpaid

charges for the examinations, pain-management injections, and related procedures,

and for supplementary relief, attorneys’ fees, interest, and costs as this Court

deems equitable, just and proper.

JURY DEMAND

Pursuant to Federal Rule of Civil Procedure 38(b), State Farm demands a

trial by jury.

Dated this 25th day of August, 2014.

MILLER, CANFIELD, PADDOCK &

STONE P.L.C.

By: s/ Matthew P. Allen

Thomas W. Cranmer (P25252)

Matthew P. Allen (P57914)

Miller, Canfield, Paddock & Stone

P.L.C.

840 W. Long Lake Road, Suite 200

Troy, Michigan 48098

(248)-267-3381

cranmer@millercanfield.com

allen@millercanfield.com

Ross O. Silverman (IL 6226560)

John W. Reale (IL 6282236)

Katten Muchin Rosenman LLP

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525 West Monroe Street

Chicago, IL 60661-3693

(312) 902-5200

ross.silverman@kattenlaw.com

john.reale@kattenlaw.com

Attorneys for Plaintiff State Farm

Mutual Insurance Company

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