Medical Necessity Review — Pain Management

What Is Medical Necessity Review?

Medical necessity review is a physician's structured analysis of whether a specific treatment, procedure, device, or course of care was clinically indicated for the documented diagnosis at the time it was ordered, authorized, or rendered. In pain management litigation, medical necessity is frequently the central disputed issue — not whether an injury occurred, but whether the treatment claimed as a result of that injury was clinically warranted.

A proper medical necessity opinion does not apply a payer's coverage criteria to a claim form. It applies published clinical guidelines, peer-reviewed evidence, and the clinical judgment of a qualified specialist to the full medical record of a specific patient. The opinion must be specific, defensible, and grounded in the same standards that govern clinical practice — not administrative review.

Dr. Dardashti provides medical necessity opinions across the full spectrum of pain management interventions: epidural steroid injections, medial branch blocks, radiofrequency ablation, spinal cord stimulation, intrathecal pump therapy, peripheral nerve stimulation, long-term opioid management, and related diagnostic and therapeutic procedures. Opinions are available for plaintiff and defense counsel, insurance carriers, mediators, and courts.

Why Medical Necessity Matters in Litigation

Medical necessity is a threshold question in virtually every pain management damages dispute. It determines whether treatment was compensable, whether future care projections are supportable, whether insurance coverage applies, and whether a treating physician's decisions are defensible against a malpractice claim. Despite its centrality, medical necessity is frequently litigated on inadequate evidence — payer denial letters, utilization review summaries, and unsupported assertions from treating physicians who have never articulated the clinical basis for the treatment they rendered.

When a medical necessity dispute reaches a jury, the question is not whether a payer's criteria were met but whether the treatment was clinically appropriate for the patient's documented condition under the standards that govern physician practice. That question requires a physician expert — not a claims adjuster, a utilization review nurse, or a non-treating physician who reviewed a summary rather than the complete record.

In personal injury and workers' compensation litigation, medical necessity disputes commonly arise in three distinct contexts:

• Coverage disputes: Whether an insurer's denial of treatment authorization was supported by the clinical record and applicable guidelines, or whether the denial was pretextual, non-individualized, or inconsistent with the evidence.
• Damages disputes: Whether treatment already rendered was medically necessary and therefore compensable as a litigation damage, or whether the treatment was elective, premature, or beyond what the diagnosis supported.
• Future care disputes: Whether proposed future treatment — including implanted devices, repeat injections, long-term medication management, or surgical intervention — is medically indicated for the documented condition, and whether the proposed cost projection reflects that indication.

In each context, the medical necessity opinion is the evidentiary centerpiece of the dispute. An opinion that cannot withstand cross-examination on the clinical standards applied, the record reviewed, and the reasoning employed will not sustain a damages award or prevail on a coverage motion.

Medical Necessity vs. Standard of Care

Medical necessity and standard of care are related but analytically distinct concepts. Attorneys who conflate them invite problems at deposition and trial that a prepared opposing expert will exploit.

Medical necessity is a threshold determination: was the treatment clinically indicated for this patient's documented condition? It asks whether intervention was warranted at all — whether the diagnosis justified the proposed treatment, whether conservative measures were appropriately trialed first, and whether the selected modality was within the published indications for that diagnosis.

Standard of care is a performance determination: if the treatment was indicated, was it performed in conformity with accepted clinical practice? It asks whether the physician who performed the procedure did so in a manner consistent with what a qualified specialist would do under similar circumstances — addressing technique, documentation, informed consent, complication management, and follow-up.

A procedure can be medically necessary but performed below the standard of care. A procedure can also be performed flawlessly but not medically indicated in the first place. Both issues arise in pain management malpractice, personal injury, and insurance coverage litigation. When both are in dispute, each requires a separate analytical framework in the expert opinion, and each will be addressed separately on cross-examination.

Dr. Dardashti evaluates both medical necessity and standard of care, and can structure an opinion that addresses each independently, together, or sequentially depending on the case requirements.

Medical Necessity vs. Causation

In personal injury and workers' compensation litigation, causation and medical necessity are the two most frequently contested physician-opinion issues — and they are not the same question.

Causation asks: did the subject incident produce the condition that required treatment? The causal analysis evaluates the mechanism of injury, the temporal onset of symptoms, the pre-incident medical baseline, and the biological plausibility of the claimed causal pathway.

Medical necessity asks: given the documented condition — however it arose — was the treatment rendered or proposed clinically warranted? The medical necessity analysis evaluates whether the diagnosis justified the treatment, not how the diagnosis came about.

Both issues arise in most personal injury cases, and both must be addressed with physician-level specificity. A defense expert who concedes causation but challenges medical necessity forces the plaintiff to defend each treatment decision on its clinical merits. A plaintiff expert who establishes causation but cannot defend the necessity of expensive interventional or device-based treatment is vulnerable on the damages side.

For cases requiring both opinions, see the Causation Analysis service page. Dr. Dardashti can provide both analyses in a single engagement or in sequenced opinions depending on the case timeline.

Medical Necessity vs. Future Medical Care

Every legitimate future medical care projection must be grounded in a medical necessity determination. A proposed future treatment that cannot survive a medical necessity challenge should not appear in a future care projection — and if it does, opposing experts will dismantle it at deposition.

The relationship is this: the future medical care review projects the treatment a claimant will require and its associated costs. The medical necessity review provides the clinical foundation for that projection — the documented diagnosis, the applicable indication, the guideline-based frequency and duration, and the evidence that the proposed modality is appropriate for this patient. Without that foundation, a future care projection is speculative. With it, the projection is defensible at trial.

When future care includes high-cost interventions such as spinal cord stimulation or intrathecal pump therapy, the medical necessity analysis is particularly critical. These devices involve significant implantation costs, follow-up requirements, and device replacement cycles that will be scrutinized by defense experts, insurance carriers, and courts. A future care projection that projects SCS without addressing the medical necessity of neuromodulation for the specific documented condition will not withstand that scrutiny.

Pain Management Procedures Commonly Reviewed for Medical Necessity

The following interventions represent the procedures most frequently at issue in pain management medical necessity disputes. Each has published indications, guideline-based criteria, and an established body of evidence that governs when the procedure is warranted and when it is not.

Epidural Steroid Injections

Epidural steroid injections (ESIs) are among the most common pain management procedures and among the most frequently challenged on medical necessity grounds. The medical necessity analysis for an ESI addresses: whether the documented diagnosis — disc herniation, spinal stenosis, radiculopathy — is consistent with the clinical and imaging findings; whether conservative treatment was trialed before injection; whether the injection approach (interlaminar, transforaminal, caudal) was appropriate for the documented pathology; whether fluoroscopic guidance was medically indicated; and whether the frequency of injections exceeded guideline-based limits.

Disputes arise when carriers deny injection authorization, when defense experts claim injections were not indicated, and when plaintiff experts project serial injection series as future care. In each scenario, the medical necessity analysis applies the same clinical standards to the same documentation.

Medial Branch Block and Radiofrequency Ablation

Medial branch blocks (MBBs) are diagnostic procedures used to confirm facet-mediated pain before proceeding to radiofrequency ablation (RFA). The medical necessity analysis for this procedure sequence addresses: whether the clinical presentation is consistent with facet-mediated pain; whether the diagnostic MBB sequence — typically two blocks before proceeding to RFA — was completed and documented; whether the percentage of pain relief from diagnostic blocks met published threshold criteria; whether the RFA technique was appropriate for the level and side treated; and whether the interval between repeat RFA procedures was clinically justified.

Disputes frequently arise when a carrier denies RFA authorization because the diagnostic block documentation is incomplete, when defense experts challenge whether the MBB responses met the threshold for RFA, or when repeat RFA procedures are claimed as future care without documentation of prior response. Each scenario requires the same granular analysis of the diagnostic sequence documentation.

Spinal Cord Stimulation

Spinal cord stimulation (SCS) is one of the most contested medical necessity determinations in pain management litigation because of its high cost and the complexity of its indications. The medical necessity analysis for SCS addresses: whether the underlying pain condition — post-laminectomy syndrome, CRPS, refractory radiculopathy, peripheral neuropathy — is documented and consistent with published SCS indications; whether a meaningful trial of conservative and interventional treatments preceded the decision to escalate to neuromodulation; whether the psychological evaluation and screening required before implant was completed; whether the trial stimulation period was adequate and the trial response documented; and whether the implanting surgeon's documentation supports the clinical decision.

Defendants and carriers commonly challenge SCS necessity by arguing that the failure-of-conservative-care requirement was not met, that the trial response was inadequately documented, or that the patient was not a good surgical candidate based on comorbid conditions. Plaintiffs counter with the clinical record of failed treatments and the documented trial response. An expert who can evaluate both arguments against the published indications criteria is essential in these disputes.

Intrathecal Pump Therapy

Intrathecal pump therapy (ITP), also called intrathecal drug delivery (IDD), delivers medication directly into the intrathecal space via an implanted catheter and pump. Medical necessity for ITP is evaluated against published Polyanalgesic Consensus Conference (PACC) guidelines, which specify patient selection criteria, drug selection criteria, and documentation requirements for implantation. The analysis addresses: whether the patient's pain condition meets the PACC indication criteria; whether systemic opioid therapy has been trialed and produced intolerable side effects or inadequate relief; whether the intrathecal trial documented adequate pain relief before proceeding to permanent implant; and whether the medical and surgical risks of implantation were appropriately weighed given the patient's comorbidities.

Future care projections for ITP must address the full cost trajectory: drug refill visits, catheter maintenance, and pump replacement on manufacturer-specified intervals. The medical necessity analysis underpins each projected cost item.

Peripheral Nerve Stimulation

Peripheral nerve stimulation (PNS) applies electrical stimulation to a targeted peripheral nerve to modulate neuropathic pain. The published indications for PNS are more limited than for SCS, and the evidentiary support for specific applications is evolving. The medical necessity analysis for PNS addresses: whether the documented neuropathic pain condition corresponds to a peripheral nerve distribution amenable to stimulation; whether the peripheral nerve target has been identified with appropriate diagnostic precision; whether prior treatments — pharmacological, interventional, and physical — have been trialed; whether a percutaneous trial demonstrated adequate pain relief; and whether the published evidence base at the time of implantation supported the proposed application.

Disputes arise when carriers deny PNS authorization for indications not yet explicitly covered by their coverage policies, or when defense experts challenge whether the evidentiary basis for the specific PNS application met the clinical necessity threshold. The opinion must engage the evidence base honestly, acknowledging where it is strong and where it remains developing.

Documentation Requirements for Medical Necessity Review

A defensible medical necessity opinion is only as strong as the documentation on which it is based. Attorneys should assemble the complete medical record before requesting a medical necessity review. The opinion will address what the record shows, and gaps in documentation are themselves a finding — relevant to whether the treating physician adequately established medical necessity at the time of treatment.

The following records are required for a complete medical necessity review:

• Treating physician notes: Office visit records from the treating pain physician covering the relevant treatment period, including the clinical assessments, diagnosis documentation, and treatment rationale.
• Procedure records: Operative reports, fluoroscopy records, anesthesia records, and post-procedure notes for each intervention at issue.
• Diagnostic imaging reports: MRI, CT, X-ray, and other imaging studies with reports, not merely images. The imaging findings must correspond to the documented diagnosis to support medical necessity.
• Prior treatment records: Documentation of conservative treatment — physical therapy, chiropractic, medication trials — preceding any interventional or device-based care. Failure-of-conservative-care is a prerequisite for most interventional indications.
• Prior authorization correspondence: Payer authorization requests, denial letters, peer-to-peer review notes, and appeal correspondence, where the dispute involves insurance coverage.
• Pharmacy records: Medication history relevant to whether pharmacological options were trialed before escalating to procedural intervention.
• Device records: For implanted device disputes — SCS, ITP, PNS — trial records, implant operative reports, device representative records, and post-implant programming notes.
• Psychological evaluation records: Required before implanted device procedures; relevant to the adequacy of the pre-implant evaluation.

Clinical Guidelines and Evidence-Based Review

Medical necessity determinations in pain management are not made in a clinical vacuum. Published guidelines from specialty societies provide the evidentiary framework against which individual clinical decisions are evaluated. Understanding which guidelines apply — and which are most current and authoritative — is essential to an opinion that will withstand cross-examination.

The primary guidelines applied in pain management medical necessity review include:

• ASIPP Evidence-Based Guidelines: The American Society of Interventional Pain Physicians publishes comprehensive evidence reviews covering epidural steroid injections, facet joint interventions, radiofrequency procedures, neuromodulation, and related modalities. These are among the most widely cited guidelines in litigation.
• PACC Consensus Guidelines: The Polyanalgesic Consensus Conference guidelines govern intrathecal drug delivery patient selection, drug protocols, and implantation criteria.
• North American Neuromodulation Society (NANS) Guidelines: Govern patient selection and clinical practice for SCS and PNS.
• CDC Prescribing Guidance: The CDC's clinical practice guideline for prescribing opioids for chronic pain establishes the evidentiary basis for opioid medical necessity assessments in non-cancer chronic pain.
• California MTUS: In California workers' compensation, the Medical Treatment Utilization Schedule adopts ACOEM guidelines and governs authorization for most pain management treatments in the WC setting.
• Payer LCD/NCD Policies: Medicare Local and National Coverage Determinations define coverage criteria that are often adopted as proxy medical necessity standards by commercial payers. Where a payer's internal criteria differ from published guidelines, the discrepancy is itself relevant to the dispute.

An expert who cannot identify which guidelines apply to a specific procedure, cannot articulate what those guidelines require, and cannot explain how the documented care does or does not satisfy those requirements will not withstand cross-examination. Dr. Dardashti's medical necessity opinions are explicitly grounded in the applicable guidelines, with citations to the specific provisions relevant to the treatment at issue.

Utilization Review vs. Independent Physician Expert Review

Utilization review (UR) is an administrative process in which payer employees — typically nurses or non-physician reviewers — apply payer-specific criteria to a request for treatment authorization. A UR denial is a coverage determination, not a medical opinion.

The distinction matters in litigation for several reasons:

• UR reviewers typically do not examine the patient, do not review the complete medical record, and do not engage the treating physician's clinical reasoning.
• UR criteria may reflect payer cost-management objectives rather than the published clinical evidence base.
• UR denials are frequently issued by reviewers who lack specialty-specific expertise in pain management.
• In California, UR decisions in workers' compensation are appealable through Independent Medical Review (IMR), which applies the MTUS — not an individualized clinical analysis.

When a UR denial is challenged in litigation — whether in a bad faith insurance claim, a third-party liability case, or a workers' compensation dispute — the question before the court is not whether the denial was procedurally compliant. It is whether the treatment was medically necessary under clinical standards. That question requires a physician expert, and the physician's opinion is what the jury evaluates.

Dr. Dardashti's medical necessity opinions are prepared specifically for the litigation context, not as an administrative review. They engage the full record, apply the published clinical standards, and are structured to withstand the cross-examination that a UR denial letter was never designed to survive.

Medical Necessity in Personal Injury Cases

In personal injury litigation, medical necessity is a damages question. The defendant argues that treatment was not caused by the accident (causation) or that it was not clinically warranted even if causation is conceded (medical necessity). Both lines of attack target the same goal: reducing or eliminating the compensable damages.

Medical necessity is contested in personal injury cases across the treatment continuum:

• Emergency and acute care: Whether emergency treatment immediately following the accident was necessary, or whether the plaintiff was treated beyond what the injuries warranted.
• Diagnostic imaging: Whether the frequency and type of imaging obtained — multiple MRIs, CT myelograms, functional imaging — were clinically indicated given the evolving presentation.
• Interventional procedures: Whether a series of injections, nerve blocks, or ablation procedures was medically warranted, or whether the procedures exceeded the clinical indication for the documented injury.
• Surgical and device-based care: Whether implanted devices, surgical intervention, or spinal procedures were medically necessary at the time they were performed, and whether the escalation from conservative care to invasive treatment was appropriately documented and clinically supported.
• Future care projections: Whether the future treatment proposed by plaintiff's experts is within published guidelines for the documented condition, and whether the proposed cost projection reflects the medically indicated scope rather than the maximum possible treatment.

Medical Necessity in Medical Malpractice Cases

In medical malpractice litigation, medical necessity intersects with standard of care in a specific way: the plaintiff must establish not only that the physician's conduct fell below the standard of care, but often that the departure caused identifiable harm — including unnecessary treatment, avoidable complications, or failure to provide care that was warranted.

Medical necessity issues arise in pain management malpractice claims in several contexts:

• Unnecessary procedures: Whether injections, ablation procedures, or implanted devices were performed without adequate clinical indication, exposing the patient to procedural risk without expected therapeutic benefit.
• Inadequate prior authorization documentation: Whether the treating physician failed to document the clinical rationale for treatment in a manner that supports a medical necessity finding — a documentation failure that may affect both the malpractice analysis and the insurance coverage dispute.
• Failure to escalate: Whether a treating physician failed to pursue medical necessary treatment — neuromodulation, referral to a specialist, or a specific interventional approach — when the clinical record supported escalation.
• Overprescribing and underprescribing: Whether opioid prescribing exceeded or fell below the medically necessary level for the documented condition, under the applicable prescribing guidelines in effect at the time of the prescribing decision.

Medical Necessity in Workers' Compensation Cases

Workers' compensation medical necessity disputes in California are governed primarily by the Medical Treatment Utilization Schedule (MTUS), which is administered by the Division of Workers' Compensation and adopts the ACOEM Occupational Medicine Practice Guidelines as its evidence base. The MTUS applies to claims for treatment authorization on an ongoing basis, and disputes about denied treatment are subject to Independent Medical Review (IMR).

However, in broader litigation — employer liability suits, third-party claims, disputes about the adequacy of the IMR process itself, or civil claims against insurers for bad-faith denial — the MTUS is not the only relevant standard. The broader clinical evidence base, including specialty society guidelines not incorporated in the MTUS, may be relevant to whether treatment was medically necessary under a more comprehensive clinical analysis.

Dr. Dardashti evaluates medical necessity in workers' compensation cases against both the MTUS standard and the broader clinical guideline literature, providing attorneys with an opinion that engages the specific standard most relevant to their legal theory.

Medical Necessity in Catastrophic Injury Cases

Catastrophic injury cases — those involving spinal cord injury, severe traumatic brain injury combined with chronic pain, major limb loss, or severe burns — typically involve the highest medical necessity stakes. Future care projections in catastrophic cases may project decades of device-based pain management, serial interventional procedures, and high-cost pharmacological management. The medical necessity analysis for each projected item must be defensible over a long time horizon against expert scrutiny.

In catastrophic cases, Dr. Dardashti's medical necessity review addresses the following additional dimensions not typically present in standard personal injury matters:

• Device replacement cycles: Whether the frequency and cost of SCS battery replacement, ITP pump exchange, or PNS device replacement is consistent with manufacturer data and clinical experience.
• Long-term opioid management: Whether the scope and duration of intrathecal or systemic opioid management projected over a multi-decade period reflects evidence-based practice rather than maximum possible treatment.
• Emerging treatment modalities: Whether novel pain management techniques projected as future care in catastrophic cases — emerging neuromodulation approaches, regenerative interventions — are medically necessary or represent speculative future treatment.
• Interaction between pain management and other catastrophic care needs: How the pain management component of a life care plan interacts with the other elements, and whether the proposed pain interventions are consistent with the patient's overall medical condition and comorbidities.

Attorney Retention Scenarios

Medical necessity review engagements arise in a variety of litigation contexts. The following scenarios are among the most common:

• Defense evaluation of plaintiff's claimed damages: Defense counsel retains a pain management physician to evaluate whether the treatment rendered by the plaintiff's treating physicians was medically necessary, and whether the future care projection offered by the plaintiff's expert is within guideline parameters.
• Plaintiff support for treatment that was denied: Plaintiff counsel retains a pain management physician to establish that treatment the insurance carrier denied was clinically indicated and within published guidelines, in support of a bad-faith insurance claim or to rebut a defense expert who supports the denial.
• Rebuttal of defense IME: Plaintiff counsel retains a pain management physician to review and rebut a defense IME that opined the treatment was not medically necessary, identifying where the defense opinion is inconsistent with the record or with the applicable clinical standards.
• Pre-litigation coverage dispute: An attorney or claims professional retains a pain management physician to evaluate a pending treatment authorization before litigation is filed, to assess the strength of the medical necessity basis for either approving or denying the requested care.
• Deposition and trial testimony: Any of the above engagements may be extended to include deposition testimony on the medical necessity opinion, cross-examination preparation, or trial testimony depending on the case trajectory.

Record Types Commonly Reviewed

A complete medical necessity review engages a broader set of records than most clinical consultations. The following documents are commonly reviewed:

• Office visit notes from all treating pain physicians, orthopedic surgeons, neurosurgeons, physiatrists, and primary care physicians
• Procedure notes, operative reports, and anesthesia records
• Fluoroscopy and C-arm procedural images and reports
• Diagnostic imaging — MRI, CT, X-ray, bone scan, EMG/NCS — with the interpreting radiologist's or neurologist's reports
• Physical therapy, chiropractic, and occupational therapy notes documenting the conservative treatment course
• Pain management pharmacy records and pharmacy benefit manager (PBM) history
• Prior authorization requests and payer correspondence including denial letters, peer-to-peer review notes, and appeal responses
• Utilization review decisions and Independent Medical Review (IMR) determinations in workers' compensation matters
• Device company records — trial period notes, implant programming records, device representative contact notes — for SCS, ITP, and PNS disputes
• Psychological screening and evaluation records preceding device implantation
• Deposition transcripts of treating physicians describing their clinical reasoning
• Opposing expert reports addressing medical necessity

Common Defense Arguments in Medical Necessity Disputes

Defense experts in medical necessity disputes typically advance one or more of the following arguments. Understanding these arguments allows plaintiff counsel to evaluate record gaps and prepare rebuttal before retaining an expert:

• Conservative care not adequately trialed: The most frequent defense position — that the treating physician escalated to interventional or device-based treatment without an adequate prior course of physical therapy, medication management, or less invasive procedures. Published guidelines for most interventional procedures require documentation of failed conservative care.
• Diagnosis not supported by objective findings: The argument that the diagnosis underlying the claimed treatment is not supported by the available imaging, electrodiagnostic, or physical examination findings, so that treatment for that diagnosis cannot be medically necessary.
• Frequency exceeds guideline limits: The argument that the number of injections, nerve blocks, or procedures performed in a given period exceeded the frequency permitted by published guidelines or payer policies.
• Diagnostic threshold for RFA not met: The specific argument in facet-based pain disputes that the diagnostic medial branch block response did not meet the published percentage-of-relief threshold required before radiofrequency ablation, making the RFA medically unnecessary.
• Device criteria not met: The argument that an implanted neuromodulation device was placed without the required documentation of failed prior treatment, without an adequate trial period, or without the psychological screening required by published implant criteria.
• Treatment beyond maximum medical improvement: The argument that the patient reached MMI and that ongoing treatment — particularly injections, medication management, or device programming — is palliative rather than medically necessary in a compensable sense.
• Billing inconsistencies: The argument that billing records reflect procedures not documented in clinical notes, or that the pattern of billing suggests treatment was driven by financial rather than clinical incentives.

Common Plaintiff Arguments in Medical Necessity Disputes

Plaintiff experts in medical necessity disputes typically advance the following positions:

• Documentation of failed conservative care: Establishing that the record contains adequate documentation of physical therapy, medication trials, and less invasive interventions that preceded escalation to the disputed treatment.
• Guideline compliance: Demonstrating that the treating physician's approach was consistent with published specialty society guidelines and that the denial or defense challenge is inconsistent with those guidelines.
• Payer criteria are not clinical standards: The argument that the insurance carrier's internal coverage criteria are more restrictive than published clinical guidelines, and that medical necessity under clinical standards does not require compliance with criteria that exceed those guidelines.
• UR reviewer lacked pain management expertise: The argument that the utilization review decision was made by a reviewer who lacked the specialty-specific expertise required to evaluate pain management medical necessity, rendering the denial unsupported by competent evidence.
• Functional improvement documented: The argument that the disputed treatment produced documented functional improvement — reduced pain scores, improved function, reduced medication burden — that demonstrates the treatment was beneficial and therefore medically indicated.
• Individualized analysis required: The argument that the defense's generalized critique of the treatment fails to engage with the specific patient's diagnosis, history, and clinical trajectory, and that an individualized analysis supports medical necessity even where the defense expert relies on a generalized critique.

How to Request a Medical Necessity Review

Contact Expert Medical Services LLC with the case records, the procedure or treatment at issue, and the specific medical necessity questions to be addressed. Cases involving implanted devices — SCS, ITP, PNS — benefit from early record assembly that includes the full pre-implant evaluation, trial period documentation, and any payer correspondence. For cases also requiring causation analysis, see the Causation Analysis service. For cases requiring an in-person examination in addition to records review, a concurrent Independent Medical Evaluation may be appropriate.

Medical necessity opinions are available as written record review reports, supplemental declarations responding to opposing expert opinions, and deposition or trial testimony. Dr. Dardashti provides opinions for plaintiff and defense counsel, insurance carriers, mediators, and courts in California and nationwide.