Case Study: Incomplete SCI — Neuropathic Pain and Spasticity Management on a Pharmacy Lien

James Wong — Founder & Pharmacist, LienScripts | February 5, 2025 | 6 min read

A 48-year-old man suffered an incomplete spinal cord injury in a highway multi-vehicle accident. His individual market insurer denied his neurological medications as 'experimental.' A pharmacy lien provided uninterrupted access for 22 months of litigation — and the medication record became central to his damages case.

Case Study: Incomplete SCI — Neuropathic Pain and Spasticity Management on a Pharmacy Lien

Details have been modified to protect patient privacy. This is a composite account based on real scenarios encountered in our practice.

Spinal cord injury cases present some of the most complex medication management challenges in personal injury practice. The injuries are catastrophic, the medication regimens are multi-drug and evolving, and the timeline from accident to resolution is measured in years rather than months. When an insurance carrier decides to contest the necessity of neurological medications for an incomplete SCI patient, the consequences — in terms of both health and case integrity — are significant.

This case involved all of those complications. A pharmacy lien resolved them.

[!KEY] Raymond, 48, sustained a T6 incomplete spinal cord injury and had his gabapentin and baclofen denied as "experimental" — a pharmacy lien covered the full regimen for 22 uninterrupted months, and the documented titration sequence became central evidence for his structured settlement.

Patient Background

Raymond was 48 years old, a project manager for a commercial HVAC company, when his vehicle was struck from behind at highway speed and pinned against a center divider during a multi-vehicle accident. The initial impact caused hyperflexion of the cervical and thoracic spine. He was intubated at the scene and airlifted to a regional trauma center.

His spinal cord injury was classified as T6 ASIA B — incomplete, at the sixth thoracic vertebral level. An incomplete SCI means that some motor or sensory function is preserved below the level of injury. For Raymond, that meant retained partial lower extremity function — he could stand with assistance and ambulate short distances with a walker — but also meant that the intact nerve pathways transmitted pain signals continuously, including the severe neuropathic pain that is a hallmark of incomplete SCI.

His injury profile included:

• Neuropathic pain — burning, electric shock sensations, and allodynia across the lower thorax, hips, and lower extremities, present at rest and dramatically worsened by touch or temperature change
• Spasticity — involuntary muscle contractions in the legs and trunk, which disrupted sleep, interfered with rehabilitation, and caused secondary musculoskeletal pain
• Neurogenic bladder — impaired voluntary bladder control arising from the disruption of spinal cord signals governing urinary function
• Depression and sleep disruption — both directly attributable to the injury's neurological and functional consequences

The Medication Regimen

Raymond's SCI physiatrist and neurologist co-managed his pharmaceutical regimen. It evolved over the first several months as his symptoms were characterized and treatment was titrated:

Neuropathic pain:

• Gabapentin, titrated from an initial 300mg dose to a maintenance dose of 1,800mg per day — the therapeutic target for SCI-related neuropathic pain, which typically requires higher doses than post-surgical or musculoskeletal neuropathy
• Duloxetine — used both as an antidepressant and for its evidence-based efficacy in neuropathic pain augmentation; functions synergistically with gabapentin

Spasticity:

• Baclofen, titrated to 80mg per day — the primary pharmacological agent for SCI-related spasticity, working via GABA-B agonism to reduce the involuntary muscle hyperexcitability that produces spasms

Neurogenic bladder:

• Oxybutynin — an anticholinergic agent that reduces involuntary bladder contractions, improving continence and reducing the urgency and frequency associated with neurogenic bladder

Sleep and mood:

• Trazodone — for sleep disruption, chosen because it does not carry the dependence risk of benzodiazepines and is appropriate for long-term use in this patient population
• Low-dose oxycodone — for breakthrough pain on days when gabapentin and duloxetine did not adequately control neuropathic flares

[!KEY] Gabapentin and baclofen are first-line, evidence-based treatments for SCI neuropathic pain and spasticity — an insurer denial claiming they are "experimental" is clinically indefensible, but the 34-day gap before the appeal resolved had documented health consequences that demonstrate exactly why a pharmacy lien must be enrolled immediately.

The Insurance Denial

Raymond carried individual market health insurance — purchased through the ACA marketplace following a gap in employer coverage the prior year. When his insurer received authorization requests for the neurological medications, they denied the gabapentin and baclofen on the grounds that these medications were "experimental" for his specific diagnostic coding.

The denial was clinically indefensible. Gabapentin is a first-line agent for SCI neuropathic pain with extensive clinical evidence. Baclofen is the standard of care for SCI spasticity. Neither is experimental for these indications. But the appeals process — which required the treating physiatrist to submit peer-reviewed literature, a detailed medical necessity letter, and a peer-to-peer consultation with an insurer medical reviewer — took 34 days. During that period, Raymond's prescriptions went unfilled.

The 34-day gap had clinical consequences. Without consistent gabapentin, his neuropathic pain increased significantly. Without baclofen, his spasticity worsened to the point where he was unable to complete his physical therapy sessions for two weeks.

The Pharmacy Lien Intervention

Raymond's attorney filed the personal injury claim against the at-fault driver and the vehicle's owner. At the time of intake — after the insurance denial — she enrolled Raymond in a LienScripts pharmacy lien.

The lien resolved the access problem completely. All of Raymond's SCI medications — gabapentin, baclofen, oxybutynin, duloxetine, trazodone, and oxycodone — were covered at zero upfront cost from enrollment forward. There were no authorization requirements, no prior authorization delays, and no appeals to file. When his physicians adjusted dosages or added medications as his condition evolved, those changes were reflected in the lien in real time.

Raymond's medication access was uninterrupted for the 22 months of litigation.

The Pharmacy Record as a Damages Document

SCI cases involve large and complex damages. The foundation of Raymond's damages argument was the ongoing, sustained nature of his neuropathic pain, spasticity, and functional impairment. A jury or a mediator evaluating those damages needs to understand that the injury was not a discrete event with a clean recovery arc — it was a permanent alteration of Raymond's nervous system with daily medication-dependent management requirements.

The pharmacy record documented that reality in precise, timestamped detail.

The 22-month pharmacy record showed:

• Gabapentin titration — the dosage increase from 300mg to 1,800mg documented the severity of neuropathic pain that required therapeutic escalation to bring under control
• Baclofen titration — the escalation to 80mg daily documented spasticity that was not controlled at standard doses
• Continuous multi-drug regimen — five separate medications maintained continuously across 22 months, without tapering, documented the ongoing and permanent nature of his SCI management requirements
• Consistent fills with no gaps — the absence of missed fills after lien enrollment (compared with the documented gap during the insurance denial period) showed the medications were taken as prescribed and were clinically necessary

The insurance denial period — the 34 days of missed fills before the lien was enrolled — also appeared in the record. Combined with Raymond's treating providers' documentation of the setbacks during that gap, it illustrated what life without medication access looked like for a patient with his injury profile.

"A 22-month uninterrupted pharmacy record documenting continuous multi-drug management is one of the most powerful damages exhibits possible in a spinal cord injury case — it shows the permanent, daily medication burden in timestamped detail."

Structured Settlement for Lifetime Needs

SCI cases often resolve with structured settlements designed to account for lifetime care costs. Raymond's case was no exception. The settlement included provisions for his expected ongoing pharmaceutical needs — gabapentin, baclofen, and the supporting medications — over a time horizon that reflected his life expectancy.

The pharmacy lien was resolved from settlement proceeds. The structured settlement component addressing future medication costs was supported, in part, by the 22-month pharmacy record demonstrating what his actual medication regimen looked like and how stable it had remained once access was assured.

Key Takeaways for Attorneys

1. Insurance denials of SCI medications are often clinically unsupportable — but they take time to overturn. Gabapentin and baclofen for SCI are standard of care. Appeal those denials — but also enroll your client in a pharmacy lien immediately so they do not experience treatment gaps while the appeal proceeds.

[!TIP] When an insurer denies first-line SCI medications as "experimental," enroll your client in a pharmacy lien the same day while simultaneously appealing the denial — the 34-day gap Raymond experienced before lien enrollment had documented clinical consequences that should never happen to your client.

2. Dosage titration in the pharmacy record documents injury severity. When gabapentin titrates from 300mg to 1,800mg over three months, that titration is clinical evidence of the severity and persistence of neuropathic pain. Courts and mediators understand that higher doses mean the symptom required more treatment — not that the patient was simply receiving more medication.

[!KEY] Gabapentin titrating from 300mg to 1,800mg daily is not a red flag — it is clinical documentation of neuropathic pain severity that required escalating doses before adequate control was achieved, and a structured settlement expert will cite that titration sequence in calculating lifetime medication costs.

3. A 22-month uninterrupted pharmacy record is a powerful damages exhibit. Continuous multi-drug management for nearly two years documents the permanent, daily medication burden of an incomplete SCI in a way that witness testimony alone cannot replicate.

Key Takeaways for Patients

1. If your insurer denies your SCI medications, you do not have to wait. A pharmacy lien can cover your medications while the insurance appeal is pending. You should not experience treatment gaps — with their documented health consequences — because a prior authorization is stuck in an administrative queue.

2. Spasticity medication is as important as pain medication. Baclofen for SCI spasticity is medically necessary — not optional. Undertreated spasticity impairs rehabilitation, disrupts sleep, and causes secondary injuries. If your spasticity medication is denied, escalate immediately, and ask your attorney about a pharmacy lien to bridge the gap.

3. Your ongoing medication needs are part of your damages. A lifetime of managing neuropathic pain and spasticity with prescription medications is an economic reality. Make sure your attorney is accounting for your future medication costs — and that your pharmacy record documents the current medication burden on which future cost projections are based.

Related Resources

• Spinal Cord Injury Medications and Long-Term Management
• Baclofen for Spinal Injury Spasticity
• Gabapentin vs. Pregabalin for Nerve Pain
• Insurance Denial and Medication Access
• For Attorneys: How LienScripts Works
• Pharmacy Services for Personal Injury Clients: How It Works