This is a 64-year-old male with a 1/31/2012 date of injury. A specific mechanism of injury has not been described.
DIAGNOSIS:
Cervical spine HNP
Left Shoulder Bursitis
12/12/15 Progress Report described that the patient presentd with neck pain 8/10-scale level, left shoulder pain 7/10-scale level and low back pain 6/10-scale level. The exam revealed tenderness to palpation over the cervical spine, lumbar spine and left shoulder. There were spasms noted and decreased ROM over lumbar spine, cervical spine and left shoulder. Treatment plan included medications, PT and chiropractic. Follow-up is in 4 weeks. Work Status: return to full duty.
05/24/15 MRI report of the left shoulder demonstrated 2 bone anchors entering the greater tuberosity region from previous surgery; degenerative spur formation of the AC joint with fluid collecting around …show more content…
DEA has classified Tramadol as a Schedule IV controlled substances beginning August 18, 2014. CA MTUS requires ongoing review of opioid medication management, including urine drug screens, description of extent and duration of pain relief, and functional improvement. The patient has chronic low back and neck pain. However, the duration of Tramadol use is unclear from the reports. There has been no documentation of monitoring of medication compliance, such as a UDS or CURES report. Furthermore, there has been no documentation of duration of pain relief, aberrant behaviors, use or misuse of the drug, and functional improvement with Tramadol. Recommend non-certification. Non-certification here does not imply an abrupt cessation for a patient who may be at risk for withdrawal symptoms. Should the missing criteria necessary to support the medical necessity of this request remain unavailable, discontinuance should include a tapering prior to discontinuation to avoid withdrawal
DIAGNOSIS:
Cervical spine HNP
Left Shoulder Bursitis
12/12/15 Progress Report described that the patient presentd with neck pain 8/10-scale level, left shoulder pain 7/10-scale level and low back pain 6/10-scale level. The exam revealed tenderness to palpation over the cervical spine, lumbar spine and left shoulder. There were spasms noted and decreased ROM over lumbar spine, cervical spine and left shoulder. Treatment plan included medications, PT and chiropractic. Follow-up is in 4 weeks. Work Status: return to full duty.
05/24/15 MRI report of the left shoulder demonstrated 2 bone anchors entering the greater tuberosity region from previous surgery; degenerative spur formation of the AC joint with fluid collecting around …show more content…
DEA has classified Tramadol as a Schedule IV controlled substances beginning August 18, 2014. CA MTUS requires ongoing review of opioid medication management, including urine drug screens, description of extent and duration of pain relief, and functional improvement. The patient has chronic low back and neck pain. However, the duration of Tramadol use is unclear from the reports. There has been no documentation of monitoring of medication compliance, such as a UDS or CURES report. Furthermore, there has been no documentation of duration of pain relief, aberrant behaviors, use or misuse of the drug, and functional improvement with Tramadol. Recommend non-certification. Non-certification here does not imply an abrupt cessation for a patient who may be at risk for withdrawal symptoms. Should the missing criteria necessary to support the medical necessity of this request remain unavailable, discontinuance should include a tapering prior to discontinuation to avoid withdrawal