This is an 80-year-old female with 01/14/2003 date of injury, who injured her low back and right hip when she fell out of a chair while reaching for a chart
DIAGNOSIS: Chronic low back pain with bilateral radiculitis, degenerative disc, status post laminectomy
12/23/15 Progress Report documented that the patient continues to have pain in her lower back and bilateral hip, which radiates down to the foot. There is also radiating pain to the left side of the neck. The lower back and hip pain are constant. Her neck pain is intermittent usually worse at night and with prolonged sitting. The hip pain is worse with walking. All medications were denied last month. She paid out of pocket for norco and Ativan only. The hip pain and leg burning is waking …show more content…
Pain is worse with standing and walking. She doesn't feel her medications are working as well as they once did. It appears that it is due to decreased dose and denial of celebrex. Lidoderm patch is very helpful. Her GI issues continue without her Protonix. The Zanalfex quantity has been reduced from #60 to #15. Sleep quality has been fair. The provider discussed each and every one of her medications and it's necessity and functional improvement. She notes that w/o the meds, she would be house bound and 'non-functional’. Her pain was 6/10-scale level. CURRENT MEDICATIONS: Ambien CR (zolpidem), Celebrex. Cymbalta, Gralise, Lidoderm (lidocaine) patch, morphine, OxyContin, Protonix (pantoprazole), Zanaflex (tizanidine). The exam showed low back pain and pain to L/S junction c/w spondylosis and facet regeneration since last RFA. The leg pain is bilateral but minimal. She is tender over R SI joint as well. Treatment plan included medication. UDT on 11/19/14 and 07/18/13 showed that the patient was consistent to the …show more content…
The reports noted that the patient had a prior RFA in 2011. The patient has ongoing residual low back pain and pain to L/S junction c/w spondylosis and facet regeneration since last RFA. However, there is no documentation of functional benefit and the extent of pain relief from the previous procedure. The levels and the lumbar side of the prior RFA have not been documented and there are no reports of the procedure available for review. In addition, CA MTUS states that no more than two joint levels will be performed at one time. The current request is for three levels i.e. L2, L3, L4 and L5. Medical necessity of repeat bilateral RFA has not been established. Recommend
DIAGNOSIS: Chronic low back pain with bilateral radiculitis, degenerative disc, status post laminectomy
12/23/15 Progress Report documented that the patient continues to have pain in her lower back and bilateral hip, which radiates down to the foot. There is also radiating pain to the left side of the neck. The lower back and hip pain are constant. Her neck pain is intermittent usually worse at night and with prolonged sitting. The hip pain is worse with walking. All medications were denied last month. She paid out of pocket for norco and Ativan only. The hip pain and leg burning is waking …show more content…
Pain is worse with standing and walking. She doesn't feel her medications are working as well as they once did. It appears that it is due to decreased dose and denial of celebrex. Lidoderm patch is very helpful. Her GI issues continue without her Protonix. The Zanalfex quantity has been reduced from #60 to #15. Sleep quality has been fair. The provider discussed each and every one of her medications and it's necessity and functional improvement. She notes that w/o the meds, she would be house bound and 'non-functional’. Her pain was 6/10-scale level. CURRENT MEDICATIONS: Ambien CR (zolpidem), Celebrex. Cymbalta, Gralise, Lidoderm (lidocaine) patch, morphine, OxyContin, Protonix (pantoprazole), Zanaflex (tizanidine). The exam showed low back pain and pain to L/S junction c/w spondylosis and facet regeneration since last RFA. The leg pain is bilateral but minimal. She is tender over R SI joint as well. Treatment plan included medication. UDT on 11/19/14 and 07/18/13 showed that the patient was consistent to the …show more content…
The reports noted that the patient had a prior RFA in 2011. The patient has ongoing residual low back pain and pain to L/S junction c/w spondylosis and facet regeneration since last RFA. However, there is no documentation of functional benefit and the extent of pain relief from the previous procedure. The levels and the lumbar side of the prior RFA have not been documented and there are no reports of the procedure available for review. In addition, CA MTUS states that no more than two joint levels will be performed at one time. The current request is for three levels i.e. L2, L3, L4 and L5. Medical necessity of repeat bilateral RFA has not been established. Recommend