DOI: 1/13/2015. Patient is a 54-year-old male trimmer who sustained multiple injuries when he fell from a tree. MRI of the left knee dated 6/5/15 revealed complete tear of the mid fibers of the posterior cruciate ligament which appears chronic in nature. There is complete tear of the proximal lateral collateral ligament which also appears chronic in nature. There is complete tear of the popliteus tendon. There is oblique tear of the body and posterior horn of the lateral meniscus extending to the inferior articular surface with marked extrusion of the body. There is mild tricompartmental osteoarthritis. Based on the latest medical report dated 03/14/16, the patient presents for follow-up for his left hindfoot soft tissue injury and flap coverage.
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He is currently taking Caltrate with Vitamin D3. On examination of the left ankle/foot, there is tenderness of the medial, lateral and gutter ankle, calcaneal tuberosity, sinus tarsi and anterior talofibular ligament. Active range of motion shows dorsiflexion of -10 degrees. The left anterior drawer has a stability of 1+. Sensation is decreased at the superficial peroneal and saphenous nerves. There is tenderness upon palpation of the lateral left calcaneus over the skin graft, which is unchanged. The posterior heel has a “Free Flap” healed and benign. Gait is antalgic. Patient ambulates with a cane. Patient was diagnosed with closed fracture of the metatarsal bone and foot injury. A cortisone injection was administered to the left subtalar joint on this visit. Patient will try a topical anti-inflammatory cream to be applied on the left leg. Is the request for 1 Compound Topical Anti-Inflammatory Cream (Amantadine 10%/Diclofenac 5%/Baclofen 2 %/Bupivacaine 1%/Cyclobenzaprine 2 %/Gabapentin 6% and Ibuprofen 3%) between 4/26/2016 and 6/10/2016 medically necessary? C-4 for Preauthorization Request. (Kindly use the NY Medical Treatment Guideline as primary
He is currently taking Caltrate with Vitamin D3. On examination of the left ankle/foot, there is tenderness of the medial, lateral and gutter ankle, calcaneal tuberosity, sinus tarsi and anterior talofibular ligament. Active range of motion shows dorsiflexion of -10 degrees. The left anterior drawer has a stability of 1+. Sensation is decreased at the superficial peroneal and saphenous nerves. There is tenderness upon palpation of the lateral left calcaneus over the skin graft, which is unchanged. The posterior heel has a “Free Flap” healed and benign. Gait is antalgic. Patient ambulates with a cane. Patient was diagnosed with closed fracture of the metatarsal bone and foot injury. A cortisone injection was administered to the left subtalar joint on this visit. Patient will try a topical anti-inflammatory cream to be applied on the left leg. Is the request for 1 Compound Topical Anti-Inflammatory Cream (Amantadine 10%/Diclofenac 5%/Baclofen 2 %/Bupivacaine 1%/Cyclobenzaprine 2 %/Gabapentin 6% and Ibuprofen 3%) between 4/26/2016 and 6/10/2016 medically necessary? C-4 for Preauthorization Request. (Kindly use the NY Medical Treatment Guideline as primary