DOI: 11/2/2014. Patient is a 43-year old male field technician who sustained injury to his back when he was moving an object. Per OMNI, he was initially diagnosed with lower back strain.
Per medical report dated 11/12/14, the patient was referred to massage therapy and advised to use heat and to continue Flexeril.
Based on progress report dated 06/04/15, the patient presents with constant and sharp low back pain, which radiates down the right leg posteriorly to his foot with numbness and tingling. Intermittently, he will experience a burning sensation underneath the underside of his right foot. Pain is rated at 7/10 and increased with prolonged sitting/standing, twisting, turning, lifting, bending, pushing or pulling. It is decreased with rest, change …show more content…
He was diagnosed with lumbar disc herniation with myelopathy.
Plan is for lumbar laminectomy with discectomy and interbody fusion at L3-4 and L4-5 along with posterior fusion and instrumentation at L3-4 and L4-5. He will not improve with time, modification of activity, chiropractic care, PT, injections or any other means.
Per verification to the MD’s office on a previous review, the IW has had no psychological evaluation in relation to this request and the patient has had PT, acupuncture, and steroid injections. Requested for therapy notes and procedure reports, as well as the most recent MRI and Xray reports, however, they refused to release medical records.
On the statement of medical necessity on the C-4 form dated 07/02/15, herniated discs are noted on the right side at L3-4 and L4-5 with stenosis as shown on the MRI (no official report). Patient is suffering from a low back pain with right lower extremity radicular pain. Request is for a lumbar laminectomy with discectomy and interbody fusion at L3-4 and L4-5 along with posterior fusion and instrumentation at L3-4 and L4-5. Bone growth stimulator is needed due to multilevel
Per medical report dated 11/12/14, the patient was referred to massage therapy and advised to use heat and to continue Flexeril.
Based on progress report dated 06/04/15, the patient presents with constant and sharp low back pain, which radiates down the right leg posteriorly to his foot with numbness and tingling. Intermittently, he will experience a burning sensation underneath the underside of his right foot. Pain is rated at 7/10 and increased with prolonged sitting/standing, twisting, turning, lifting, bending, pushing or pulling. It is decreased with rest, change …show more content…
He was diagnosed with lumbar disc herniation with myelopathy.
Plan is for lumbar laminectomy with discectomy and interbody fusion at L3-4 and L4-5 along with posterior fusion and instrumentation at L3-4 and L4-5. He will not improve with time, modification of activity, chiropractic care, PT, injections or any other means.
Per verification to the MD’s office on a previous review, the IW has had no psychological evaluation in relation to this request and the patient has had PT, acupuncture, and steroid injections. Requested for therapy notes and procedure reports, as well as the most recent MRI and Xray reports, however, they refused to release medical records.
On the statement of medical necessity on the C-4 form dated 07/02/15, herniated discs are noted on the right side at L3-4 and L4-5 with stenosis as shown on the MRI (no official report). Patient is suffering from a low back pain with right lower extremity radicular pain. Request is for a lumbar laminectomy with discectomy and interbody fusion at L3-4 and L4-5 along with posterior fusion and instrumentation at L3-4 and L4-5. Bone growth stimulator is needed due to multilevel