DOI: 2/4/2014. The patient is a 44 -year-old male laborer who sustained a work-related injury when he was putting beams together and fell on black ice between beams from elevated surface.
Per the IME report by Dr. Nathan on 7/20/15, MMI has been reached and there is no medical necessity for further PT, orthopedic treatment or diagnostic testing from an orthopedic standpoint.
MRI of the lumbar spine performed on 03/18/14 showed posterocentral disc herniation as noted at the L5-S1 level, which demonstrated ventral impingement on the thecal sac as well as impingement on the intervertebral foraminal bilaterally. There was mild narrowing of the anmteroposterior diameter of the spinal cal noted at L5-S1 level. Mild scoliosis is seen. Posterior …show more content…
Range of motion shows flexion of 45 degrees, extension of 15 degrees, and bilateral lateral extension and rotation to 20 degrees. He is unable to walk on his heels and toes. Manual muscle strength testing shows 4-/5 with left knee extension and 4/5 with left knee flexion. Deep tendon reflexes are 1+. Sensation is decreased in the left foot dorsal aspect. Straight leg raising test is positive on the left. Current medications include Vimovo and Ultram. IW was diagnosed with lumbar intervertebral disc displacement and radiculopathy. It was noted that the IW’s response to treatment are the following: reduce pain to 60%; improve functional outcome, active range of motion, manual muscle testing and flexibility to 60%; activities of daily living to 25%; and overall functional assessment/PT goal achievement to 60%. Short term goal is to reduce pain to 2/10. Long term goals are as follows: reduce pain to 1/10; and improve range of motion to 20 degrees and functional status.
On the statement of medical necessity on the MG2 form dated 12/28/15, new MRI study is requested as his condition is getting worse.
Per verification to the provider’s office, the patient has attended 65 PT sessions from 10/2014 through
Per the IME report by Dr. Nathan on 7/20/15, MMI has been reached and there is no medical necessity for further PT, orthopedic treatment or diagnostic testing from an orthopedic standpoint.
MRI of the lumbar spine performed on 03/18/14 showed posterocentral disc herniation as noted at the L5-S1 level, which demonstrated ventral impingement on the thecal sac as well as impingement on the intervertebral foraminal bilaterally. There was mild narrowing of the anmteroposterior diameter of the spinal cal noted at L5-S1 level. Mild scoliosis is seen. Posterior …show more content…
Range of motion shows flexion of 45 degrees, extension of 15 degrees, and bilateral lateral extension and rotation to 20 degrees. He is unable to walk on his heels and toes. Manual muscle strength testing shows 4-/5 with left knee extension and 4/5 with left knee flexion. Deep tendon reflexes are 1+. Sensation is decreased in the left foot dorsal aspect. Straight leg raising test is positive on the left. Current medications include Vimovo and Ultram. IW was diagnosed with lumbar intervertebral disc displacement and radiculopathy. It was noted that the IW’s response to treatment are the following: reduce pain to 60%; improve functional outcome, active range of motion, manual muscle testing and flexibility to 60%; activities of daily living to 25%; and overall functional assessment/PT goal achievement to 60%. Short term goal is to reduce pain to 2/10. Long term goals are as follows: reduce pain to 1/10; and improve range of motion to 20 degrees and functional status.
On the statement of medical necessity on the MG2 form dated 12/28/15, new MRI study is requested as his condition is getting worse.
Per verification to the provider’s office, the patient has attended 65 PT sessions from 10/2014 through