Neck Pain Case Studies

715 Words 3 Pages
This is a 45-year-old male with a 2-20-2015 date of injury. A specific mechanism of injury has not been described.

DIAGNOSIS: Sprain of joints and ligaments of unspecified parts of neck, initial encounter

01/11/16 Progress Report describes that 15 minutes were spent in review of the results from the urinary drug screen, which was administered at the previous visit and deciding whether any modifications are appropriate to the treatment regimen. The pain is better and down to a 3/10. The neck pain remained mild. She had a neurology evaluation, but the EMG was denied. The patient has right upper extremity numbness, tingling and weakness. She has been dropping items due to her weakness. The sciatic pain has resolved. She has completed PT and
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ODG states that evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, to monitor the patient’s progress, and make any necessary modifications to the treatment plan. The patient has neck pain with right upper extremity numbness, tingling and weakness. On exam, there was positive cervical and lumbar tenderness. There were muscle spasms noted in the paraspinal muscles. The cervical and lumbar ROM is reduced. The patient is currently on medications and has been performing home exercise program. There are clear functional deficits and the treatment regimen needs to be monitored and evaluated. Medical necessity of upper extremity evaluation has been substantiated. Recommend …show more content…
Patient selection criteria to be used if interferential stimulation was prescribed anyway included pain ineffectively controlled due to diminished effectiveness of medications; pain ineffectively controlled with medications due to side effects; history of substance abuse; significant pain from postoperative conditions limit the ability to perform exercise programs/physical therapy treatment; or unresponsive to conservative measures.
The patient has a chronic injury since 02/20/15 and the treatment to date includes medications, PT and home exercises. The patient reported neck pain and right upper extremity numbness, tingling and weakness. However, the documentation submitted for review does not indicate the failure of conservative treatment (e.g, repositioning, heat and medications). The reports do not indicate that the pain is ineffectively controlled due to diminished effects of medications. The severity and quality of pain has not been documented using Visual Analog Scale. In addition, there is no documentation of side effects of the medications. Furthermore, there is no history of substance abuse in the reports. Medical necessity of Meds-4 IF unit has not been substantiated. Additionally, the patient has been regularly performing home exercises and there is no documentation of significant pain that limits the ability to perform exercise programs.

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