DOI: 2/18/2012. Patient is a year old female home health aide who sustained injuries to his neck, back abdomen, left foot and both legs when he slipped and fell after bathing a client. Per OMNI, he was initially diagnosed with cervical and lumbar strain.
Based on the latest medical report dated 02/22/16 by Dr. Islam, the patient presents for a follow up consultation. She continues to complain of pain to her cervical spine, lower back and right knee, rated as 6-7/10 and described as intermittent, burning and aching.
Upon the examination, the following findings were noted: limping gait; tightness; tenderness; and muscle spasm. Patient has difficulties on stair ambulation, sit to stand, squats, sitting and standing for prolonged period. Patient has activities of daily living (ADLs) difficulties such as bathing, brushing, cooking, doing laundry and cleaning. The range of motion of the cervical spine reveals flexion and extension of 30 degrees, lateral flexion of 25 degrees and rotation of 60 degrees to both sides. Muscle testing is 4/5.
Lumbar spine range of motion reveals flexion of 50 degrees, extension of 10 degrees, lateral flexion of 15 degrees, and rotation on both sides of 30 degrees. Muscle testing is 4/5.
Right knee range of motion reveals flexion of 100 degrees. Muscle testing is 4/5. Sensation is decreased to light touch, pinprick and deep pressure on lower extremities dermatomes. Straight leg raise (SLR) testing showed …show more content…
Plan is PT 2 times per week for 8 weeks.
Attached is the IME report by Dr. Apazidis dated 11/18/13.
Is the request for 16 Physical Therapy Visit for the Neck, Lower Back and Right Knee between 2/25/2016 and 4/25/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary
Based on the latest medical report dated 02/22/16 by Dr. Islam, the patient presents for a follow up consultation. She continues to complain of pain to her cervical spine, lower back and right knee, rated as 6-7/10 and described as intermittent, burning and aching.
Upon the examination, the following findings were noted: limping gait; tightness; tenderness; and muscle spasm. Patient has difficulties on stair ambulation, sit to stand, squats, sitting and standing for prolonged period. Patient has activities of daily living (ADLs) difficulties such as bathing, brushing, cooking, doing laundry and cleaning. The range of motion of the cervical spine reveals flexion and extension of 30 degrees, lateral flexion of 25 degrees and rotation of 60 degrees to both sides. Muscle testing is 4/5.
Lumbar spine range of motion reveals flexion of 50 degrees, extension of 10 degrees, lateral flexion of 15 degrees, and rotation on both sides of 30 degrees. Muscle testing is 4/5.
Right knee range of motion reveals flexion of 100 degrees. Muscle testing is 4/5. Sensation is decreased to light touch, pinprick and deep pressure on lower extremities dermatomes. Straight leg raise (SLR) testing showed …show more content…
Plan is PT 2 times per week for 8 weeks.
Attached is the IME report by Dr. Apazidis dated 11/18/13.
Is the request for 16 Physical Therapy Visit for the Neck, Lower Back and Right Knee between 2/25/2016 and 4/25/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary