This is a 58-year-old male with a 3/26/2003 date of injury. A specific mechanism of injury has not been described.
DIAGNOSIS: Shoulder Pain
11/10/15 Progress Report described that the last urine toxicology was in July. A new UDS was done and the results are pending. The patient has right shoulder, right wrist, right thigh and lumbar spine pain. He is going to see an IME doctor on 11/13/15. Constant use of Opioids since < 6 months. The average pain level is 6/10 with 5/10-scale level at it’s best and 10/10-scale level at it’s worst. Medication coverage: fair with breakthrough pain. The physical exam of the cervical spine and thoracic spine showed normal ROM and revealed no muscle tenderness. Lumbar spine: there were trigger points at the …show more content…
This is a chronic pain patient and has been on opioids since at least a year. The latest progress report described that the patient has continued pain in the right shoulder, right wrist, right thigh and the lumbar spine. On exam there were trigger points noted on palpation of the shoulders and lumbar spine. There was a limitation in the range of motion of the lumbar spine as well. However, there is no documentation of VAS pain levels with and without the use of the medication. There is no discussion of 4 A’s assessments. There is no reported functional benefit, continued efficacy, and pain relief from the medication. Furthermore, the latest progress report does not indicate the absence of aberrant behaviors and side effects of opioids. In addition, there is no documentation of a trial or failure of other first-line analgesics such as antidepressant for chronic pain; NSAID's and/or a Home Exercise Program. Prior review from 08/19/2015 denied Oxycodone, Oxycontin and Ambien. 09/10/2015 IMR noted partial overturn of Oxycontin 10mg for one …show more content…
They are not recommended for long-term use because long-term efficacy is unproven and there is a risk of dependence. Most guidelines limit use to 4 weeks. This is a chronic pain patient with a 2003 date of injury. He has been on Ambien since at least a year. The exact duration of use in unclear from the medical records. The November progress note documented that the patient is no longer on Ambien due to price increase and low dose Restoril was discussed and recommended. Both the drugs are benzodiazepines and the guidelines do not support long-term use of these agents. In addition, there is no documentation of sleep hygiene, education and adherence. The exact sleep problem like an initiation sleep or staying asleep is also unclear from the notes. Medical necessity has not been substantiated. Recommend
DIAGNOSIS: Shoulder Pain
11/10/15 Progress Report described that the last urine toxicology was in July. A new UDS was done and the results are pending. The patient has right shoulder, right wrist, right thigh and lumbar spine pain. He is going to see an IME doctor on 11/13/15. Constant use of Opioids since < 6 months. The average pain level is 6/10 with 5/10-scale level at it’s best and 10/10-scale level at it’s worst. Medication coverage: fair with breakthrough pain. The physical exam of the cervical spine and thoracic spine showed normal ROM and revealed no muscle tenderness. Lumbar spine: there were trigger points at the …show more content…
This is a chronic pain patient and has been on opioids since at least a year. The latest progress report described that the patient has continued pain in the right shoulder, right wrist, right thigh and the lumbar spine. On exam there were trigger points noted on palpation of the shoulders and lumbar spine. There was a limitation in the range of motion of the lumbar spine as well. However, there is no documentation of VAS pain levels with and without the use of the medication. There is no discussion of 4 A’s assessments. There is no reported functional benefit, continued efficacy, and pain relief from the medication. Furthermore, the latest progress report does not indicate the absence of aberrant behaviors and side effects of opioids. In addition, there is no documentation of a trial or failure of other first-line analgesics such as antidepressant for chronic pain; NSAID's and/or a Home Exercise Program. Prior review from 08/19/2015 denied Oxycodone, Oxycontin and Ambien. 09/10/2015 IMR noted partial overturn of Oxycontin 10mg for one …show more content…
They are not recommended for long-term use because long-term efficacy is unproven and there is a risk of dependence. Most guidelines limit use to 4 weeks. This is a chronic pain patient with a 2003 date of injury. He has been on Ambien since at least a year. The exact duration of use in unclear from the medical records. The November progress note documented that the patient is no longer on Ambien due to price increase and low dose Restoril was discussed and recommended. Both the drugs are benzodiazepines and the guidelines do not support long-term use of these agents. In addition, there is no documentation of sleep hygiene, education and adherence. The exact sleep problem like an initiation sleep or staying asleep is also unclear from the notes. Medical necessity has not been substantiated. Recommend