Lumbar Spine: A Case Study

This is a 54-year-old male with a 08/28/08 date of injury. A specific mechanism of injury has not been described.

12/11/15 Pain Management Follow-up and Appeal to UR indicated that the patient presented with complains of chronic pain in his low back and ankles together with feet bilaterally. The pain is 4/10-scale level. He is having chiropractic treatment and PT of the lumbar spine, which is increasing his ROM and functional capacity status. He is taking Norco 10/325 mg an Gabapentin 300 mg for pain control. He is taking Ambien periodically but not daily. Unfortunately, a denial of additional chiro for the right ankle X 12, additional chiro for lumbar spine X 12, additional PT for the lumbar spine X 12. And additional PT for the right knee
…show more content…
Physical Medicine Guidelines – Allow for fading of treatment frequency. The patient reported chronic lumbar spine, right ankle and right foot pain. Review completed on 11/02/15 denied additional chiropractic for right ankle/foot 3 X 4; additional chiropractic for lumbar spine 3 X 4; additional physiotherapy for lumbar spine 3 X 4; and additional physical therapy for right knee 3 X 4. The prior review noted that Nancy from Dr. Kohan’s office explained that this request for additional physiotherapy for the right knee 3x4 is a typographical error. The latest progress report and appeal to UR indicated that the patient did report significant amount of improvement in regard to ROM and functional capacity from prior chiropractic treatment and PT. However, as per guidelines there are no clearly defined goals and patient’s progress in meeting those goals. In addition, there are no reports from PT evaluation available for review. Number of sessions of PT completed to date in not clear from the progress notes. Furthermore, on exam there was increased ROM of the lumbar spine on flexion and extension. There was minimal spasms and tenderness noted over the lumbar spine. Improved ROM was noted on dorsiflexion and plantarflexion of the right ankle. Recommend

Related Documents