DOI: 11/8/2014. Patient is a 61-year-old female care taker who sustained a work-related injury while she was turning a patient and felt that her back popped. Per OMNI, she was diagnosed with severe stenosis secondary to disc protrusion and facet cyst. She is status post laminectomy on 05/27.
Based on the progress report dated 07/05/16, the patient is scheduled for a 3-level global fusion on 07/22/16 and 07/25/16. She reports that her back pain is rated as 7 /10. Yesterday was worse. The pain radiates into the right buttock, dorsolateral thigh, wrapping around the right knee, and into the dorsolateral calf and ankle into the last three toes with right lower extremity weakness. She now has pain in the same dermatomal distribution however, it is not as severe or intense. She is taking Percocet 10/325 mg 3 tablets a day.
On examination, standing range of motion is 30 degrees. Straight leg raising is 80 degrees on the right and 90 degrees on the …show more content…
She was given a prescription for Percocet, Flexeril and tramadol.
Per the adjuster’s notes, the patient is recovering post-operatively and the request is for in-patient skilled nursing for physical therapy 1 x 5. Per verification to the provider’s office, the patient is status post 1 Posterior Global Arthrodesis at the L2-L3, L3-L4, and L4-L5 Levels on 07/22/16 and 07/25/16. Requested for recent nurse’s notes and operative reports; however, no callback/reports were received prior to the submission of this request to PA.
Current request is for 5 Days In-Patient Stay to a Skilled Nursing Facility between 8/9/2016 and
Based on the progress report dated 07/05/16, the patient is scheduled for a 3-level global fusion on 07/22/16 and 07/25/16. She reports that her back pain is rated as 7 /10. Yesterday was worse. The pain radiates into the right buttock, dorsolateral thigh, wrapping around the right knee, and into the dorsolateral calf and ankle into the last three toes with right lower extremity weakness. She now has pain in the same dermatomal distribution however, it is not as severe or intense. She is taking Percocet 10/325 mg 3 tablets a day.
On examination, standing range of motion is 30 degrees. Straight leg raising is 80 degrees on the right and 90 degrees on the …show more content…
She was given a prescription for Percocet, Flexeril and tramadol.
Per the adjuster’s notes, the patient is recovering post-operatively and the request is for in-patient skilled nursing for physical therapy 1 x 5. Per verification to the provider’s office, the patient is status post 1 Posterior Global Arthrodesis at the L2-L3, L3-L4, and L4-L5 Levels on 07/22/16 and 07/25/16. Requested for recent nurse’s notes and operative reports; however, no callback/reports were received prior to the submission of this request to PA.
Current request is for 5 Days In-Patient Stay to a Skilled Nursing Facility between 8/9/2016 and