The patient is a 59 year-old male with a 12/31/09 date of injury. A specific injury occurred while performing executive chef duties. Diagnosis was depression.
12/24/15 DWC Form RFA for Sertraline 100 mg, Mirtazapine 15 mg and Adderall 5 mg.
12/17/15 Notice of denial for medications: dextroamphetamine-amphetamine 5 mg # 30, Sertraline HCL 100 mg # 60 and Mirtazapine 15 mg # 30.
12/04/15 request for additional information for medications: dextroamphetamine-amphetamine 5 mg # 30, Sertraline HCL 100 mg # 60 and Mirtazapine 15 mg # 30. Arissa requested current progress report with subjective and objective findings from the requesting physician, IW and IW’s attorney (if applicable).
12/03/15 Progress Report noted that the patient was slightly better with the use of Sertraline. The patient has considered volunteering with the police in Carlsbad. The training is in January, but he thinks this is out of his league. He wants to able to get out of the house. His anxiety has increased but he tries not to get angry. He occasionally feels that’s he is a burden on his wife and children. He has no motivation. Objective findings showed that the mood was depressed. His motor activity was calm. Speech, thought pattern, language, and knowledge were normal. His thought process was coherent. Judgment, mental status, memory and attention were intact. The gait was antalgic and he uses a cane. Treatment plan included Sertraline, Mirtazapine and Adderall. Follow-up is in one month. 11/17/15 Notice of Modification for partial certification of Sertraline and Mirtazapine with no refills. 10/21/15 notice of denial for sertraline HCL 100 mg # 45. 10/20/15 progress note described he had been good but “blah” when his wife goes away. He was not able to let his injury go and it made him weary, especially when he interacted with his wife who also had depression. He had no energy. He ate fair. He was a chef and he felt he could slap together a sandwich. He would rather see activation with psychological means that change medications. Clinically, he appeared well groomed. His affect was appropriate, constricted and depressed. Mood was depressed. He utilized a cane. Memory was intact. Gait was slightly antalgic. He was advised to return in 6 to 8 weeks. Prescribed medications were Sertraline and Mirtazapine. The provider recommended that the patient have more activity for social contract and advised him to consider volunteering for a few hours to help with motivation. The provider …show more content…
In addition, ODG identifies that anxiety medications in chronic pain are recommended for diagnosing and controlling anxiety as an important part of chronic pain treatment. This patient has chronic pain and major depression. He has been taking Sertraline and Mirtazapine. Sertraline made the patient feel better, but her depression has been unchanged. An additional month was given to document the continued efficacy of these medications on 11/17/15, considering the ongoing persistent psychiatric symptoms and presence of neuropathic pain. The medications were requested again on 12/03/15 and Arissa denied them later due to lack of information and due to the absence of latest progress notes. Now, the provider is requesting the medications again per 12/24/15 RFA. However, no new progress notes are available for review. There is no documentation of additional benefits derived from Sertraline in combination with Mirtazapine. Medical necessity of these drugs has not been substantiated. Recommend
12/24/15 DWC Form RFA for Sertraline 100 mg, Mirtazapine 15 mg and Adderall 5 mg.
12/17/15 Notice of denial for medications: dextroamphetamine-amphetamine 5 mg # 30, Sertraline HCL 100 mg # 60 and Mirtazapine 15 mg # 30.
12/04/15 request for additional information for medications: dextroamphetamine-amphetamine 5 mg # 30, Sertraline HCL 100 mg # 60 and Mirtazapine 15 mg # 30. Arissa requested current progress report with subjective and objective findings from the requesting physician, IW and IW’s attorney (if applicable).
12/03/15 Progress Report noted that the patient was slightly better with the use of Sertraline. The patient has considered volunteering with the police in Carlsbad. The training is in January, but he thinks this is out of his league. He wants to able to get out of the house. His anxiety has increased but he tries not to get angry. He occasionally feels that’s he is a burden on his wife and children. He has no motivation. Objective findings showed that the mood was depressed. His motor activity was calm. Speech, thought pattern, language, and knowledge were normal. His thought process was coherent. Judgment, mental status, memory and attention were intact. The gait was antalgic and he uses a cane. Treatment plan included Sertraline, Mirtazapine and Adderall. Follow-up is in one month. 11/17/15 Notice of Modification for partial certification of Sertraline and Mirtazapine with no refills. 10/21/15 notice of denial for sertraline HCL 100 mg # 45. 10/20/15 progress note described he had been good but “blah” when his wife goes away. He was not able to let his injury go and it made him weary, especially when he interacted with his wife who also had depression. He had no energy. He ate fair. He was a chef and he felt he could slap together a sandwich. He would rather see activation with psychological means that change medications. Clinically, he appeared well groomed. His affect was appropriate, constricted and depressed. Mood was depressed. He utilized a cane. Memory was intact. Gait was slightly antalgic. He was advised to return in 6 to 8 weeks. Prescribed medications were Sertraline and Mirtazapine. The provider recommended that the patient have more activity for social contract and advised him to consider volunteering for a few hours to help with motivation. The provider …show more content…
In addition, ODG identifies that anxiety medications in chronic pain are recommended for diagnosing and controlling anxiety as an important part of chronic pain treatment. This patient has chronic pain and major depression. He has been taking Sertraline and Mirtazapine. Sertraline made the patient feel better, but her depression has been unchanged. An additional month was given to document the continued efficacy of these medications on 11/17/15, considering the ongoing persistent psychiatric symptoms and presence of neuropathic pain. The medications were requested again on 12/03/15 and Arissa denied them later due to lack of information and due to the absence of latest progress notes. Now, the provider is requesting the medications again per 12/24/15 RFA. However, no new progress notes are available for review. There is no documentation of additional benefits derived from Sertraline in combination with Mirtazapine. Medical necessity of these drugs has not been substantiated. Recommend