DOI: 6/18/2012. Patient is a 64-year-old female employee who sustained a work related injury when she got struck with a metal bar in the bathtub. Per OMNI, she suffered injuries to her forehead, neck, and shoulders.
Per IME report dated 01/26/15 by Dr. Katz, patient’s diagnoses include resolving cervical spine sprain/strain, status post right shoulder arthroscopic surgery on 04/24/14 and left shoulder sprain/strain, resolved with MMI reached. It w as opined that the IW’s right shoulders and cervical spine condition warrants further care. Additional orthopedic care is recommended including cortisone injection to the right shoulder and PT 3 times per week for 6 weeks with re-evaluation upon completion.
Per medical report dated 07/06/15, …show more content…
Impression is status post right shoulder arthroscopy and continued neck pain. Plan is to continue PT.
Based on medical report dated 07/20/15, the patient complains of pain and stiffness of the neck, right shoulder and trapezius. She reports feeling better with PT. She has lessened pain and better mobility.
On examination, there is an increased muscle spasm to the cervical paraspinal muscles, shoulder and trapezius. Right shoulder range of motion is decreased.
Diagnoses are cervical radiculopathy, muscle spasm and right shoulder pain.
She was given a prescription for Ibuprofen. Plan is to restart PT.
Per OMNI payment screen, the patient has completed approximately 53 PT sessions for the neck and right shoulder from 07/21/2014 through 06/24/2015.
Unable to include other clinical notes as medicals submitted are handwritten and is to some extent illegible.
Is the request for 24 Physical Therapy Visits for the Right Shoulder and Neck between 7/29/2015 and 9/12/2015 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary
Per IME report dated 01/26/15 by Dr. Katz, patient’s diagnoses include resolving cervical spine sprain/strain, status post right shoulder arthroscopic surgery on 04/24/14 and left shoulder sprain/strain, resolved with MMI reached. It w as opined that the IW’s right shoulders and cervical spine condition warrants further care. Additional orthopedic care is recommended including cortisone injection to the right shoulder and PT 3 times per week for 6 weeks with re-evaluation upon completion.
Per medical report dated 07/06/15, …show more content…
Impression is status post right shoulder arthroscopy and continued neck pain. Plan is to continue PT.
Based on medical report dated 07/20/15, the patient complains of pain and stiffness of the neck, right shoulder and trapezius. She reports feeling better with PT. She has lessened pain and better mobility.
On examination, there is an increased muscle spasm to the cervical paraspinal muscles, shoulder and trapezius. Right shoulder range of motion is decreased.
Diagnoses are cervical radiculopathy, muscle spasm and right shoulder pain.
She was given a prescription for Ibuprofen. Plan is to restart PT.
Per OMNI payment screen, the patient has completed approximately 53 PT sessions for the neck and right shoulder from 07/21/2014 through 06/24/2015.
Unable to include other clinical notes as medicals submitted are handwritten and is to some extent illegible.
Is the request for 24 Physical Therapy Visits for the Right Shoulder and Neck between 7/29/2015 and 9/12/2015 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary