Chronic Low Back Pain Case Summary

Patient has been previously denied with 60 Tablets of Diclofenac Sodium XR 100 mg and 90 Tablets of Cyclobenzaprine 7.5 mg on 05/17/16 (Review 261084).

Per progress report dated 03/04/16, the patient complains of pain of pain in the neck and lower back. Current medication is for Norco and Gabapentin.

Per the Request for Authorization form dated 09/23/16, IW was prescribed with trazodone 50 mg #30 1 tablet at bedtime with 4 refills and provided with a refill of Vicodin 5/300 mg #60 1 tablet twice daily and Miralax 527 grams twice daily with 4 refills. IW will discontinue Restoril.

Based on the progress report dated 09/12/16, the patient reports more frequent pain with activity since the last

She demonstrates a steady tandem gait. Sensation to light touch to the upper extremities is grossly intact. Reflexes to the upper extremities is 2+. Tinel's is positive at the elbow and wrist on the right.

Per office visit notes dated 8/7/2016, patient presents for a follow up for neck pain, left elbow pain and bilateral wrist pain. Current medications include Naprosyn EC 500 mg, Tramadol 50 mg, Lyrica 50 mg and Levora-28 0.15/0.03 mg. Patient was recommended retrial of Celexa for her depressed mood related to her chronic

Current request is for 4 Patches of Butrans (Buprenorphine) 10 mcg/hr; and 15 Patches of Fentanyl Patch 75 mcg/hr between 4/15/2016 and 6/14/2016.

Based on the medical report dated 02/01/16, the patient presents for a routine follow-up visit regarding her chronic neck pain with radiation down the left upper extremity into the thumb with numbness and tingling. She reports no change in her pain since her last follow-up visit. She states she stopped taking the Lyrica because it was making her feel weird and her head felt cloudy. She did wean off of it as instructed without problems. Authorization for acupuncture treatments was denied by the insurance because it stated the left hand pain was not part of her claim. Patients hand pain only developed after she had the neck surgery, which was anterior cervical discectomy and fusion (ACDF) at C5-C6.

Patient has been previously certified with 60 Tablets of MS Contin 15 mg between 3/2/2016 and 5/1/2016, and 19 Tablets of Dilaudid 4 mg between 1/29/2016 and 3/14/2016 (Review 247826).

Based on the latest medical report dated 02/10/16, the patient has undergone extensive PT. She was diagnosed with sprain/strain derangement of the cervical spine, cervical subluxation complex, and cervical brachial radiculopathy, sprain/strain derangement of the lumbar spine, lumbar subluxation complex and lumbar radiculopathy.

As per medical report dated 2/18/16, patient complains of constant low back pain in a L4-5 distribution. Patient has undergone physical therapy as well as medication management without amelioration of the pain and continues to be symptomatic. He had previous epidural steroid injection. He also had acupuncture

Based on the medical report dated 12/13/16, the patient presents for follow-up. Lumbar discomfort is described as sharp, aching, burning, shooting, severe and continuous, comes and goes, discomfort, pain, random, varying with activity, increasing with movement, tightness, and throbbing. It is rated as 9/10 without medications and 6/10 with medications. The symptoms are aggravated by changing positions, lifting, pulling, pushing, carrying, sitting, twisting,

The case that was selected is John Doe 91 years old male has a history of end stage renal failure, osteoarthritis, falls, and past surgeries. Norco 10-325 prn q 4 hours, tylenol 650 q 6 hours, restoril 15mg at bedtime was prescribed to control the patient’s pain

DOI: 05/01/2001. This is a 71-year old female teacher’s aide who sustained injuries to her back and bilateral knees as a result of tripping on the sidewalk. The patient is subsequently diagnosed with lumbar, spondylosis without myelopathy or radiculopathy; and low back pain.

Based on the progress report dated 03/12/15 by Dr. Esposito, the patient has reached a plateau state. She has had no major flare-ups since the last evaluation. She is still taking Norco 10/325 mg on occasion twice a week for flare-up. She is also taking gabapentin 600 mg twice a day as well as Aleve. She has backache with left leg radicular symptoms.