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Chronic Low Back Pain Case Summary

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OI: 11/22/2009. Patient is a 46-year-old female certified nursing assistant who sustained a work-related injury to her low back while helping move/lift a patient. Per OMNI, the patient is diagnosed with status post lumbar laminectomy surgery on 07/26/10, lumbar degenerative disc disease, and lumbar radiculopathy. She was deemed to have reached permanent and stationary status by PQME Dr. Well last 12/01/11.
Per progress report dated 1/19/2016, patient presented with complaints of chronic low back pain, right lower extremity paresthesia and right lower extremity pain, failed back syndrome, and on Amoxicillin for sinus infection. She now presents with ongoing symptoms of pain. She reports that her dose of Lyrica was weaned down and she is having …show more content…

She has full mobility of the lumbar spine and movements are pain free. The right AFO fits appropriately and she has a mostly normal gait with it in place.
Current medications include hydrochlorothiazide 25 mg daily, Neurontin 900 mg daily, pravastatin 40 mg daily, Baclofen 10 mg twice daily, levothyroxine125 mcg daily, Lipitor 40 mg daily, Mobic 7.5mg daily, Vitamin C 1 000 mg daily, Calcium 500 mg daily, Niacin 100 mg daily, hydrocodone-acetaminophen 10-325 mg twice daily and Lyrica 225 mg.
As of this report, last urine drug screen, Controlled Substance Utilization Review and Evaluation System (CURES) and Pain contract were dated 01/29/14.
Patient was diagnosed with lumbago and thoracic spine pain.
Treatment plan includes continuation with home exercise program and Lyrica.
Patient has been previously certified with 13 Tablets of Norco 10/325mg and 30 Tablets of Lyrica 225mg on 01/29/16 (Review 247182) for weaning purposes.

Requested verification from the provider’s office on ; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 60 Tablets of Norco 10/325mg; and 60 Capsules of Lyrica 225mg between 5/20/2016 and

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