Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.
Attached are chiropractic and PT notes. Patient has been previously denied with same request on 12/01/15 (Review
Per verification to the PT facility, the patient has attended 31 PT sessions for the lower back from 09/29/15 through 03/30/16.
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.
As per progress report on 5/24/16, the patient is still having a lot of low back pain that radiates to his lower extremities. He continues to find his
Per the medical report dated 03/29/2016 by Dr. Waghmarae, the patient believes that her left buttock pain has increased over the last month. She describes her pain as aching, throbbing and stabbing. She rates her pain symptoms as 8/10. Pain is relieved by medication, heat, ice and use of a Transcutaneous Electrical Nerve Stimulator (TENS) unit, and is increased by movement and standing for long periods of time. She states that her bilateral legs have also increased in pain severity over the last month. She believes because she is doing a lot of standing and trying to clean up her house. She states that pain is increasing in her left buttock. She is not involved in physical therapy, chiropractic, massage therapy or acupuncture. Palpation of the lumbosacral spine reveals abnormalities along the bilateral facet joints. There is pain in her axial lower back in all planes of lumbar motion that is
The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.
10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on
His symptoms included pain in his neck, mid back, upper back, lower back, and left knee pain. Plaintiff described his neck pain as a 3 on the pain scale, his back pain as a 5 and his knee pain as a 6 on the pain scale. Plaintiff was prescribed 3 sessions per week for 6 weeks of physical therapy.
Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained
On the statement of medical necessity per MG-2 form dated 07/13/16, patient has been experiencing severe lumbar spine pain/spasms since the injury. She complains of lumbar spine pain with cramps in the lower extremity going down to the feet, associated with tingling sensation. There is left greater than right L3-S1 pain and spasms, left greater than the right L3-4, L4-5 and L5-S1 facet joint pain, upon posterolateral extension at 45 degrees. There is bilateral sacroiliac joint tenderness. There is tenderness over the right lateral quadriceps muscle. Range of motion (ROM) is limited secondary to
Per PT note dated 05/09/14, the patient has had 36 post-operative PT sessions for the back.
As per medical report dated 3/10/2016, patient complains of low back pain rated at 7/10 with left lower
Based on the progress report dated 02/09/16, the patient presents for follow-up. He describes ongoing difficulty with pain in both shoulders, wrists, low back and the bilateral lower extremities from the knees to the calves. His symptoms include pain, spasms, numbness and tingling. He rates his pain level as a 9/10 in intensity, but it is reduced to a 7/10 with use of his medications. He reports that morphine is helping, but he is still taking 5-6 Norco a day. He is also taking a stool softener three times a day as well as Linzess. However, he continues to have significant constipation.
DOI: 05/07/1980. The patient is a 73-year-old male foreman who sustained a work-related injury to his lumbosacral spine, left knee, and right heel when a pile of lumbar fell on him. Patient is diagnosed with lumbar post laminectomy syndrome, foot drop, and non-union fracture. He has a history of hypertension and diabetes. He is status post 3 back surgeries, laminectomy at L4 to S1 in 1973, bilateral decompression laminectomy and discectomy at L4 to S1 in 1981, and 2-level fusion with failed fusion in 1991.