IME Report Sample

Attend the next appointment with Dr. Taha on 10/24/17 to address work status, bone healing, replacement services, attendant care. Obtain projections for recovery.

It was noted that the patient has neck pain, facet arthropathy and spondylosis, suggestive of facer joint origin, 80% relief from previous facet nerve injection/block, prior rhizotomy more than 6 months and cervical/thoracic facet medial branch nerve block which has been helpful, failed conservative treatments with nonsteroidal anti-inflammatory medications (NSAIDS), PT, chiropractic care and home exercises.

In addition, CA MTUS criteria for the use of epidural steroid injections include an imaging study documenting correlating concordant nerve root pathology; and conservative treatment. As noted above, this is an appeal to the previously denied request on 02/09/16. The appeal letter states that the patient has low back pain. MRI report showed disc bulge at L5-S1 with left neural foramina narrowing. However, 01/06/16 progress report noted that there was no radiculopathy with a negative SLR on exam. The guidelines require documentation of radiculopathy on exam. In addition, there is no documentation of a trial or failure of conservative treatment, including PT, as recommended by the guidelines. Furthermore, there is no documentation of any focal neurological deficits on the exam that would indicate nerve pathology. The motor and sensory exam was normal. Medical necessity has not been established. Recommend

Patient was encouraged to continue with heat, followed by his home exercise program and ice. He will continue with his transcutaneous electrical nerve unit (TENS). Patient was given an ice pack to use, to reduce pain. He was given a 60 mg Toradol injection on this visit.

Treatment plan includes follow-up with orthopedics, follow-up with psychology, Dr. Gandolfo for additional treatments for major depressive disorder, additional PT 2 x 3 sessions to treat the lumbar spine, additional PT for vestibular rehabilitation, follow-up with neurologist, referral for psychology and follow-up with primary care physician (PCP).

Is the request for 12 Physical Therapy Visits for the Left Knee between 6/13/2016 and 8/12/2016 medically necessary?

DOI: 8/6/2015. Patient is a 51-year-old female licensed vocational nurse who sustained a work-related injury to her back and hips while moving a client. As per OMNI, she was diagnosed with muscle spasm, pain over the low back and thoracic region. She is status post right carpal tunnel release on 02/26/16.

Current request is for 12 Physical Therapy Visits for the Left Shoulder between 1/17/2017 and

On examination, he has moderate pain to palpation to the lumbar spine and paravertebral muscles over the bilateral facet joints at L4-L5-S1. He has a positive straight leg raise test to the right.

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.

Assessments include lumbosacral intervertebral disc disorders with radiculopathy, lumbar spondylosis without myelopathy or radiculopathy and myalgia.

DOI: 5/13/2014. The patient is a 29-year old female manufacturing lead who sustained a work-related injury to her back when she was lifting two ostellation trays which weigh about 30 pounds.

DOI: 03/11/2009. Patient is a 60-year-old male truck driver who sustained a work-related injury to his back when he tried to catch a box from falling. He is status post two back surgeries on 07/06/2009 and has reached Maximum Medical Improvement as of 06/19/2012.

Patient is status post transforaminal Epidural Steroid Injection (ESI) at bilateral S1 per operative report dated 05/18/09.

ODG Physical Therapy Guidelines recommend 10 visits over 8 weeks of physical therapy for medical treatment of intervertebral disc disorder with myelopathy and spinal stenosis. In this case, the claimant continued to have low back pain with lumbar radiculopathy. It was noted that the claimant had been doing physical therapy with improvement in left leg pain. However, there was no documentation of PT visits and the total number of sessions completed. There was insufficient objective evidence to support the subjectively reported benefit from prior PT visits. Therefore, the request for physical therapy reevaluation with traction/decompression, 16 visits, per 12/09/17 order is not medically necessary.