Mmi Case Studies

Is the request for 16 Physical Therapy Visits for the Lower Back between 4/11/2016 and 6/10/2016 medically necessary?

Treatment plan includes saliva toxicology, lumbar MRI with and without contrast and lumbar back brace to provide symptomatic relief for chronic low back pain and to reduce pain by restricting mobility of the trunk and to support the weak spinal muscles. Goal is to facilitate healing of the lumbar spine.

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

11/13/14 MRI of the lumbar spine showed 4mm left paracentral and foraminal disc protrusion at L4-5, which mildly impinges upon the thecal sac and the proximal left L5 nerve root. The disc protrusion also moderately narrows the left foramen and lateral recess. There was also a 2mm posterior central disc protrusion at L5-S1. A 2mm disc bulge at L2-3 was seen. There was a mild degenerative facet and ligament flava hypertrophy at L4-5 and

On the statement of medical necessity per MG-2 form dated 10/18/16, the patient wants to repeat left L5-S1 x 1 for longer lasting pain relief. History and physical examination was consistent with lumbar radiculopathy/radiculitis (radiating pain and concordant MRI findings). She has failed conservative treatment options including nonsteroidal anti-inflammatory drugs (NSAIDS),exercise, core strengthening and PT. Pain limits the patient’s function, as well as restricts Activities of Daily Living. It is reasonable to try a left L5-S1 ESI x 1 for pain relief. If there will be no benefit, an interlinear approach will be attempted.

DOI: 11/13/2014. Patient is a 32-year old male technician who sustained injury at the time he was breaking loose a pulser component, he felt a sharp pain to his right side, low back buttocks and right leg. The patient was subsequently diagnosed with lumbar degenerative disc disease, radiculopathy and, lumbar spinal stenosis. Per MRI of lumbar spine without contrast dated 12/23/14 revealed at L4-5 there is disc space height loss, disc bulging and facet degenerative change; at L5-S1 there is posterior disc bulging resulting in mild narrowing of the central canal, and; at T11 to T12 there is posterior disc bulging resulting in mild narrowing of the central canal. As per focused history and physical dated 3/17/15, patient is presented to the office

Lumbar intervertebral disc prolapse most commonly occurs at L4 or L5. Disc prolapse involving at much higher level may be associated with a negative straight leg raising test instead there may be a positive femoral stretch test which is tested by making the patient prone and knee of the patient is made to flex with one hand of the examiner at the popliteal fossa, will cause pain radiating along the anterior aspect of the thigh, for which a high lesion should be suspected .In addition, these lesions may occur with a more diffuse neurological complaint without significant localizing neurological signs. Often the neurological signs associated with disc disease vary over time.

Patient Description: Patient is a 46 yr old male; 3 months post traumatic spinal cord injury. Patient is dependent and bed bound for majority of the day. Patient presents with BUE weakness and poor control and sensation in BLE. Patient also demonstrates poor trunk control and has extensive pain in LUE.

On examination, there is tenderness on palpation of the lumbosacral area. There is lumbosacral spine pain elicited by motion. Lumbosacral spine motion was normal with mild pain. Sensation to light touch is decreased over the dorsal aspect of the left great toe. Assessments are lumbar sprain and left L4-5 herniated disc. Patient was provided a script to continue with PT.

Guidelines Utilized: According to the Official Disability Guidelines, The anticipated length of disability for the diagnosis Other spondylosis with radiculopathy lumbar region M47.26 is 16 to 32 days, Other spondylosis with radiculopathy lumbosacral region M47.27 is 16 to 32 days, Sacroiliitis M46.1 is 15 to 122 days, Sacrococcygeal disorders M53.3 is 28 to 116 days, Low back pain M54.5 is 17 to 50 days. Other intervertebral disc displacement, lumbar region M51.26 is 71 to 164 days. On 12/14/16 Chronic Pain Syndrome diagnosis was added projection for recovery is 124 to 365 days. On 6/29/17 Dr. Rampersaud added

DOI: 12/14/1995. Patient is a 66 year-old male truck driver who sustained injury to his back while unloading a truck by hand. Per OMNI, patient is diagnosed with failed back syndrome. MRI of the lumbar spine dated 6/9/16 revealed postsurgical changes of the lumbar spine with resection of the posterior elements from L1-L2 to L5-S1 and mild to moderate disc degenerative disease of the lumbar spine at T12-L1, L2-L3 and L3-L4. Per progress report dated 5/03/2016, patient presents for follow up evaluation. He reports that he decided not to proceed with the pain pump trial as he does not want to add more medication to his regiment. He would prefer to start physical therapy for his pain instead of medication. He has been able to control his pain with regimen. He notes at least 40% improvement with

The rationale for this plan was that reducing muscle guarding and tone surrounding the lumbar spine to allow for greater lumbar and bilateral LE AROM aiding in a decrease of symptoms. Once acute symptoms were managed, incorporation of stabilization techniques, strengthening and aerobic exercise would be prescribed to reduce the risk of lumbar re-injury and control fibromyalgia symptoms, addressing the musculoskeletal and neuromuscular examination findings. It was recommended that the patient’s intervention plan consist of 2-3 sessions a week for 4 weeks. After 4 weeks the patient’s progress would be measured to determine the efficacy of the current POC. The patient’s progress would be informally measured prior to each treatment session with a subjective pain rating and patient feedback regarding any improvements, declines, or stasis in the patient’s

Patient was diagnosed with lumbar radiculitis with possible radiculopathy. The IW will undergo a series of two lumbar epidural injections with epidurography and fluoroscopic guidance. This is diagnostic and potentially therapeutic. If the IW fails to achieve any response to axial pain, lumbar facet injections may be considered, as well as disc decompression, provocative discography.

Current request is for 1 Magnetic Resonance Imaging of the Lumbar Spine between 12/16/2016 and

DOI: 3/2/2016. Patient is a - year old female who sustained a work related injury when she tripped/fell backwards on to a pallet. As per medical report dated 5/2/16, it was noted that the patient had a trigger point injection last time, which relieved some of the tightness that she had in the low back. Pain is exacerbated with bending and extension activities. Pain level is 8. Lumbar spine examination revealed that there is 50% of normal range of motion with 80 degrees of flexion, 20-30 degrees of extension, 35 degrees of lateral bending, and 45 degrees of lateral rotation. Positive facet maneuvers, mostly on the right side is noted. Impression includes lumbar disc protrusion at L3-L4 and L5-S1 and facet hypertrophy at L3-L4 and L5-S1. It was