This is an appeal to a previously denied request for C6-C7 interlaminar ESI.
This is a 55-year-old female with a 3/25/2015 date of injury. A specific mechanism of injury has not been described.
Diagnosis: Myalgia
Cervical Radiculopathy
12/21/15 Progress Report noted that the patient has a history of pain in the neck and left arm. He is s/p C7-T1 interlaminar injection on 11/17/15. She reports some improvement post injection overall, but still some pain. Current medications: Gabapentin, Butalb/Acetaminophen/Caffeine (Fioricet). Tramadol, Hydrocodone/Acetaminophen (Norco 5/325 mg), Paroxetine (Paxil), Tizanidine, Alprazolam, Meloxicam, and Valsartan/Hydrochlorothiazide (Diovan). She has pain from the down the left arm to the elbow. She
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On examination the cervical ROM was restricted in all planes. Spurling’s test was positive on both sides, worse on the left. Sensations to light touch were decreased in the left hand 1-2 digits, which indicates sensory losses at C6-C7 levels. This level is most remarkable on the imaging as well. The MRI revealed 3mm protrusions at C6-7, with mild canal stenosis at this level; and mild to moderate foraminal stenosis greater on the left at C6-7. The patient has tried and failed conservative treatment including, PT, TPI, and medications. In addition, the patient reported functional improvement and pain relief from the first ESI, which was performed at a different, level i.e. C7-T1. CO Guidelines state indications for ESI :injections are allowed for only a small subset of patients with radicular findings. They may be used for patients who are having significant pain that is interfering with daily functions and the active therapy necessary for recovery despite medical pain management and active therapy. Injections should be preceded by an MRI. Interlaminar injections should not be done above level C6-C7. Guidelines have been met. Medical necessity of cervical ESI has been established. Recommend
DOI: 9/18/2000. Patient is a 59-year-old female technician who sustained a work-related injury due to being jostled and jolted in the back of a golf cart which ran over a pothole. As per OMNI, she was diagnosed with post cervical protrusions, facet syndromes with headaches, lumbar facet syndrome and status post right shoulder repair/resection.
DOI: 6/23/2016. Patient is a 42-year-old female registered nurse who sustained injury to her neck/left shoulder when she twisted to keep the attachment from falling to the floor. Per OMNI, she was initially diagnosed with strain to multiple body parts.
This is a 52-year-old male with a 9/24/2014 date of injury. A specific mechanism of injury has not been described.
This is a 54-year-old male with a 1/17/2012 date of injury. A specific mechanism of injury has not been described.
The patient is a 36-year-old individual who sustained an injury on 01/30/17 due to lifting.
Electrodiagnostic consultation report dated 10/02/15 revealed normal study of both upper limbs and cervical paraspinals. No evidence of cervical radiculopathy. No median or ulnar neuropathy.
DOI: 11/16/2010. The patient is a 60-year-old female floor person who sustained a work-related injury when she slipped and fell on unknown slippery surface.
This is a 51-year-old male with a 1/21/2014 date of injury. A specific mechanism of injury has not been described.
12/08/15 Progress Report described that the patient presented with pain in lower back and buttocks without radiation to the lower extremities. The patient reported significant pain relief due to intra-articular facet block done on 04/14/14 for his left side. TPIs have been improving his pain. The patient noted exacerbation of low back pain after moving appliances yesterday. Pain level was 7/10 with the use of medications. He would be starting PT next week. The patient underwent right-sided transforaminal ESIs at L4 and L5 levels without any significant long-term pain relief. It was helpful for a short duration. Facet joint injections caused increase in lower back and buttock pain. SI joint injection has improved his pain to 3/10. The lower back pain is aching, sharp, shooting, sore, and throbbing with pins and needles. The pain is constant and the pain aggravates with ambulation and standing. The patient also has bilateral leg pain due to varicose veins. The patient is currently on Elavil, Planquenil, Lunesta, Flexeril, Ompeprazole, compounding cream, Tramadol, Vitamin B12, Gabapentin, Voltaren gel and Duloxetine. Exam revealed an antalgic gait. There was significant tenderness to
Based on the medical report dated 12/15/16, the patient complains of pain to her neck and bilateral wrists. Patient has right sided cervical pain with numbness and tingling down the right arm,
26 year old white female post partum 2 weeks, is here for medication refill, ot establish new primary care physician. Patient reports she has history of substance abuse, Benzos, and current smoker (1/2 packs/day X 12 year). Patient denies chest pain, SOB, plapitations, N/V/D, fever. Patient reports that she was diagnosed with Fibromyalgia by Grayson, will sign consent form to obtain medical records.
Myalgia or muscle discomfort is incredibly common for beginner athletes and people who work out with heavy equipment, due to the fact the most widespread causes for the condition is overuse or over-stretching of muscles. Muscle pains can cause severe discomfort and are typically the reason why people lose the determination to work out or even do anything beyond moderate physical activity. This is due to the fact that by the time you recover from myalgia, you'd have already lost that inital excitement in the thought of obtaining good health.
DOI: . Patient is a 30- year old -male - who sustained a work related injury
DOI: 11/10/2006. The patient is a 54-year-old female customer service representative who sustained a sprained right ankle while going down stairs leaving work.
This is a 38-year-old female with a 1/10/2013 date of injury. A specific mechanism of injury has not been described.