Pain Management Case Summary

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DOI: 12/19/2015. Patient is a 23-year-old male field technician who sustained injury while removing a ladder from a truck. Per OMNI, he was initially diagnosed with back sprain/strain.
Based on the progress report date03/16/16, the patient has been managed conservatively with PT and has continued to experience discomfort. His pain has migrated from primarily thoracic to more localized lumbar pain.
He describes the pain as primarily in the low back, left greater than right which is constant. He gets intermittent mid to upper back pain in the midline which tends to be short lived and self resolving. He also gets radiation into the bilateral hips and occasionally the left groin is also intermittent.
Pain is described as achy, cramping, deep, radiating, sharp, shooting,
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He is currently taking Advil and Tylenol.
On examination of the lumbar spine, range of motion is full in flexion and limited in extension. Lumbar facet loading maneuvers are positive.
There is tenderness to palpation over the entire lumbar paravertebral region bilaterally, left greater than right. Deep tendon reflexes are 1 + and symmetrical at the patellar and 1+ to the left Achilles and absent right Achilles.
Patient was assessed to have lumbar region spondylosis without myelopathy or radiculopathy. Patient presents with evidence of lumbar facet arthropathy and thoracic myofascial pain. In order to identify the facet joints as pain generators, a lumbar medial branch injections at the left L1-L4 levels is recommended. Pending response, consideration will be given to the contralateral facet joints as well as potentially discogenic sources of pain.

Is the request for 1 Medial Branch Block at Left L1, L2, L3, and L4 Levels between 3/28/2016 and 5/27/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary
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