Patient Case Report: Lumbar Spine

He underwent an interlaminar injection in May 2015 which improved his lower extremity pain by 99%. This has lasted him up until 1 month when he has had recrudescences of pain emanating from the low back radiating intermittently into the left lower extremity in a sharp shooting fashion, average pain 5/10, and worse pain 81/0. The pain is frequent and is associated with numbness and tingling. There is some difficulty with walking. Over the past 1 month, the pain has been severe. Home exercises and nonsteroidal anti-inflammatory medications (NSAIDS) have not been effective in reducing his pain and the pain is severe at times and limiting his ability to lift and sit. Walking, exercise and standing increased the pain. Lying down reduce the

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.

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

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

Current request is for 6 Physical Therapy Visits for the Lumbar Spine between 3/8/2016 and

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

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

10/30/15 Medical Evaluation reported neck, low back, and left sacroiliac pain. Physical examination of the lumbar spine revealed decreased ROM on

01/11/16 PT Evaluation Report documented that the patient is showing good progress towards goals, with a decrease in pain in the right lower leg, ankle and foot when ambulating. But the remaining impairments, including reduced strength, limited ROM and gait deviations cause poor ability to ambulate. Continue skilled PT is necessary in order to address the remaining deficits. Sort-term and long-term goals were discussed.

Is the request for 16 Physical Therapy Visits for the Back with Re-evaluation between 2/29/2016 and 4/29/2016 medically necessary?

Per IME report dated 9/27/2013 by Dr. Philip D’Ambrosio, the patient has reached MMI to the right shoulder, right ankle, right elbow, and right knee. At this time, he requires no further treatment other than for documented exacerbation.

Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar

Per Dr. Lichtenberg’s referral, Mr. Rascon presented to Movements Dynamic for physical therapy treatment. His complaints remained the same. Mr. Rascon reported not being able to return to work due his pain and limited range of motion.

It was noted that continued physical therapy once a week for the next eight weeks is appropriate

Based on the latest medical report dated 03/14/16, the patient returns for a follow-up visit and reports low back pain with radiation to the right lower extremity with stiffness. She felt difficulty with flexion and decreased flexibility.