Physician 1st Quarter 2016 Interventional Pain IRR - Case Study #1
Plan: Blue Shield California
Requested CPT(s): 62311
56-year-old male with 3–8/10 constant low back pain. He has had previous epidurals (recent report that caudal epidural did not help after sitting up from the procedure but request for repeat caudal epidural from 12/2/15 states that caudal epidural on 6/12/15 with pain relief) and narcotic pain medication. His pain is increased with standing, sitting, and walking.
On physical examination, he has tenderness to palpation in the thoracic and L1–2 paraspinals aggravated by trunk flexion, antalgic gait with flexed posture, negative straight leg raise. MRI of the lumbar spine on 5/23/13 showed L4–5 bulge indenting the thecal sac. The provider requests interlaminar/caudal lumbar epidural, level not defined.
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