Physician 1st Quarter 2016 Interventional Pain IRR - Case Study #4
Plan: Coventry Healthcare Commercial Texas
Requested CPT(s): 64635, 64636
50-year-old female with constant sharp pain in the lumbar spine gradual in onset over 4 years. It did go to the right lower extremity which precipitated surgery to remove a facet cyst. The pain returned and she underwent fusion. She had injections and then spinal cord stimulator which resolved the right leg pain. She now has left leg pain to the knee. She had 75- 90% improvement for 1 week after a left sacroiliac joint injection.
Physical exam shows sacroiliac joint pain on end range of motion in external rotation, decreased sensation right lower extremity, myelogram 3/18/15 showed L5–S1 fusion without loosening, narrowing of the thecal sac at L4-5 and L5–S1. The provider requests right sacroiliac joint radiofrequency.
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