Physician 1st Quarter 2016 Interventional Pain IRR - Case Study #5
Plan: Coventry Pennsylvania Medicare
Requested CPT(s): 62311
60-year-old male with low back pain to the right lower extremity x 1 month. He has had chronic low back pain for several years after a motor vehicle accident. He went to the ER and his family doctor. He has used narcotics, a 5-day course of Prednisone, and is now on Gabapentin 900mg TID. He tried PT, but it was too painful. He is in aqua therapy.
On examination, he is in a wheelchair. He arises easily. He has pain to palpation of the right buttock. He flexes and extends with extension worse. He has good rotation and lateral bending. Reflexes are intact and symmetric, EHL is symmetric and strong. MRI of lumbar spine from 12/21/15 showed grade 1 anterolisthesis L4–5, L1–2 right disc protrusion, L2–3 small disc osteophyte complex, L3–4 moderate bilateral foraminal narrowing, L4–5 severe foraminal narrowing, L5–S1 fluid within the facet joints and severe bilateral foraminal narrowing. The provider requests unknown level of interlaminar epidural steroid injection.
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