Physician 1st Quarter 2016 Interventional Pain IRR - Case Study #6
Plan: Blue Shield California
Requested CPT(s): 64483
49-year-old female with 2-10/10 low back pain to left leg for 18 months. She has tried PT, Tylenol, Flexeril, acupuncture, and osteopathic manipulation.
Examination showed 4/5 in left EHL and anterior tibilalis and decreased sensation on dorsum left foot, positive straight leg raise. MRI on 10/9/15 showed right paracentral disc protrusion at L4–5 causing moderate right lateral recess stenosis and mild disc bulge L5–S1. The provider requests unknown side transforaminal epidural steroid injection.
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