Physician 1st Quarter 2016 Spine Surgery IRR - Case Study #3
52-year-old male with prior authorization request for cervical artificial disc replacement (CPT 22856).
Patient was involved in a motor vehicle accident on March 16, 2015 in which he was the restrained driver. He was seen initially on March 16, 2015 by a chiropractor and subsequently referred to a spine specialist on March 30, 2015.
Chiropractic treatment has been ongoing and patient was noted to be experiencing numbness in his fingers and difficulty moving his left arm.
Past surgical history includes C4-C7 ACDF.
Physical examination revealed 5-/5 of the left shoulder flexion and abduction. There was Limited range of motion of the cervical spine with multiple trigger points including a positive Spurling test to the left, which was negative to the right.
Subsequent MRI of the cervical spine showed prior surgical fusion of C4 through C7 and cervical disc herniation at C3-4.
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