Physician 2nd Qtr 2016 Radiology IRR Case Study #1 – Spine
64yoM CIGNA SI-PPO/OAP
Provider Specialty: Urgent Care
Request Initiated: 03/26/2016
CPT: 72158
MRI Lumbar Spine, (spinal canal and contents), without and with contrast
ICD10: M54.5 Low back pain
Nurse Reviewer Note:
Per ACDS notes/fax: Urgent Care req MRI L spine wow for 64yoM c/o back pain, pain to left hip down left leg with numbness in left foot x unspecified duration.
Reason: Evaluation.
FOV: 02/05/2016 LOV: 03/25/2016
PE: 03/25/2016 ROM positive seated leg raise, mild decreased patellar reflex on left. Axial loading painful.
PMH: Hx of back surgery in 1999 (L4-L5 fusion). No personal hx of CA or recent injury.
TX: Robaxin, ketorolac, aspirin x duration unspecified.
Prior Imaging: 02/05/2016 X-ray L spine - Degenerative changes.
Reviewed ACDS notes and fax.
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