Physician 2nd Quarter 2016 Radiology IRR Case Study #4 – Oncology
3yoM AETFL SI-PPO
Requesting Provider: Pediatric Oncology
Request Initiated: 05/17/2016
CPT:
72142 MRI Cervical Spine, (spinal canal and contents); with contrast material
72147 MRI Thoracic Spine, (spinal canal and contents); with contrast material(s)
72149 MRI Lumbar Spine, (spinal canal and contents); with contrast material
70553 MRI BRAIN (head); with and without contrast
ICD10: 191.1 Malignant neoplasm of frontal lobe of brain
Oncology Member History Details:
Cell Type & Location: Atypical teratoid rhabdoid tumor, frontal lobe, right
Treatment History Dates: Ongoing; 03-07-16
Treatment Type and Site: Chemo; protocol SJC07; craniospinal irradiation
Nurse Reviewer Note:
Per ACDS notes/clinical notes/fax: Oncology req MRI C/T/L Spine w and MRI Head wow for 3yoM.
LOV: 05/13/2016
Reason: Completed 2 cycles of chemo, evaluation for tx response/disease status.
ONC Member Hx: Updated.
Prior Imaging: None.
PE: Surgical scar noted on the scalp which is healing by primary intention. A small swelling, about 1x1cm is noted on the right side of forehead which is non tender with no overlying erythema. Patellar: Absent patellar reflex bilaterally. Lansky Score: 90.
SX: Small swelling over his forehead on the right side
Labs: LFTs and tumor markers not provided.
ACDS note reviewed.
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