Physician 2nd Quarter 2016 IRR – Spine Surgery Case Study #2
36yoM with prior authorization request for cervical discectomy and decompression CPT 63020.
Patient has had progressive right sided neck and right upper extremity pain for 3 months with exacerbation at night. Patient was prescribed gabapentin and neck rest on the initial visit.
The patient was referred by a chiropractor although there is no documentation of type or duration of treatment.
Physical examination revealed restricted ROM of the cervical spine with diminished sensation in the C5-6 distribution with no motor deficit.
MRI of the Cervical Spine showed a large focal HNP at C5-6 on the right with canal and foraminal narrowing.
This quiz requires you to log in.
Please enter your Quia username and password. |
|
