Physician 2nd Quarter 2016 IRR – Spine Surgery Case Study #3
32yoF with prior authorization request for lumbar discectomy and decompression L5-S1 CPT 63030.
Patient has complaints of 80% left leg pain and 20% back pain for the last 6 months. Her symptoms have not improved with formal PT, epidural steroid injections and medications. Her quality of life is significantly impacted.
Physical examination revealed 4/5 weakness of left foot plantarflexion with a positive straight leg test on the left at 20 degrees.
MRI Lumbar Spine showed L5-S1 central and left disc herniation with encroachment on the traversing S1 nerve root.
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