Physician 2nd Quarter 2016 IRR – Spine Surgery Case Study #4
56 year old female with prior authorization request for Cervical C6-T1 decompression and foraminotomies CPT 63045, 63046.
Patient reports a 3 month history of right sided neck pain with radicular symptoms including numbness in the fingers on the right side.
Physical examination revealed triceps and grip strength graded 4/5 on the right side with a positive Spurling’s test with turning to the right.
MRI suggests spondylosis and foraminal narrowing on the right side at C6-7 and C7-T1 without cord compression.
Physical therapy and epidural steroids were discussed as treatment alternatives.
The surgeon is requesting surgical decompression.
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