Physician 2nd Quarter 2016 IRR – Spine Surgery Case Study #5
38yoM with prior authorization request for lumbar laminectomy, decompression and discectomy CPT 63030.
Patient has complained of low back pain and right leg pain with numbness and tingling into leg for the last several months. He has had epidural injections and physical therapy for the last 8 weeks without relief.
Physical examination revealed restricted ROM of the lumbar spine with a positive straight leg raise test and femoral stretch test on the right. He has diminished DTR of the knee on the right.
MRI suggests L3-4 HNP on the right side.
The surgeon has requested L3-4 discectomy.
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