Physician 2nd Quarter 2016 IRR – Spine Surgery Case Study #6
67yoM with prior authorization request for lumbar spine fusion CPT 22630.
Patient has low back and left leg pain for 6 months. He denies tingling and numbness and has tried 6 weeks of formal physical therapy without benefit. He has taken NSAIDs and muscle relaxers.
Physical examination revealed a mild antalgic gait with mild restriction in lumbar ROM. There is absence of left ankle DTR, with 4/5 left plantar flexion strength.
MRI Lumbar Spine shows bilateral foraminal stenosis and advanced degenerative disc disease at L5-S1 with Modic changes.
The surgeon has requested a Lumbar spine fusion at L5-S1.
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