3rd Qtr Physician 2016 Spine Surg Case Study #2
Health Plan: BSCA
Lumbar Laminectomy -CPT 63047
This 61 y/o M patient has a long history of low back pain without leg pain and was evaluated on 7/28/2016 with no prior visits documented. He reports a decreased walking tolerance and symptoms of neurogenic claudication.
He has had epidural injections in the past with only temporary relief of his back pain and no documented dates or other treatments were provided.
Past medical history is unremarkable.
Physical examination suggests a slightly flexed posture with good coronal balance with weakness in the left EHL (not graded) and sciatic notch tenderness.
MRI dated 7/21/2016 shows advanced spinal stenosis at L4-5.
A request for Lumbar Decompression L4-5 was made.
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