Qtr 1 Physician IRR 2017 (IP) case study # 1
AETNJ-MEDICARE
Case initiated 01/18/2017
67 yo male with a prior authorization request for bilateral C4-5 and C5-6 conventional facet joint radiofrequency ablation - CPT 64633 mod 50, 64634 mod 50
*Pt has had neck pain for more than 6 months. Patient recently underwent a 360 degree (anterior and posterior) cervical fusion from C4-6 and presents with severe bilateral neck and shoulder pain. Patient continues with his comprehensive pain program including supervised physical therapy. Patient reports that pain is limiting his ADLs. Prior to the recent surgery patient had an RFA at the same levels with inadequate relief of symptoms.
Physical exam is significant for severe pain and guarding with all ranges of motion in the cervical spine. There are no gross motor, sensory, nor reflex deficits. Palpation reveals severe bilateral cervical paraspinal muscle spasm
Recent x-rays suggest inadequate fusion. Post-op imaging does not reveal any other significant pathology such as disc herniations or residual stenosis.
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