Qtr 1 Physician IRR 2017 (IP) case study # 2
Cigna commercial
Case initiated 01/25/2017
48 yo male with a prior authorization request for with request for left L4 and left L5 therapeutic transforaminal epidural steroid injections - CPT 64483, 64484
Patient complains of 100% axial lower back pain without radiating symptoms.
Patient has completed at least six weeks of conservative treatment including exercise, physical therapy, NSAIDs and muscle relaxants. Patient continues to participate in an active rehabilitation program and is working full time. There is no documented need for diagnostic injections at this time.
Physical examination reveals mild pain and guarding on forward flexion and left lateral flexion. There are no motor, sensory, nor reflex deficits noted. There is moderate bilateral lumbar paraspinal spasm.
MRI reveals annular disc bulges with mild facet hypertrophy at L3-4, L4-5, and L5-S1 levels. Electrodiagnostic testing was negative.
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