Qtr 1 Physician IRR 2017 (IP) case study # 3
AETNA NNJ MEDICARE
Case initiated 01/26/2017
Patient is a 67 yo male with a prior authorization request for request for C7-T1 interlaminar epidural steroid injection with image guidance - CPT 62321.
Patient reports severe neck pain that radiates to his bilateral upper limbs in a C7 and T1 dermatomal distribution.
The patient has failed to improve after at least two months of conservative treatments and continues to participate in his comprehensive pain management program. He has been attending physical therapy and continues to work with psychology for concomitant depression and anxiety. He is on a multimodal oral medication regimen that includes oral and topical NSAIDs, muscle relaxants and Percocet 10/325 po q6 prn for severe pain.
Physical exam reveals guarding on active bilateral lateral flexion and forward flexion, motor weakness in the bilateral triceps and finger abductors, absent bilateral brachioradialis reflexes, and severe bilateral lower cervical paraspinal muscle spasm. There is a positive bilateral Spurling’s maneuver noted which reproduces patient’s concordant pain.
Imaging performed last month revealed disc herniations at the C6-7 and C7-T1 levels with bilateral neural foraminal narrowing at these levels.
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