Qtr 1 Physician IRR 2017 (IP) case study # 4
Cigna commercial
Case initiated 01/25/2017
Patient is a 66 yo female with a prior authorization request for a L4-5 interlaminar epidural steroid injection - CPT 62323
Patient reports that he is noticing lower back pain radiating to his lower limbs.
For the last two months he has taking oral NSAIDs and muscle relaxants but does not want to exercise. He was informed that the injection can help and he wants to get his pain better controlled. He reports that he has been informed by his PCP he needs to participate in an exercise program.
Physical examination reveals pain limited ROM in all planes with no notable motor or reflex deficits. Patient does have abnormal sensation in bilateral L4 and L5 dermatomes.
Imaging reveals a disc bulge at L2-3, L3-4, and L4-5 levels. No electrodiagnostic testing has been performed.
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