Qtr 1 Physician IRR 2017 (IP) case study # 5
CIGNA SI-PPO/OAP Commercial
Case initiated 02/10/2017
46 yo male with a prior authorization request for L5-S1 interlaminar epidural steroid injection - CPT 62323
Patient presents with severe lower back and radiating lower limb pain and that is limiting his ADLs. He has completed the appropriate conservative care including NSAIDs, acetaminophen, and physical therapy over the past six weeks. The patient continues to participate in an active rehabilitation and therapeutic exercise program.
Physical examination reveals pain with forward flexion, motor strength of 4/5 in the bilateral EHL and APF muscles, decreased sensation in bilateral L5 and S1 dermatomes, and absent bilateral Achilles reflexes. There is positive bilateral straight leg raise testing.
Imaging reveals a disc herniation at L5-S1 with concomitant bilateral L5 nerve root impingement. Electrodiagnostic testing is positive for bilateral L5 radiculopathies.
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