Qtr 1 Physician RBM 2017 (Ortho) case study # 8
AETOH FI-PPO Commercial
72158- MRI Lumbar Spine, (spinal canal and contents), without and with contrast
43 y/o F
Case initiated 01/17/2017
59 year old male with prior authorization request for MRI Upper Extremity, Any Joint, without contrast (right shoulder) CPT 73221
FOV 12/27/2016, LOV 1/09/2017
This patient has complained of Right shoulder pain which started 1 week after installing a fence 2 months prior to FOV, although this is not the primary complaint. Patient thought he would mention it when he came in for an acute eye problem. Cannot lift arm past the waist.
Exam shows decreased ROM (can’t lift arm past 45 degrees), tenderness, and decreased strength.
No history of prior treatment or injury, no history of cancer or surgery.
Treated with prednisone x 8 days starting at FOV.
No prior imaging.
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