Qtr 1 Physician IRR 2017 MSK (Spine Surg) case study # 1
Horizon Commercial/eviCore Spine guidelines
15 year old male with prior authorization request for Lumbar Discectomy, Laminotomy CPT 63030.
This patient is a non-smoker and has complained of low back pain with radiation down the left leg, with tingling and numbness into the left calf for several months which is exacerbated by activities. He has seen his family physician as well as pain management physicians and has been treated with NSAIDs, and a physical therapy program with only slight improvement.
Physical examination revealed a 5’8”, 145 lb male with limited ROM of the spine and (+) straight leg test at 45 degrees with no noticeable motor deficit.
Recent MRI showed a large left HNP L4-5.
Treatment has also included recent Left L4-5 transforaminal ESIs on 2 occasions, however there was no significant improvement.
Pre-operative Oswestry Index was obtained and all other sources of pain have been addressed.
Surgeon is requesting Lumbar Discectomy as conservative treatments have failed for over 20 weeks
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