Qtr 1 Physician IRR 2017 MSK (Spine Surg) case study # 2
HAP/Medicare/eviCore Spine Guidelines- Michigan State
This patient is a 68 year old male with prior authorization request for Cervical Laminectomy CPTs 63045 and 63048.
The patient complained of “trouble walking” which has been coming on gradually, worse x 2-3 months with poor balance and difficulty walking without an assistive device. He has clumsiness with his left hand and trouble controlling his legs with tingling and numbness in his hands and feet.
Pertinent physical examination revealed gait to be abnormal with scissoring, (-) Romberg, 3+ reflexes in upper extremities with absent ankle reflexes, upgoing toe on the right and downgoing toes on the left with decreased fine finger movements on the left.
Cervical MRI shows severe canal compromise of the cervical spine particularly at C3-4 with cord changes at C3-4 and narrowing form C3-C7.
The treating surgeon’s impression was that of Cervical Myelopathy, and he felt that the patient would benefit from decompression of the spinal cord.
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