Case Report: Work Related Injury
DOI: 07/07/1995. The patient is a 60-year-old female server who incurred a work-related injury to her right knee when she slipped on the floor. Per OMNI, she has bilateral knees reflex sympathetic dystrophy (RSD). She continues with medications and PT. She is status post right knee arthroscopy/chondroplasty lateral release.
Based on medical report dated 05/07/15, the patient complains of, “my legs and arms are on fire.” Pain is located on the right knee and entire body.
Pain is described as burning, aching and stabbing. Pain is unchanged, which has been present for 20 years. Pain is relieved by opioid analgesics (Morphine injections) and PT, and exacerbated by weather, vibration, touch and noise. Pain is rated at 7-10/10.
Associated symptoms are difficulty sleeping and walking. …show more content…
The patient’s functional status is limited as follows: ability to work, perform activities of daily living, participate in aerobic activity, participate in hobbies, perform housework, maintain normal sleep pattern and maintain social relationships.
Past treatment includes opioid analgesics, PT and home exorcise. It was noted that she needs PT due to the physical modalities she is not able to do at home. She is more than willing to exercise at home, but also needs the manual treatments at therapy.
PT allows her to get dressed, be able to wear clothing, and use her hands. It allows her to increase activity and decrease pain medication by 50%. She had 1 emergency room (ER) visit in the last 3 months. The last time she did not have PT, she was in the ER every 2 weeks for pain. She continues with PT 3 times a
week.
On examination, limb pain is noted to the bilateral upper and lower extremities. Hyperpathia is noted to the knee.
Current medications are B-12 tablets, Bethanecol chloride, Caltrate, Imitrex, Loratadine, magnesium, Miralax, Morphone sulfate, Nexium,Ondansetron, Oxycodone-acetaminophen, Pro-biotic, Skelaxin, Vitamin D3, Vivelle-Dot, Voltaren gel and Zetia.
Assessment is RSD.
Treatment plan includes PT 3 times per week for 26 weeks for the whole body and follow-up in 3 months.
IW is participating in a home exercise program and is encouraged to continue.
On the statement of medical necessity on the MG-2 form dated 06/03/15, PT is requested based on pertinent information and/or past treatment effectiveness. PT modalities include myofascial release, joint mobilization, soft tissue manipulation and desensitization. PT indicated for her reflex sympathetic dystrophy (RSD), is the only treatment that allows her to maintain some mobility and not to regress. It has helped her avoid ER visits, and control her pain level. 60% of pain relief was provided. Functionality increased by 90. She would be bedridden if she did not have PT.
Per IME report dated 08/02/10, the patient has reached MMI and with no further orthopedic treatment required. She has been attending PT continuously over the last 15 years and she indicates that she would have regression and would not be able to function without PT. It was opined that regardless if this has been going over this timeframe, she will likely have withdrawal symptoms possibly psychologically mediated if this is withdrawn quickly. MD will continue to allow PT 2-3 times per week for the next 3-6 months and to taper over that timeframe. A psychological or psychiatric evaluation is also recommended.
Per PT daily therapy note dated 04/22/15, the patient has attended 155 sessions for diagnoses of RSD and chronic pain syndrome.
Patient was previously denied with 78 Physical Therapy Visits on 10/06/14.
Is the request for 78 Physical Therapy Visits for the Whole Body between 6/15/2015 and 7/30/2015 medically necessary?
C-4 for Preauthorization Request.
(Kindly use the NY Medical Treatment Guideline as primary reference).
Based on medical report dated 05/07/15, the patient complains of, “my legs and arms are on fire.” Pain is located on the right knee and entire body.
Pain is described as burning, aching and stabbing. Pain is unchanged, which has been present for 20 years. Pain is relieved by opioid analgesics (Morphine injections) and PT, and exacerbated by weather, vibration, touch and noise. Pain is rated at 7-10/10.
Associated symptoms are difficulty sleeping and walking. …show more content…
The patient’s functional status is limited as follows: ability to work, perform activities of daily living, participate in aerobic activity, participate in hobbies, perform housework, maintain normal sleep pattern and maintain social relationships.
Past treatment includes opioid analgesics, PT and home exorcise. It was noted that she needs PT due to the physical modalities she is not able to do at home. She is more than willing to exercise at home, but also needs the manual treatments at therapy.
PT allows her to get dressed, be able to wear clothing, and use her hands. It allows her to increase activity and decrease pain medication by 50%. She had 1 emergency room (ER) visit in the last 3 months. The last time she did not have PT, she was in the ER every 2 weeks for pain. She continues with PT 3 times a
week.
On examination, limb pain is noted to the bilateral upper and lower extremities. Hyperpathia is noted to the knee.
Current medications are B-12 tablets, Bethanecol chloride, Caltrate, Imitrex, Loratadine, magnesium, Miralax, Morphone sulfate, Nexium,Ondansetron, Oxycodone-acetaminophen, Pro-biotic, Skelaxin, Vitamin D3, Vivelle-Dot, Voltaren gel and Zetia.
Assessment is RSD.
Treatment plan includes PT 3 times per week for 26 weeks for the whole body and follow-up in 3 months.
IW is participating in a home exercise program and is encouraged to continue.
On the statement of medical necessity on the MG-2 form dated 06/03/15, PT is requested based on pertinent information and/or past treatment effectiveness. PT modalities include myofascial release, joint mobilization, soft tissue manipulation and desensitization. PT indicated for her reflex sympathetic dystrophy (RSD), is the only treatment that allows her to maintain some mobility and not to regress. It has helped her avoid ER visits, and control her pain level. 60% of pain relief was provided. Functionality increased by 90. She would be bedridden if she did not have PT.
Per IME report dated 08/02/10, the patient has reached MMI and with no further orthopedic treatment required. She has been attending PT continuously over the last 15 years and she indicates that she would have regression and would not be able to function without PT. It was opined that regardless if this has been going over this timeframe, she will likely have withdrawal symptoms possibly psychologically mediated if this is withdrawn quickly. MD will continue to allow PT 2-3 times per week for the next 3-6 months and to taper over that timeframe. A psychological or psychiatric evaluation is also recommended.
Per PT daily therapy note dated 04/22/15, the patient has attended 155 sessions for diagnoses of RSD and chronic pain syndrome.
Patient was previously denied with 78 Physical Therapy Visits on 10/06/14.
Is the request for 78 Physical Therapy Visits for the Whole Body between 6/15/2015 and 7/30/2015 medically necessary?
C-4 for Preauthorization Request.
(Kindly use the NY Medical Treatment Guideline as primary reference).