IME Report Summary
DOI: 1/31/2004. Patient is a 62-year-old male sales employee who sustained injury when he loaded a cake on the rolling rack and he felt pain in his neck. Per the IME report dated 07/08/19, the patient has reached maximum medical improvement from non-surgical treatment modalities. There is no indication for further causally related PT or orthopedic treatment. Symptomatic follow-up care should be authorized to provide medication on an as needed basis. On the addendum to the IME dated 09/20/09, the patient has a moderate partial disability which should be considered permanent in nature.
Based on the latest medical report dated 05/02/16, the patient complains of bilateral neck pain rated as 6/10. He reports that his right superior shoulder
pain continues. There is increased pain with increased and overhead activity. Bilateral elbow pain continues and increases with activity or repetitive motion. Patient has difficulty with activities of daily living (ADLs).
On examination of the cervical spine, paracervical and trapezius tenderness is noted with palpable spasm, bilaterally. There is bilateral cervical root tenderness with radiation to both hands. Active range of motion (ROM) is decreased by 45%. Strength is 4/5. Plan is for medical massage, 2 times a week for 6 weeks.
Requested verification from the provider’s office on the number of massage therapy visits completed to date or if this is an initial request; however, no callback was received prior to the submission of this request to PA.
On the statement of medical necessity on the MG2 form dated 05/13/16, the patient relates neck pain with radiation to bilateral hands with constant numbness and tingling.
Is the request for 12 Medical Massage Treatments for the Cervical Spine between 5/18/2016 and 7/17/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary reference).
Based on the latest medical report dated 05/02/16, the patient complains of bilateral neck pain rated as 6/10. He reports that his right superior shoulder
pain continues. There is increased pain with increased and overhead activity. Bilateral elbow pain continues and increases with activity or repetitive motion. Patient has difficulty with activities of daily living (ADLs).
On examination of the cervical spine, paracervical and trapezius tenderness is noted with palpable spasm, bilaterally. There is bilateral cervical root tenderness with radiation to both hands. Active range of motion (ROM) is decreased by 45%. Strength is 4/5. Plan is for medical massage, 2 times a week for 6 weeks.
Requested verification from the provider’s office on the number of massage therapy visits completed to date or if this is an initial request; however, no callback was received prior to the submission of this request to PA.
On the statement of medical necessity on the MG2 form dated 05/13/16, the patient relates neck pain with radiation to bilateral hands with constant numbness and tingling.
Is the request for 12 Medical Massage Treatments for the Cervical Spine between 5/18/2016 and 7/17/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary reference).