Left Foot Pain Case Study
This is a 47-year-old female with a 1/28/2008 date of injury. A specific mechanism of injury has not been described.
DIAGNOSIS: - Pain in left foot
12/16/15 Progress Report documented that the patient has left foot pain, which is described as stabbing, aching pain, which shoots up the leg with excessive walking and standing. The patient benefited greatly from a sympathetic nerve block. She was able walk and sensitivity of the foot was restored. The pain is rated 3/10-scale level with medications. There are no side effects, no aberrant behavior to the meds. The med provide good pain relief. She is currently taking Oxycodone, Norco and Gabapentin. The musculoskeletal exam revealed joint pain, swelling, muscle cramps, muscle weakness and stiffness. Treatment plan included Sympathetic nerve block for RDS. Follow-up is in 1 month. …show more content…
11/18/15 Progress note reported left foot pain described as stabbing, aching, and shoots up the leg at times with excessive walking and standing.
The pain was rated 3/10 in severity with the medications. Physical examination of the left foot revealed swelling and tenderness with 3/5 weakness on the left EHL, plantarflexion, and dorsiflexion. Treatment plan discussed includes medication refill, sympathetic nerve block (she has received significant relief in the past with the block), and consideration for another SCS trial.
Treatment to date includes medication; exercise, left foot surgery, SCS trial, and sympathetic nerve root block.
The request is for 1. IS THE PROPOSED Sympathetic Nerve Root Block left foot, CPT: 64520, 77002 RECOMMENDED AS MEDICALLY NECESSARY AND APPROPRIATE?
CONCLUSION:
Regarding Sympathetic Nerve Root Block left foot, the patient has an old injury since 2008. She has chronic left foot pain and RDS. She is noted to have had previous surgery, SCS trial, and a sympathetic nerve root block. The most recent progress report documented that the patient benefited greatly from the previous sympathetic nerve block. CA MTUS does not recommend regional sympathetic blocks. Additionally, ODG states that the therapeutic use of sympathetic blocks is only recommended in cases that have positive response to diagnostic blocks and diagnostic criteria are fulfilled. These blocks are only recommended if there is evidence of lack of response to conservative treatment including pharmacologic therapy and physical rehabilitation. There should be evidence that physical or occupational therapy is incorporated with the duration of symptom relief of the block during the therapeutic phase. There was no documentation of the degree and duration of pain relief and functional improvement from the previous block. In addition, it is unclear when the last injection was done, as well as the total number of injections given to date. There was also no discussion of PT or OT that will be done with the planned sympathetic nerve root block. Medical necessity of sympathetic nerve block left foot has not been established. Recommend non-certification.
DIAGNOSIS: - Pain in left foot
12/16/15 Progress Report documented that the patient has left foot pain, which is described as stabbing, aching pain, which shoots up the leg with excessive walking and standing. The patient benefited greatly from a sympathetic nerve block. She was able walk and sensitivity of the foot was restored. The pain is rated 3/10-scale level with medications. There are no side effects, no aberrant behavior to the meds. The med provide good pain relief. She is currently taking Oxycodone, Norco and Gabapentin. The musculoskeletal exam revealed joint pain, swelling, muscle cramps, muscle weakness and stiffness. Treatment plan included Sympathetic nerve block for RDS. Follow-up is in 1 month. …show more content…
11/18/15 Progress note reported left foot pain described as stabbing, aching, and shoots up the leg at times with excessive walking and standing.
The pain was rated 3/10 in severity with the medications. Physical examination of the left foot revealed swelling and tenderness with 3/5 weakness on the left EHL, plantarflexion, and dorsiflexion. Treatment plan discussed includes medication refill, sympathetic nerve block (she has received significant relief in the past with the block), and consideration for another SCS trial.
Treatment to date includes medication; exercise, left foot surgery, SCS trial, and sympathetic nerve root block.
The request is for 1. IS THE PROPOSED Sympathetic Nerve Root Block left foot, CPT: 64520, 77002 RECOMMENDED AS MEDICALLY NECESSARY AND APPROPRIATE?
CONCLUSION:
Regarding Sympathetic Nerve Root Block left foot, the patient has an old injury since 2008. She has chronic left foot pain and RDS. She is noted to have had previous surgery, SCS trial, and a sympathetic nerve root block. The most recent progress report documented that the patient benefited greatly from the previous sympathetic nerve block. CA MTUS does not recommend regional sympathetic blocks. Additionally, ODG states that the therapeutic use of sympathetic blocks is only recommended in cases that have positive response to diagnostic blocks and diagnostic criteria are fulfilled. These blocks are only recommended if there is evidence of lack of response to conservative treatment including pharmacologic therapy and physical rehabilitation. There should be evidence that physical or occupational therapy is incorporated with the duration of symptom relief of the block during the therapeutic phase. There was no documentation of the degree and duration of pain relief and functional improvement from the previous block. In addition, it is unclear when the last injection was done, as well as the total number of injections given to date. There was also no discussion of PT or OT that will be done with the planned sympathetic nerve root block. Medical necessity of sympathetic nerve block left foot has not been established. Recommend non-certification.