Nursing Case Summary
DOI: 8/16/2015. Patient is a 34-year-old female cabin cleaning supervisor who sustained injury while she was going up jet bridge stairs when she tripped and landed on her left knee. Per OMNI, she was initially diagnosed with left knee sprain/strain.
She is status post left knee arthroscopy, partial lateral meniscectomy with chondroplasty of lateral tibial plateau and synovectomy of the medial and patellofemoral compartments on 12/01/15.
Based on the follow-up examination report by Dr. Burszlyn dated 12/11/15, the patient presents for reevaluation of her left knee. She is a week and half status post left knee arthroscopy. She is complaining of postoperative pain.
On examination of the left knee, range of motion is from 0 to 20 degrees due to pain and she does ambulate with an antalgic gait. …show more content…
Sutures were removed and dressings were applied on this visit.
She was given a prescription for postoperative physical therapy and Vicodin.
Per PT note dated 12/23/15, the IW reported no change in symptoms. She still complains of left knee pain. On examination of the left knee, tenderness is noted. Swelling is also seen. Gait is antalgic. Plan is to continue management.
On the statement of medical necessity on the MG2 form dated 12/01/15, the patient is status post left knee arthroscopic surgery on 12/01/15. PT is medically necessary in order for the IW to regain strength and mobility back into the knee in order to maximize recovery.
Per verification to the PT facility, the patient has attended 16 post-operative PT sessions for the left knee from 12/01/15 through 02/19/16. Requested for the most recent PT note, however, no medical records received at the time of submission of the review to PA.
Is the request for additional 18 Physical Therapy Visits for the Left Knee between 2/22/2016 and 4/22/2016 medically necessary? MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary
reference).
She is status post left knee arthroscopy, partial lateral meniscectomy with chondroplasty of lateral tibial plateau and synovectomy of the medial and patellofemoral compartments on 12/01/15.
Based on the follow-up examination report by Dr. Burszlyn dated 12/11/15, the patient presents for reevaluation of her left knee. She is a week and half status post left knee arthroscopy. She is complaining of postoperative pain.
On examination of the left knee, range of motion is from 0 to 20 degrees due to pain and she does ambulate with an antalgic gait. …show more content…
Sutures were removed and dressings were applied on this visit.
She was given a prescription for postoperative physical therapy and Vicodin.
Per PT note dated 12/23/15, the IW reported no change in symptoms. She still complains of left knee pain. On examination of the left knee, tenderness is noted. Swelling is also seen. Gait is antalgic. Plan is to continue management.
On the statement of medical necessity on the MG2 form dated 12/01/15, the patient is status post left knee arthroscopic surgery on 12/01/15. PT is medically necessary in order for the IW to regain strength and mobility back into the knee in order to maximize recovery.
Per verification to the PT facility, the patient has attended 16 post-operative PT sessions for the left knee from 12/01/15 through 02/19/16. Requested for the most recent PT note, however, no medical records received at the time of submission of the review to PA.
Is the request for additional 18 Physical Therapy Visits for the Left Knee between 2/22/2016 and 4/22/2016 medically necessary? MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary
reference).