Post Ortho AME Case Summary
DOI: 12/29/2005. The patient is a 35-year-old male carpenter who sustained injury to his lower back after falling from a ladder while nailing some plywood. Per OMNI, he was diagnosed with status post lumbar fusion at L5-S1 on 09/01/09, spondylolisthesis at L5-S1, and L5-S1 spinal fusion on 09/27/12. Patient is status post spinal cord stimulator trial on 01/04/13 with poor response. Per Ortho AME dated 03/28/13 by Dr. Fernandez, the patient has permanent impairment with 26% whole person impairment rating. Future medical care includes occasional doctor visits 6-8x/year with prescription medicines, 12 PT sessions for flare-up, which could be exchanged with acupuncture or chiropractic treatments on a one-on-one basis, 2 epidural injections per year, permanent electrical stimulator, further surgery with
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hardware removal, 6-month gym membership and pool availability. Per progress report dated 7/2/14, the patient’s medications include Duragesic, Norco, Prilosec, and Lexapro.
Urine drug screen obtained on 01/2016 showed positive for opiates.
Based on the progress report dated 8/11/16, the patient continues to have high levels of pain in the lower back.
He does have some pain control with the use of the Duragesic patches and Norco. It was noted that the psychological evaluation has helped him cope with pain level. The patient is complaining of a new pain in lower back, that is worse when he sits and it is radiating down the legs. He is wondering if there is anything that can be done. He said he has had injections in the past that seemed to help in 2012. Current medications include Duragesic, Norco, Lexapro, Prilosec, Xanax, and Tegaderm. Of note, last urine drug screen is dated 7/14/16 (no report). Objective findings notes that the patient is in mild distress and arises slowly from a seated position. He has tenderness across the lumbosacral junction. He has pain with flexion and extension. With straight leg raising, he is complaining of symptoms down the posterior thighs and calves bilaterally. IW was diagnosed with status post lumbar fusion at L5-S1 on 9/7/2009, spondylolisthesis at L5-S1, status post cord stimulator trial on 1/4/13 with poor response; and depression/anxiety due to his chronic
pain.
Requested for recent progress report dated 09/08/16, and most recent urine drug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no medical records received at the time of submission of the review to PA.
Patient has been previously denied with 60 Capsules of Prilosec 20 mg with 3 Refills and certified with 160 Tablets of Norco 10/325 mg on 008/03/16 (Review 270399).
Current request is for 10 Patches of Fentanyl 25mcg/hr; 60 Capsules of Prilosec 20mg with 3 Refills; and 180 Tablets of Hydrocodone/Acetaminophen 10/325mg between 9/14/2016 and 10/29/2016.
This is 1 out of 2 referrals.
hardware removal, 6-month gym membership and pool availability. Per progress report dated 7/2/14, the patient’s medications include Duragesic, Norco, Prilosec, and Lexapro.
Urine drug screen obtained on 01/2016 showed positive for opiates.
Based on the progress report dated 8/11/16, the patient continues to have high levels of pain in the lower back.
He does have some pain control with the use of the Duragesic patches and Norco. It was noted that the psychological evaluation has helped him cope with pain level. The patient is complaining of a new pain in lower back, that is worse when he sits and it is radiating down the legs. He is wondering if there is anything that can be done. He said he has had injections in the past that seemed to help in 2012. Current medications include Duragesic, Norco, Lexapro, Prilosec, Xanax, and Tegaderm. Of note, last urine drug screen is dated 7/14/16 (no report). Objective findings notes that the patient is in mild distress and arises slowly from a seated position. He has tenderness across the lumbosacral junction. He has pain with flexion and extension. With straight leg raising, he is complaining of symptoms down the posterior thighs and calves bilaterally. IW was diagnosed with status post lumbar fusion at L5-S1 on 9/7/2009, spondylolisthesis at L5-S1, status post cord stimulator trial on 1/4/13 with poor response; and depression/anxiety due to his chronic
pain.
Requested for recent progress report dated 09/08/16, and most recent urine drug screen and Controlled Substance Utilization Review and Evaluation System (CURES) reports; however, no medical records received at the time of submission of the review to PA.
Patient has been previously denied with 60 Capsules of Prilosec 20 mg with 3 Refills and certified with 160 Tablets of Norco 10/325 mg on 008/03/16 (Review 270399).
Current request is for 10 Patches of Fentanyl 25mcg/hr; 60 Capsules of Prilosec 20mg with 3 Refills; and 180 Tablets of Hydrocodone/Acetaminophen 10/325mg between 9/14/2016 and 10/29/2016.
This is 1 out of 2 referrals.