Sample Medical Summary
INICAL SUMMARY:
DOI: 1/11/2013. The patient is a 67-year-old retired female group teacher who sustained a work-related injury to her left shoulder, back, left hip and right knee when she turned and fell over a child on a bike.
Per PT note dated 10/01/15, the patient has been attending PT for her right knee. Plan is to continue with treatment plan. Goals are to decrease pain and improve mobility, flexibility and function.
Based on the latest medical report by Dr. Wilson dated 02/10/16, the patient presents for follow-up of her right knee and left hip. She underwent a right total knee replacement in 2012. She is having discomfort in the right knee and is requesting an injection.
On examination of the right knee, the midline incision is well healed without any erythema. Range of motion …show more content…
is 0 to about 110 degrees. There is tenderness about the pes bursa. IW was assessed to be stable following a right total knee replacement and left hip bursitis.
An injection to the pes bursa was administered on this visit.
She was advised to ice her knee down and take it easy for the next couple of days. She will continue with physical therapy which is to include aqua therapy. She states that her hip is improving after the injection. She will follow up in six to eight weeks.
Per PT note dated 02/13/16, the IW reports feeling better but with some discomfort on the hip. On examination, there is tightness of the left hamstring.
Hip strength testing shows 3+/5 with hip abduction and 4/5 with hip adduction and flexion. Gluteus maximus strength is 4/5.
Goals include the following: increase ambulation tolerance to 5 city blocks with “SAC;” increase sitting tolerance to 30 minutes; and normal reciprocal stair negotiation for 1 flight.
Plan is to continue therapy 2 visit per week and increase home exercise program.
Per the IME report by Dr. Bregman dated 01/07/16, patient was diagnosed with resolved sprain of the lumbar spine and left hip, resolved contusion of the right knee and status post left shoulder arthroscopy on 02/02/15. It was opined that there is no medical necessity for further treatment from an orthopedic standpoint. There is no need for PT. MMI has been reached.
Per verification to the provider’s office, the patient has attended 22 PT sessions to the right knee from 07/27/15 through 10/01/15 and the request will not include aqua therapy.
Per verification to the PT facility, the patient has attended 6 PT sessions for the left hip to date.
Is the request for additional 18 Physical Therapy Visits for the Right Knee between 2/23/2016 and 4/23/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary reference).
This is 1 of 2
referrals.
DOI: 1/11/2013. The patient is a 67-year-old retired female group teacher who sustained a work-related injury to her left shoulder, back, left hip and right knee when she turned and fell over a child on a bike.
Per PT note dated 10/01/15, the patient has been attending PT for her right knee. Plan is to continue with treatment plan. Goals are to decrease pain and improve mobility, flexibility and function.
Based on the latest medical report by Dr. Wilson dated 02/10/16, the patient presents for follow-up of her right knee and left hip. She underwent a right total knee replacement in 2012. She is having discomfort in the right knee and is requesting an injection.
On examination of the right knee, the midline incision is well healed without any erythema. Range of motion …show more content…
is 0 to about 110 degrees. There is tenderness about the pes bursa. IW was assessed to be stable following a right total knee replacement and left hip bursitis.
An injection to the pes bursa was administered on this visit.
She was advised to ice her knee down and take it easy for the next couple of days. She will continue with physical therapy which is to include aqua therapy. She states that her hip is improving after the injection. She will follow up in six to eight weeks.
Per PT note dated 02/13/16, the IW reports feeling better but with some discomfort on the hip. On examination, there is tightness of the left hamstring.
Hip strength testing shows 3+/5 with hip abduction and 4/5 with hip adduction and flexion. Gluteus maximus strength is 4/5.
Goals include the following: increase ambulation tolerance to 5 city blocks with “SAC;” increase sitting tolerance to 30 minutes; and normal reciprocal stair negotiation for 1 flight.
Plan is to continue therapy 2 visit per week and increase home exercise program.
Per the IME report by Dr. Bregman dated 01/07/16, patient was diagnosed with resolved sprain of the lumbar spine and left hip, resolved contusion of the right knee and status post left shoulder arthroscopy on 02/02/15. It was opined that there is no medical necessity for further treatment from an orthopedic standpoint. There is no need for PT. MMI has been reached.
Per verification to the provider’s office, the patient has attended 22 PT sessions to the right knee from 07/27/15 through 10/01/15 and the request will not include aqua therapy.
Per verification to the PT facility, the patient has attended 6 PT sessions for the left hip to date.
Is the request for additional 18 Physical Therapy Visits for the Right Knee between 2/23/2016 and 4/23/2016 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary reference).
This is 1 of 2
referrals.