Work-Based Pain Management Case Summary
DOI: 11/5/2005. Patient is a 58-year-old female home attendant who sustained a work related injury when she strained her lower back while lifting a client from a wheel chair. Per OMNI, she has suffered from depression. She underwent a lumbar laminectomy in 09/16/08 and a spinal cord stimulator trial in 06/20/14.
Based on the medical report dated 02/02/16 by Dr. Schwartz, the patient presents with severe post-operative low back pain and stiffness/tightness and intermittent spasms and referred numbness/tingling into both legs, left greater than the right with intermittent tightness and spasms. She still walks with a limp and easily fatigues. Patient has intolerance to prolonged sitting/standing positions and ambulation of short distances and stair activities. IW is awaiting replacement of lumbosacral orthosis and transcutaneous electrical nerve stimulation (TENS) unit. She takes Zorvolex for post-operative pain management. Pain is rated as 70/100 mm scale. IW maintains post-operative home exercises.
On examination, she is in mild distress. A 9 cm operative scar persists in the lumbar spine. There is …show more content…
more pain reproduced on palpation of the trigger points and spasms throughout the right lower lumbosacral paraspinals, extending into the right upper gluteal region. Mild right gastrocnemius atrophy persists. Range of motion shows flexion of 15 degrees and extension of 10 degrees. Sensation to light touch is diminished at the right L3, L4 and L5 dermatomes. Muscle grade testing shows 5-/5 at the lumbosacral paraspinals, right tibialis anterior and extensor hallucis longus. Deep tendon reflexes showed ¼ to the right Achilles. Straight leg raising in supine and seated position is positive on the right. Femoral nerve stretch test remains positive on the right.
IW was diagnosed with lumbosacral derangement, status post operatively.
She was given a prescription for Zorovolex.
Treatment plan includes replacement of thoraco lumbosacral orthosis and TENS unit to help control exacerbations of symptomatology, home attendant 8 hours per day and 5 days per week, Tempur-Pedic mattress to help provide more support to her post-operative back, referral to orthopedic spine specialist and pain management specialist and to maintain home e2exercsies.
Per IME report by DR. Varriale dated 10/22/13, it was opined that the patient does not need further therapy or orthopedic treatment at this time. Maximum medical improvement has been reached.
Is the request for 1 Transcutaneous Electrical Nerve Stimulator (TENS) Unit between 2/16/2016 and 4/16/2016 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.
Based on the medical report dated 02/02/16 by Dr. Schwartz, the patient presents with severe post-operative low back pain and stiffness/tightness and intermittent spasms and referred numbness/tingling into both legs, left greater than the right with intermittent tightness and spasms. She still walks with a limp and easily fatigues. Patient has intolerance to prolonged sitting/standing positions and ambulation of short distances and stair activities. IW is awaiting replacement of lumbosacral orthosis and transcutaneous electrical nerve stimulation (TENS) unit. She takes Zorvolex for post-operative pain management. Pain is rated as 70/100 mm scale. IW maintains post-operative home exercises.
On examination, she is in mild distress. A 9 cm operative scar persists in the lumbar spine. There is …show more content…
more pain reproduced on palpation of the trigger points and spasms throughout the right lower lumbosacral paraspinals, extending into the right upper gluteal region. Mild right gastrocnemius atrophy persists. Range of motion shows flexion of 15 degrees and extension of 10 degrees. Sensation to light touch is diminished at the right L3, L4 and L5 dermatomes. Muscle grade testing shows 5-/5 at the lumbosacral paraspinals, right tibialis anterior and extensor hallucis longus. Deep tendon reflexes showed ¼ to the right Achilles. Straight leg raising in supine and seated position is positive on the right. Femoral nerve stretch test remains positive on the right.
IW was diagnosed with lumbosacral derangement, status post operatively.
She was given a prescription for Zorovolex.
Treatment plan includes replacement of thoraco lumbosacral orthosis and TENS unit to help control exacerbations of symptomatology, home attendant 8 hours per day and 5 days per week, Tempur-Pedic mattress to help provide more support to her post-operative back, referral to orthopedic spine specialist and pain management specialist and to maintain home e2exercsies.
Per IME report by DR. Varriale dated 10/22/13, it was opined that the patient does not need further therapy or orthopedic treatment at this time. Maximum medical improvement has been reached.
Is the request for 1 Transcutaneous Electrical Nerve Stimulator (TENS) Unit between 2/16/2016 and 4/16/2016 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.