Work Related Injury Case Study
DOI: 10/1/2010. Patient is a 61-year-old male technician/specialist who sustained a work-related injury due to repetitive motion. Per OMNI, he sustained injuries to his bilateral elbows, shoulders, wrists, and neck. He underwent anterior cervical discectomy and fusion at C3-C6 on 9/25/12.
Per procedure reports, patient underwent cervical facet injection at levels C3, C4 and C5 on 10/09/15, 12/11/15, 04/29/16 and 07/01/16.
Based on the latest medical report dated 11/10/16, the patient has been under the care of Dr. Siddiqui and has had several different radiofrequency ablations and other modalities to help treat his pain. Over the last few months, overall he notices it is progressing and presents for evaluation. He is trying to stay as active as he can, however anything does significantly limit him. His pain is across his shoulder blades into his shoulders with numbness and tingling down his arms and varies based on activity. More often, his pain has been on the right, however lately he has been noticing it is worse on the left. …show more content…
Review of systems is positive for change in vision, ringing in his ears, pain and stiffness in his bones and joints, arthritis, headaches, easy bruising and bleeding, anxiety.
Of note, an MRI of the cervical spine done on 10/24/16 (no official report) showed postoperative changes, hardware intact, good alignment, no back out, fracture or lucency. It does show fusion across the disk
spaces.
An updated MRI to assess for any adjacent segment disease or residual stenosis, a CT to assess for any osteophytes or any foraminal stenosis, as well as the hardware fusion, and bilateral upper extremity EMG nerve conduction study.
IW was diagnosed with other spondylosis with radiculopathy, cervical region.
Attached is the IME report dated 07/19/2012.
Requested verification from the provider’s office on the number of massage therapy visits and requested for a copy of the MRI report; however, no report was received prior to the submission of this request to PA.
Is the request for 1 Electromyography of the Bilateral Upper Extremities between 11/23/2016 and 1/22/2017 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.
Per procedure reports, patient underwent cervical facet injection at levels C3, C4 and C5 on 10/09/15, 12/11/15, 04/29/16 and 07/01/16.
Based on the latest medical report dated 11/10/16, the patient has been under the care of Dr. Siddiqui and has had several different radiofrequency ablations and other modalities to help treat his pain. Over the last few months, overall he notices it is progressing and presents for evaluation. He is trying to stay as active as he can, however anything does significantly limit him. His pain is across his shoulder blades into his shoulders with numbness and tingling down his arms and varies based on activity. More often, his pain has been on the right, however lately he has been noticing it is worse on the left. …show more content…
Review of systems is positive for change in vision, ringing in his ears, pain and stiffness in his bones and joints, arthritis, headaches, easy bruising and bleeding, anxiety.
Of note, an MRI of the cervical spine done on 10/24/16 (no official report) showed postoperative changes, hardware intact, good alignment, no back out, fracture or lucency. It does show fusion across the disk
spaces.
An updated MRI to assess for any adjacent segment disease or residual stenosis, a CT to assess for any osteophytes or any foraminal stenosis, as well as the hardware fusion, and bilateral upper extremity EMG nerve conduction study.
IW was diagnosed with other spondylosis with radiculopathy, cervical region.
Attached is the IME report dated 07/19/2012.
Requested verification from the provider’s office on the number of massage therapy visits and requested for a copy of the MRI report; however, no report was received prior to the submission of this request to PA.
Is the request for 1 Electromyography of the Bilateral Upper Extremities between 11/23/2016 and 1/22/2017 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.