DOI: 06/05/12. Patient is a 50-year-old male construction laborer who sustained a work related injury to his back due to lifting heavy objects off a conveyor.
Based on medical report dated 5/0115, the patient complains of severe, and on and off middle and lower back pain with difficulty with all activities. Pain is described as constant, burning, aching, dull, sharp, throbbing and tingling. Pain is rated at 7-8/10. There is radicular pain to the left buttocks/leg. It was noted that the patient is status post lumbar ESI x 1.
On examination, he has tenderness and spasms to the bilateral spinous processes, facet paravertebrae, paraspinals, erector spinae and quadratus lumborum. Range of motion reveals flexion of 45 degrees, and extension
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Goals are to decrease pain, increase range of motion, increase muscle strength, re-establish optimal functional activities/status and independence in activities of daily living.
On the statement of medical necessity on the MG2 form dated 05/01/15. Based on physical examination, the patient has improved but has not reached MMI. MD expects that with extended treatment, the patient will continue to exhibit objective functional improvement.
Per IME report dated 04/24/15, the patient has a mild to moderate disability at 33%. The patient has reached MMI. In spite of prior IME indicating that the IW required no further treatment, the patient continued to receive chiropractic and acupuncture treatment. The patient has exceeded maximum duration and frequency to both modalities.
Attached is the Addendum to the IME report dated 05/12/15.
Is the request for 12 Physical Therapy Visits for the Lower Back between 6/11/2015 and 7/26/2015 medically necessary?
MG-2 for a Request for Approval of Variance.
(Kindly use the NY Medical Treatment Guideline as primary