DOI: 6/21/2016. Patient is a 22-year-old male maintenance technician who sustained injury while he was pushing a piece of sheet metal, he slipped and sustained laceration to the dorsal aspect of the hand. Per OMNI, he was initially diagnosed with laceration to the right hand middle and ring fingers.
Based on the medical report dated 07/01/16, the patient‘s wounds were irrigated and sutured following the injury. He complains of weakness of the ring finger and inability to fully extend at the metacarpophalangeal joint (MCP).
On examination of the right hand, there are lacerations overlying the dorsal aspect of the middle and ring finger, just distal to the MCP joint. Each laceration measures approximately 2 cm. The wounds appear to be healing well, though there is slight overlapping of the skin margins. There is mild swelling and minimal tenderness along the laceration site. Digital motion is unrestricted in flexion. 10-15 degrees extensor lag is present to the right ring finger at the MCP joint. The extensor tendon function is not intact at the ring finger at the level of the MCP joint. “2-PD is less than 5mms.” Of note, X-rays of the right hand demonstrate no evidence of fracture or dislocation. The joint spaces are reduced, concentric with no
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Patient will plan to proceed with surgical procedure.
On the statement of medical necessity on the C4 form dated 07/05/16, the patient has a right hand laceration with right finger Extensor Digitorum Communis laceration. He has undergone nonsurgical treatment but unfortunately, he has failed to improve or adequately alleviate the symptoms. Given the failure to improve with nonsurgical treatment, further nonsurgical treatment is always an option but not likely to provide long term relief of symptoms. Given the nature of the medical problem, a significant delay in treatment (surgical intervention) is not