Left Foot Pain Case Study

This is a 47-year-old female with a 1/28/2008 date of injury. A specific mechanism of injury has not been described.

DIAGNOSIS: - Pain in left foot

12/16/15 Progress Report documented that the patient has left foot pain, which is described as stabbing, aching pain, which shoots up the leg with excessive walking and standing. The patient benefited greatly from a sympathetic nerve block. She was able walk and sensitivity of the foot was restored. The pain is rated 3/10-scale level with medications. There are no side effects, no aberrant behavior to the meds. The med provide good pain relief. She is currently taking Oxycodone, Norco and Gabapentin. The musculoskeletal exam revealed joint pain, swelling, muscle cramps, muscle weakness and stiffness. Treatment plan included Sympathetic nerve block for RDS. Follow-up is in 1 month.
The pain was rated 3/10 in severity with the medications. Physical examination of the left foot revealed swelling and tenderness with 3/5 weakness on the left EHL, plantarflexion, and dorsiflexion. Treatment plan discussed includes medication refill, sympathetic nerve block (she has received significant relief in the past with the block), and consideration for another SCS trial.

Treatment to date includes medication; exercise, left foot surgery, SCS trial, and sympathetic nerve root block.

The request is for 1. IS THE PROPOSED Sympathetic Nerve Root Block left foot, CPT: 64520, 77002 RECOMMENDED AS MEDICALLY NECESSARY AND APPROPRIATE?