Ime Report Sample
CLINICAL SUMMARY:
DOI: 1/11/2010. Patient is a 67-year-old male folder who sustained injury while he was pulling out towels out of a hopper. Per OMNI entry, he was initially diagnosed with neck and upper back strain. It was noted that the IW continues with chiropractic care.
Per the Addendum to the IME report dated 10/08/13, it was opined that the IW has reached maximum medical improvement from chiropractic care.
Based on the medical report dated 10/24/16, the patient was recommended chiropractic adjustments, modalities, electric stimulation and manual traction twice weekly for one month, then re-evaluate.
Based on the medical report dated 12/16/16, the patient complains of 8/10 frequent bilateral cervical pain, numbness, burning, tingling and sharp.
Patient also reports 8/10 bilateral thoracic pain, numbness, burning, tingling and sharp. …show more content…
These complaints have regressed since the previous visit.
On examination, there is tension noted upon palpation at C1-7 and T1-8.
Patient was diagnosed with cervical disc displacement C3-C7 and C7-T1 and sprain thoracic spine ligaments.
Recommendation was made for chiropractic adjustments, modalities, electric stimulation and manual traction twice weekly for one month, then re-evaluate.
Requested verification from the provider’s office on the number of visits attended to date; however, no callback/report was received prior to the submission of this request to PA.
On the statement of medical necessity per MG-2 form dated 12/22/16, chiropractic care is requested based on past treatment effectiveness, reported by the patient. Patient reported a 50% reduction in pain while receiving chiropractic care. Patient also reports marked improvements in ambulation, increased ability to perform activities of daily living, as well as more coherent sleep
DOI: 1/11/2010. Patient is a 67-year-old male folder who sustained injury while he was pulling out towels out of a hopper. Per OMNI entry, he was initially diagnosed with neck and upper back strain. It was noted that the IW continues with chiropractic care.
Per the Addendum to the IME report dated 10/08/13, it was opined that the IW has reached maximum medical improvement from chiropractic care.
Based on the medical report dated 10/24/16, the patient was recommended chiropractic adjustments, modalities, electric stimulation and manual traction twice weekly for one month, then re-evaluate.
Based on the medical report dated 12/16/16, the patient complains of 8/10 frequent bilateral cervical pain, numbness, burning, tingling and sharp.
Patient also reports 8/10 bilateral thoracic pain, numbness, burning, tingling and sharp. …show more content…
These complaints have regressed since the previous visit.
On examination, there is tension noted upon palpation at C1-7 and T1-8.
Patient was diagnosed with cervical disc displacement C3-C7 and C7-T1 and sprain thoracic spine ligaments.
Recommendation was made for chiropractic adjustments, modalities, electric stimulation and manual traction twice weekly for one month, then re-evaluate.
Requested verification from the provider’s office on the number of visits attended to date; however, no callback/report was received prior to the submission of this request to PA.
On the statement of medical necessity per MG-2 form dated 12/22/16, chiropractic care is requested based on past treatment effectiveness, reported by the patient. Patient reported a 50% reduction in pain while receiving chiropractic care. Patient also reports marked improvements in ambulation, increased ability to perform activities of daily living, as well as more coherent sleep