Work-Based Pain Management Case Summary
DOI: 11/5/2005. Patient is a 58-year-old female home attendant who sustained a work related injury when she strained her lower back while lifting a client from a wheel chair. Per OMNI, she has suffered from depression. She underwent a lumbar laminectomy in 09/16/08 and a spinal cord stimulator trial in 06/20/14.
Based on the medical report dated 02/02/16 by Dr. Schwartz, the patient presents with severe post-operative low back pain and stiffness/tightness and intermittent spasms and referred numbness/tingling into both legs, left greater than the right with intermittent tightness and spasms. She still walks with a limp and easily fatigues. Patient has intolerance to prolonged sitting/standing positions and ambulation of short distances and stair activities. IW is awaiting replacement of lumbosacral orthosis and transcutaneous electrical nerve stimulation (TENS) unit. She takes Zorvolex for post-operative pain management. Pain is rated as 70/100 mm scale. IW maintains post-operative home exercises.
On examination, she is in mild distress. A 9 cm operative scar persists in the lumbar spine. There is …show more content…
She was given a prescription for Zorovolex.
Treatment plan includes replacement of thoraco lumbosacral orthosis and TENS unit to help control exacerbations of symptomatology, home attendant 8 hours per day and 5 days per week, Tempur-Pedic mattress to help provide more support to her post-operative back, referral to orthopedic spine specialist and pain management specialist and to maintain home e2exercsies.
Per IME report by DR. Varriale dated 10/22/13, it was opined that the patient does not need further therapy or orthopedic treatment at this time. Maximum medical improvement has been reached.
Is the request for 1 Transcutaneous Electrical Nerve Stimulator (TENS) Unit between 2/16/2016 and 4/16/2016 medically necessary?
MG-2 for a Request for Approval of
Based on the medical report dated 02/02/16 by Dr. Schwartz, the patient presents with severe post-operative low back pain and stiffness/tightness and intermittent spasms and referred numbness/tingling into both legs, left greater than the right with intermittent tightness and spasms. She still walks with a limp and easily fatigues. Patient has intolerance to prolonged sitting/standing positions and ambulation of short distances and stair activities. IW is awaiting replacement of lumbosacral orthosis and transcutaneous electrical nerve stimulation (TENS) unit. She takes Zorvolex for post-operative pain management. Pain is rated as 70/100 mm scale. IW maintains post-operative home exercises.
On examination, she is in mild distress. A 9 cm operative scar persists in the lumbar spine. There is …show more content…
She was given a prescription for Zorovolex.
Treatment plan includes replacement of thoraco lumbosacral orthosis and TENS unit to help control exacerbations of symptomatology, home attendant 8 hours per day and 5 days per week, Tempur-Pedic mattress to help provide more support to her post-operative back, referral to orthopedic spine specialist and pain management specialist and to maintain home e2exercsies.
Per IME report by DR. Varriale dated 10/22/13, it was opined that the patient does not need further therapy or orthopedic treatment at this time. Maximum medical improvement has been reached.
Is the request for 1 Transcutaneous Electrical Nerve Stimulator (TENS) Unit between 2/16/2016 and 4/16/2016 medically necessary?
MG-2 for a Request for Approval of