Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample (Page 3 of 8) in pdf

RE: CARTER, LINDA J.

DOE: January 12, 2015

Page 3

mandates an aquatic therapy to the patient’s cervical spine

and lumbar spine.

AQUATIC THERAPY

1. Recommended as an optional form of exercise therapy,

The patient is not attending any therapy at this time. It was

where available, as an alternative to land-based physical

documented in the past aquatic therapy has been beneficial

therapy.

to her. [PR-2 dated 12/05/2014]

2. Aquatic therapy (including swimming) can minimize the

The patient’s height is 5’4” and she weighs 237.4 pounds.

effects of gravity, so it is specifically recommended where

Therefore, the BMI is 40.7 which signifies obesity (BMI of 30

reduced weight bearing is desirable, for example extreme

or greater). Also, she has difficulty with ambulation.

obesity.

3. Water exercise improved some components of health-

The patient is diagnosed with fibromyalgia and currently has

related quality of life, balance, and stair climbing in females

the following symptoms: (1) Constant severe neck pain that

with fibromyalgia.

she rates as 8/10 on a pain scale; (2) Constant severe low

back pain that she rates as 8/10 on a pain scale; (3) Review

of systems reveals weakness and fatigue; (4) Tenderness in

the left trapezius and paracervical muscles; and (5)

Tenderness in the paralumbar muscles.

The above

mentioned symptoms in my experience and expertise as an

orthopedic surgeon, is consistent with the guidelines and

evidence-based medicine to support the request for aquatic

therapy to the patient’s cervical spine and lumbar spine.

2. Authorization for an MRI scan of the cervical spine.

Pursuant to the guideline California Code of Regulations, Title 8, Article 5.5.2 Medical Treatment Utilization Schedule (MTUS), Section

“Treatment shall not

9792.20 et seq., Effective July 18, 2009, § 9792.21 Medical Treatment Utilization Schedule, Subdivision (c), page 2,

be denied on the sole basis that the condition or injury is not addressed by the MTUS. In this situation, the claims administrator shall

authorize treatment if such treatment is in accordance with other scientifically and evidence-based, peer-reviewed, medical treatment

guidelines that are nationally recognized by the medical community, in accordance with subdivisions (b) and (c) of section 9792.25, and

pursuant to the Utilization Review Standards found in section 9792.6 through section 9792.10.”

ODG Treatment in Workers Comp

(2013), Eleventh Edition, Procedure Summary – Neck and Upper Back, page 1197, under Magnetic Resonance imaging (MRI),

“In determining whether or not the patient has ligamentous instability, magnetic resonance imaging (MRI) is the procedure of choice,

but MRI should be reserved for patients who have clear-cut neurologic findings and those suspected of ligamentous instability.” Also,

“MRI imaging studies are valuable when physiologic evidence indicates tissue insult or nerve impairment. … MRI is the test of choice for

patients who have had prior back surgery. (Bigos, 1999) (Bey, 1998) (Volle, 2001) (Singh, 2001) (Colorado, 2001)”

The patient meets the criteria in the guidelines:

Based on the following clinical evidence provided in

the records:

1. In determining whether or not the patient has ligamentous

The patient has the following signs and symptoms that

instability, magnetic resonance imaging (MRI) is the

suggest ligamentous instability: (1) Constant severe neck

procedure of choice.

pain that she rates as 8/10 on a pain scale; (2) Examination

of the cervical spine reveals mild torticollis to the left; (3)

Tenderness over the C3-C5 spinous processes, bilaterally; (4)

Examination of the cervical spine reveals restricted range of

motion in all planes; and (5) Left levator scapula has

swelling/inflammation.

Therefore, an MRI scan of the

cervical spine is the appropriate medical procedure under the

applicable guidelines in determining whether the patient has

ligamentous instability.

Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample Page 3

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