Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample Page 4
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8RE: CARTER, LINDA J.
DOE: January 12, 2015
Page 4
2. MRI should be reserved for patients who have clear-cut
Aside from suspected ligamentous instability, the patient also
neurologic findings and those suspected of ligamentous
has clear-cut neurological findings based on the following
instability.
findings in the examination of the cervical spine: (1) Constant
severe neck pain associated with numbness and tingling
sensation radiating to the upper extremities; (2) Mild
torticollis to the left; (3) Cervical compression test and
Spurling’s test are positive to the left; (4) Biceps reflex is
diminished with a grade of 1+; and (5) Dorsum of the hand
has diminished sensation. An MRI scan of the cervical spine
is the appropriate procedure that complies with the
guidelines.
3. MRI imaging studies are valuable when physiologic
The patient shows the following physiologic evidence, which
evidence indicates tissue insult or nerve impairment.
indicate tissue insult and nerve impairment: (1) Pain to the
neck is aggravated by moving her head from side to side; (2)
Cervical compression test and Spurling’s test are positive to
the left; (3) Biceps reflex is diminished with a grade of 1+;
and (4) Dorsum of the hand has diminished sensation. Also,
the patient is diagnosed with brachial plexus lesion.
Therefore, an MRI scan of the cervical spine is valuable for
the patient under the applicable guidelines.
4. MRI is the test of choice for patients who have had prior
The
patient
is
status
post
left-sided
L3-4,
L4-5
back surgery.
laminectomy/microdiscectomy surgery from May 4, 2013.
3. Authorization for an MRI scan of the lumbar spine.
Pursuant to the guideline California Code of Regulations, Title 8, Article 5.5.2 Medical Treatment Utilization Schedule (MTUS), Section
9792.20 et seq., Effective July 18, 2009, § 9792.21 Medical Treatment Utilization Schedule, Subdivision (c), page 2,
“Treatment shall not
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,
"Recommended for
Eleventh Edition, Procedure Summary – Low Back, pages 893-894, MRIs (magnetic resonance imaging),
indications below. MRI's are test of choice for patients with prior back surgery. … Magnetic resonance imaging has also become the
mainstay in the evaluation of myelopathy.” Furthermore, “Imaging is indicated only if they have severe progressive neurologic
impairments or signs or symptoms indicating a serious or specific underlying condition. …
The patient meets the criteria in the guidelines:
Based on the following clinical evidence provided in
the records:
1. MRI’s are test of choice for patients with prior back
The
patient
is
status
post
left-sided
L3-4,
L4-5
surgery.
laminectomy/microdiscectomy surgery from May 4, 2013.
2. Magnetic resonance imaging has also become the
The patient has the following signs and symptoms: (1)
mainstay in the evaluation of myelopathy.
Constant severe low back pain that she rates as 8/10 on a
pain scale and the pain is aggravated by lifting heavy objects
or bending; (2) Difficulty with ambulation; (3) Examination of
the lumbar spine reflects slight flattening of the lumbar
lordosis; (4) Tenderness over the L3-S1 spinous processes,
bilaterally; and (5) Examination of the lumbar spine reveals
restricted range of motion in all planes.
The above
mentioned signs and symptoms in my experience and
expertise as an orthopedic surgeon, together with the
applicable guidelines, mandate an MRI scan of the lumbar
spine in the evaluation of myelopathy.
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