Andrew Rider of Michigan Insurance Company referred this file for medical case management. Instructions were given to meet with Chris Simonson and assist with coordination of appropriate and related medical care, and identify needs to facilitate recovery. INTERVIEW SETTING On 8/25/16 I met Mr. Simonson at the office of Mid Michigan Orthopedics. Mr. Simonson drove independently to the appointment.…
Payment was denied because the documentation did not support the medical necessity for the injection procedure. The documentation did not support the trigger points as reasonable and necessary. There was no indication of symptoms or physical findings that would support the medical necessity of the service at the level billed, in accordance with Medicare Guidelines. For the procedure code 20553 to be considered medically necessary and reasonable, an appropriate payable diagnosis needs to be billed as outlined in the Local Coverage Determination (LCD) (L30155).…
Group I, Category 19 Incorrect RFC Decision ISSUE DDS proposed a denial determination. The evidence in file supports a more restrictive RFC, as a result, additional vocational documentation is required. CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES) This 57-year old is filing a DIB claim alleging disability due to loss of right eye, COPD, high blood pressure, edema of both legs and feet, back surgery, weight gain, depression, and neuropathy, as of 10/22/2014.…
PT was aox4 with CC of lumbar back pn around his spine. PT stated that he was walking and lost his footing and sat down on his but onto a rock. Pt has chronic pn in his lumbar area and tingling in his legs. Pt statest that his chroinc pn is slightly worse since the fall.pt states pn 9/10 Pt had no other complints. PT was place in full c-spine precaustions and carried to the ambulance.…
The doctor explains he has muscle spasms originally in his lower back but they have moved up to the neck. It is a pattern of pain that begain in the mid-low back, migrated to the neck and shoulder. The doctor feels this is directly in association with his lumbar pain. If he had not had pain…
On 11/15/2016, the claimant reported a return of symptoms and stated that she started having spasm while working. On 11/18/2016, the claimant complained of right sacroiliac joint pain and sacrum pain that was described as moderate and constant which was rated as 5/10. There was also mild-moderate and constant right hip pain that was rated as 4/10 as well as moderate and constant neck pain that was rated as 6/10. The neck pain was unchanged since the last visit while the pain in the right sacroiliac joint, sacrum, and right hip were getting better. Examination revealed that there was increased myospasms in the right paralumbar, right parathoracic, and right paracervical muscles.…
This writer address with the patient about his UA result dated on 5/15/2017 as there were mutliple reschedule and cancellation from this writer and the patient. This writer address with the patient about the opiate and benzo use. The patient was admit that he haven't relapse on any benzo since his last conversation with this writer and honestly feels that the benzo could potentially have been in the "dope." This writer discuss the seriousness with the patient about his recovery and discuss clinical intervention with the patient. First and foremost, this writer discuss with the patient about his depression but according to the patient, he is not depress anymore.…
Summary of Case Study Bill is a 34 year old male who is in good health. He likes to work out as well as swim and go scuba diving. Bill began feeling discomfort in his right hip, so he decided to visit the doctor. He was prescribed medicine for his discomfort, but it did very little so he decided to return back to his doctor. He returned with the pain still in his right hip, but also mentioned the pain could now be found in his left hip as well.…
300.82 Somatic Symptom Disorder with Predominant Pain and Persistent – Severe V61.03 Disruption of family by separation or divorce V61.10 Relationship distress with spouse or intimate partner V62.29 Other problem related to employment Justification of 300.82 - Somatic Symptom Disorder with Predominant Pain and Persistent – Severe Matt has more than one somatic symtom present that is causing him distress and significant disrution in his daily life. Matt has overal pain, specifcilly absominal pain, and has aches, feels sore, and tired (Criterion A). Matt has not been able to work for 2 years now due to the increase in pain.…
The claimant has a past medical history of depression and anger. He had suicidal thoughts and felt desperate but unable to function. He reported obsessive repetitive thoughts and hopelessness. He had tried Lexapro, but had a negative reaction, including uncontrolled rage and attacking his girlfriend. He was unable to make some follow-up visits and to have psychiatric evaluation due to insufficient funds.…
History of the Presenting Problem: Client stated that current problems have been persistent for every day, multiple times a day for 6 months. She reports noticing symptoms in September of this year, when the…
D-The patient arrived on time for her session. Before the session started, this writer allow the patient to dose first. Upon conducting the session, the patients reports about her Valium still being "in her system" and got in trouble for it. This writer reviewed the patient's script and notice the patient was not prescribed for the medication and asked the patient as to how she got the medication. According to the patient, she would get the medication from a friend and is aware of the danger of doing this.…
Community Resource Name of Facility: O.Z. lives near to the community resources such as Mid City Clinic, Sharp Grossmont Hospital, City Heights Family Health Center of San Diego, and The Salvation Army Kroc Center. The rationale for this community resources recommendation and client specific service(s): she lives a few miles away from these facilities. These facilities are all accessible by public transportation. For example, Sharp Grossmont Hospital and Senior Resource Center provide a free service under a project called Community Action to Reach the Elderly (CARE).…
As per office notes dated 5/12/16, the patient complains of persistent moderate to severe burning back pain located in the right thoracic area. The symptoms are aggravated by exertion. The symptoms are relieved by rest. The back pain is described as mild to moderate. He continues…
D-The patient arrived late to her appointment and had thought her appointment was tomorrow. Reported stable on her dose; however, this writer addressed with the patient about her not feeling stable during the last conversation. Patient responded, " I know, Charlene." This writer informed the patient that her dose change request was denied due to her illicit use. The patient appeared to be understanding about the denial and made a comment that she is working on discontinuing her use because she does not want to keep on using, which led to a conversation about alternatives to avoid having a relapse.…