I have carefully reviewed the documentation presented. The patient complained of pain in the low back and right hip. Examination revealed right hip tenderness, lumbar spine tenderness with a decreased range of motion and spasm. A request was made for acupuncture therapy. However, there was no documentation that the medications prescribed were reduced or not tolerated. Furthermore, there …show more content…
The patient was climbing down a unit-haul truck when she suddenly sustained a right hip pain. The pain started to shoot down to her entire right lower limb. She also developed numbness in the right leg.
The patient was diagnosed with a right side sciatica and bursitis of the right hip.
Treatments rendered to date included medications, activity modification, steroid injection, physical therapy (PT), and chiropractic care.
The right hip x-ray dated 08/22/16 revealed no significant interval change, no acute fracture, no significant joint disease, and no significant soft tissue abnormality identified. The alignment was normal. There was a mild multilevel degenerative disk disease with marginal osteophytosis present in the dorsal spine.
An MRI of the lumbar spine dated 8/2016 revealed facet disease and disc bulge on the right.
Medical records reviewed included Primary Treating Physician’s Progress Report (PR-2) dated 05/23/17, Request for Authorization (DWC Form RFA) dated 05/24/17, and Mitchell, UR Notice of Prospective Authorization Decision dated 08/23/16 and