Left Shoulder Pain Case Summary

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DOI: 5/23/2016. Patient is a 48-year-old male sales employee who sustained injury due to a car accident. Per OMNI, he was initially diagnosed with cervical and left shoulder sprain/strain. Based on the latest medical report dated 07/15/16, the patient notes his neck pain radiating to his left upper extremity is now described as 5/10 in intensity and notes the associated tingling on his left arm is now worse. He states his left shoulder pain is improving and is now described as 7/10 in intensity. He was recommended physical therapy on a three times per week and participate in a home exercise program. He has attended a total of fourteen physical therapy sessions since his previous evaluation. On examination of the cervical spine, range of motion…show more content…
Long term goals include a return to his prior level of functioning including full duty work as well as safely perform all activities of daily living. Assessments include cervical spine strain/sprain, rule-out disc herniation and left shoulder strain/sprain. The patient will begin physical therapy three days per week where he will receive moist heat, cold packs, and ultrasound treatment to the cervical paraspinals and left shoulder, electrical stimulation treatment to the left shoulder, massage treatment for the cervical spine, range of motion and strengthening exercises for the cervical spine and left shoulder, with the goals of reducing pain, improving range of motion, and improving overall function. He was advised to continue follow-up with orthopedic surgeon, for further evaluation and management of his left shoulder pain. Is the request for 18 Physical Therapy Visits for the Left Shoulder and Neck between 8/15/2016 and 10/14/2016 medically necessary? MG-2 for a Request for Approval of

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