Frieda Menzer Case

A visit note from Gregory Carico, MD (Internal Medicine), dated 01/23/2017, indicated that the claimant presented with a history of depression. She was involved in a motor vehicle accident on December 9th. She was relieved from work duties from 12/09 to 01/04 and was able to return to work on 01/10. She was again off work on 01/12 for therapy. She had pain in the thoracic part of the back and lower neck to middle back. She was diagnosed with a sprain of ligaments of the thoracic spine. An

A review of the records reveals the member to be an adult male with a birth date of 03/28/1966. The member has a diagnosis of non-small cell lung cancer (NSCLC). The member’s treating provider, Brion Lock, MD a VeriStrat® testing for the member, which was performed on 02/11/2016.

The carrier has denied coverage of continued occupational therapy from 07/29/2015 - forward as not medically necessary. There is a letter from the carrier to the member, dated 03/29/2016, which states in part:

On the Statement of Medical Necessity on MG-2 form dated 03/14/16 by Dr. Charles Gordon, patient presented with neck pain. The symptom is alleviated by injections and medication. It is located in the mid neck area, trapezius muscle, and in lower cervical/shoulder area. It is d described as pressure, shooting and burning, and radiating to the scapula and shoulder. Plan is to undergo a left cervical facet rhizotomy at C3-4, C4-5 and C7-T1 then right cervical facet rhizotomy at C3-4, C4-5 and C7-T1.

As per medical report dated 4/19/16, a lumbar MRI with and without contrast was requested to evaluate for a discogenic and/or facetogenic etiology for pain. MRI would also allow evaluation of conditions such as spinal stenosis.

Scharf utilized Diagnosis Related Estimate cervical category II and assigned an 8% Whole Person Impairment. Dr. Scharf noted the MRI study of the cervical spine right disc extrusion at C5-C6, but there are no verifiable radicular symptoms in light of the result of the EMG/NCV studies, despite the applicant’s subjective complaints of radicular symptoms into the bilateral upper extremities. Since there are no verifiable radicular symptoms, the placement into DRE category II seems appropriate.

On examination of the cervical spine, there is tenderness and tight muscle band is noted on both the sides of the paravertebral muscles. There is pain with extension and palpation of right facets.

The carrier has denied coverage of FDG-PET scan as not medically necessary. A letter from the carrier to the member, dated 05/08/2016, states in part:

Dr. Abiera had reviewed a September 3, 2010 MRI of the cervical spine that revealed central protrusion/herniation at C3/C4, left paracentral protrusion/herniation at C7/T1, Disc bulges C4/C5, C5/C6 and C6/C7, left paracentral extrusion/herniation at T3/T4 and straightening of cervical lordosis. In addition, Dr. Abiera noted an August 11, 2010 x-ray of the cervical spine which revealed blastic lesions, incidental Clay Shovelers Fractures of C7 and an August 11, 2110 x-ray of the thoracic spine which was

MRI of the cervical spine dated 08/17/16 showed at C3-4 and C4-5, there is mild posterior disc bulging.

Dr. Adams reviewed the MRI films. The family found a man who makes custom cervical collars in Florida and they asked for a order so they could try and have one made. Dr. Adams said he is more concerned about the Kyphosis. He asked if the collar had been removed. Mr. Messing said he thought the collar could be removed, Ms. Messing said it has not been removed. Dr. Adams said a custom collar is not the solution, he feels she needs a Halo. He said he doesn’t do those any longer. He recommends Henry Ford, Beaumont or the U of M hospital. He ordered a new ct scan to be done. While were in the exam room Mr. Messing called his daughter a nurse practioner and Dr. Adams spoke with her. She will speak with the neurosurgery department at her hospital and find the appropriate doctor. I spoke with Gail after the appointment as she had requested and provided her with an update. Gail had requested an open claim letter so she could make arrangements for her mother to see her neurologist and her PCP but needs a open claim letter. The letter was obtained and faxed to Dr. Kala

Per the medical report dated 08/12/16 by Dr. Gunderson, the patient had neck pain, as well as headaches, dizziness and blurred vision. The neck pain radiated into both shoulders, but more so on the right, and occasionally she had tingling in her upper extremities. She described the neck pain as severe and intermittent, and not related to any specific activity, and relieved with massage. The pain in her lower back was in the beltline and radiated into both lower extremities, more so on the left. She described the pain as moderately severe and constant, and not related to any activity, and only relieved with nerve medicines. On examination, the patient had tenderness in the lower cervical region about C5 to C7. Range of motion of her neck was 75% of normal. Motor, sensory, and reflex examinations in the upper extremities were normal. On examination of the lumbar spine, the patient could dress and undress without difficulty. She had a bent forward posture and gait. She had reduced lumbar motion and with maximum forward flexion, her fingertips were 12 inches from the floor. Lateral flexion was 50% of normal, and she had no active extension in the lumbar spine. Motor, sensory, and reflex examinations in the lower extremities were normal. There was paravertebral tenderness about L4-5 bilaterally, as well as in both sacroiliac and sciatic notch regions. Straight leg caused hip and thigh pain at 50 degrees bilaterally. Of note, X-rays of the cervical spine demonstrated disc degeneration at C5-6. X-rays of the lumbar spine were normal. Patient sustained

12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is

Based on the medical report dated 03/25/16, the patient continues to have significant headaches and bilateral neck and shoulder pain. IW has numbness and tingling in both arms with neck pain.

The patient, Miss Tedo, is a 69-year-old female with a diagnosis of cervical degenerative joint disease, also known as cervical osteoarthritis or neck arthritis. Miss Tedo complains that she has neck stiffness and pain rated as 6/10. Miss Tedo also reported that she has tingling and pain rated as 5/10 that radiates down the right arm to the little finger. Upon her visit to the clinic, Miss Tedo presented with limited cervical range of motion, 30o of rotation bilaterally and 10o of lateral flexion bilaterally. She exhibits moderate cervical paravertebral muscle hypertonus with a forward flexed posture and poor postural awareness.