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Utilization Review Success Story Aug 2010 |
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Aug 2010: Cervical Spine Surgery Avoided
- 38 year old grocery clerk
- Date of Injury: November 2007
- Diagnosis: Left shoulder pain with marked restriction of movement after grabbing a 25 lb. bag of potatoes that was falling off the check out stand
- Medications, physical therapy, and activity modifications failed to relieve pain
- MRI was performed which as interpreted as showing a rotator cuff tear
- Arthroscopy was performed
- Post op physical therapy results in restored range of motion but continued pain
- Further testing done - normal nerve testing and an MRI of the C-Spine which showed minimal degenerative changes but no herniated disc nor nerve compression
- Workers' doctor submitted request of cervical spine discectomy
- Date of Utilization Review: March 2009
- An EK Health utilization review physician who specializes in and performs spin surgeries denied the request and explained that ACOEM guidelines require both clinical (weakness, pain, tenderness, abnormal reflexes, etc.) and imaging (x-ray, MRI, etc.) data for surgery requests
- The insurer arranged a second medical expert to examine the MRI results and said that the discectomy would not accomplish much for the patient because "the neural foramina on the left is wide open." In other words, the expert opined that there was no compression of the relevant nerves on the left side. Thus, an unnecessary painful and expensive surgery was avoided
- Dollar savings from the avoided surgery alone were $75,000-$100,000.
To request a Utilization Review, please contact us at (877) 861-1595.
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V. 2010 
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