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Pain Management Case Report

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DOI: 1/22/2013. Patient is a 50-year-old male cook/crew member who sustained a work-related injury when he lifted a 40-pound tray of chicken and felt back pain. Per OMNI, he had a lumbar sprain/strain with right sciatic component.
Based on pain management follow up evaluation report dated 06/26/15, the patient complains of lumbar spine pain, which he rates at 5/10. He notes that the pain has decreased since his last visit ( 05/29/15) due to a sacroiliac joint injection on 06/08/15. He reports that the procedure helped (100%) and he is pain free for two weeks and he was not taking any medication. He states that he had better mobility and he slept well. Now, he is indicating that the pain has returned. He has been taking his medication regularly and …show more content…
He has failed conservative treatment in the form of physical therapy, chiropractic manipulation, medication, rest and home exercise program.
He was given a refill prescription for Tramadol 100 mg one 1 tablet twice daily #60, Motrin 800 mg 1 tablet twice daily #60, Flexeril 10 mg one 1 tablet twice daily #60 and Prilosec 20 mg 1 tablet daily.
Treatment plan includes a right sacroiliac joint rhizotomy/neurolysis, continuation with non-strenuous aerobic activity and follow-up in 4-6 weeks.
The patient will undergo a random urinary drug screening on today’s visit. It was noted that the urinary screening from 05/29/15 is negative for all medications tested.
IW has been previously certified with 15 Tablets of Cyclobenzaprine (Flexeril) 10 mg between 4/23/2015 and 6/7/2015 and denied with Pirlosec and Motrin on 05/12/15. Per previous review (#217247), the PA noted that the patient has been using Flexeril as early as 01/2013.
Current request is for 30 Capsules of Prilosec 20 mg; 60 Tablets of Tramadol 100 mg; 60 Tablets of Motrin 800 mg; and 60 Tablets of Flexeril 10 mg between 7/29/2015 and

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