DOI: 12/2/2015. Patient is a 41-year-old male yard helper who sustained an injury when he slipped and fell over a pipe. Per OMNI entry, he is status post L5-S1 fusion on 9/29/2016.
Based on the medical report dated 12/22/16, the patient presents 3 months post operatively from a L5-S1 anterior lumbar interbody fusion.
He reports that his back pain has been worse in the last 2 weeks. He is having lower back pain that is more constant and severe.
The numbness on his left leg is back and it happens in the mornings when he wakes up, but as the day goes by, the numbness goes away. He is still taking Percocet and is also doing muscle relaxers. Standing and sitting for prolonged time increases his symptoms.
He is still wearing his back brace. He rates his pain level at 8/10. …show more content…
Current medications include cyclobenzaprine, Neurontin and Norco.
IW is diagnosed with low back pain, lumbar radiculopathy, prolapsed lumbar intervertebral disc and lumbar discogenic pain.

Plan is for physical therapy to strengthen his core, electrical stimulation, ultrasound but no extension exorcises.
Please note that the provider did not specify the number of PT visits requested. If this will be certified, please determine the number of approved PT visits.
Current request is for Physical Therapy Visits for the Lumbar Spine with Evaluation between 12/28/2016 and