ࡱ> MOL` 1bjbjss .01$(</p5/7/7/7/7/7/7/$R1h3n[/jjj[/p/@@@j 5/@j5/@@M,.d WkSt,y./0/,(4(4(.(4.x"@[/[/6 /jjjj @@ ICD-9 Code: 724.6 Narrative: Chronic lumbosacral sprain/strain (BWC Diagnosis) Other Names: Failed Back Syndrome (in absence of surgery), chronic low back pain; sacroiliac (SI) dysfunction; sacroiliac (SI) instability ODG Ohio Specific Disability Outcomes: 30th Percentile 50th Percentile ODG Median All Claims including Surgical Cases 10 32 15  HYPERLINK "http://www.odg-twc.com/bp/724.htm" \l "724.6" ODG RTW Best Practices: (From ODG 724.5) Condition SeveritySurgical ProcedureSedentary Work: <10 lbClerical/Light Work:<20 lbsManual Work:<50 lbsHeavy Work: >50 lbNone0-3 days7-14 days14-28 days Description: Ongoing symptoms referred to low back that have not been sufficiently relieved despite adequate evaluation, consultation, and treatment. This condition requires treatment for another allowed condition and studies fail to diagnose another source for the symptoms such as herniated disc, spinal stenosis, or degenerative disc disease. It reflects chronic (usually for more than one year) ongoing symptoms despite efforts to treat the symptoms. BWC Required Diagnostics: BWC criteria. Evaluation and treatment as described above Ongoing symptoms not sufficiently relieved by treatment to date Adequate evaluation to diagnose and treat cause of symptoms. Most likely requires file review or IME to determine and offer recommended treatment options Common Treatment Procedures (CPT Codes): Trial of physical modalities TENS Unit Consultations Interdisciplinary pain program Variety of pain management procedures may have been tried Epidural steroid injections Physical Therapy Guidelines: 9 visits over 8 weeks (Note: Most patients have already had trial of physical therapy. Authorization based on response to treatment and indications.) Additional authorization based on clinical course Chiropractic Treatment Guidelines: Trial of 6 visits over 2 weeks. (Note: Many patients may have already had chiropractic and/or physical treatment for this work injury.) Additional authorization based on clinical course Common Surgical Procedures: None Surgery would require another additional allowance Common Restrictions: Restrictions lessen (less restrictive) with improvement of symptoms. Sedentary: Lifting with knees (with a straight back, no stooping) not more than 5 lbs up to 3 times/hr; squatting up to 4 times/hr; standing or walking with a 5-minute break at least every 20 minutes; sitting with a 5-minute break every 30 minutes; no extremes of extension or flexion; no extremes of twisting; no climbing ladders; driving car only up to 2 hrs/day. Clerical/Light:Lifting with knees (with a straight back) not more than 25 lbs up to 15 times/hr; squatting up to 16 times/hr; standing or walking with a 10-minute break at least every 1-2 hours; sitting with a 10-minute break every 1-2 hours; extremes of flexion or extension allowed up to 12 times/hr; extremes of twisting allowed up to 16 times/hr; climbing ladders allowed up to 25 rungs 6 times/hr; driving car or light truck up to a full work day; driving heavy truck up to 4 hrs/day. Early Case Management: 12 days Essential Case Management: 14 days Common Case Management Issues: Early Clinical Status Planned Treatment Work Restrictions and whether Restricted Duty Work Available Placement in alternative job or accommodation to limit lifting, bending, and usually twisting of the lower back Additional Services Necessary Diagnostic or Consultation Possibility of Consultation or Surgery Follow-up Clinical Status Consultations Why Unable to Return to Work Address any Barriers If not progressing as expected Identify any reason for failing to improve as expected Any need for diagnostic studies/consults Any need for ergonomic analysis/job modifications Address any barriers Additional Allowances Consider IME by Neurosurgeon, Orthopedist, or PM&R OP]q    d e f ȾxxgYP*B*phZY@Z e Document Map-D M CJOJQJ^JaJ10P4e )=PQRW`akvwxyz{|}~IJsyz1MNk45X16ij ! 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