Review queue

Member

Synthetic M-40221, 54 F, Commercial PPO (sample)

Service

CPT 72148 MRI lumbar spine without contrast

Diagnosis

M54.16 Radiculopathy, lumbar region

Provider

Lakeside Orthopedics, Orthopedic surgery, in-network

Policy

DEMO-IMG-014 MRI of the lumbar spine for low back pain

Patient: Dana Whitfield   DOB: 03/14/1972   MRN: 00482231
Callback: (555) 201-4478

Subjective: 54 y/o F with low back pain radiating down the left leg to the lateral foot for 11 weeks. Started physical therapy on 08/10/2026, 2x weekly, and has completed 14 sessions. Taking naproxen 500 mg BID since 08/04/2026 with partial relief. Leg pain persists despite therapy and now limits walking to about one block.

Exam: Positive straight-leg raise on the left at 40 degrees. Decreased sensation over the left lateral foot (S1 dermatome). Left ankle reflex diminished compared with right. Strength 5/5.

Assessment: Left lumbar radiculopathy, likely S1, not improving after 8 weeks of physical therapy and NSAIDs.

Plan: Request MRI lumbar spine without contrast to evaluate for disc herniation before considering epidural steroid injection.

2025-03-11  99213  Office visit, primary care  M54.50
2026-07-22  72100  X-ray lumbar spine, 2-3 views  M54.50
2026-08-04  99204  New patient visit, orthopedics  M54.16
2026-08-10 to 2026-09-30  97110 x14  Therapeutic exercise  M54.16
2026-10-02  99214  Established visit, orthopedics  M54.16
No claims for CPT 72148, 72149 or 72158 in this period.