Pending Claim and Additional Evidence

[gs106]

I have a pending claim for lower extremity radiculopathy secondary to degenerative disc disease.  The claim has been in preparation for decision status for 3 or 4 weeks with an estimated completion date 6/4/2016 to 7/4/2016.  I had a second epidural injection on 2 June and the doctor was unable to put the injection where needed due to lack of disc space (partial doctor notes below).  Should I submit the notes now and risk the claim decision being delayed or hold onto it and submit it with a likely NOD?  It's bad to anticipate having to file a NOD but based on other claim decisions, it is inevitable.  Is there anything here that would help with SC or percentage? 

The patient underwent a lumbar epidural steroid injection for symptoms of lumbar radiculitis back on 04/19/2016.  He reports approximately 65% relief for 2 to 3 weeks, but then the pain has gradually returned and he reports mostly numbness and annoying discomfort, but overt pain he dismisses.  He continues to complain of some right calf pain, but is more concerned with left leg pain.  Reviewing the MRI and upon further discussion with the patient, we opted to change the procedure today to a left-sided transforaminal epidural steroid injection at the L5-S1 level.  The MRI shows probable impingement of the descending S1 nerve root on the left within its lateral recess due to a disk bulge and posterior element hypertrophy.  There is moderate foraminal narrowing bilaterally with probable impingement of both exiting L5 nerve roots.  Dr. Hardy, the radiologist, notes that it is more likely on the left.  The patient understands the goals of the transforaminal epidural steroid injection and agrees to proceed.

He was placed in a prone position on the examination table.  He was prepped and draped in the usual sterile fashion.  Then, 1% lidocaine was used a local anesthesia.  A 3-1/2 inch 22 gauge spinal  needle was then used in an attempt to enter the left L5 neural foramen.  He has quite a bit of loss of disk height at the L4-L5 and L5-S1 levels.  The left iliac crest proved to be too difficult to work around and I was unable to place the needle in the right location.  Lateral views show quite a bit of anterolisthesis of L4 on L5 due to pars defects as noted on the MRI.  This made it impossible for me to get into the appropriate location and the procedure was aborted.

The patient had been consented for the lumbar epidural steroid injection and was injected and this procedure was carried out at the L4-L5 level, there being no real interlaminar space at the L5-S1 level.  A 17 gauge needle was used to enter the epidural space using loss-of-resistance technique and a left paramedian approach.  No blood, paresthesias, or cerebrospinal fluid (CSF) was noted.  Then, 80 mg of methylprednisolone and 2 mL of 0.25% bupivanaine, along with 3 mL of preservative-free normal saline was injected into the epidural space and the needle was removed.

  

[brokensoldier244th]

I would submit it. It can't hurt, and why assume the worst and file a NOD if you dont have to. That will be guaranteed to take a long time.