Letter of Medical Necessity

letter of medical necessity patient name michael petro 12/30/2024 participant name michael petro participant’s employer usps this form should be completed by the attending physician to confirm treatment is necessary for a specific medical condition complete the following describe the diagnosed medical condition being treated (include diagnosis code) • (m99 03) segmental and somatic dysfunction of lumbar region • (m54 17) radiculopathy, lumbosacral region • (m99 02) segmental and somatic dysfunction of thoracic region • (m54 6) pain in thoracic spine • (m62 830) muscle spasm of back • (m54 2) cervicalgia examination findings cervical compression test positive maximal cervical compression test positive bilaterally foraminal compression test positive bilaterally bechterew's sitting test positive bilaterally kemp's test positive bilaterally valsalva's test negative straight leg raising test positive bilaterally describe the recommended treatment and duration of treatment physical medicine and chiropractic progressive rehabilitation to facilitate care , a properly fitting ergonomic work chair should be provided to this patient to prevent exacerbation of his condition and facilitate healing and recover goals of treatment reduction of pain and strengthening of patient core musculature to assist with healing and speed recovery, the proper support during working hours will increase productivity and allow for minimal exacerbations of his condition this treatment is medically necessary to treat the specific medical condition described above signature of attending physician date dr clifton mays print name address 3755 admiral dr suite 106, high point, nc 27265 phone (336) 887 9460