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