Patient intakestub
Demographics
Claimant<sample>
Age band40–49
JurisdictionNew York
Date of injury<sample>
Requested treatment
ProcedureMRI lumbar spine w/o contrast
CPT72148
Requested by<sample> · orthopedic
Clinical context
Sample summary: persistent lumbar radiculopathy with failed conservative management (PT × 6 weeks, NSAIDs). Exam findings include positive straight-leg raise. No red-flag features noted.