Of $22,400 billed, $18,200 is defensible reasonable value (a 18.8% reduction, mostly diagnostic and facility charge trimming). The treatment arc — imaging, conservative care, one epidural, surgical referral — is coherent and mechanism-concordant. The recommended L5–S1 microdiscectomy (CPT 63030; est. $36,000–$42,000, not in the past-specials figure) may be supportable as future specials if the operative rationale documents failed conservative care and the radicular findings.
| Category | Code(s) | Billed | Reasonable value |
|---|---|---|---|
| Diagnostics — ED visit + lumbar MRI | 99284, 72148 | $9,200 | $7,400 |
| Conservative care — physical therapy + chiropractic | 97110, 97140, 98940 | $6,800 | $5,200 |
| Lumbar transforaminal epidural steroid injection (L5–S1) | 64483 | $4,100 | $3,600 |
| Specialist consults (new + follow-up) | 99205, 99214 | $2,300 | $2,000 |
| Past medical specials | $22,400 | $18,200 |
Medicare ≠ chargemaster ≠ negotiated rate ≠ reasonable value. Reasonable value is anchored to a market percentile from a licensed charge-and-allowed-amount database (e.g., FAIR Health) with CMS PFS/RBRVS as a reference floor — not to the billed total. The governing measure of medical damages is jurisdiction-dependent; the substantiated figure is the defensible floor.
Imaging-confirmed L5–S1 herniation concordant with the documented radiculopathy; conservative care and one epidural injection attempted before surgical referral. Necessity for single-level decompression is supportable; to firm it up for future specials, obtain the surgeon’s operative rationale (failed conservative care, neurologic findings, why further injections are inappropriate).