Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with low back pain, cervical radiculopathy, cervical disc degeneration, dorsopathies, muscle spasm, postural kyphosis of the cervical and thoracic spine, and segmental and somatic dysfunction of the cervical, lumbar, and sacral regions. The patient reported her cervical, upper thoracic, and lumbar pain had improved with chiropractic treatment but worsened with activities of daily living and stress. She rated her pain as five out of 10. Physical examination findings included antalgic gait, a head forward posture, and a high left shoulder and right hip. Muscle spasm was also noted. The records noted approximately 15 chiropractic sessions from 1/1/20 through 2/12/20. The patient has requested authorization and coverage for 30 to 60 chiropractic treatments over the next year. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether chiropractic treatment is medically necessary and if so, are 30 to 60 chiropractic treatments over the next year medically necessary for the treatment of the patients medical condition. Bryans and colleagues reported, Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used. A randomized controlled trial by Walker and colleagues noted, Greater treatment satisfaction was reported by those in the usual chiropractic group in comparison to those receiving the sham intervention (78% satisfied versus 56% satisfied). In this case, the patient has chronic low back pain and neck pain. The patient also reported improvement with prior chiropractic treatment. However, the request for 30-60 chiropractic treatments is excessive.  Gross and colleagues reported, Low quality evidence showed manipulation alone compared to a control may provide short-term relief following one to four sessions and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache. The medical evidence supports a portion of the requested services in this clinical setting. Therefore, 30-60 chiropractic treatments over the next year are not medically necessary for the treatment of this patient. In this patients case, four to 12 chiropractic treatments would be reasonable, given the functional improvement. Therefore, four to 12 chiropractic treatments are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.