Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Segmental and somatic dysfunction of the lumbar spine.

Treatment: Current Procedural Terminology (CPT) code 98940, chiropractic manipulative treatment (CMT); spinal, 1-2 regions.

The insurer denied coverage for CPT code 98940, chiropractic manipulative treatment (CMT); spinal, 1-2 regions.

The denial is upheld. 

This is a female patient with a history of migraines and segmental and somatic dysfunction of the lumbar spine. She presented to the Chiropractor's office for spinal adjustments. She reported no complaints. The Chiropractor palpated the spine. There were spasms, hypomobility and end point tenderness indicative of subluxation at cervical (C) spine level C2 and lumbar (L) spine level L5. Spinal adjustments were performed to improve the function of the segments of the spine that were fixated. Approximately a week later, the patient reported 4 out of 10 pain in the back of the neck. There were spasms, hypomobility and end point tenderness indicative of subluxation at C2 and thoracic (T) vertebra T11. 

The patient reported no complaints on the 1st date of service (DOS) in question and the dates before that. Without any subjective complaints, it appears that treatment on these dates of service could be considered maintenance care and may need to be revisited by the insurer for coverage. The patient reported on the 2nd DOS in question "intermittent dull discomfort in the back of the neck" with a visual analog scale (VAS) of 4/10. The patient care notes (PCN) did not support a completed history, or examination of the body region affected, a treatment plan that would indicate a new complaint or exacerbation of same, or medical decision making (MDM) of a meaningful level to proceed with performing chiropractic on this individual or establishing medical necessity for treatment. The PCN suggests that continued chiropractic care would be considered maintenance care for the 1st DOS in question. The patient was not presenting with necessity for treatment and the treatment plan listed strongly suggests a maintenance treatment plan of 1x/per week without supporting documentation to support the clinical rationale for this continued treatment. 

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) guidelines states that for a trial of care to be considered beneficial, it must be substantive, meaning that a definite improvement in the patient's functional capacity has occurred. Table 3 (Pg.11) in the CCGPP guidelines supports a treatment regimen related to an exacerbation of a chronic condition having occurred, been properly documented through an evaluation with scientific evidence, and a reasonable treatment plan of 2-3 treatments per week for 2-4 weeks.  

The records reviewed failed to utilize outcome assessment forms (OAFs), appropriate examinations and MDM to document medical necessity and also supported ongoing maintenance care. The records did not support medical necessity for the treatment received on the dates of service under review. 

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for Current Procedural Terminology (CPT) code 98940, chiropractic manipulative treatment (CMT); spinal, 1-2 regions, is upheld. Medical necessity is not substantiated.