Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower back pain

Treatment: 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 patient is a female who returned for chiropractic treatment the patient presented to the office with complaints of lower back pain and stiffness, multiple trigger points in the lumbar paraspinals and decreased lumbar mobility point tenderness to lumbar vertebrae and sacroiliac joints as well as a short leg. According to a document for dates of chiropractic services noted, the patient had spinal manipulation treatment.  
The exam findings listed in the records, revealed subjective complaints of lower back pain that varied without change between a 5 to 6 out of 10 severity, with frequency of 50-75%, dull, achy, stiffness that flares up with sitting and interferes with daily activity (ADL).  The provider listed the condition during this treatment regimen as "unchanged", "slightly improved" and/or "slightly worse without any measured functional assessment. Objective findings included physical exam that showed muscle hypertonicity and muscle tenderness with restricted movement, (without change).  The treatment rendered was same or similar for all date of service records submitted which included a chiropractic manipulative treatment (CMT), Moist Heat, and Exercise. The patient's diagnosis was not listed in the notes.

According to the Chiropractic Care Guidelines and Practice Parameters (CCGPP), the determination to for continuation of care is determined by whether the patient has made clinical improvement. The CCGPP states, "A determination of the necessity for additional treatment should be based on the response to the initial trial of care and the likelihood that additional gains can be achieved." The dates of service (DOS) in question did not show meaningful and measurable improvement with the current treatment protocols and suggested that the Maximum Therapeutic Benefit (MTB) was achieved by the patient prior to these DOS, and the treatment rendered in question would be considered maintenance care and not a covered service for these same, chronic clinical conditions.  

The CCGPP guidelines also states, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment."  The patient's records did not support additional meaningful and measurable improvement with the current clinical condition, and did not support a rationale for expectations of additional clinical improvement to be achieved with ongoing chiropractic treatment. The record suggested that ongoing chiropractic care would be considered as maintenance care, and not medically necessary.

The records submitted for review did not include measurable outcomes and did not support that a continued trial of care would be beneficial.  Pain scales had minimal change, functional improvement failed to be established and OAFs were not utilized in the records submitted. Thus, the requested service was not medically necessary to treat this patient's medical condition.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for the Current Procedural Terminology (CPT) code 98940 (Chiropractic Manipulative Treatment (CMT); spinal, 1- 2 regions), for dates of service is upheld. The medical necessity is not substantiated.