Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain

Treatment: Chiropractic manipulative treatment 

The insurer denied coverage for chiropractic manipulative treatment 

The denial is upheld

According to the documentation submitted, this is the case of a patient with a history of low back pain, and muscle spasm. The patient's physician's note stated that the patient had the following orthopedic tests: passive lumbar extension, active lumbar extension, yeoman's test, Milgrams, and Kemp's test were found to be positive causing increased symptoms in the lumbar and left sacroiliac region(s). The patient had 1-2 region manipulation, electrical stimulation, trigger point therapy, stretching, therapeutic exercise and cryotherapy. The physician recommended the patient continue with the treatment plan.

The Current Procedural Terminology (CPT) codes: 98940- Chiropractic manipulative treatment (CMT) was not considered medically necessary due to lack of meaningful and sustaining improvement over 17 months of ongoing treatment. Denial for chiropractic treatment was considered appropriate and supports maintenance care of a chronic condition that has reached Maximal Medical Improvement (MMI).

The CTN (Certified Traditional Naturopath) did not provide sufficient evidence to overturn this denial. According to Policy #84, the CTN supported that the patient no longer demonstrates meaningful clinical improvement, meaningful improvement measured by Outcome Assessment Tools (OATs), has not been achieved and there was insufficient information documented in the records to reliably validate response to treatment. Denial is appropriate. 

The treatment records did not include any OATs, functional deficits, or functional goals to support clearly that meaningful improvement was achieved and/or the likelihood of additional meaningful improvement that would be achieved with continuing chiropractic care. Denial is appropriate. 

The CTN reviewed did not support ongoing improvement or meaningful change from ongoing treatment that also resembles maintenance care for a chronic condition, and not medically necessary per the Health Plan. Denial is appropriate. 

The CTN failed to support that the treatment rendered had a direct therapeutic relationship to the patient's condition and provided reasonable expectation of meaningful recovery or improvement of function. Denial is appropriate.

The records reviewed from all providers strongly suggest that continued chiropractic care would be considered maintenance / supportive care and not a covered service according to the Health Plan. Denial is appropriate.

The CTN did not include appropriate OATs or successive objective measurements for improvement. The CTN did not support that the clinical condition is showing meaningful improvement in response to therapy. Denial is appropriate.

In conclusion, the denial for this appeal is recommended to be upheld, as the records submitted for review did not support meaningful improvement with approved chiropractic care, failed to utilize OATs to document functional improvement and failed to identify functional deficits, which would be a foundation for ongoing care. Physical modalities and therapies listed in the treatment for the DOS (date of service) in question, were not supported in the CTN and denial is also recommended for those procedures. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for chiropractic manipulative treatment is not substantiated.