Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Chiropractic Services.

The insurer denied the chiropractic services.  The denial is upheld.

The patient is a male. He presented to the office of the chiropractic provider with a complaint of low back pain secondary to household chores, computer use, prolonged sitting and lifting an infant. On a scale of 0 to 10, the low back pain was rated at 6-7/10. Cervical and dorsal pain was also indicated to be 5- (negative). Cervical range of motion was indicated to be near-normal. Spinal palpation was reported to be painful with muscle spasm and restricted motion. Lumbar range of motion was within a few degrees of normal 6/10. Diagnoses were not initially reported, nor was a treatment program.

The provider performed a re-examination with all of the reported findings being unchanged from the initial examination. The provider reports subluxations of C1 (first cervical spine vertebra), C2 (second cervical spine vertebra), C5 (fifth cervical spine vertebra), C6 (sixth cervical spine vertebra), T4 (fourth thoracic spine vertebra), T5 (fifth thoracic spine vertebra), T8 (eighth thoracic spine vertebra), L3 (third lumbar spine vertebra), L4 (fourth lumbar spine vertebra), and the right pelvis.

The treatment was reported to be spinal manipulation to all areas, mechanical traction, therapeutic exercises in the form of a vibration plate, and the provider billed for extra spinal manipulation, although the records do not indicate extra spinal manipulation was performed.

At question is the medical necessity of treatment rendered on different dates of service. Prior to those dates of service, there were several visits completed with no definitive progress reported by way of improved objective findings. Carrier records indicate diagnoses of M 99.03, segmental dysfunction of the lumbar spine, M 54.50 low back pain, M 99.05, segmental dysfunction of the pelvis, and M 99.01 segmental dysfunction of the cervical spine.

Comparative evaluation of the initial examination and the re-examination performed on  document that after previous visits of treatment, there were no improved objective findings documented. The treatment again is reported with unchanged objective findings.

No, the chiropractic services were not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The treatment again is reported with unchanged objective findings, which supports a stabilization in response to continued chiropractic care. This indicates that the patient has reached maximum therapeutic benefit from ongoing chiropractic care.

The patient had been showing progress, but from that point on the daily records do not document further therapeutic gains being made. Therefore, MTB (Maximum Therapeutic Benefit) had been reached.

The health plan's denial was reasonable and based on guidelines that are consistent with the standard of care in the Chiropractic community. The guidelines are well-founded and clearly address therapeutic value of treatment rendered as well as the point when the MTB has been reached. The plan description of MTB is very comprehensive and clearly details the documentation that there has been no objective progress.

Therefore, given the above, the chiropractic services were not medically necessary.