Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Radiculopathy.
Treatment: Service codes 97110 (therapeutic exercise procedure), 97012 (intersegmental traction), 98940 (CMT (chiropractic manipulation treatment) 1-2 regions), and 97035 (Therapeutic ultrasound).

The insurer denied coverage for service codes 97110 (therapeutic exercise procedure), 97012 (intersegmental traction), 98940 (CMT (chiropractic manipulative treatment)1-2 regions)), and 97035 (Therapeutic ultrasound).

The denial is upheld. 

This is a case of a female with a listed history of radiculopathy, cervical region, and subluxation complex (vertebral) of cervical region. She presented with tenderness in the cervical and thoracic regions. She described the pain as achy, dull, sharp, and stiff. It occurs with repetitive movement. The pain interfered with daily activities of desk work and some loss of range of motion (ROM).  The documented symptoms have not displayed any meaningful change with treatment, nor has a home exercise plan or management plan (HEP) been established to strengthen these symptoms, intending to reduce the incidence of clinical flare ups from activities of daily living (ADL). The provider chart notes (PCN) did not confirm a significant exacerbation or new injury that would support a higher level of evaluation and management (E/M) other than what would be bundled with treatment for dates of service. The patient does not show compliance to recommended treatment plans indicated in the records reviewed. The patient appears to return for treatment at their prerogative, which may support recommended treatment is not necessary. Outcome assessment tools were not utilized or included in the records reviewed. 

The documentation submitted clearly indicates the recommended treatment plans that the provider believed necessary to provide meaningful improvement for each of the clinical flare ups. The patient did not comply with the recommendations and averaged 1 treatment per month during this extended period of care. This non-compliance to care would strongly suggest that treatment was not necessary or beneficial in the view of the patient and symptoms were manageable by self without ongoing chiropractic care. No significant exacerbations were documented, and flare ups were due to "simple activities of daily living."

The provider did not utilize appropriate documentation and outcome assessment forms (OAFs) to document functional improvement from treatment that would support meaningful improvement and necessity for ongoing care.  

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) indicate, "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."

Nationally accepted guidelines from the Centers for Medicaid and Medicare services (CMS) - Maintenance therapy, "When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The PCN supports that continued chiropractic care would be considered maintenance care and therefore not a covered service by the Oxford definitions that include," The patient no longer demonstrates meaningful clinical improvement which is measured by standardized outcome assessment tools." And "Meaningful improvement has not been achieved." And "There is insufficient documentation to reliably validate response to treatment."  

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

The insurer's denial of coverage for service codes (97110), (97012), (98940), (97035) is upheld. Medical Necessity is not substantiated.