Appeal type: Medical necessity
Decision: Upheld

Orthopedic / Musculoskeletal - Neck Problem/Pain
Chiropractic Services

The patient is a female who presented for ongoing complaints of neck stiffness and achiness, and low back pain, with reported radiation. It is unclear if the patient experienced prior similar symptoms or treatment. No examination findings, subjective or objective information was submitted for review. 

The patient was given a primary diagnosis of M54.12 radiculopathy, cervical region. The provider added diagnosis of M54.13, radiculopathy, cervicothoracic region. The patient received continuous treatment 2-4x per month for a year, which included 98940, chiropractic manipulative treatment 1-2 regions, 97035, therapeutic ultrasound and 97012 mechanical traction. Home exercises, stretching and self-care were recommended.
Short term goals included reduction of pain and improving ability to perform activities of daily living (ADL's), while long term goals were to alleviate pain and maximize functional capacities for ADL's. 

Each 4 week course of care was followed by recommendations to continue treatment at a frequency of 2x every 2-4 weeks, with re-evaluation. Patient Visual Analog Scale (VAS) pain levels fluctuated between 5-7/10 for the cervical region and 3-6/10 for the thoracic region. It appeared that the patient had shown improvement with the initial course of chiropractic care, however, no further clinically sustained improvement was noted beyond. 

The patient was treated approximately 41 times over the course of one year. The subject under review is the medical necessity for services for one date of service. 

The health plan's determination is upheld, in whole. 

No. The requested health service/treatment of Chiropractic services are not medically necessary for this patient. The patient initially reported complaints of neck and upper back pain and stiffness and was treated weekly to bimonthly on a consistent basis for similar complaints, without reporting significant sustained improvement. Similar patient complaints and Chiropractic treatment continued for 5 additional months. The patient had received extensive treatment for this condition, at a frequency of 1x/week to 2x/month consistently, to the DOS under appeal. 

According to the appeal letter from the provider for medical necessity, the patient presented to the provider's office with complaints of neck, upper back and shoulder (side not specified) pain and stiffness, similar to those reported on initial intake. The patient had been continually treated from initial intake for similar symptoms with no lapse in care. No exacerbation or extenuating circumstances were noted. Upon patient assessment on the DOS in question, the provider noted muscle hypertonicity, joint tenderness and decreased range of motion (no specific ranges or numerical values were supplied). All findings were similar to prior patient assessments. The provider reported that the patient had a history of "compressed disc and narrowed joint spaces" according to the provider, however, no confirmation of diagnostic findings were included in the medical records for this patient. The provider, in addition, reported joint fixations/subluxations, which claimed to render the treatment "medically necessary".
This alone does not constitute the medical necessity of treatment. The provider reported joint fixations/subluxations in prior DOS, however, additional criteria must be met to establish medical necessity for treatment of subluxations. 

According to The Council on Chiropractic Guidelines and Practice Parameters, to establish that the treatment is reasonable and medically necessary and accepted by the General Medical Community, the patient must show progressive sustained improvement. The provider did not establish the medical necessity of treatment in the submitted documents, as it appears the patient did not show sustained, progressive improvement. When a patient's measurable outcome no longer shows improvement, and the patient's clinical status has reached maximum improvement, additional treatment is not medically necessary and would be considered maintenance. Simply because the provider reported patient subluxations, does not make the treatment medically necessary. 

Based on submitted records, the treatment for the DOS in question, was not appropriate in terms of being considered effective for the patient's condition, not required for the direct care and treatment of that condition. 

This patient had been treated for the same condition and symptoms as initially reported, with continuing care through the DOS under review. No exacerbation or extenuating circumstances were reported. The treatment under review, appeared to be merely a continuation of months of chiropractic care resulting in no significant, sustained improvement. The patient had most likely attained her maximum therapeutic benefit (MTB) for this condition when no further improvement was reported. Continuous care, as reported, would not likely result in further improvement. When a patient's condition reaches MTB for a condition, additional treatment is no longer medically necessary.
For this patient, there is no evidence of improvement in functionality. 

In addition, the patient was recommended to perform exercises at home helping to prevent future exacerbations. After months of treatment, the patient should have then been well-versed in a home exercise program to address any remaining deficits and flare-ups. 

A patient-self approach focusing on self-management, along with a healthy lifestyle, is important to restore and maintain function, to improve chronic conditions in the long term, and to provide a management plan instead of a cure. Self-management support, as an overall approach to persistent musculoskeletal disorders and their multifaceted origin, may help in the long-term management of these conditions. This allows patients to have the skills and knowledge to actively manage their condition, well after the initial treatment period has ended. 

Educating a patient in self-management support allows the focus on teaching skills that can be generalized and allows patients to manage their own health conditions independently after the cessation of treatment. The patient has completed an adequate amount of chiropractic sessions prior to the DOS under review. It is expected that the patient would be very well-versed in a home exercise program at this time to address any remaining deficits and flare-ups. The documentation does not outline significant objective functional improvement from prior chiropractic services to support the requested appeal. There is no documentation of an attempt and failure of an independent home exercise program alone to address remaining deficits to require continued skilled chiropractic services. As the patient did not provide evidence of significant sustained functional gains from the recent course of chiropractic treatment, or evidence to support exceptional circumstances to require continued care over a home exercise program, the medical necessity of chiropractic treatment for the DOS in question, is not established.